Debating, theorising and researching ‘obesity’ in challenging times

The past decade has witnessed a cacophony of calls to combat ‘the obesity epidemic’ and the ‘impudent lifestyles’ claimed to cause it. Reportedly affecting most adults and a growing number of children (but considered especially problematic among the poor, notably working-class mothers), overweight/obesity/fatness is presented by various ‘entrepreneurs’ (Monaghan et al, 2010) as a massive public health crisis that not only threatens individual health but also national wealth. This concern is evidenced across a range of national contexts, though ‘the obesity epidemic’ is largely deemed ‘modernity’s scourge’ (Gard and Wright, 2005, p. 68) and thus the blight of nations such as the United States, or Britain that is typified by the Academy of Medical Royal Colleges (AMRC, 2013, p. 3) as ‘the “fat man” of Europe’. The degradation of fatness is not new, but the sheer scale of this seems to be quite fitting under current social, political and economic conditions. Indeed, concerns about economic fitness and fatness have considerable resonance following the near collapse of capitalism in 2008 and conditions of (unresolved) global crisis (Wallerstein, 2011). Amidst austerity, comprising cuts to publicly funded health services and social welfare, the ‘larger public’ are routinely extolled to literally exercise greater self-discipline and ‘tighten their belts’. Lean times, we are told, necessitate lean, efficient, healthy bodies and the cutting of unwanted, aberrant flesh that is weighing us all down.

Social Theory & Health (STH) has served as an important forum for debating, theorising and presenting challenging research on medicalised fatness/weight. Ruth Graham’s (2013, p. 286) endorsement of this journal as a ‘slightly edgy discursive space’ wherein everyday health matters are integrated with more formal, abstract theory is a fitting sentiment that goes beyond her substantive interests in anorexia and death. Indeed, STH offers ‘plenty of food for thought’, so to speak, on related issues of fatness that implicate social and not just fleshy bodies. Hence, it was with considerable interest and pleasure to have been invited to compile this special issue. My instructions were to select eight previously published papers from STH on obesity and write an editorial.

There are enough papers on this topic in STH to fill two special issues. My exclusion of certain contributions is largely a pragmatic decision and is not meant to imply that such papers are irrelevant to the broader debate. Any omission should not be interpreted to mean that I am unsympathetic towards other authors’ disciplinary and philosophical commitments. For example, to note two papers that are not included – Crossley (2004) and Patterson and Johnston (2012) – the former is aligned with my own professional disciplinary concerns (sociology), while both speak to my interest in critical realism as a non-conflationary meta-theory that has salience when engaging social and biological matters (see also Monaghan, 2013). At the same time, certain assumptions in these writings, wherein obesity is a behavioural problem ultimately caused by modern lifestyles, must be critically evaluated rather than treated as axiomatic. Obesity science is an uncertain business but it does suggest there could be many ‘putative contributors to secular trends in obesity’ beyond ‘the Big Two’ (that is, diet and physical inactivity) (Keith et al, 2006). While fatness or higher levels of body mass need not be medicalised/pathologised as overweight and obesity, with some clinicians rejecting such biomedical constructs (Aphramor and Gingras, 2011), it is also the case that a population’s supposedly expanding waistline might be accounted for in terms of pharmaceutical iatrogenesis, decreased smoking, sleep debt, endocrine disruptors in the environment (Keith et al, 2006) or a combination of other factors, including maternal undernutrition and foetal programming in an inequitable world (see below).

