Debating Obesity: Critical Perspectives

Debating Obesity Also by Emma Rich EDUCATION, DISORDERED EATING AND OBESITY DISCOURSE: Fat Fabrications (co-authored ...

Author: Emma Rich | Lee F. Monaghan | Lee Monaghan | Lucy Aphramor

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Debating Obesity

Also by Emma Rich EDUCATION, DISORDERED EATING AND OBESITY DISCOURSE: Fat Fabrications (co-authored with John Evans, Brian Davies and Rachel Allwood) THE MEDICALIZATION OF CYBERSPACE (co-authored with Andy Miah)

Also by Lee F. Monaghan MEN AND THE WAR ON OBESITY: A Sociological Study BODYBUILDING, DRUGS AND RISK

Debating Obesity Critical Perspectives Edited by

Emma Rich University of Bath, UK

Lee F. Monaghan University of Limerick, Ireland

Lucy Aphramor Coventry University, UK

Selection and editorial matter © Emma Rich, Lee F. Monaghan and Lucy Aphramor 2011 Individual chapters © their respective authors 2011 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6-10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2011 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978–0–230–22267–0 hardback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Debating obesity : critical perspectives / edited by Emma Rich, Lee F. Monaghan, Lucy Aphramor. p. cm. ISBN 978–0–230–22267–0 (hardback) 1. Obesity. 2. Physical-appearance-based bias. I. Rich, Emma, 1977– II. Monaghan, Lee F., 1972– III. Aphramor, Lucy, 1967– RC628.D428 2010 616.3 98—dc22 2010027547 10 9 8 7 6 5 4 3 2 1 20 19 18 17 16 15 14 13 12 11 Printed and bound in Great Britain by CPI Antony Rowe, Chippenham and Eastbourne

Contents List of Table and Boxes

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List of Contributors

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Editors’ Acknowledgements

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1 Introduction: Contesting Obesity Discourse and Presenting an Alternative Emma Rich, Lee F. Monaghan and Lucy Aphramor

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2 Does Fat Kill? A Critique of the Epidemiological Evidence Paul Campos

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3 Bodily Sensibility: Vocabularies of the Discredited Male Body Lee F. Monaghan and Michael Hardey

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4 ‘You Can’t Be Supersized?’ Exploring Femininities, Body Size and Control within the Obesity Terrain Irmgard Tischner and Helen Malson

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5 Doing More Good than Harm? The Absent Presence of Children’s Bodies in (Anti-)Obesity Policy Bethan Evans and Rachel Colls

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6 Children’s Bodies, Surveillance and the Obesity Crisis Emma Rich, John Evans and Laura De Pian

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7 Fat Lib: How Fat Activism Expands the Obesity Debate Charlotte Cooper

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8 Helping People Change: Promoting Politicised Practice in the Health Care Professions Lucy Aphramor and Jacqui Gingras

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9 Conclusion: Reflections on and Developing Critical Weight Studies Lee F. Monaghan, Emma Rich and Lucy Aphramor

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Index

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List of Table and Boxes

Table 3.1 A typology of fat bodily sensibility

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Boxes 5.1 NSC findings (DH, 2006: 22–23) 5.2 Justifications for the NCMP

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128 130


Lucy Aphramor RD is an NHS dietitian and an honorary research fellow at Coventry University. Lucy’s work seeks to advance a socially integrated approach towards improving well-being and reducing inequalities. Together with Sharon Curtis, she is co-founder of HAESUK, a group established to raise awareness of the benefits of health at every size in and beyond health care. She has published work on critical dietetics, frequently in collaboration with the Canadian dietitian, Jacqui Gingras. Paul Campos is Professor of Law, University of Colorado. He is the author of The Obesity Myth: Why America’s Obsession with Weight is Hazardous to Your Health (New York: Gotham Books, 2004), subsequently republished in 2005 as The Diet Myth. He has also published critical work on obesity in The International Journal of Epidemiology. Paul regularly writes for Scripps Howard News Agency. Rachel Colls is Lecturer in Human Geography at Durham University. She is interested in researching with and theorising ‘the body’. She has published work on women’s experiences of clothing consumption, weighing and measuring children in schools, feminist theory and materiality and critical geographies of obesity. She is currently working on research on the production and experiences of size-friendly spaces. Charlotte ‘The Beefer’ Cooper is a queer fat activist based in London, and currently a Government of Ireland PhD scholar at the University of Limerick, courtesy of the Irish Social Sciences Platform. Charlotte’s background is in DIY culture and queer journalism. She authored the fat rights manifesto Fat and Proud: The Politics of Size (1998) and the novel Cherry (2002). Charlotte is ‘the boss bitch’ of The Chubsters. She blogs about fat activism and Fat Studies at: www.obesitytimebomb.blogspot. com. Laura De Pian is a doctoral research student in the School of Sport, Exercise and Health Sciences, Loughborough University. She is a former vii

