On Fatness and Health

Here at MH Blog we've posted some skeptical perspectives on food science and obesity policy.  From a medical humanities perspective, there seems a very great deal of stigma and notions of deviance wrapped up into the talk of the "obesity epidemic," the word "epidemic" being a rich marker of cultural and social significance.  What's more, attitudes towards the connection between fatness and disease generally do not acknowledge the tremendous uncertainty involving metabolism, weight, and health, as Gard and Wright so ably demonstrate.

The idea, of course, is not that morbid obesity is good for one's health, but (1) that the attitude of certainty and self-evidence typically displayed when discussing weight and health belies the rather significant uncertainty in food science and metabolism; and (2) the stigma attached to fatness -- witness recent studies pointing to its contagiousness and its epidemic status -- promote an untoward focus on lifestyle and behavior as the cause of much chronic disease.  Of course, it is undeniable that weight is in some significant sense connected to many chronic diseases, but a narrow focus on individual behavior obscures the larger social structures that mold and shape individual choices.  It is true that smoking causes lung disease; but it is also true that smoking adheres to a robust social gradient, with members of lower socioeconomic classes smoking at much higher rates.  Unsurprisingly, the same populations report higher incidences of obesity, diabetes, and cardiovascular disease.

Thus, to simply point to behaviorial preferences such as smoking is a thin inquiry if not connected to an awareness and an analysis of the social determinants of behavior.  I mention all of this as context for the news of a new study appearing in JAMA reporting that fitness level was a strong predictor of mortality, while obesity had little influence.  The study cohort was comprised of adults aged 60 and older, and demonstrates what fat activists have been arguing for years: fatness is relevant to health, but less so than fitness.  From a policy persective, then, much greater resources and attention should be devoted to exercise promotion, and much less devoted to obesity policy and BMI measurement, especially insofar as the latter is deeply stigmatizing.

Thoughts?

Comments

[Felice Aull]

Dan -- thanks for being skeptical and calling attention to the social and structural factors that have an impact on health, as well as to the uncertainty about the value of BMI measurements, et cetera. But it is troubling that so many children now fall into the category of what is being labeled as obese, because inevitably, there will be long-range health consequences. It seems likely that such data signal the need to clarify all of the determinants of overweight in children, the populations that are particularly affected, their socioeconomic conditions -- which may turn out to show the same health correlations as those found in adults. Since children are involved, there may be more of an impetus to address the structural problems than there have been thus far. Perhaps the stigma issue will become less of a factor as more and more children are "larger."

[Daniel Goldberg]

Hey Felice,

Well, as Eric Oliver shows, the defining criteria for obesity (a sufficient BMI) is itself socially constructed and has historically been a moving target. This, of course, is not to argue that it is useless or impractical, but merely to suggest that I think skepticism is also warranted in thinking about the ways we categorize people and/or children in terms of fatness.

As for long-range consequences, the question must be asked: are these consequences attendant with fitness or with fatness? If indeed more and more children are becoming obese -- itself a datum that can be questioned, as Gard and Wright do -- there nevertheless remains much uncertainty regarding the long-term health consequences. If more children are fat and yet more children exercise, it it is not at all clear what the long-range health consequences will be.

In any case, I am certainly not arguing that obesity is good for children's health, but simply that some skepticism -- which is all too often totally absent from public discourse -- is warranted in thinking both about the categorization of fat children and about the consequences of fatness itself.

[Felice Aull]

Yup--I'm with you on the skepticism. And long range consequences certainly remain to be seen. Your points are all important ones that need to be out there. But being "heavy" (if we accept that heaviness is on the increase in children, and maybe we should not) makes exercise more difficult for most people, makes weight bearing joints more vulnerable to degeneration, which makes exercise more difficult. etc. I don't know the answer!

[Heather]

Your points are certainly well-made, and I'm glad that someone is raising these issues. One thing your latter comment brings to mind though:

"From a policy perspective, then, much greater resources and attention should be devoted to exercise promotion..."

To whom - exactly - are those "resources and attention" to be devoted? Because if, like always, it's every fat person who walks in the door, I still foresee problems. There is the inherent assumption that if a person entering a doctor's office is thin, they must be doing everything right (even if they seldom exercise and eat low-nutrient food). And that every fat person, by turn, must be doing it all wrong. Which, on a case-by-case basis, is ridiculous and insulting. It just seems like yet another way for clinicians to make assumptions and push a moralistic agenda onto every individual who doesn't meet the biomedically-defined notion of "normal" weight. That's troubling to me.

Having said that, this is a great post. I glad the social sciences are starting to problematize the "fat" issue. It's gone unquestioned in this country for far too long.

[Daniel Goldberg]

Heather,

You raise some excellent points. In terms of policy, extra caution is needed to ensure that the resources directed to fitness are not targeted to fat people. Indeed, the whole point of thinking primarily about fitness in place of fatness is because the former produces health benefits for all regardless of one's fat status.

Finally, one minor quibble: it's those of us working in the medical humanities -- not just the social sciences -- who are also trying to problematize the fat issue.

[Frank]

I like the move from emphasizing "less fatness" to "more fitness." The latter is not as appearance-driven as the former. . . .and as I've often worried, appearance-competition can become a big driver of wasteful positional jockeying.

On the other hand, perhaps fitness is just as driven by such concerns...here are some thoughts from Maxwell Gregg Bloche, Obesity and the Struggle Within Ourselves, 93 Geo. L.J. 1335-1359 (2005):

"Visceral needs and desires can be allies in this effort. We all want to be sexy, though some of us suppress this more than others. Sensual awareness is a potent motivator for fitness and dietary restraint, as the well-toned bodies in clingy attire on jogging routes attest. An erotic sensibility suffuses our culture-our stage and screen, music, fashion, humor, and casual conversation. We have become accustomed to worrying about this: we fear its coarsening effects, its challenge to faith and moral values, and its contribution to the spread of AIDS and other sexually transmitted illnesses. But to the extent that erotic awareness encourages attitudes and behaviors that keep calorie intake and use in balance, it is a potential tool in the campaign against obesity."

[Daniel Goldberg]

Hey Frank,

You're absolutely right to note that a focus on fitness is hardly a panacea, though I wonder how much of that is because we've connected fitness and weight so completely in our discourse that it's difficult to conceive of fitness apart from body image.