Nov 1 2013
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A Closer, More Dispassionate Look at Obesity

Abigail Saguy, PhD, is an alumna of the Robert Wood Johnson Foundation Scholars in Health Policy Research program (2000–2002). In January, she published the book, “What's Wrong with Fat?”

Human Capital Blog: You argue in your book that the focus on the “obesity epidemic” obscures a deeper, more important question: How has fatness come to be understood as a public health crisis at all? How do you answer that question?

Abigail Saguy: It’s multilayered. On the deepest level, the fact that we perceive obesity as a public health crisis is related to the fact that fatness, or corpulence, has become an undesirable social characteristic. It has not always been that way, and it is not that way everywhere even today. In many places and times in history, being heavier has been considered a positive social characteristic, particularly in times and places where food is scarce. This is why, in certain contexts, women or girls are fattened up for marriage; there, the woman’s fatness symbolizes the wealth or status of their families.

HCB: When did that change?

Saguy: Some historians argue that it became socially undesirable to be heavy in the United States in the early 20th century. At the end of the 19th century, you would find ads offering treatments to help people gain weight. At the beginning of the 20th century, you might find weight-gain ads coexisting with weight-loss ads. By the 1920s, it’s all about weight loss. Over time, the preference is for thinner, and thinner, and thinner bodies. This was happening in a social context in which food is more abundant, and cheaper food is more caloric. The meaning of body fat shifts so that being thinner is the sign of status and wealth.  You need to have a personal trainer, a personal chef, and leisure time to construct that thin body.

It’s important to see this happening within a context. Before obesity became a public health crisis, it became a medical problem, and before it became a medical problem, it became a social problem. So before doctors started talking about obesity as medical problem, middle-class white women began begging doctors to help them lose weight. And they were doing so not because of health but because of fashion.

HCB: When did it become a medical problem?

Saguy: Fatness became a medical problem in the middle of the 20th century. It is at this time that doctors start publishing scientific journals on bariatric medicine, begin using the word “obesity” to mark corpulence as a medical – as opposed to moral or aesthetic – issue, and position themselves as weight-loss experts. It is not until the late 1990s that we start talking about obesity as a public health crisis, or as a population-level problem requiring state intervention. Several things contributed to this new understanding. For one, statistics were published that showed an increase in the proportion of the U.S. population with a body mass index over 30—the official definition of obesity—in the 1980s and again in the 1990s. And vested interests such as the International Obesity Task Force (IOTF) were working hard to make obesity a public health priority. The IOTF is lobbying group whose mission is to make obesity a public health priority. Its funding sources include pharmaceutical companies who have an interest in convincing the public that obesity is a major problem. The greater the perceived risks associated with obesity, the greater the need for weight loss drugs and the greater the tolerance for potential negative side effects. It is important to remember that all of this is happening within a context, in the contemporary United States, in which it is already taken for granted that fat is bad.

HCB: How do social perceptions of weight affect medical interpretations of it?

Saguy: We tend to be more skeptical of evidence that challenges our deeply held beliefs and to uncritically accept information that is consistent with them. This is called confirmation bias, and it affects how journalists—and the general public—interpret medical studies related to body weight. For instance, a study was published in 2004 that estimated that overweight and obesity were associated with 400,000 excess annual deaths. Since that finding was consistent with the idea that obesity is a public health crisis, journalists reported on it as providing confirmation of what was already known.

The following year a different study estimated that there were only 26,000 annual deaths associated with being overweight or obese combined.  And, in fact, being overweight was associated with 90,000 fewer deaths. The Centers for Disease Control and Prevention ultimately accepted the second study as providing the better estimate. However, when that study was published, journalists were more likely to question the results. They tried to explain the results away because they contradicted their deeply held assumptions that fat is bad.

HCB: So do you feel that there are valid health concerns related to being overweight or obese?

Saguy: I don’t argue that there are no risks associated with being heavy; there is a very clear association with higher body mass index and Type 2 diabetes. It’s a linear relationship. That said, there are some things to keep in mind. First of all, genetics play the most important role in determining who gets Type 2 diabetes. And secondly, we do not know what the causal mechanism is. It may be that heavier weight or more body fat causes Type 2 diabetes, but it is also possible that Type 2 diabetes causes weight gain. And it may be that some third factor, such as poor nutrition, a sedentary lifestyle, poverty or stress, causes both weight gain and Type 2 diabetes.

In some cases being heavier actually seems to be protective, and that’s also something we rarely discuss. There is a large and growing body of literature that is referred to among researchers as the ‘obesity paradox’ literature that shows that, among clinical populations of people who have cardiovascular disease or Type 2 diabetes, those in the obese category are less likely to die than those in the normal weight category. We don’t know what is causing this association, but the association is very robust. It’s a big mistake to assume that people who are normal weight are healthy and people who are overweight or obese are unhealthy. The relationship is much more complex than that.

HCB: What does that mean for public health?

Saguy: We shouldn’t focus on weight per se but rather on other factors that may be the underlying causes of disease like physical activity, social inequality, poverty, and stress.

There are also problems with the production and distribution of food in this country, but these are issues for people of all sizes, and they not only affect what people eat but also animal rights, worker rights, and the environment. There are real issues in terms of the kind of food we’re serving for lunch in schools and the lack of physical education classes. And of course, we have growing inequalities in this country that are also at the root of many health problems, particularly for the disadvantaged. I think we need to get our focus back on that.

We use the fear of becoming fat as a way of scaring people into adopting healthy practices. I think that’s very dangerous. It makes fat kids and adults the victims of bullying, it leads to eating disorders for others, it reinforces this idea that it’s bad to be fat and that fat people are lazy, and it worsens weight-based discrimination. We should avoid scare tactics and instead emphasize the positive: that everyone deserves the opportunity to be able to nurture their bodies.

Read more about Saguy’s work.

Tags: Human Capital, Nutrition, Obesity policy, Public health, Research & Analysis, Scholars in Health Policy Research, Voices from the Field