viii List of Contributors

Research Associate on an Economic and Social Research Council (ESRC)funded project ‘The Impact of New Health Imperatives on Schools’. Bethan Evans is Lecturer in Geography and Medical Humanities at Durham University. Her research interests involve a critical engagement with health policy and its implications for those involved. She has published work on young people’s gendered experiences of sport, critical geographies of obesity, children’s position in biopolitical, pre-emptive health policy and health interventions in schools. She is currently researching the role of urban design professionals in anti-obesity policy. John Evans is Professor of Sociology of Education and Physical Education at Loughborough University. He teaches and writes on issues of equity, education policy, identity and processes of schooling. With Emma Rich and Laura De Pian, he currently is researching the relationships between formal education, health and the embodiment of subjectivity. He has authored and edited a number of papers and books in the Sociology of Education and Physical Education including Education, Disordered Eating and Obesity Discourse: Fat Fabrications, co authored with Emma Rich, Brian Davies and Rachel Allwood (Routledge, 2008). Jacqui Gingras, PhD, RD is an assistant professor at the School of Nutrition, Ryerson University, Toronto, Canada. Her research involves theoretical and experiential explorations of critical dietetics epistemology. She has a particular interest in how dietetic students’ and professionals’ subjectivities are constituted by power and discourse to inform advocacy, policy and pedagogy. Her research engages auto-ethnographic, narrative and arts-informed methods as a means for situated and particular understandings of dietetic theory, education and practice. Her work appears in Food, Culture & Society, Radical Psychology, Feminist Media Studies and Journal of Agricultural and Environmental Ethics. Michael Hardey is reader in social science at the Hull/York Medical School and the Department of Social Science, University of Hull. He is an associate director of the Science and Technology Studies Unit (SATSU) at the University of York. He has written widely about eHealth and is engaged in research with the Open University of Catalonia in relation to European health care. His work includes: public-professional relationships, heterosexual male lifestyles, health and the body. He is also involved in a number of Web 2.0 initiatives.


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Helen Malson is a reader in Social Psychology in the Centre for Appearance Research at the University of the West of England, Bristol. Her research focuses around feminist post-structuralist analyses of girl’s and women’s ‘eating disordered’ subjectivities and practices and, more recently, service users’ and service providers’ accounts about the treatment of ‘eating disorders’. Her publications include The Thin Woman: Feminism, Post-Structuralism and the Social Psychology of Anorexia Nervosa (Routledge, 1998) and, with Maree Burns, Critical Feminist Approaches to Eating Dis/orders (Routledge, 2009). Lee F. Monaghan is Senior Lecturer in Sociology, Department of Sociology, University of Limerick. He teaches the sociology of health, illness and the body; social theory and qualitative research. He has published articles on the obesity debate and fatness in journals such as Body & Society, Social Theory & Health and Sociology of Health & Illness. His latest monograph is titled Men and the War on Obesity: A Sociological Study (Routledge, 2008). He is currently working on the second edition of Key Concepts in Medical Sociology (Sage, edited with Jonathan Gabe). Emma Rich is Senior Lecturer in Sport and Education at The University of Bath. She has published work related to the body, education and health in journals such as Sociology of Health and Illness, Discourse, Health, and Gender and Education. She is co-author of the books The Medicalization of Cyberspace (with Andy Miah, Routledge 2008) and Education, Disordered Eating and Obesity Discourse: Fat Fabrications (with Jon Evans, Brian Davies and Rachel Allwood, Routledge 2008). Irmgard Tischner is a lecturer in Social Psychology at the University of Worcester and associate member of the Centre for Appearance Research at the University of the West of England, Bristol. Focusing on poststructuralist, feminist and critical psychological approaches, her research interests include issues around embodiment and subjectivity particularly in relation to (gendered) discourses of body size and ‘being large’ in contemporary Western societies.

Editors’ Acknowledgements

When formulating the idea for this edited book, and working on it from inception to completion, we incurred numerous debts. We do not have space to thank everybody for their support but we would like to take this opportunity to acknowledge at least some key people and organisations that have made our ongoing work in this field, and the publication of this volume, possible. First, we would like to thank the staff at Palgrave Macmillan for their ongoing support. In particular, we owe a big thank you to the Social Sciences division of Palgrave. Names include Philippa Grand (Publisher) and Olivia Middleton (Assistant Editor). Second, others in the developing field of Fat Studies have provided support, inspiration and motivation for this book. We would like to give special mention to Bethan Evans and Rachel Colls (who have been leading an ESRC funded seminar series on Fat Studies and Health at Every Size: Bigness beyond Obesity), Corinna Tomrley (convenor of the first Fat Studies seminar in the United Kingdom and co-editor of Fat Studies UK reader), Charlotte Cooper, Karen Throsby and Sharon Curtis. Individually, Emma would like to thank colleagues who contributed to the research project (The Impact of New Health Imperatives on Schools) informing some of this book, including: Dr Tina Byrom, Professor John Evans, Dr Valerie Harwood, Laura, Dr Lisette Burrows, Dr Hazel Mycroft and Professor Jan Wright. That project would not have been possible without the financial support from the UK’s ESRC (grant number: RES-000-22-2003). Lee would also like to acknowledge early financial support for his research on ‘weight issues’ from the ESRC (grant number: RES-000-22-0784) and current support from Ireland’s Higher Education Authority, particularly, funding received under the Programme for Research in Third-Level Institutions (PRTLI Cycle IV). Finally, Lucy would like to thank The West Midlands Primary Care Clinical Trials and Research Unit and NHS West Midlands Buy Out Scheme for their financial support for research projects that inform her work on body weight management in dietetics.

