What's Wrong With Fat? (9 page)

The medical frame has been promoted by doctors and by medical associations. Indeed, the American Society of Bariatric Physicians in 1949 and the Association for the Study of Obesity in 1966 formed for the explicit purpose of advancing the medical frame. Specialty journals, including
Bariatric Medicine, International Journal of Obesity, Obesity Research,
and
Obesity and Metabolism
followed. Professional events, such as the first International Congress on Obesity in 1974, further drew attention to fatness as a medical problem, that is, as
obesity
.
In 1985, the NIH held a “consensus conference” on “obesity,” further legitimizing the sense that fatness represented an important medical concern. 52 A 1995 WHO report, entitled “Physical Status: The Use and Interpretation of Anthropometry,” defined
obesity
as “the degree of fat storage associated with clearly elevated health risks.” 53

Once physicians were able to convince society that fatness was a medical problem, they could use medical procedures and interventions to treat it.
Technological interventions included jaw wiring, intestinal bypass surgery, gastric bypass surgery, liposuction, weight-loss pills, laxatives, and diuretics. While the medical profession was dominated by men, it was middle-class, white women, desperate to lose weight for social reasons, who created a high demand for these interventions, despite (or because of) the fact that their results were typically not permanent. 54 Psychiatrists considered “obesity” as resulting from unconscious compulsions to overeat and proscribed weight loss through psycho-behavioral interventions and behavior therapy. Current understandings of obesity as stemming from “food addiction” represent a continuation of this approach. People, and especially middle-class women, increasingly engaged in weight-loss dieting under a physician’s care, and many weight-loss organizations applied a medical model to weight loss, often in cooperation with physicians. This served to legitimize weight-loss organizations, while providing a source of revenue to physicians. 55

This period corresponded to a time of medical expansion, in which medicine came to exercise greater authority over areas of life not previously under its purview, including childbirth, baldness, depression, menopause, attention-deficit/hyperactivity disorder (ADHD), and erectile dysfunction.
Scientific and technological innovation facilitated this medical expansion, in that doctors were increasingly able to medically treat various ailments that had previously been considered social in nature. The deregulation and expansion of the pharmaceutical industry in the 1980s, loosening pharmaceutical and Food and Drug Administration (FDA) regulations and allowing direct-to-consumer (DTC) marketing, further accelerated medical expansion. 56

People who ascribe to a medical frame compare obesity to other diseases, such as cancer, or to other risk factors, most notably, smoking. For instance, obesity researcher Theodore VanItallie compares obesity to cancer to justify the use of weight-loss treatments, despite their low success rates and associated risks: “If I had a patient with cancer I would usually recommend treatment for it even though the patient might ultimately succumb to the cancer. You do the best you can with the tools that you have at hand.” Obesity researcher Kelly Brownell also drew on a cancer analogy to argue that one must never give up the fight: “If somebody has a disease that really can be horrible for them, like cancer, and the treatments don’t work very well, you don’t give up treating, because you try to do the best you can.” James Hill goes so far as to equate the fat acceptance movement with a “cancer acceptance movement” that would say: “You’ve got cancer; just accept it and live with it….’ I can’t do that because I know this is a disease... that has the potential to have devastating societal consequences.”
In week 3 of the popular reality show
Biggest Loser Couples
,
which aired in 2011, UCLA Associate Professor of Clinical Medicine Robert Huizenga similarly compares the prognosis of “morbid obesity” to cancer and says that it requires treatments that are equally aggressive. He explains to a 21-year-old male contestant that his inner age was 44 and tells another contestant that his death is imminent, as his young-adult daughter sheds tears at his side. “This is about saving their lives,” he says. 57

PUBLIC HEALTH CRISIS FRAME

Beginning in the mid-1990s, fatness was increasingly framed not only as a medical problem of relevance to an individual person and to his or her doctor, but also as a public health crisis that concerned society as a whole and warranted government intervention. Like the medical frame, the
public health crisis frame
suggests that fat bodies are a health problem. However, whereas the medical frame presents fat bodies as individual medical problems, the public health crisis frame suggests that the growing number of fat bodies at a population level represents a public crisis warranting collective solutions. Like the medical frame, the public health crisis frame draws on a master frame of health, but it views health at a population, rather than at an individual, level.

The public health crisis frame also draws on an economic master frame.
That is, proponents of a public health crisis frame bemoan the alleged obesity epidemic not only because of the predicted nefarious implications for the health of the nation but also because of the financial implications.
For instance, a 2010 research article estimated that total costs of obesity in the United States may exceed $215 billion annually. 58 Drawing on previous studies, they estimate four different kinds of costs, including direct medical costs, productivity costs, transportation costs, and human capital costs. The article concluded that these costs “underscore the importance of the obesity epidemic as a focus for policy and a topic for future research.”

Whereas advocates of a medical frame liken obesity to cancer and/or smoking, proponents of a public health crisis frame treat it as an epidemic.
The smoking analogy is also highly relevant in the public health crisis frame, in that public health intervention in smoking is widely regarded as one of the greatest recent successes of public health as a discipline. While the main proponents of the medical frame have been bariatric doctors and medical journals, the main proponents of the public health crisis frame have included influential organizations such as the CDC, the WHO, the IASO, the North American Association for the Study of Obesity (NAASO), and the IOTF.

