Understanding obesity now and then
Megan B. McCullough and Jessica A. Hardin (eds.)
Reconstructing Obesity: The Meaning of Measures and the Measure of Meaning, New York and Oxford, Berghann Books (Food, Nutrition, and Culture volume 2), 2013, 245 pp., $120.00/£75.00 (hardback), ISBN:978178238141-9.
Georges Vigarello
The Metamorphoses of Fat: A History of Obesity by (translated from the French by C. Jon Delogu), New York, Columbia Press (European Perspectives), 2013, 261 pp., $35.00/£24.00 (hardback), ISBN: 9780231159760.
Reviewed by
Isabel Fletcher, Edinburgh Law School, University of Edinburgh,
Since its designation as a global epidemic by the World Health Organization (WHO, 2000), obesity has become a major topic in both popular and academic writing. Social scientists from a wide range of disciplines have dissected biomedical understandings of the relationship between bodyweight and health (Jutel, 2001, Gard and Wright, 2005, Monaghan, 2005, Campos et al., 2006), as well as producing accounts of the media coverage of obesity (Saguy and Ameling, 2005, Boero, 2007), the effects of obesity stigma (Rich and Evans, 2005) and the politics of obesity discourses (Guthman, 2006, Kwan, 2009, LeBesco, 2011). Such scholarship partially overlaps with a new discipline known as fat studies or critical weight studies (Aphramor, 2005, Cooper, 2010). Detailed critiques of the framing of obesity as an epidemic have been produced (notably Gard and Wright, 2005), but due to the greater availability of evidence, much of this work considers material from a small number of developed countries, usually the US, the UK and Australia.
Reconstructing Obesity addresses many of these issues using a series of cross-disciplinary and anthropologically informed case studies that draw on ideas of cultural difference, embodiment and local knowledge in order to better understand obesity in a range of social and geographical contexts. In their introduction, the editors criticise current obesity scholarship for ‘a lack of attention to the lived experience of people, how and why they eat what they do, and how people in cross-cultural settings understand risk, health and bodies’ (p.3). Chapters describe research using a range of ethnographic methods and conducted in a range of countries that include Guatemala, Cuba, Samoa and the United Arab Emirates. This is a welcome corrective to the restricted focus of much obesity research and policy writing, and is particularly valuable for countries such as Samoa and Cuba, which are regularly discussed in public health nutrition policy.
The collection aims to create a constructive dialogue across anthropology, sociology and public health. This is a challenging target given the continuing dominance of biomedical framings of body size, diet and health, and the consequent lack of attention paid to social scientific analyses of the problem with such understandings. In their introduction, the editors challenge the idea that obesity equals sickness and begin to develop a hybrid model of ‘obesities’, rather than a unitary obesity, that incorporates and moves between both scientific and cultural understandings of the phenomenon (p. 7). As part of this reframing, they want to problematize both the measurement of obesity and underlying models of its causes, arguing that
intervention and health promotion work could benefit from not assuming that the “individual” is universal, rights-baring and agentive, but rather see the individual as a culturally located concept best understood in context (p. 8).
For them, a highly individualised and rationalised account of behaviour leads to an excessively instrumental use of culture in obesity research (p. 9) where the influence of an individual’s social and physical environment is reduced to the limited and unhelpful category of ‘lifestyle choices’. Finally, they wish to exhume and examine the ‘moral assumptions and stigmatizing characterizations implied or buried in research and intervention practices’ (p.10), increasing awareness of the existence and effects of obesity stigma. The negative health effects of this stigmatisation are recognised as an important source of harm to those labelled as overweight or obese (Puhl and Heuer, 2010), yet individuals still report experiencing stigmatisation, particularly in medical contexts. For example, in her chapter Megan McCullough describes her experiences as a fat pregnant woman.