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1 Introduction: Contesting Obesity Discourse and Presenting an Alternative Emma Rich, Lee F. Monaghan and Lucy Aphramor

Formidable authorities continue to issue warnings about a global ‘obesity crisis’ (UK Parliament, 2004; WHO, 1998), ultimately the result of inactive lifestyles and poor diets. What medicine calls ‘obesity’, and its precursor ‘overweight’, must be fought, we are told, because they lead to escalating morbidity and mortality from, among other conditions, hypertension, diabetes, stroke, heart disease and cancers. These twin ideas of runaway population weight gain and ‘excess’ bodyweight being intrinsically associated with poor health have achieved such momentum in developed nations that it is difficult in the contemporary discursive terrain to imagine fatness as anything other than obesity: unhealthy, morally defunct and something to be corrected. As such, obesity is an issue that routinely pervades all corners of our late modern cultural landscape,1 albeit through a limited and often reductive way of thinking which not only restricts how we come to understand it, but which can explode into knee-jerk reactionary panics. Presenting an alternative perspective is the obesity challenge we tackle throughout this book. We recognise this is a difficult undertaking. Among other things, many people are personally invested in seeing and treating ‘weight’ (a crude and efficient proxy for fatness) as a problem and are seeking solutions to what is often experienced as a personal, private trouble. In everyday life the fight against fat is often seductive and is partly fuelled by a powerful ‘epidemic psychology’ consisting of unjustified fear, moralising action and intense forms of social stigmatisation that are potentially more corrosive than actual biological risks (Strong, 1990, cited by Monaghan, 2005a). We do not intend to trivialise these and other obesity-related concerns here; on the contrary, there is much in 1

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Introduction: Contesting Obesity Discourse

this book that seeks to empathise with people who struggle daily with weight issues. What is problematic for us, however, is how medicalised concerns about ‘excess’ weight socially construct fatness as a pathological, morally inflected condition that must be combated or remedied. This is at a historical juncture when the majority of adults and increasing numbers of children in nations such as the United States, Britain, Canada, Ireland and Australia are medically deemed overweight or obese and thus ill, diseased or at risk (WHO, 1998). Such definitional practices, inseparable from embodied hierarchies of moral worth and the exercise of power or ‘biopower’ (Evans et al., 2008; Wright and Harwood, 2009), are ubiquitous and consequential for many people’s embodied relationships, identities and practices. Whilst medicine is not omnipotent and is intertwined with other cultural practices, institutions and discourses that centre the body and ‘bodywork’ (e.g. the fashion and cosmetic industries), we are particularly mindful of medicalised meanings since one of the most pervasive ways in which people come to understand their bodies, and other people’s, is through authoritative health discourses. And, it is no exaggeration to state that highly publicised discourses about obesity are often alarming, if not alarmist. In constructing the obesity crisis, strands of medical discourse, commonly recycled in the news media and government reports, emphasise a sense of impending disaster that must be averted through collective and individual action. This representation is accomplished through the selective use of statistical data, graphs, disparaging images of people who are deemed morbidly obese and metaphors; for example, the idea that obesity is an ‘epidemic’ or ‘time bomb’, a putative threat that one US Surgeon General called ‘the terror within, a threat that is every bit as real to America as weapons of mass destruction’ (Carmona, 2004). Whether intended or not by specific individuals, notions of deviance, blame and culpability infuse this ubiquitous public morality play where ‘the disease metaphors of obesity [ . . . ] have not refuted the nagging culture-wide suspicion [that] fat people are still their own worst enemies’ (Edgley and Brissett, 1990: 262; cited in Monaghan, 2008: 39). Indeed, fatness is routinely framed as a deficiency of social and individual responsibility, the unholy sins of gluttony and sloth (UK Parliament, 2004). In that respect, ‘fat people’ are constituted as ‘folk devils’ (Cohen, 2002), though it should also be recognised that literally millions of people are being categorised as (potential) weight-deviants in these ‘epidemic’ times. Such a framing is consequential. Within this discursive context, many people – including carers of children, more often mothers – are deemed