Those who push a public health crisis framing of obesity typically refer to an “obesity epidemic” to convey a sense of crisis. This is a departure from the original meaning of the term
epidemic
as the rapid and episodic onset of infectious diseases. Instead, it is in keeping with a growing tendency to use
epidemic
as a metaphor to speak of the increasing prevalence of a range of social ills including alcoholism, teenage pregnancy, drug addiction, automobile accidents, and obesity. 59 Some have argued that appealing to epidemics or, in some cases, “hidden epidemics,” “is virtually a code phrase used to launch public relations campaigns for new disorders.” One researcher notes that “a casual Google search of the term yields the hidden epidemics of autism, depression, bipolar disorder, sexually transmitted diseases, celiac disease, asthma, chronic fatigue syndrome, hepatitis C, drug addiction, sexual violence, obesity, dissociation disorder, birth defects, heart disease, and, of course, concussions in rugby as well as foot-and-mouth disease.” 60
An epidemic, in other words, has become a routine strategy for drawing public attention to a new social or medical issue. As Charles Rosenberg has noted, “The intent is clear enough: to clothe certain undesirable yet blandly tolerated social phenomena in the emotional urgency associated with a ‘real’ epidemic.” 61 The epidemic language also serves to validate public health as a field and to increase its authority, recognition, and capital. 62

Between 1980 and 2010, there has been a sharp rise in the use of the term
epidemic
in medical journals. The increase has been greatest for non-infectious, compared to infectious, conditions and especially for obesity. 63
Even if obesity is not an infectious disease in any literal sense and any associated health consequences occur at some unknown future date, the epidemic metaphor blurs these distinctions. Moreover, some researchers have employed the term quite literally or have made claims about obesity being socially contagious via social networks or as spreading via viruses. 64 As can been seen in figure 2.2, the use of the term
obesity epidemic
,
as measured by the number of news articles containing the term
obesity epidemic
in the full text in four select news publications, increased in 2000 and continued to climb through 2003, remaining high through 2010.

In the United States, CDC Director for the Division for Nutrition and Physical Activity William Dietz and CDC scientist Ali Mokdad have done as much as anyone to present the trend in higher BMI as evidence of an epidemic, widely publicizing this perspective via a PowerPoint presentation that they made publicly and freely downloadable. This presentation used a series of maps to depict obesity as an epidemic spreading across the nation. 65 Each slide contained a map of the United States with states color-coded for the rate of obesity (BMI greater than 30), beginning in 1985.
States with less than 10 percent were light blue, those with 10 to 14 percent were a medium blue, and those with 15 to 19 percent were an even darker blue. States with 20 percent or more people with a BMI greater than 30 were colored bright red. As the slides progressed from 1985 to 1999, more and more states “begin to ominously dim from light to darker blue.
Then suddenly, in 1997, the first three “red” states dramatically appear, quickly followed by six more in 1998, and eleven more in 1999. Rather than simply showing a trend, the maps conveyed something far more urgent: a spreading infection.” 66

Figure 2.2:
Articles published in
The New York Times, Newsweek, US News & World Report, or
the
Washington Post
containing
obesity epidemic
in the full text.

Increases in population weight in the United States and elsewhere were real. The U.S. population really had gotten significantly fatter on average between the 1970s and 1980s and again between the 1980s and 1990s, and this meant that increased numbers of people’s BMI crossed the threshold over 25 and 30, the cutoffs for overweight and obesity respectively. (But rates of obesity among the adult U.S. population leveled out in the first decade of the twenty-first century. 67)

However, one could have framed this trend as part of a positive trend in greater human robustness. A 2006
New York Times
article provides a glimpse of what this line of argument might have looked like. 68 It describes Valentin Keller, who, in 1962 at 26 years old, enlisted in the army as “a small, slender man, 5 feet 4 inches tall.” He was honorably discharged the following year “sick and broken” and died at age 41. The fact that Keller’s descendants are both heavier and healthier is consistent with the article’s central message: “The Keller family illustrates what may prove to be one of the most striking shifts in human existence—a change from small, relatively weak and sickly people to humans who are so big and robust that their ancestors seem almost unrecognizable.” The rest of the article describes the marked improvements in health, longevity, and even IQ that have accompanied increases in both height and weight. 69 Those who see the steady increase in population weights as part of larger positive trends, however, have been decidedly in the minority.

In the United States and abroad, organizations including the CDC, WHO, and IOTF, as well as obesity researchers, have actively promoted the public health crisis frame. The IOTF, which is now part of the IASO, “was originally convened in 1995 by Professor Philip James to prepare the first scientific research report on the global epidemic of obesity 70 with generous funding from Hoffman-La Roche (the maker of weight-loss drug Xenical) and Abbott Laboratories (the maker of the weight-loss drug Meridia).” 71
This report served as “a working draft” for the first WHO expert consultation on obesity in Geneva in 1997. Representing obesity as a public health crisis of the greatest magnitude, it was distributed to all health ministers at the World Health Assembly in 1998 and was eventually published as an official WHO Expert Technical Report in 2000, entitled “Obesity: Preventing and Managing the Global Epidemic.” The WHO imprimatur gave authority to the report’s representation of obesity as a disease that was spreading at an epidemic rate, while the IOTF’s considerable resources from pharmaceutical companies assured that it would have impact. Indeed, according to the IASO’s website, this report marked a “turning point in governments’ acceptance of what was described by WHO as ‘the biggest unrecognized public health problem in the world.’” 72