Emily Yates-Doerr’s chapter problematizes obesity measurement by describing the limitations of three different measures – body mass index, abdominal circumference and bioelectrical impedance analysis. She highlights the kinds of knowledge produced by each technique and the complexities of obtaining this knowledge, particularly in resource-poor settings. In particular she describes how, in her fieldwork in Guatemala, participants saw measurement as appropriate for commodities, but not for bodies – which could not be compared to each other in this fashion. Yates-Doerr is not arguing for better (more accurate or reliable) measurements, rather she is interrogating ideas of accuracy and the belief that ‘measurement can reveal the interior health of the body’: she argues that the concern for more accurate measurement means that ‘the representational qualities of numbers – and the experiences and people they purport to represent – become easily forgotten.’ (p. 50). Such omissions can occur throughout population health sciences but are a particular problem for individuals and communities who do not (and often cannot) fit mainstream biomedical models of health and behaviour.
Hanna Garth addresses such individualised models of obesity causation by describing the effects of past food insecurity on current understandings of diet and dietary restriction for weight loss in Cuba. She focuses on the impact of the period of economic hardship 1991-5 (following the collapse of the Soviet Union) on increasing rates of obesity within the country. Her interviewees describe a variety of responses to years of food scarcity including habitual over-eating or under-eating and problems in regulating their diet due to uncertainties about future supplies. As Garth points out, this uncertainty is also influenced by reliance on government food rations. She argues that
after a decade of food scarcity, the link between obesity, concepts of healthy bodies, and how one retains control over the body must be problematized; indeed for some Cubans maintaining extra food fat is seen as a form of control and a physical protection against potential future food insecurity (p. 92).
Body size is often understood as an attribute that is under individual control, whereas Garth’s case study demonstrates the flaws in this common sense idea, and invites the reader to question how reliable such ideas are in other contexts. This chapter is also a valuable corrective to the way in which Cuba is discussed within public health literature, as an example of the health benefits of economic scarcity (Willett, 2013).
Two chapters in this collection describe research conducted in Samoa that demonstrates the cultural embeddedness of ideas about eating and bodies. The first by Rochelle Rosen discusses the tensions between anthropological and behavioural medicine approaches to diabetes interventions, suggesting social science approaches can be used to develop methods that ‘incorporate culture in a way that respects sociocentric dynamics around health’ (p. 141). In the Samoan context, she argues that this would involve developing interventions that acknowledge traditional attitudes to body size, low levels of physical activity in older adults and frequent and abundantly catered cultural events. The second chapter by Jessica Hardin analyses fasting practices amongst Samoan Evangelical Christians. As Hardin points out (p.106), Samoans - and other Pacific Islanders - are known within anthropology and public health for their lavish food practices, focus on the communal aspects of eating, and exceedingly high rates of obesity and diabetes. This makes the common practice of fasting seem anomalous and even counterintuitive. However, there is a spiritual dimensions to this form of food abstention – it improves moral status and, unlike dieting, individuals can use God’s help to abstain without experiencing hunger. Moreover,
Fasting socializes abstaining from eating, which without this moral meaning is considered an uncomfortable and selfish practice. Thus fasting takes an individualistic activity of abstaining from eating and reformulates it as a social activity concerned with cultivating Samoan persons. (p. 124)
In a similar fashion to Rosen, Hardin argues that public health practitioners should work with Samoan community members in order to develop more effective health interventions that draw on these shared ideas about the individual and social benefits of abstention.
This collection contains interesting and well written case studies that provide nuanced critiques of contemporary obesity policies, focusing on the harmful effects they have on particular patients and groups and, inter alia, on their inappropriateness for many resource-poor settings. Its geographical reach and the care with which its authors present useful, specific critiques of particular understandings and practices make it a valuable contribution to an increasingly crowded academic field.
Alongside the critical social science literature on obesity outlined above, there is also a more historical body of work that documents changing understandings of excess body weight and attitudes to body size (e.g. Schwartz 1986, Sobal, 1995, Stearns, 2002). Georges Vigarello is an eminent French scholar whose previous work has examined the history of posture, health, cleanliness, beauty, and rape. His history of obesity, The Metamorphoses of Fat (previously published in French as Les metamorphoses du gras and now translated into English by C. Jon Delogu) is an impressive addition to this body of literature. In this relatively short work, Vigarello surveys more than seven hundred years European history, beginning with 14th century famines and ending with 21st century responses to the obesity epidemic. He synthesises an enormous amount of material to give an erudite and informative account of the ways in which Western European understandings of fat and fat bodies have developed since medieval times.