Emma Rich, Lee F. Monaghan and Lucy Aphramor

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to be ‘deservedly’ open to stigma, criticism and depreciatory comments about their own and/or their children’s size. Disturbingly, some advisors to government even maintain that ‘it might be helpful if more stigma [was] attached to obesity so that people made more effort to lose excess weight’ (UK Parliament, 2004: 104). Sizism, or intolerance and insensitivity towards people labelled ‘fat’, remains a commonly accepted prejudice (Smith, 1990; also, in this volume, see Cooper, Chapter 7 and Monaghan and Hardey, Chapter 3). Going beyond the specific prejudices and arguably ‘barbaric’ injunctions (Scambler, 2009) of some government health committee advisors, scientists and prominent public figures routinely, if unintentionally, amplify sizism with exaggerated and scientifically unsubstantiated claims. Indeed, some even compare the health consequences of the ‘obesity epidemic’ to the far-reaching ramifications of global warming. In the United Kingdom, for example, in October 2007 the government Health Secretary Alan Johnson stated that the public health threat posed by obesity was a ‘potential crisis on the scale of climate change’ (BBC News, 2007). Such words, reiterated by other ministers and critiqued by a prominent psychoanalyst for constituting an ‘ignorant and gullible stance . . . towards the myth of obesity’ (Orbach, 2009: 24), are pervasive and have various consequences. They not only legitimate a sense of moral panic, urgency and disaster that fuel the mongering of obesity as a disease category (Jutel, 2006) but also have the effect of suppressing dissenting voices. Such alarming claims also obscure the role of political expediencies and medical ambiguity in setting the anti-obesity agenda (Bacon, 2008). As Monaghan (2008) suggests, such definitional practices, while not inventing fat hatred afresh, manufacture fatness as a correctable health problem on an unprecedented scale. It is this phenomenon that we render problematic, not fatness. In that respect, and to follow Campos (2006: 3), our use of the biomedical words ‘overweight’, ‘obesity’ and even ‘morbid obesity’ (sic) ‘should always be read with an implicit “so-called” modifying them’. We know that some contributors, such as fat activists, believe less attention should be given to obesity because it detracts attention from more pressing health issues (Saguy and Riley, 2005). Social scientists offer parallel arguments. For Gard and Wright (2005), authors of The Obesity Epidemic, one conclusion following their critique of obesity science is for the scientific and medical community ‘to “get over” body weight altogether’ (p. 190). As editors, we appreciate, and to some extent endorse, such arguments though we would maintain that the current debate should be extended in order to incorporate and explore such

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conclusions – conclusions which, as noted by Gard and Wright (2005: 190) ‘enjoy a good deal of scientific support’. For us, expanding discussion is necessary because, in the current medico-moral context, ‘the obesity debate’ is hardly a debate at all (Evans et al., 2008; Monaghan, 2005a). Although debate on obesity does exist within popular understandings, such as television documentaries or chat shows, it is often packaged as a polarised dichotomy with little room for more nuanced engagements: people are either for or against the idea that obesity is a (self-inflicted) problem. Fatness is variously held up as funny, horrific or freakish, and supporting commentary is frequently rife with value-laden pejorative assumptions that ignore the constraints usually afforded people with medicalised conditions. Examples of resistance within popular culture and elsewhere notwithstanding, the debate largely focuses upon proposed ‘solutions’ to a taken-for-granted problem rather than questioning the social construction of fatness as obesity and the consequences of such definitional practices in the social world. The pervasive, yet unrealised, concern to find ‘solutions’ to the obesity epidemic has raised questions not only for public policy makers, but also for scholars, health practitioners, counsellors, journalists and those working within the education sector. Obesity as a topic, and something to be fought, is granted extensive (or, rather, disproportionate) coverage in news articles (Saguy and Almeling, 2008) and in new digital media associated with cyberspace (Miah and Rich, 2008). Apparently faced with serious health problems, and associated imminent decline (WHO, 1998), central governments, health organisations, the food and drink industry, families and, most critically, individuals come ‘entrepreneurial selves’ (Petersen and Lupton, 1996; also see Monaghan et al., 2010) are enjoined to act against obesity. Such is the preoccupation with the putative problem of, and solution to, a global obesity crisis, that ‘obesity discourse’ offers a framework of thought, talk and action concerning the body in which ‘weight’ is privileged not only as a primary determinant but a manifest index of well-being, surpassing all antecedent and contingent dimensions of ‘health’. (Evans et al., 2008: 13) When debating obesity, we thus need a more contextualised understanding of how fatness comes to be renamed ‘obesity’. We also need to move beyond the rather limited range of theoretical and analytical tools that have so far been drawn upon to define ‘weight’/‘fatness’ as


