Richard Zimmer (Sonoma State University)
Megan McCullough and Jessica Hardin have compiled an excellent series of essays as to how different societies and professional groups define and evaluate obesity. Briefly, the writers of these essays, including the two editors themselves, make several points. First, measures of obesity are not standardized, nor are they reliably accurate. Second, people from different societies, for historical and contemporary reasons, do not define obesity as do many Western health professionals. Third, the implications of the aforementioned mis-measurement and varying definitions of obesity affect how people do or do not receive services and how they may come to think and feel about themselves regarding weight. Consequently, “erroneous measurement” and “stigmatization” may affect the health of individuals and groups of individuals. Lastly, an important strength of the book is that the literature on this subject is well-reviewed and ample.
McCullough and Hardin set the stage in their introduction, showing how cultural assumptions about health and obesity distort weight understanding and services provided. As with the other contributors, they deconstruct the cultural assumptions behind the characterization of obesity: “The underlying message from popular media and health studies argues that there are direct, easily identifiable links between obesity and ill health. (p.7.)” They conclude that “…[a]pproaches to obesity should expand the scope of health intervention, promotion, and intervention beyond the individual to engage deeply with culture to account for gendered dynamics, models of embodiment, histories, globalization, and a host of other factors. (p.17.)”
Part I concerns itself with the measurement of obesity.
Anne E. Becker details different “fatness” and “obesity” measures. These measures, she contends, are culture-bound to Western ideas of agency.. Weight loss programs, however, focus on what the person “should be.” Most important, and this is a recurrent theme throughout the book, health care professionals expect the “overweight” person to accept an overweight characterization and to address by herself prescribed “necessary” remedies to lose weight—often, despite cultural pressures to the contrary. (pp.31-2.) I specifically use “herself” here because more pressure is put on women than on men. As Becker and the other authors suggest, this way of proceeding generally causes failure to lose weight, with serious other consequences, both medical and psychological.
Emily Yates-Doerr reviews and critiques in detail the measures used by health professionals to characterize obesity. One example she offers is the use of the BMI. Yates-Doerr relates how public health professionals in Guatemala would subtract the weight of the outer garments the women wore from their measured weight. But they would vary in terms of how much they estimated those garments weighed (p. 52.) Consequently, the BMI measures can be seriously misleading. She concludes: “How are risk of morbidity and mortality determined; what remains unspoken and what concerns are not attended to by using weight as a key determinant of health? (p. 67.)”
Darlene McNaughton focuses on the relationship in terms of health programs between diabetes and obesity. She terms this focus “diabesity.” Drawing on feminist theory and other perspectives, she says: “Overweight and obese people are imagined either as diabetic or becoming diabetic. (p. 77)” McNaughton couples these perceptions with a generalized fat prejudice, particularly in countries like Australia—because “fat” is visible (pp.78-82.) “Fat” people thus are stigmatized and experience the consequences of that judgmental stigmatization.
Part 2 focuses on Histories of “Fat”
Hannah Garth looks at the history of food scarcity in Cuba after the Revolution . She cites a previous study by J. Alvarez from 2004: the Cuban government instituted a system of food rationing “…because of an increase in the need for food due to increased purchasing power and decreases in domestic food production resulting from the shift towards state ownership of farmland and food production enterprises (p. 90.)” The collapse of the Soviet Union brought in the “Special Period,” where there was even less food than before. Many people remember when there was very little or no food. In the present, they feel insecure about the availability of food. Thus, any program that addresses dieting and obesity runs into difficulties because people resist changes to their food consumption and eating habits. As Garth notes about several of her informants, people eat when they find food available (p.98.)
Jessica Hardin explores obesity and disease in Western Samoa, analyzing how culture and cultural/religious contradictions affect obesity determination and health programs in the area. Western Samoa is often thought of as one of the most obese areas in the world. In the past and in the present, many Samoans feasted at important family occasions, consuming large amounts of food. Moreover, higher status Samoans tended to eat more, and their size was a measure of their importance (p.110, et seq.) In addition, they tend to eat processed and fast food and other nutritionally deficient food. Trying to introduce dieting runs counter to this value and practice. Since many Samoans are Christians, many fast as part of their religious practice. They do so, however, in church, which contradicts family social practices and weakens family ties. Furthermore, fasting by itself is not necessarily healthy. Hardin concludes by saying that programs that focus only on a metric basis for health must be replaced by a more sophisticated understanding of the “…intersections of health and religious belief [are] critical domains for use in health interventions, but they may provide new ways for thinking about the multiple meanings o f health and alternative modes of measuring health. (p.125.)”
Part 3 Focuses on How Different Cultures Address “Fat”
Rochelle Rosen draws important lessons about caring for diabetes and obesity in American Samoa. To best address the two conditions, she contends that health practitioners must incorporate each society’s often multiple cultural understandings of both conditions. Otherwise, the focus is on the person or client’s individual agency and individual responsibility to change. In particular, she notes: “Where health is communal, interventions predicated on individual self-care may fail to help. (p.142.)” Anthropologists and behavioral scientists, she contends, should continue to elicit these behaviors from the “…emic perspective of the people who engage in them …(p.142.)” to be effective.
