Neoliberalism and Health Part 1: The Obesity Epidemic

Two of my big interests are neoliberalism and health–how it is experienced, constructed, and cared for. As you can imagine, I’m a hit at parties. For one of my term papers I argued that the current paradigm of health in which health is something we DO rather than something that we ARE or HAVE is a way that neoliberalism is played out in the body. And it was super interesting to write! So I’m going to share excerpts of it over the next few blog posts, because it helped me put into language a lot of things about bodies and health that I had only sort of intuitively known before. My aim in academic writing is always to make it as accessible as possible so I hope that it isn’t overly theoretical and if it is, I apologize. And I have left citations in APA format because it seems the most clear way to allow readers to understand what and where I have sourced ideas.

Obesity Epidemic?

While much of the mainstream construction of “health” revolves around weight, “there is little evidence…that obesity can kill, but rather obesity is one of the side-effects of the fat-laden standard American diet, eaten by largely sedentary people” (Aggers, 2010, p. 4). Thus, this paper will critically interrogate the concept of the “obesity epidemic” while also exploring the factors that facilitate largely sedentary lifestyles and energy-dense but nutrient-poor diets.

The Body Mass Index

The Body Mass Index (BMI) is a calculation that uses a person’s height and weight to estimate body fat (Canadian Diabetes Association [CDA], 2014). The formula divides weight (in kilograms) by the square of height (in metres). The healthy weight range is defined as that falling between 18.5 and 24.9 BMI, with anything below 18.5 being considered underweight, while anything above 25.0 BMI is considered overweight, with obesity being considered as anything at 30 BMI and above (CDA, 2014; National Heart, Lung, and Blood Institute, 2014). The Canadian Diabetes Association (2014) characterizes the BMI as appropriate for most adults between 18 and 65 years old but cautions that it may not be appropriate for certain types of athletes, pregnant women, children and the elderly.

            Development of the BMI. Before the Body Mass Index (BMI), there was the Quetelet Index, formulated by a 19th century statistician in pursuit of quantifying the characteristics of the “normal man” (Eknoyan, 2007). The Quetelet Index is based on Adolphe Quatelet’s observation that weight (in kg) is approximately proportional to height (in m) squared (Pekar, 2011). In the early 1970s, an American scientist named Ancel Keys confirmed the reliability of the Quetelet Index and renamed it the Body Mass Index (Eknoyan, 2007).

Prior to the introduction of the BMI, the vice-president of the Metropolitan Life Insurance Company (Met Life) released tables linking the height-weight ratio and longevity, in a bid to determine “ideal weights” (Pekar, 2011; Eknoyan, 2007). These tables were later used by the National Institutes of Health (among others) to formulate “ideal weight” values (Pekar, 2011). The World Health Organization also adopted the Met Life-influenced “ideal weight” in conjunction with the BMI to evaluate obesity (Pekar, 2011).

Several issues have been suggested in regards to the use of BMI to evaluate obesity. First, is the fact that the Met Life data was collected from a primarily Caucasian sample, yet the BMI recommendations are used for people of all ethnic backgrounds (Pikar, 2011), and have been found to overestimate obesity in African American individuals (The Endocrine Society, 2009) and underestimate obesity and correlated disease risks in Asian individuals (Pikar, 2011). The second is that the BMI was developed to assess populations rather than individuals (Pikar, 2011). In conjunction with it’s limitations regarding certain ethnicities and populations (athletes, pregnant women, the elderly), this likely makes the BMI an inappropriate measure to be employed at the individual level. A third issue is that the BMI does not take into account different body compositions, and tends to be skewed for people on either end of the height spectrum (Pikar, 2011).

            Overnight Epidemic. For much of human history, what is today called “overweight” represented good health (Eknoyan, 2007). In the mid-20th century, the insurance industry began to notice a relationship between obesity and mortality, which lead to the development of the actuarial tables by Met Life detailed in the preceding section (Eknoya, 2007; Pikar, 2011). And though there had been concern in academic and medical circles around increasing obesity rates in America since the late 1980s, the idea did not gain traction in the popular media until 2000 (Oliver, 2006).

Oliver (2006) traces the nearly overnight shift in how both researchers and the public conceptualized obesity. The use of highly evocative maps (and the availability of them for free on the website of the Centers for Disease Control and Prevention) helped to change the medical conception of obesity from one being thought of in numerical terms to one thought of in spatial terms (Oliver, 2006). The use of maps, Oliver argues, portrayed obesity as a “spreading infection” (2006, p. 614). However, these maps suffered from several methodological problems. For one thing, the maps reveal only the percentage of people in each state with a BMI above 30 (and thus in the “obese” category), and not the spread of a disease as they imply. Second, because the maps do not take into account population density, they may exaggerate the extent of obesity in the country as a whole as, for example, x percent of North Dakota’s population is not equivalent to that same percentage of Pennsylvania’s population (Oliver, 2006). Oliver also takes issue with the use of colour in these maps, as they give “the impression of increasing danger from an epidemic ‘hot zone’” (2006, p. 616). Finally, these maps imply a spreading infection, while the reality is that weight gain remains concentrated along class and race lines (Oliver, 2006).