I have also omitted papers for other reasons. For instance, although I have contributed five papers on obesity/weight/fatness to STH, given an obvious need for polyvocality I have only selected one fairly short paper (Monaghan, 2005). I chose that because it has served as a recurrent point of reference for other contributors to STH and it was accompanied by two excellent papers in the same issue, which I wanted to include here (Aphramor, 2005; Rich and Evans, 2005). These two papers on dietary approaches to weight loss and fat politics have grabbed the attention of many STH readers as gauged by citation metrics. Accordingly, I have sought, as far as possible, to collate a range of critical and hopefully thought provoking articles, which speak to different aspects of a public issue and contingent private trouble that traverses other binaries such as: nature/culture, reason/emotion, majority/minority and normal/deviant. In so doing, I have not only selected theoretical, or discussion-oriented, articles but also empirical papers (which are theoretically informed), incorporating contributions that are attentive to socially constructed discourses, body materiality and/or embodied health practices. A unifying theme across these papers is a commitment to social justice and challenging hegemonic understandings. My view is that at a time when there is much misrecognition and symbolic/structural violence in class-divided, sexist, ageist, ableist and racist societies, the war on obesity should be challenged in the interests of fostering more peaceful self-body relations. Moreover, as will be seen, there is scope for traversing disciplinary ‘silos’ and deceptive epistemologies as part of a collaborative endeavour that is well-informed, and, dare I say, well-rounded. In sum, I have included papers that ‘feed’ a growing concern to foster critical, reflexive knowledge that could have implications for a range of parties, including health professionals who are placed on the frontline in the war on obesity and policymakers who all too often seem to be looking for evidence to support pre-existing beliefs.

The first three papers in this collection (Aphramor, 2005; Monaghan, 2005; Rich and Evans, 2005) reflect my own early forays and fortuitously established alliances within this nascent field of study. My 2005 Discussion Piece: A Critical Take on the Obesity Debate was written after my interest was piqued by claims that most men in England are overweight or obese, that ‘excess’ weight/fatness is unacceptable and this must be tackled as a matter of national urgency. The more I looked into this alleged public health crisis the more critical I became, much in line with a sociology of rather than for medicine. I therefore approached the editors of STH with my idea to ‘expand the obesity debate’ (following engagements with the United Kingdom’s Men’s Health Forum in the run up to their Department of Health-funded conference on men’s and boys’ weight issues). During this time Lucy Aphramor, Emma Rich and John Evans also accepted my invitation to write two accompanying articles.

In her 2005 STH paper, the second article in this collection, Aphramor unhinges certain dietary ideologies and the dominant weight-centred health framework. Written from the vantage of a practising dietician, her central theme is that ‘the current weight-loss schema helps to naturalise a fatness discourse that not only represents large people in offensively stereotyped ways but also fails to integrate people’s lived experience as gendered, situated bodies in an inequitable world’. Refusing to ‘swallow things whole’, Aphramor calls upon fellow clinicians, policymakers, researchers and others to ‘throw their weight around’ in order to effect change that is evidence-based and ethically justifiable. Her article includes challenging insights pertaining not only to gender inequity but also globalisation, racism as well as biological pathways linking the social body to ill-health. Such reasoning might disorientate some readers, but she advises: ‘A first step in getting to grips with fatness may be to dismantle the old ordinances and draw up new maps’. Aphramor has subsequently authored numerous works that extend such thinking, often in collaboration with other critical dieticians in North America who promote alternative clinical paradigms and arena for debating transdisciplinary concerns (for example, Aphramor and Gingras, 2011; Bacon and Aphramor, 2011; Brady et al, 2013; see also the Journal of Critical Dietetics, which was launched in 2009).

The third paper by Rich and Evans (2005) interrogates obesity discourse and associated negative unintended consequences. For these sociologists of physical education, problems not only include the unfounded certainty of those seeking to promote a ‘healthy weight’ but also the institutionalisation of size discrimination and the possibility that obesity discourse may ‘propel some people towards ill-health via disordered relationships with food, exercise and the body’. Moral and ethical issues are again underscored as part of their efforts to reclaim body politics and the influence of social factors on health. Related concerns include the ways in which biomedical narratives, often recycled with a sense of alarm in the mass media, dominate public understandings and obfuscate social structures through the culture of healthism and individualism (see also Evans et al, 2008; Rich et al, 2011).