Sarah Trainer examines the ways in which modern women in the United Arab Emirates (UAE) think about the categories of “fat” and “thin”, nutrition, their concerns about them, and how to address these concerns. Emirati women, she says, are concerned about being ” thin, but not skinny” , using a variety of weight loss aids and exercise (pp.152-156.) But the focus is not always maintained and consistent. In one of her studies, she notes “…sedentary patterns…coupled with nutritionally poor diets among the participants (p.156.)” Continuing with the critique of using standardized measurements, such as BMI and body fat percentage data, she says that “…none of these possible threats to health, nor the verbally expressed stress of many young women, would be obvious…[from the aforementioned data.] (p.156.)” As a result, public health, she contends, is not getting better (p.162,), despite increased governmental surveillance–because women want to be thin, regardless of many of the consequences of doing so (p.162.)
Tracey Galloway and Tina Moffat explore the efficacy of school-based childhood obesity preventions in Canada. Many of these programs originated in the United States. They are largely behaviorist based, and often very strict. Children’s self-reports included the following: not being allowed to get up when eating, having to eat at one’s desk, and having food inspected and “unacceptable” items removed, to be returned at the end of the day (p.174.) Furthermore, girls and boys differed both in their perceptions of foods and the restrictions placed upon themselves. Girls saw more restrictions on what they should and should not eat, while boys saw more restrictions on where they could move within the classroom (pp.174-5.) Galloway and Moffat go further: “…very few of the rules, restrictions, and rewards around food and beverage consumption in schools are related to nutrition or health…But it is surprising that these [positive] messages about food [issued by the Ontario Ministry of Education] are largely absent from the children’s perceptions of the rules and regulations governing their lunch and snack times (p. 178.”) They also note that children are rarely consulted in the design of programs. In addition, children’s privacy itself is invaded in the program process. Following the above genderization of food programs, they cite a previous study which shows that “…teachers socialize girls early into the idea that boys should be fed to satiety while girls should exercise restraint (p.183.)” Nevertheless, according to relatively recent research on school diets in Canadian schools, children are eating more healthy foods (https://www.cambridge.org/core/journals/public-health-nutrition/article/examining-differences-in-school-hour-and-school-day-dietary-quality-among-canadian-children-between-2004-and-2015/EE852354AB74B07F23B88313348084AE/core-reader
Lisa Rubin and Jessica Joseph examine what it means to be “fat” or “thin” in the United States, among girls and women, and especially among African American women. Starting with the statistics on being overweight and obese, they note the result—a “war” on obesity (p.200.) The programs that have developed to address these issues focus on individual action and on “…biomedical intervention or surgery” (p.201.) This focus persists despite the evidence they cite from earlier researchers that suggests “…poverty, stress, and discrimination contribute significantly to the onset and maintenance of conditions often associated with obesity (p.201.)” Reviewing the literature on African American women, they note that these women saw that attempts to redress their weight and obesity issues were “…’part of an effort to diminish black [sic] womanhood.’ (p.209.)” They conclude that “…[m]ore research is needed to examine concerns about eating disorders, overweight, and obesity among Black women from their own perspective. Rather than one imposed by a dominant medical, or eating disorder establishment P. 211.)”
Megan McCullough starts off her essay this way: “I am a fat anthropologist and not an anthropologist who is fat. (p. 215.)” She then stated that if someone had seen her, that person would have decided that she was fat or obese (p.215.) McCullough put out this preface because she will then take us through her experience with her pregnancy as she encountered the medical establishment’s treatment of her. She felt stigmatized, judged, misjudged, and shamed by medical personnel throughout. She quotes a nurse who said to her: “’I don’t have any extra large robes in here so you will have to make do with this and a sheet…’ (p.213.)” As a result of these experiences, and acknowledging that there are dangers in terms of obesity, McCullough raises larger questions: “ What kinds of care are obese African-American or Hispanic women receiving? What about obese lesbian mothers? P.230.)”
Stephen McGarvey, in his Afterword, restates the central concern of these essays—mismeasurement, stigmatization, medicalization, focus on individual agency, and a failure to address historical and cultural circumstances. What he proposes is that attention must be paid to the effects all of these have on research, program, and treatment (pp.235-237.) The Afterword’s and the whole book’s focus on individual agency is itself of particular importance because ” A survey of more than three hundred international policy makers found that 90 percent of them still believe that personal motivation-a.k.a.–willpower–was a very strong cause of obesity. (Wilson 2019:21.)” McGarvey intends to have the issues he delineates addressed in a more sensitive and successful fashion.