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a health problem. Thankfully, inroads are being made in this direction from contributors within and allied to the social sciences. The form and content of contemporary talk about bodyweight, especially the adequacy and ‘certainties’ of knowledge produced within primary research fields, have now come under critical scrutiny from a range of scholars (Aphramor, 2005, 2009; Bacon, 2008; Bacon et al., 2005; Burns and Gavey, 2004; Campos, 2004; Campos et al., 2006a, 2006b; Cogan, 1999; Cohen et al., 2005; Colls and Evans, 2009; Evans, 2004, 2006; Gaesser, 2002; Gard and Wright, 2005; Herndon, 2005; Jutel, 2005; LeBesco, 2004; Miller, 1999; Monaghan, 2005a, 2008; Oliver, 2006; Rich and Evans, 2005; Warin et al., 2007). Many of these writers might be collectively described as operating within the field of critical weight studies, challenging the construction of fatness as ‘obesity’ and ‘obesity’ as an epidemic or pandemic.2 A number of these contributors are sceptical of the ways in which obesity discourse seems to offer ‘certainty’ and ‘authority’ of ‘fact’ and knowledge yet, upon closer inspection of the primary research field, few such certainties exist. When engaging obesity science, sceptics have developed different lines of argument, either questioning the conventional wisdom as inconclusive (Gard and Wright, 2005) or incorrect (Campos, 2004). Either way, there is much to suggest that the apparent conviction or certainty of facts about fat and the treatment of obesity are not as clear-cut as we might be led to believe. Obesity science has produced few reliable truths and is characterised by studies of limited transferability; indeed, much scientific evidence contradicts the ‘orthodox view’. For example, there are large-scale epidemiological studies in different countries that point to the health benefits of being overweight (Bacon, 2008). Also, there is accumulating evidence on the role of lifecourse events and poor social networks, rather than eating and exercise behaviours, in pathways predisposing people to metabolic irregularities associated with obesity-related conditions (see Chapter 8 of this volume, Aphramor and Gingras). For Gard and Wright (2005), because obesity science is currently an ‘imprecise business’ the ‘alarmist’ claims in the media and by scientists are difficult to reconcile. Taking a stronger stance, Campos (2006: xvii) maintains that ‘the war on fat is an outrage to values’ such as equality and fairness. Yet, as indicated by Herrick (2009) when critiquing the food and drink industry’s use of Corporate Social Responsibility strategies, it is under current neo-liberal conditions that efforts to tackle obesity are widely lauded. In seeking to further debate on obesity under these challenging conditions, and in a way that is attuned to social scientific concerns

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(e.g. morality, ideology, justice, the political economy, the humanistic dimensions of bodies and institutional practices), we have invited contributions from scholars who are taking a leading edge in critical weight studies, or what some, such as Cooper (Chapter 7 in this volume) and Tomrley and Kaloski-Naylor (2009), term ‘Fat Studies’. Coming from a range of disciplinary and professional backgrounds, contributors may have various interpretations as to what the relevant issues are and how these should be conceptualised, though there is a shared conviction that there is a need for critical thinking and scepticism when presented with dominant obesity discourse. This is a position that we, as editors, fully endorse, and we would do so in a reflexive way that is conscious of our own positioning and what others might misrecognise as ‘biases’. Hence, this book also includes commentary on and responses to the uptake and interpretation of our work in a field of power/knowledge and the need to defend, clarify, revise or expand upon our own positions. Quite self-consciously, and in following Young’s (1990) useful contribution to debates on social justice, our work entails substituting a concern with ‘impartiality’ with the pursuit of ‘public fairness in a context of heterogeneity and partial discourse’ (p. 112). Centrally, if we are to be positioned in some way and declare our partiality, our primary aim is to extend the obesity debate because we consider it to be often limited and limiting. In qualifying our position, we would agree that for some people being very fat can present health problems. Additionally, we recognise fatness and efforts to tackle it raise disability issues, as recently discussed by one of us in Disability & Society (Aphramor, 2009). A crucial point, though, is that what is defined and understood as a ‘health problem’ can never be divorced from the structures of society and embodied socio-cultural meanings. When critiquing obesity discourse and concurring with other sceptics, who maintain bodyweight is not as reliable an indicator of current or future health as is often suggested, we do not deny the physicality of the body nor trivialise health problems typically associated with corporeal ‘extremes’. Yet, very fat people represent a minority percentage of the population even in supposedly ‘fat nations’ such as Britain and, in terms of medical risk and population numbers, people classed as moderately ‘underweight’ arguably present more urgent clinical and economic problems than extreme fatness (BAPEN, 2009), conspicuously without the stamp of moral censure. More generally, this book derives from our conviction that certain features of contemporary obesity discourse may not encourage personal or policy responses which are conducive to ‘health’ (broadly defined).


