What's Wrong With Fat? (4 page)

Rejecting the obesity problem frame entirely would imply different conclusions about what should be done and why. For instance, fat acceptance groups assert that the central question is not about medicine or public health but about civil rights. They reclaim the word
fat
as a neutral or positive descriptor, as the civil rights movement reclaimed
black
and the gay rights movement reclaimed
queer
.
45 This movement argues that we would do better as a society to invest public resources in raising consciousness about the negative social implications of weight-based stigma and discrimination, rather than engage in a futile and unethical attempt to eliminate fat people. Drawing on the disability movement, they demand public accommodations for larger bodies, as well as weight-based antidiscrimination laws and full access to respectful medical care. They affirm the moral values of equal access and equal protection. Some fat rights activists support programs to improve access to fruits and vegetables in inner cities, efforts to reform the food industry, or raising the minimum wage. However, they insist that those initiatives be justified on their own terms, and not as means to ending the “obesity epidemic.” For, they argue, raising alarm about obesity worsens anti-fat stigma. Despite the symbolic sway of arguments about the importance of equal rights, fatness is only rarely discussed in these terms. This is because the personal responsibility framing of “obesity” makes people unable to see fatness as an ascribed trait. In other words, frames vary in their power and those differences matter as much as the frames themselves.

BUT ISN’T IT UNHEALTHY TO BE FAT?

“But, isn’t it unhealthy to be fat?” you ask. The argument that obesity is unhealthy is deployed to various ends. It is used to invalidate the claim that fatness should be accepted, treated as a basis for rights claims, or valued as a form of human diversity. (How can we accept or value ill health or disease?) It is also used to suggest that, if we perceive obesity as a health problem, it is because it
is
.
In other words, the facts speak for themselves.
But, as sociologists of science have shown, we only become aware of “the facts” through social processes. 46 Even if there were irrefutable scientific evidence that being overweight or obese causes ill health—and this is, in fact, hotly contested 47 —it would still require social action to bring this issue to public attention and make it a public health priority. Indeed, by current standards, more than 50 percent of the U.S. population were overweight in the 1970s. Yet it took more than twenty years and concerted advocacy before widespread public concern erupted over an “obesity epidemic.” This is consistent with research on social problems, which shows that an issue only becomes recognized as a social or public problem when “members of a society define a putative condition as a social problem.” 48

Moreover, it is important to recognize how frames inform understandings of health risk. 49 For instance, African American men have extremely high mortality relative to other groups. There are heated debates about whether this can or should be addressed via biomedical treatment or requires intervention into underlying causes of inequality. 50 However, no one proposes to solve this problem by making black men white, since, unlike weight, race is perceived as immutable and, in many circles, as a valuable form of diversity.

Social values also influence which choices are seen as desirable, or even possible. Consider that an average American man has a shorter life expectancy than an average American woman. There is also evidence that castration would increase men’s life spans. 51 Should we encourage men to seek castration, as a means of prolonging their individual lives? Should we finance a public castration campaign to improve rates of mortality at the population level, in order to stem the “epidemic of virility”? Clearly, no one in their right mind would seriously recommend or publicly finance this
choice
as a means of decreasing mortality, because masculinity and its associated organs are socially valued. 52 In the context in which fatness is socially devalued, amputating a part of a healthy stomach—through bariatric surgery—is an increasingly popular weight-loss treatment. In other words, even if there are some health risks associated with higher body mass, this does not—in itself—tell us why public concerns about obesity have reached such a fever pitch, why blame and responsibility are discussed in the specific ways they are, and what the social implications of all this talk are.

That said, many readers will still want to know where I stand on the medical and public health risks, and so I will briefly address that. I believe there are some health risks associated with higher body mass, but I am also aware that there are some health risks associated with lower and, in some cases, “normal” body mass. Careful epidemiological studies demonstrate that people who are “obese” (but not those who are only “overweight”) are, on average, more likely to die of cardiovascular disease than those people who are of “normal weight” (have a BMI between 18.5 and 25). Yet they further show that people who are “underweight” (have a BMI below 18.5) or of “normal weight” are, on average, more likely than those with a BMI between 25 and 35 (“overweight” and “grade I obese”) to die of chronic respiratory disease, acute respiratory and infectious disease, or infections. 53

While obesity is a risk factor for developing cardiovascular disease in the first place, among those who already have heart disease, it has been shown that being overweight or obese
lowers
mortality risk. 54 Having a BMI over 30 has been shown to increase risk of breast cancer among postmenopausal women but to decrease risk of breast cancer among premenopausal women. 55 What this book will show, is how our uncritical reliance on a medical and public health crisis frame of corpulence lead us to emphasize the risks associated with overweight and obesity, while glossing over the health risks associated with “underweight” or “normal weight,” as well as those cases where being “overweight” or “obese” seems to be protective of health.
This begs a social, not a medical, explanation.
Moreover, as college students will learn in any introductory course in statistics or epidemiology, association is not the same as causation. Many studies that point to an association between “obesity” and a negative health outcome do not adequately examine whether both “obesity” and the negative health outcome may, in fact, be caused by a third unmeasured variable.

Cervical cancer is a case in point. “Obese” women have higher rates of cervical cancer, and yet the causal mechanism appears to be mainly social rather than physiological. Namely, weight-based prejudice and discrimination on the part of medical-care professionals make fat women more likely than thinner women to avoid doctor’s visits, resulting in infrequent Pap smears. 56 In fact, there is some evidence that many doctors refuse to perform Pap smears on fat women. 57 In this case, to say that obesity
causes
higher rates of cervical cancer is misleading. A more accurate statement would be that weight-based stigma represents a barrier to health care access, which, in turn, leads to later detection and increased rates of cervical cancer among “obese” women. Similarly, higher rates of heart disease among people categorized as obese may be caused by poor nutrition, sedentary lifestyle, or stress produced by discrimination—all factors that are more common among those categorized as obese and positively associated with heart disease—rather than by obesity per se.

