Rethinking the Obesity Epidemic

    • May 2, 2013

A new take on obesity. When you talk to Abigail Saguy, PhD, prepare to have your assumptions challenged.

"We've heard so often and for so long that we are facing an 'obesity crisis,'" says Saguy, "that most of us can't imagine thinking of fatness in other than medical or public health terms. We don't ask how it is we have come to think of body size as a medical and public health problem—rather than, say, a civil right issue."

Saguy believes we should. Saguy, a sociologist, has spent more than a decade researching attitudes about fat, culminating with the publication in January 2013 of her book What's Wrong With Fat? She concludes that contemporary concerns about the "obesity epidemic" presume a public health framing of fat. Like any frames, this frame draws attention to some aspects of reality—e.g., higher rates of mortality among those in the heaviest weight categories—while obscuring others—e.g., among heart disease patients, heavier patients die at lower rates.

Saguy shows that there are other ways of thinking about fatness, including as a form of diversity and a basis of discrimination, akin to race, gender, and sexual orientation. "According to the 'fat rights frame,'" she says, "weight-based discrimination and bullying—and not people's body sizes—is the real problem. It is not just that these issues are missed in talk of obesity as a public health crisis. By representing fatness as a medically pathological state that people bring upon themselves, such talk, may, in fact, worsen these problems." As she puts it in the introduction to What's Wrong With Fat?, "There have been a lot of books written about the causes of obesity or of the 'obesity epidemic.' This book turns that question on its head by asking what obesity, as a frame, causes."

Saguy doesn't deny that higher body mass can be unhealthy. But, as she pointed out in a January 2013 essay for the Washington Post, the etiology of diseases commonly associated with obesity isn't entirely understood. Other factors, including nutrition, stress, and genetics, have to be taken into account, but often aren't. "Scores of studies have shown that medical providers typically regard fat patients as lazy, self-indulgent, and noncompliant," she wrote. "As a result, heavy patients don't always receive the health care they deserve."

Saguy elaborated on that point in an interview. "We know that women with a BMI (body mass index) over 30 have high rates of cervical cancer," she said. "We also know that they're less likely to get pap smears. Studies that have looked into this find that these women are not getting pap smears in part because they experience the doctor's office as a hostile environment and they're avoiding it."

A Robert Wood Johnson Foundation (RWJF) program shapes a career. Saguy didn't start out focusing on obesity, but she remembers quite clearly the moment it attracted her attention. It was a snowy day in January 2001 and Saguy was sitting around a table at Yale University with her colleagues from the RWJF Scholars in Health Policy Research program.

The Scholars program provides outstanding newly minted PhDs in economics, political science, and sociology with two-year fellowships to bring their disciplines into the field of health policy research. The program is based on the belief that engaging talented young people from these disciplines in debate about health policy will result in better health policy, and ultimately in better health. See Program Results Report for more information.

Saguy called her experience with the Scholars program "just amazing. It carved out time for me early in my career, time in which I wasn't bogged down with teaching obligations and committee work. The exposure to political scientists and economists was especially useful."

Saguy's experience is just what RWJF and the Scholars program had in mind. The political scientists in the program "were asking very 'political science' questions," Saguy recalls. "They were asking, 'Why wasn't this on the public agenda?' They were taking it as a 'given' that obesity is a public health problem."

Saguy says the sociologist in her "was thinking about 'political' differently from the political scientists." She asked, "Is this a question of identity politics? Are there competing ways of understanding heavier body weight as a medical or political issue?"

Looking into those questions, Saguy soon discovered the fat acceptance groups whose members declared they were no longer going to be ashamed of themselves for not conforming to conventional ideas of beauty. "I found them fascinating," she says. "They were a very small group, and not classically marginalized—they're mostly middle-class White women. In other ways, though, they were up against one of the most powerful forms of social stigma there is. It just seemed like a perfect David and Goliath story."

Saguy has been studying fat people ever since, and credits the RWJF Scholars program for the inspiration. "There is no doubt in my mind that I wouldn't have embarked on this research if I hadn't been in the fellowship," she says.

Though obesity was a new subject for Saguy, analyzing it in terms of framing was consistent with earlier work she'd done on the different perspectives of sexual harassment as defined in United States and in France. That was the focus of her first book, What is Sexual Harassment? From Capitol Hill to the Sorbonne, published in 2003.