Oliver (2006) also points to what he terms “the diseasing of America” (p. 617) as playing a part in the conceptualization of the obesity epidemic. He traces this to the changing nature of the supply and demand of medicine. As more and more infectious diseases were eradicated or at least well-contained, the health infrastructure branched out in order, in Oliver’s words, “to justify their existence or, in the case of private companies, maintain their profits” (2006, p. 617). On the demand side of things, as health and affluence increased across much of the population, attention turned to less urgent health matters. Oliver (2006) also points to the increasing classification of new diseases based on their association with established illness (for example, the correlation between hypertension and strokes allowed hypertension to be understood as a health problem itself). Oliver also points to the “health-industrial” complex, made up of academic researchers, physicians and drug companies, which relies on the continual classification and treatment of new conditions for market expansion.

Another factor in the obesity epidemic was the introduction in June, 1998 of new guidelines by the National Institutes of Health which reduced the normal weight/overweight cutoff from 27 BMI to 25 BMI. Overnight, several million Americans became obese (Guthman & DuPuis, 2006). Guthman and DuPuis (2006) suggest the rhetoric of “epidemic” must be viewed in light of such a drastic change. Rich and Evans (2005) also point out that the measurement of weight and its corollary BMI are inexpensive and easy, while the measurement of fat is not, which has lead to a conflation of overweight and obesity which “exaggerates the seriousness of ‘the epidemic’ and may create a moral panic where none is necessary” (p. 343).

            The Controversy. Issues surrounding the framing of obesity as “an epidemic” go beyond simply the limitations of the BMI in measuring certain populations and the perhaps inflammatory language used. Guthman and DuPuis (2006) argue that the use of BMI as an indicator of health misses the “many other variables that could affect what is considered to be the optimal weight for different people” (p. 433), while Scrinis (2008) notes that BMI is often used in a reductive manner that ignores factors such as exercise and food behaviours when determining individuals’ health. Guthman and DuPuis (2006) further point out that the concept of optimal weight has been constructed in a cultural context that pushes thinness as the primary indicator of health. They suggest, therefore, that popular and medical constructions of the ideal body are less about health and more about the narratives we imbue bodies with (Guthman & DuPuis, 2006).

A second complication is that the literature linking overweight and obesity to poor health is a lot less clear cut than the prevailing discourse would have you believe (Rich & Evans, 2005; Monaghan, Colls, & Evans, 2013). Rather, the evidence that “weight-loss will improve health is contradictory” (Monaghan, et al., 2013, p. 250), and “precious few texts on obesity reflect upon the methodological limitations, ambiguities, uncertainties and contradictions that reside in the databases of the primary research field” (Rich & Evans 2005, p. 343). There is also a concern that size-based approaches to health have negative consequences including increased prevalence of eating disorders and stigmatization, as well as an elision of the social determinants of health in favour of an individualistic construction of health (Monaghan, et al., 2013). Another concern with size-based approaches to health is that people with culturally-sanctioned thin bodies may have poor food, exercise, and health habits but be lulled into a sense of complacency as thinness is conflated with good health (Guthman & DuPuis, 2006).

Critical Responses. Some scholars, activists, and members of the public have engaged critically with the concept of the “obesity epidemic”. Some scholars use critical theory to link the “ideal weight”/thinness norms to “other projects to control, dominate, or marginalize racialized and gendered others” (Guthman & DuPuis, 2006, p. 433). In this vein, Critical Obesity Research uses a poststructuralist framework to challenge the dominant discourses around obesity, and to argue that these discourses and the construction of obesity and fatness are situated within a positivist framework that privileges certain types of knowledge (Colls & Evans, 2009). Others have taken a political economy perspective to question the degree to which the framing of obesity as an epidemic is due to powerful actors such as the dieting and pharmaceutical industries relying on a continued cultural fear of fat (Monaghan, et al., 2013). Still others questioned the foundational “truths” of the obesity epidemic—namely that fatness is necessarily unhealthy and that the best treatment is individual work on the body—and argued that these underlying beliefs “are reliant on moral and cultural ideologies to mask the underlying uncertainties in biomedical knowledge” (Monaghan, et al., 2013, p. 250).

Stay tuned for Neoliberalism and Health Part 2: The Fat Body in The Neoliberal Context

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