As I have noted, the book is an important contribution to addressing what is a significant concern in the understanding of weight issues. I would like to address the issues raised from a somewhat different angle, hoping to add to future research, program, and treatment. In terms of my background, I am an anthropologist. I am also a psychologist. One of my specialties is that I assess clients who are going to get gastric bypass, laparoscopy, gastric band and gastric sleeve surgeries. The stated purpose of these surgeries is to enable a person who has had significant difficulties in losing weight to lose weight. These clients have tried diets, often to no avail. They are at risk for Type II diabetes and other medical problems, including heart conditions, etc. The purpose of the assessment is to make sure that the client has no underlying psychopathology or substance abuse that would prevent her or him from understanding the nature of the surgery and following the doctor’s post-operative orders.
My role is to assess, not say whether the surgery itself is indicated. Generally, the population I see for gastric bypass surgery is severely [ the preferred term] obese, even considering the issues of mismeasurement raised by many of the essay writers. The laparoscopy and other surgeries population is severely overweight, but not necessarily severely obese. Laparoscopy and the other mentioned surgeries is a less invasive surgical procedure, which is why it is used for this condition. All the patients I have seen have had difficulties with different diets. Approximately 70% have Type II diabetes. About 60% have either been molested or raped, equally across categories of their gender, sexual identity, or sexual preference.
The surgeries for severe obesity are often successful for reducing the presence and risk of Type II diabetes (see, for example, https://care.diabetesjournals.org/content/34/Supplement_2/S361. The site offers a useful description of the measures used to determine severe obesity and the different types of surgeries considered.) The surgeries do entail risks, including rupture of the surgery area. The person must be careful in following all the post-operative instructions, including changing long-term eating patterns. Those receiving gastric bypass surgery can no longer drink carbonated beverages and must eat very small portions of food.
The physicians for whom I do the surgery assessments run support groups for their patients. Many of their patients have talked to family and friends who have had the surgery and they get ample visual and written material as well. As noted above, my “sample of clients” shows a high level of being sexually abused. Rarely have they gotten therapy for that abuse. I do recommend that they see a therapist. Depending on the circumstances, I may set this as a precondition of the surgery. My statistics may be slightly higher than other studies, as, for example:” Obesity rates were not different across groups in childhood or adolescence. By young adulthood (ages 20–27), abused female subjects were significantly more likely to be obese (42.25%) than were comparison female subjects (28.40%). Hierarchical linear modeling growth-trajectory analyses indicated that abused female subjects, on average, acquired body mass at a significantly steeper rate from childhood through young adulthood than did comparison female subjects after controlling for minority status and parity. (https://pediatrics.aappublications.org/content/120/1/e61?download=true.)” Other researchers have also seen the link between being sexually abused as a child and obesity, as, for example: https://www.obesityaction.org/community/article-library/sexual-abuse-and-obesity-whats-the-link/
There may be other co-occurring [the preferred term] conditions that may require stronger interventions than dieting and/or exercise. I also treat clients from Workers Compensation or with disabilities from non-work-related accidents. Many of them can no longer move easily and are often depressed as well. They often gain large amounts of weight, some moving into the category of severely obese. One client was hurt on the job so that he could not walk or move easily. Before the accident, ironically, he had the gastric bypass surgery, because he weighed 350 pounds. After the accident, he could barely move. Furthermore, his weight climbed to 450 pounds. He did not want to take medications and he did not want to come to therapy, either—even after the risks were explained to him. I offer details about these cases because I think the book should help further address how to best address populations with these kinds of issues.
Some of the essays specifically concern how weight issues affect African American women. The American Psychological Association issued a report on ideas and changes that should be made concerning this population: https://www.apa.org/pi/women/resources/reports/obesity.pdf
As the book recommends, more research should be done and greater sensitivity should be shown to this population and to similar ones as well (2014: 14.) Often, however, external factors, such as no place to exercise, family dysfunction for some, lack of money—cannot easily be addressed in programs.
In sum, this is an excellent, well-written book that is useful for anthropologists, public health and policy makers, and practitioners working in the field of obesity. It would also be useful for graduate students in these same areas.
2019. Bee Wilson. The Way We Eat Now. Basic Books: New York.
https://www.apa.org/pi/women/resources/reports/obesity.pdf 2014 (Accessed August 26, 2019.)
https://www.cambridge.org/core/journals/public-health-nutrition/article/examining-differences-in-school-hour-and-school-day-dietary-quality-among-canadian-children-between-2004-and-2015/EE852354AB74B07F23B88313348084AE/core-reader 2019 (Accessed August 27, 2019)
https://care.diabetesjournals.org/content/34/Supplement_2/S361 2011(Accessed August 26, 2019
https://www.obesityaction.org/community/article-library/sexual-abuse-and-obesity-whats-the-link/ 2019 (Accessed August 27, 2019)
https://pediatrics.aappublications.org/content/120/1/e61?download=true 2007(Accessed August 26, 2019)