This point is actually not especially controversial, although many mainstream obesity researchers dismiss it as a question of semantics. Thus Professor of Pediatrics, Director of the Center for Human Nutrition at the University of Colorado, and the cofounder of the National Weight Control Registry James Hill said in an interview with me: “We’re getting all hung up in the words.... I’m happy if you want to focus on nutrition, on physical activity, on obesity, on diabetes; it’s all one cascade.... It’s really hard to separate out what’s causing what.” “Poor diet, physical inactivity, and weight kind of go together. Who knows what drives what?” asked Kelly Brownell, a psychologist, prominent obesity researcher and activist, cofounder and director of the Rudd Center for Food Policy & Obesity, and director of an eating disorders and weight-loss center. Mainstream obesity researchers readily admit that researchers rely on BMI in large part because it is easy to measure. In the words of professor emeritus of medicine at Columbia University and founder of a weight-loss clinic that bears his name, Theodore VanItallie, “Whether [obesity is] a risk factor because it is, in part, a marker for lack of exercise... needs further investigation, but obesity is something we can measure.”

My personal sense, if forced to articulate it, is that, while there are some medical risks associated with higher levels of body weight, this issue has been blown out of proportion. I have seen little empirical support for many claims that are taken as fact, including that this generation of children will die at a younger age than their parents due to obesity or that obesity will soon overtake smoking as the leading cause of death. That these claims are so widely accepted also begs a social explanation, which I offer in this book (see especially chapter 4 ). However, the goal of this book is not to demonstrate that concerns over obesity have been overblown or, for that matter, to get to the
truth
of obesity as a medical or public health crisis. 58 Rather, it takes a step back to reveal that debates over obesity-related health risks are part of larger framing contests over the meaning of fat bodies. Drawing on a long tradition of research on social problem construction, this book puts “the process by which members of a society define a putative condition as a social problem”
at the heart of the analysis. 59 The use of the word
putative
,
or
reputed
,
hypothesized
,
or
inferred
,
emphasizes that, in focusing on the claims-making process, “we put aside the question of whether those claims are true or false.” 60

THE RESEARCH

To examine framing contests over fat bodies, this book draws on a rich corpus of original data and diverse sociological methodologies, including: (1) 35 in-depth interviews with people at the forefront of debates over fatness, including researchers studying various aspects of body size, nutrition, or physical activity; fat acceptance activists; and journalists; (2) AQ 1 participant observation at fat acceptance conferences and list servers; (3) analyses of the scientific literature on obesity and on weight-based stigma and key policy documents; (4) basic statistical and discourse analyses of more than 650 U.S. and French news articles written about obesity or eating disorders; and (5) experimental studies with more than two thousand participants, measuring the effects of exposure to different news media fat frames.

I draw on the interviews to illuminate the production of knowledge about fatness. The analyses of the news media and scientific literature provide detailed information about the content of popular and scientific accounts of fatness. The participant observation, at fat acceptance conferences and on list servers, supplements my understanding of both fat rights frames and fat acceptance strategy. Finally, the experiments examine the reception and impact of different fat frames. This approach reflects the view that a tripartite focus on the production, content, and reception of culture—as opposed to examining only one or two of these dimensions—provides a more complete understanding of cultural meaning. 61

BODY SIZE AND INEQUALITY

This book speaks to central concerns in sociology about the collective construction (and contestation) of social meaning and its implications for social inequality. It also contributes to the burgeoning new field of fat studies that, following in the tradition of critical race studies, gender studies, and queer studies, is “an interdisciplinary field of scholarship marked by an aggressive, consistent, rigorous critique of the negative assumptions, stereotypes, and stigma placed on fat and the fat body.” 62 My specific contribution to this new field is to provide systematic analysis of an array of different fat frames and their social implications.

Drawing on the insights of critical race theory, I examine how class, race, and gender are represented in discussions of fat and how the war on obesity affects people differently based on these characteristics. 63 For instance, while modern states have become increasingly concerned with, and therefore more likely to regulate population health, reproduction, and demography—a tendency that French philosopher Michel Foucault calls bio-politics—the poor are consistently more vulnerable to such forms of state control, given their reliance on public resources and relative lack of privacy. 64 Stereotypes of African American women as having unbridled appetites inform discussions not only of their sexuality but also of their food consumption and body weight. 65

Science studies scholar and MD Robert Aronowitz has argued that upper-middle-class Americans’ concerns about an alleged obesity epidemic is largely fueled, albeit unconsciously, by the desire to put symbolic distance between themselves and people from lower socioeconomic classes.
He argues that the primary purpose of the medicalization of fatness may, in fact, be to signal and maintain “social difference” between the upper and lower social classes. 66 I would go farther and argue that these discussions also serve to put limits on social solidarity. Discussions of lazy, fat people as a drain on public resources echo discussions of lazy, black “welfare queens,” which have been evoked to limit solidarity and the scope of U.S. social welfare programs. 67 To the extent that fat people are also poor minority women, discussions of irresponsible “fatties” shore up prejudices against women of color. However, such discussions also further limit solidarity on the basis of body size. Stated differently, fatness has become an independent (but understudied) dimension of inequality.