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Indeed, we remain concerned that obesity discourse may have unintended negative consequences, including limiting the ways in which we seek to understand complex relationships between health, eating, weight, metabolic risk and broader social structural factors (e.g. the impact of socio-economic status on health outcomes). At an individual level we recognise that, for many people, fighting fat is intimately related to concerns about survival or ‘social fitness’ (Monaghan, 2008), though we remain concerned that obesity discourse typically diverts attention from potentially more effective ‘health interventions’ at a societal level (e.g. reduction of poverty and income inequality) and it can be experienced as highly oppressive in everyday life. In that respect, we eclectically draw from, include and acknowledge various contributions, including strands of feminist and fat activist thinking that have challenged fat oppression typically enacted towards women (e.g. Brown and Rothblum, 1989; Cooper, 1998). This, we would maintain, is relevant not only to critical weight studies but also health professionals who could be ‘in the vanguard opposing the stigmatization and oppression of those who are “obese” ’ (Rogge and Greenwald, 2004: 314). This fits with a venerable tradition in critical public health that does not distinguish between being a health worker and social activist (albeit while recognising this is likely to antagonise typically middle-class defenders of the status quo) (Green and Labonté, 2008). In offering a theoretically, empirically and politically informed contribution we thus aim to bring together challenging work, offering readers alternative and developing perspectives and thinking. We do not pretend to offer the final word on a complex issue that can be deeply problematic for people – including health practitioners reconciling with poor practice. Indeed, perhaps the best we can hope for are ‘practically adequate’ rather than ‘definitively true’ understandings (Robertson and Williams, 2010: 59) – though, as an aside, we recognise some prominent North American obesity sceptics engage in the rhetoric of ‘truth’ and ‘lies’ (e.g. Gaesser, 2002). Correspondingly, this book is an invitation to further debate, including discussion on how critical weight studies might be interpreted and proceed amidst controversy, contestation, misrecognition and heterogeneity in contributors’ backgrounds and interests. Importantly, in line with our own sensibilities that are attuned to axes of power (e.g. relations of gender, social class, age and stigma), we aim to further ‘sociologically imaginative’ dialogue regardless of contributors’ disciplinary backgrounds. That is, we encourage dialogue that locates people’s biographies within larger historically unfolding social structures and where personal troubles and

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public issues are inextricably linked (Mills, 1970). As will become clear, and in response to possible countermoves by protagonists of obesity discourse, we are not anti-science nor are we against the institution of medicine, though we would repudiate obesity discourse as it is currently formulated. Rather than endorsing fat fighting and the search for a ‘magic bullet’, we aim to draw from and speak to a range of interested parties in the spirit of collaborative learning and with the hope of promoting alternative ways of engaging this issue. In short, we seek to open discussion, rather than offer reductive solutions to current thinking around health, weight and the body, and draw further lines of epistemic division across the various disciplines to which these issues might be relevant. Indeed, as Walkerdine (2009: 199) contests, we need ‘to understand the production and utilisation of knowledge in the present in a much more complex way than we are used to doing’. Hence, this demands that we also ask of our own work and epistemic communities the very questions of legitimacy and epistemology we subject anti-obesity scholars to.

Background The idea for this book emerged after several years of dialogue among the three editors about our academic and professional work on the body, health and weight-related issues. Our early discussions resulted in the publication of three articles in the journal Social Theory & Health (Aphramor, 2005; Monaghan, 2005a; Rich and Evans, 2005), soon followed by a one-day forum, mainly for health professionals, at the University of Limerick in 2006. Following that collaboration and our ongoing dialogue, we felt it timely to bring together a range of critical perspectives from other scholars that might help to expand discussion in new and productive ways. Before referring to other contributions and developments, we will say something about our own backgrounds. While Lucy is a health professional, specialising in cardiac health, diet and health promotion, Lee and Emma work within the fields of sociology and pedagogy with shared research interests in the body, health and gender. Lee and Emma first met in 2005 after an invitation to present at a conference. Lee, then based at the University of Newcastle upon Tyne, had just started an Economic and Social Research Council funded project on men and weight-related issues. Social scientific work in this field has largely focused upon women; hence, Lee sought to bring in men’s experiences in order to critically complement such thinking. Emma, along with


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her colleagues at Loughborough University, has, for a number of years, researched the relationship between obesity discourse and pedagogy, looking specifically at the impact of obesity discourse in schools, and the relationship between obesity imperatives and disordered eating (see Evans et al., 2008). Elsewhere, she has also examined how obesity discourse has been recontextualised within popular pedagogy and cyberspace (Miah and Rich, 2008). Similarly, Lee has explored the Internet and its use by people who risk the stigma of obesity (Monaghan, 2005b, 2010a, 2010b). Lucy, who is a dietitian and senior health promotion specialist in Britain’s National Health Service (NHS), and researcher at the University of Coventry, has researched size discrimination (Aphramor, 2006) and the value of an alternative clinically relevant approach to weight issues, namely, Health At Every Size. Lucy has been developing such thinking and practice, along with a Canadian dietitian and critical weight scholar (Jacqui Gingras), bringing to the debate more macro-sociological concerns such as the impact of social inequalities on metabolic health (see Chapter 8 in this volume; also, Aphramor and Gingras, 2007). This has lead to the development of what they call ‘Health in Every Respect’, which acknowledges how issues such as social status and control over life circumstances (e.g. in relation to employment) are highly consequential for people’s health and health practices and ultimately the constrained effectiveness of health professionals. Lucy’s work appealed to Lee and Emma as they sought to engage with and critique obesity discourse and consider alternative approaches. Elsewhere within the United Kingdom, although in its infancy, the growing interdisciplinary field of Fat Studies has also provided an important forum through which we have been introduced to a broad range of work exploring different aspects of the discursive production and experience of fat. In 2008, Corinna Tomrley and colleagues at The University of York (Centre for Women’s Studies) hosted the first Fat Studies UK seminar. The event brought together those interested in these issues from both an academic and activist perspective and led to the publication of Fat Studies in the UK (Tomrley and Kaloski-Naylor, 2009). In the United Kingdom, in July 2009, Louise Mansfield convened a session on ‘critical perspectives on fat and leisure’ at the annual Leisure Studies Association annual conference. More recently over the course of 2010–2011 an interdisciplinary ESRC-funded seminar series is taking place. Led by Dr Bethan Evans and Dr Rachel Colls, the series is providing vital support for the continued development of Fat Studies and Health At Every Size. To date, the seminars have not only provided a context within