In addition, I have selected five subsequently published papers from STH, which advance critical thinking. The first of these, by Warin (2011), focuses on a four-part television anti-obesity campaign, featuring an English celebrity chef, Jamie Oliver, whom she typifies as Foucault’s progeny. This typification is apt given the ways in which a whole community is selected for health promotion, with power exercised through ‘networked circuits of deployment’. Also going beyond a ‘mechanistic application’ of Foucauldian theory, Warin examines ‘the intersections of different technologies that give rise to specific lifestyle interventions, and the forms of resistance they generate’. In particular, she explores how reality TV qua cultural technology seeks to foster self-governance in a moralising neo-liberal environment wherein working-class Northern English people (especially ‘inept’ mothers) are targeted. Her paper is a powerful reminder in our media-saturated environment that it is all too easy to reproduce and validate the dominant ‘rhetorical storyline of obesity’. Moreover, in learning from townsfolk who challenged Oliver’s evangelical crusade, it is necessary to appreciate how food and the body are ‘deeply enmeshed in the socio-economic and gendered relations of people’s lives (often across generations) and [these] cannot be changed overnight (or in four episodes)’. Of course, one may also ask to what extent such behaviours and populations should be prioritised in health research calling for change, especially given the toxic illness behaviours of the very rich and powerful, the real ‘greedy bastards’, which are arguably far more consequential for public health (Scambler, 2009).

Even so, the lifestyles of the poor and ‘socially excluded’ tend to be prioritised in (typically state-funded) health research, but even then it is crucial to consider how human agency is structured. Drawing from interviews with 15 underprivileged young women in Canada, Dumas et al (2014) present a qualitative study of health, obesity and lifestyle. In order to ‘examine the meanings given to health and the body’, the authors use a branch of contemporary sociological theory that has largely been neglected in this field – that of Bourdieu on social classes, the habitus and embodied dispositions. Attuned to the constraining impact of disadvantaged life circumstances, Bourdieu’s conceptualisations sensitise us to how conditions of necessity influence people’s adaptive responses, ranging from acquired taste for particular (cheap) foodstuffs to the need to prioritise obligations to others over oneself (as with gendered child care responsibilities that eclipse injunctions to take regular exercise as a putative antidote to obesity). Dumas et al conclude by arguing that health practices are less a product of knowledge and more an outcome of the ‘choice of the necessary’ in a real material world wherein an ‘instrumental relation to the body’ is reflective of inequitable social structures.

Rail et al’s (2010) paper is also critical of the old ordinances insofar as it views obesity discourse as ‘a good example of micro-fascism’. Obesity discourse is described as a ‘fascist structure’ insofar as it is ‘saturated with ideology and intolerance’ that extend not only to weight/fatness but also alternative forms of knowledge, such as that generated by qualitative researchers. Rather than accepting the epistemic authority of state science, including the alarmist claim made by a US Surgeon General that obesity is a form of ‘domestic terrorism’, Rail et al consider what such discourses mean in practice. More specifically, they use feminist poststructuralist theory to interrogate the politics of evidence marshalled in the war on obesity among Canadian youth and associated ‘biopedagogies’, that is, disciplining and normalising practices exercised within a broader apparatus of surveillance, bodily self-regulation and governmentality. Reporting and analysing the discursive constructions of health and the body among 144 participants from diverse backgrounds, the authors ‘look into the effects of obesity discourse’ and show that young people prioritised a limited number of corporeal themes: personal responsibility for ‘being physically active, eating well and being neither too fat nor too skinny’. Moreover, these preoccupations – entwined with racialised, ableist and gendered injunctions to ‘look good’ or beautiful – often eclipsed other health promotion concerns, such as: smoking, unsafe sex and abuse of alcohol and other drugs. Although physical constructions of health were sometimes resisted, they were dominant and also eclipsed highly consequential macro-social determinants of health, such as socio-economic status, education and employment. When discussing their findings, Rail et al underscore the problematic status of obesity discourse wherein achieving an ‘ideal body weight and shape’ is conceivably more significant than health (practices) and healthy environments.