Born in New York City, Saguy earned advanced degrees in both France and the United States, graduating from Princeton University with a PhD in sociology in 2000. As of March 2013, she serves as an associate professor and vice chair in the Department of Sociology at the University of California, Los Angeles.

Listening to language. A consistent area of interest for Saguy has been the labels applied to fat people, and the labels they apply to themselves. Whenever possible, for example, she avoids using the word "obesity" because it puts a "medical frame" on people who may in fact be perfectly healthy. "Following the example of the fat rights movement, I use the word 'fat,'" she says, "which of course has its own baggage, but I'm attempting to use it in a neutral way."

In an article published in 2011 in Social Psychology Quarterly, Saguy and co-author Anna Ward examined how fat women have followed the lead of Lesbian, Gay, Bisexual, and Transgender (LGBT) communities by appropriating the language of "coming out." "When I first heard women talking about this I was quite surprised," Saguy said. "'Coming out' is a terminology that is usually used in reference to revealing something that's hidden, and when you weigh 250 or 300 pounds or more your body size is not a big secret. The article is based on interviews and asks, 'What does it mean in this context to 'come out'? It's about how cultural tropes travel from one social context to another, and how the meaning of 'coming out' changes in this new context."

In her latest study, still in progress as of April 2013, Saguy seeks to expand that research to examine the idea of "coming out" as it's used by four other groups: adult children who have gay parents, women in polygamous marriages, gays and lesbians in France, and undocumented youth.

Saguy looked at the use of language from a different angle in her essay for the Washington Post, comparing the framing of fat people by their physicians to police "profiling" of minorities. "Neither form of profiling necessarily intends to discriminate," she wrote, "but both involve judging people based on generalizations about a group to which they belong. Both types of profiling lead to false positives (people wrongfully accused or medically over-treated) and false negatives (guilty people who get away or ill people who are medically undertreated)."

In a January 2013 article published in the Los Angeles Times, Saguy described the negative framing of fat people as "bigotry" and "fatphobia." 

RWJF perspective. The Robert Wood Johnson Foundation Scholars in Health Policy Research program is designed to foster a new generation of creative thinkers in health policy research within the disciplines of economics, political science, and sociology. The fellowship program, established in 1991, annually selects a total of nine recent PhD graduates from among those three disciplines to spend two years studying at one of three participating sites (currently Harvard University, University of California-Berkeley/San Francisco, and University of Michigan).

Participants learn about health and health policy, gain exposure to the perspectives of the other two disciplines through seminars with peers, receive mentoring from prominent scholars, develop research ideas, and conduct research while receiving a stipend and benefits that free them from other professional obligations. "We're looking for people who aren't too far along in pursuing a specific research agenda. Our goal is to catch people early and tempt them into the field of health policy," says Lori Melichar, PhD, RWJF director for the program.

While in the Scholars program, participants have conducted research on issues and policies related to individual health, public health, social and economic determinants of health and health care, health care financing, and health care systems and institutions. After completing the program, alumni stay connected to their peers through a network facilitated by the Boston University Health Policy Institute, which serves as the national program office.

Scholars from the Health Policy Research Program have made significant contributions to their disciplines and to the field of health policy research. The program's 200-plus alumni, many of whom hold faculty appointments at universities and colleges, have authored hundreds of widely cited books and articles; held editorial posts at top scholarly journals; sat on scientific advisory panels; served as senior advisers to presidential, Congressional, federal agency, and national scientific councils; and received numerous professional awards for their research.

Although the original purpose of the program—to increase the number of economists, sociologists, and political scientists conducting health policy research—remains important, RWJF's focus has expanded to include "building the community" of health policy researchers and supporting them at institutions nationwide. "Now it's more about creating a critical mass so that we have a self-sustaining community [of researchers]," Melichar says.

Abigail Saguy, PhD

Abigail Saguy, PhD
RWJF Scholar in Health Policy Research, 2000–02

From the RWJF Human Capital News Roundup:

“People think that being obese means being sick, and there are some health risks, but risk is not the same thing as illness,” Abigail Saguy, PhD, an RWJF Scholars in Health Policy Research alumna and author of “What’s Wrong With Fat?,” told NPR’s Shots blog. “We are living in society in which it is so deeply ingrained that it is bad, immoral to be fat,” which can lead to bullying, weight discrimination, eating disorders, or to people avoiding “hostile” doctors. Saguy also wrote an op-ed about size profiling in the Washington Post.