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which to explore the substantive, methodological and theoretical issues of fatness and social identities, but also have facilitated interdisciplinary discussion and networking between activists, practitioners and academics seeking to develop non-discriminatory approaches to health and fatness. Similarly, included in this book are writings from scholars who are contributing to burgeoning critical thinking about weight, obesity or fatness in their different ways. Contributors have diverse theoretical predilections and interests, presenting articulations across disciplines and approaches including law, sociology, psychology, feminism, geography and education. Also, as noted above, critical contributors reside not only in academia but also in fat activism (or, as with many Fat Studies scholars, they are straddling and combining both projects). To this end, someone hoping to read this text and find a unified approach and shared consensus will be disappointed. Indeed, even within explicitly politicised thinking, approaches are fragmented – consider, for example, different appeals within fat activism, including the idea that obesity is or is not a disease, or fatness has a genetic basis, alongside the relevance or otherwise of offering such types of explanation (Cooper, 1998; LeBesco, 2004). Counter discourse and theories are not unified, and contributors who contest obesity discourse might be considered a heterogeneous and perhaps disjointed community. Correspondingly, we remain mindful of the limitations of thinking about discussants as belonging to one camp or another, or simply ‘taking sides’ in a discussion where dichotomies prevail; for example, the idea that ‘fat’ and ‘thin’ people respectively constitute ‘deviant’ and ‘normal’ groups, or where discussants are somehow ‘for’ or ‘against’ medicine, science and technology. When inviting contributors our aim has been to highlight the disciplinary, pragmatic, methodological and philosophical differences that may yield collaboration and more instructive and complex understandings. Our purpose, then, is not only to further theoretical and empirical understandings of the impact of obesity discourse, or challenge the foundations upon which the war on obesity is waged, but also to enrich our understandings of how the debate itself is constructed and how it is unfolding. What ways of thinking, epistemological and ontological frameworks, theoretical tools and experiential insights are utilised in this terrain and which routes seem most promising in advancing knowledge and praxis? We hope to raise questions and offer suggestions about what these contributions offer in terms of where we might go with this debate politically, epistemologically, theoretically, substantively and what all of this might mean for health practices and people in


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everyday life. This implores us to address the subtleties and complexities not only of obesity discourse, but also of the various branches of critical thinking that have mounted a challenge. And, we take steps in this direction not only to enrich understanding of issues concerned specifically with critical weight studies, but also to speak to broader issues concerning the social construction of health knowledge and the social distribution/determinants/experiences of (ill) health. In short, our goal is to promote dialogue among various parties in order to challenge obesity discourse in a credible and robust manner while remaining mindful of the difficulties of such an undertaking in ‘epidemic’ times.

Medicalised understandings of the obesity epidemic: Critiquing discourses on lifestyle and healthism When engaging with discussions about obesity it is incumbent to reflect on the broader social and discursive terrain within which particular ‘truths’ about obesity have been articulated and to which critical scholars have responded in their various ways. According to Lawrence (2004: 57), central to debates about obesity are concerns about ‘What kind of a problem is obesity, what should be done about it, and by whom?’ Whilst various voices across a range of organisations articulate views on these issues, public discourse on obesity has tended to draw upon lifestyle and healthism as explanatory frameworks and guides for action. As discussed further below, this has emerged in part from the broader de-politicising shifts in thinking about health as individual responsibility (see Armstrong, 1995; Crawford, 1980) – thinking that can be particularly pernicious in relation to stigma (Scambler, 2006), and a framing which means that action to address size bias as a pressing social justice issue is markedly absent from guides for action. These understandings of fatness as obesity are thus not only intimately connected with current concepts in medicine and public health, but also with broader shifts in structured social processes in the twentieth and twenty-first centuries. Drawing on Hansen and Easthope (2007: 12), these can be summarised as ‘the processes of rationality, ideologies of conservative individualism, the increasing commodification of health and health care and the “risk society” ’. These shifts broadly reflect the discursive formations underpinning the construction of an ‘obesity epidemic’ – authorised through epidemiology3 and other social practices – and we critically outline these below with reference to various writings. Hansen and Easthope (2007) argue that within a lifestyle approach, rationalisation stresses individual responsibility for health through a