The penultimate paper, by Fraser et al (2010), focuses on emotions and theorising emotions as collective social processes. For these authors the often repeated reference to ‘moral panic’ within critical writings on the obesity epidemic invites further theorisation. Advancing a feminist, embodied approach, Fraser et al reflect upon the action of emotions rather than viewing these as individual psychological phenomena. In particular, they draw on Sara Ahmed’s work on the performativity of emotions, arguing ‘that this theory offers a rich starting point for illuminating the action of emotion in both the general relationship between public discourse and subjectivity, and the specific relationship between the self, the body and the oftentimes unmet imperative to slimness’. Issues include the degree to which emotions cannot simply be dismissed as destructive, visceral responses that are antithetical to constructive reason. Rather, emotions define boundaries and subjectivities as they emerge and move between bodies, and such processes need to be theorised when developing ‘a better approach to body size’ and health. After all, emotions are often denigrated as feminine (just as fatness and softness are within obesity discourse), further underscoring the need to reframe emotions as worthy of careful consideration rather than dismissing them as ‘intrinsically negative or polluting’.

The final paper by Yoshizawa (2012) discusses the potential value of the Barker hypothesis when theorising obesity alongside the need for transdisciplinarity and social justice. The Barker hypothesis is also known as ‘the “foetal origins hypothesis” or the “developmental origins of health and disease” ’ paradigm (similarly noted in Aphramor’s paper), and it grapples with the social and temporal distribution of population health and nutritional privilege. This theory, we are told, ‘does not support solely reductionist, biophysiological paradigms of health and disease. Instead, in principle it evinces complex understandings that span biology, social positionality, place and generation’. The basic premise is that foetal development in utero is critical for future health outcomes: many diseases throughout the life course, such as coronary disease and stroke, are traceable to maternal undernutrition and inherited metabolisms across generations. Questions then arise concerning whether emergent health problems attributed to obesity could be a product of earlier ‘metabolic imprinting’ as it affects the development of the pancreas, for instance, and its function in regulating digestion and storage of energy. Yoshizawa demonstrates knowledge of fat politics and critical studies of obesity/fatness and she responds to the potential for injustice engendered by the Barker hypothesis, including its deployment within pre-emptive disciplinary regimes of gendered power and health surveillance. Accordingly, she calls for greater participation by social scientists and activists in such debates in order to transform practice through transdisciplinary collaboration. While fat studies scholars have well-reasoned grounds for challenging the pejorative status ascribed to medicalised fatness in this account, and I would surmise that the Barker hypothesis is merely one part of a much larger jigsaw, Yoshizawa’s paper is noteworthy. It underscores the point that we cannot be content to address either social constructions (language, meanings, ideologies, discourse) or biological and medical facts within a positivist epistemology. Critically, given the complexity of the social and natural worlds, human embodiment must be understood as a multidimensional, relational and emergent process that is irreducible to society or biology, and thus any single source of expertise (Shilling, 2005; Williams and Monaghan, 2013).

I will close with some musings on possible future directions. Three overlapping themes strike me as salient as we proceed into what will likely be an extremely challenging time amidst growing inequality in a bifurcating world economic system, migration as people seek better lives, the resurgence of fascism as national and embodied boundaries are transgressed, and myriad protestations against existing power structures. First, as Aphramor (2005) and Yoshizawa (2012) demonstrate, we must recognise that humans are not only stratified socially or psychologically but also biologically. Hence, an array of comingling embodied mechanisms deserve careful consideration without uncritically (prejudicially, conveniently, efficiently) accepting the ‘truth’ that higher levels of body mass are necessarily because of an individual’s ‘moral failure’ to regulate their energy balance (gluttony and sloth). For instance, in the interests of social justice can we ignore the maldistribution of nutritional privilege and metabolic imprinting in utero as potentially consequential mechanisms for health and adiposity, especially when people living in poverty migrate from (semi-)peripheral to core nations and have children? Note Aphramor’s (2005) critical reference to obesity among US Mexican boys, which undermines prejudicial allocations of irresponsibility to immigrant mothers. As she explains when reworking a well-known feminist slogan, the physiological is also political.