The medieval period was a time of famines and scarcity when, despite the Christian condemnation of gluttony, bigness was seen as a virtue
The prestige of the big person derives first of all from a certain context. The world in 1300 is one of hunger, severe restrictions and food shortages that occur at less than five year intervals. For several centuries during the Middle Ages, poor and degraded soils, inadequate storage, slow and difficult transportation networks, and vulnerability to inclement weather all contributed to raising the accumulation of calories into an ideal. (p.5)
This is an elegant exposition of a familiar argument but then he describes how, from the 15th century onwards, ideas about different kinds of big bodies start to develop and associations were made between largeness and negative characteristics, such as gluttony, clumsiness, and oafishness (p 25 and 33-8). In the Enlightenment, the importance of bodily attributes such as flexibility and tone increased these concerns, as seen by the new characterisation of obesity as a ‘lack of sense, sensibility and sensation, as well as a loss of dignity’ (p. 98). At the same time, greater knowledge led to the development of new techniques of bodily measurement and new treatments for excess bodyweight such as cold baths, tonics and electric shocks. Vigarello pays careful attention to gendered differences in acceptable body sizes and shapes, describing how a narrow waist becomes an important aspect of feminine beauty from 14th century onwards (p.22), whereas an impressive (but not too impressive) girth remains a sign of masculine material success - the ‘bourgeois belly’ - well into the 19th century (p.120-1). By discussing images of servants (p.89), he also includes a brief consideration of changing class differences in ideal body sizes.
Moving onto more familiar ground, Vigarello describes how, by the 19th century scientific research had developed the mechanistic understandings of the body that led to now familiar advice to lose weight by eating less and moving more. Finally, he outlines the early 20th century turn towards slenderness that, he argues, entailed an increased stigmatisation of obesity in the 21st century.
The range of material considered in this book is impressive compared to the more restricted focus on 19th- and 20th-century sources found in in other histories of obesity. The majority of Vigarello’s references are French, and may, therefore, be unfamiliar to English-speaking readers. By considering largely French material he also begins to extend the geographic scope of this literature (Oddy et al’s 2009 collection is one notable exception). However, it is also a frustratingly specific body of material – a fully European account should surely include a wider range of sources that includes more material from other regions and in other languages.
The earlier sections of this book - for example when Vigarello outlines humoral medicine and describes attempts to understand the causes and consequences of different forms of bigness in the medieval period (p.10-16) - were, for me, the most compelling. To a modern reader it seems obvious that the increase in body size caused by fluid retention (or dropsy) is different from the increase caused by gaining body fat, but in an age where the internal cavities of the body were not investigated and its tissues not fully differentiated, these phenomena were confusingly similar. However the sections of dealing with contemporary understandings of obesity are less successful. These sections focus on the stigmatisation of the obese and obesity, which is an important problem but one that is already well documented elsewhere (see above). Medical understandings of excess body weight now dominate our shared ideas about obesity, and so the relative lack references to medical sources in the chapters on the 19th and 20th centuries, is a weakness in Vigarello’s account. Without considering these kinds of sources, it is hard to develop a convincing analysis of contemporary understandings of overweight and obesity, which is largely framed as public health issue. Another issue is the lack, throughout, of detailed consideration of diet and eating practices. Despite the growth of academic food history (including works such as Parasecoli and Scholliers (2015) which cover the medieval and early modern periods), in my experience, this remains a common and puzzling feature of cultural histories of the body.
These books both add to our knowledge about obesity and start to fill important gaps in the academic literature. In their different ways they also address the persistence of obesity stigma and its pernicious effects. Vigarello’s book will be of most interest to those already well-acquainted with French history or cultural histories of the body. However, McCullough and Hardin’s collection should be of interest to medical anthropologists and also to social scientists who have a more general interest in understanding the contemporary phenomenon of obesity.