Second, and not unrelated, we need theoretically informed discussion and research on how sizism is implicated in the reproduction of hegemonic interests in a capitalist system during a period when usual anti-universal norms (notably racism and sexism and the biological narratives invoked to sustain them) have been seriously challenged. To extend Wallerstein (2004) slightly so as to more fully recognise body politics: how useful is it to view sizism not as a ‘norm of exclusion’ but a ‘norm of inclusion at an inferior status’ – albeit one that tends to be sugar-coated with ‘compassionate’ appeals from various entrepreneurs to ‘help’ people ‘choose health’? Surely it is no accident that obesity is more common among ‘the usual suspects’ such as ‘the darker races’ who are corporeally marked as inferior. Of course, today’s suspects not only include minority ethnic groups who are pathologised for their alleged ‘failure’ to adapt to the Western ‘obesogenic environment’ (for a critique of obesogenic accounts, see Evans, 2010; Guthman, 2011), or other ‘deviant’ groups such as Northern English townsfolk. On a more expansive note, what are we to make of obesity discourse when it incorporates the majority of the adult population in core nations? This, I would add, is at a time when US hegemony is in terminal decline, its macho militarism has proven to be impotent and deep concerns about national economic fitness prevail. Could it be argued that the overweight (read: lazy, greedy and feminised) populations of core Western nations are being ‘groomed’ for inclusion in a world-system at an inferior, or at least much diminished, social status? There is a rich body of social theory that we may draw upon when considering such questions, ranging from anthropologies of corporeal pollution (Douglas, 1966) and gendered studies of abjection (Kristeva, 1982, see also Monaghan and Malson, 2013), to world-systems analysis that appears ever more relevant following the 2008 global financial meltdown (Wallerstein, 2011). Accordingly, we may be better placed to engage multidimensional bodies as social as well as biological processes, lived bodies that are relational and embedded in global, historical, political and economic structures that are in flux and consequential for health (broadly conceived). Such a task, I would suggest, is essential even if social actors are not personally politicised or if they prioritise identity politics and fat liberation/pride as the primary axis for group mobilisation and activism (rather than categorical mechanisms that influence life chances, such as social class and location).

Finally, in ‘underlabouring’ for critical weight studies (Monaghan, 2013), it strikes me that there is much more to be done in order to clear the ground if we are to develop approaches conducive to human flourishing. Two brief points should illustrate what I have in mind here. First, in accepting that facts exist beyond meaning and discourse, is it practically adequate to claim ‘the obesity epidemic’ is a medical and social fact – as something ontologically awry in the world that humans are responding to and attempting to fix as best they can? Medicine exerts considerable institutional and cultural authority and is often invaluable. However, it is hardly controversial to state that its objects of concern are not always or necessarily pressing problems that elicit well-considered solutions. ‘Secular trends in overweight and obesity’ indicate that something is happening (Crossley, 2004), and critics or sceptics do not necessarily ignore or ‘black box’ such concerns (for example, Campos et al, 2006; Guthman, 2013). However, the question remains: To what extent does weight/fatness defined as ‘excessive’ constitute a real and ever expanding public health threat and to what extent are current interventions necessary, effective and ethical? On the basis of existing evidence and burgeoning critical studies from social scientists, clinicians and fat activists, I think there is much here that should be challenged. Second, knowledge remains fallible and it is important to reflexively subject our own contributions to informed scrutiny and carefully revise these where necessary. At the same time, we must sweep aside straw men caricatures of critical studies of weight/fatness/obesity in a broader social context where mass deception (which is not synonymous with lying), efforts to maintain secrecy and silence, obfuscation and scapegoating are commonplace (Monaghan and O’Flynn, 2013; O’Flynn et al, 2014). As discussed in this collection, social class is hardly credited in health policy outside of its misrecognition as a variable for behavioural interventions comprising calls for heightened personal responsibility, surveillance and discipline among the poor. Much remains to be done amidst myriad obstacles within and beyond the social sciences, and I imagine STH will remain an important forum for debating, theorising and researching such concerns in these challenging times.