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cost/benefit analysis of behaviours and actions, that is, one’s lifestyle choice against the prevention of disease. In obesity discourse, these costs are not only considered in relation to the individual, but following the birth of the ‘bio-citizen’ (see Halse, 2009) are judged against the impact these reportedly have on one’s family (Fullagar, 2009), occupational effectiveness (as evidenced among health professionals who are charged by some to lead the fight against obesity) (see Monaghan, 2010a, 2010b), organisations, national health services and even upon the obesity league tables that are ‘gathered and circulated by government bodies, health authorities and social agencies and periodically reproduced by the popular press’ (Halse, 2009: 54). This approach to health, which some medical sociologists theorise and critique in terms of the logics of capital accumulation and class relations alongside the resurgence of neo-liberalism (Scambler, 2006), reflects a rationalist view of the body where it is assumed ‘enterprising’ individuals (see Petersen and Lupton, 1996) can achieve control if they make the ‘right choices’ and modify their bodies and health accordingly. The view that fatness, and hence diabetes, cardiovascular disease, hypertension and other conditions might be prevented if one exercises, adopts a healthy diet and generally ‘watches one’s weight’ reflects a discourse of healthism. This is the distinctly middle-class view that ‘health can be unproblematically achieved through individual effort and discipline directed mainly at regulating the size and shape of the body’ (Crawford, 1980: 366). As others have pointed out (Evans et al., 2008; Sobal, 1995), fat operates within popular discursive representations of obesity as an immediately visible sign of lack of self-control and ‘failure’ to gain rational control over one’s body (see also Throsby, 2007). A number of scholars (Armstrong, 1995; Crawford, 1980; Lupton, 1993; Scambler, 2006), in critiquing the shift in Western culture towards individualism and allocation of personal responsibility for health, have illuminated the moral overtones of this way of thinking. The moral emphasis is particularly burdensome when applied to ‘disease categories’ such as obesity, since body size/weight (as a putative health risk) is observable and visible to others, making it more susceptible to public scrutiny: ‘As the visible aspect of the self the body is not passive but needs to be monitored by individuals as they balance opportunities and risks, virtually forced to design their own bodies’ (Annandale, 1998: 18). Discriminatory and compensatory practices this can spawn are examined from a variety of different perspectives in this book. Defining fatness as a lifestyle disease also reflects the shift in focus in society towards the avoidance or management of risk


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(Beck, 1992). Scientific research disciplines play a significant role in the identification – or even ‘fabrication’ (Evans et al., 2008) – of the risks associated with ‘excess’ weight. Perhaps most notably, epidemiology has acted as the main scientific research discipline through which obesity is understood and subsequent policy and interventions devised, including those coming from the highly profitable and powerful corporate sector that dialectically reinforces limited epidemiological understandings. For instance, there is an emerging critique of Corporate Social Responsibility initiatives that promote ‘a narrow epidemiological understanding of obesity’ (Herrick, 2009: 51). As a discipline, epidemiology utilises multivariate analyses, which generate a limited range of ‘social determinants’ of disease that ideally should be avoided or managed by individuals. However, epidemiology has been criticised for focusing on ‘decontextualised individual risk factors’ (Pearce, 1996: 679), or ‘negative behaviours’ that are deemed unhealthy: in the epidemiological approach to lifestyle, the term lifestyle is generally only considered to refer to those behaviours or actions that can be shown to impact (usually negatively) on physical health. (Hansen and Easthope, 2007: 18) Although dominant, such an approach skews understanding of the embedded relationships between social factors, personal ‘behaviours’ and health outcomes. Put another way, accepting that obesity exists as a disease, and thinking about it within an epidemiological schema, asks a particular type of question leaving others, crucial to health and social justice, unformed. Thus, fatness might be associated at a population level with hypertension, for example, but this tells us nothing about causation in the same way that associations between Black ethnicity in the United States and hypertension tell us nothing about causation – a finding, long known to researchers, which cannot be adequately explained by genetics or health behaviours (Harburg et al., 1973) and is more fully explained by gender- and ethnicity-specific responses to ‘socioecological stress’ arising from material circumstances and dominance hierarchies (Gentry et al., 1982). In a second example, sleep impacts on health, including measures of metabolic risk that are conventionally seen as obesity-related (such as blood pressure), and disparities in sleep habits contribute to health inequalities. But the pathways through which social factors influence sleep patterns and sleep decisions are largely outside individual control and have more to do with social justice than voluntary lifestyle choices (Hale and Hale, 2009). These

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are health-related political and environmental issues that are not captured by ‘rationally’ (efficiently) measuring diet and exercise behaviours but which are open to sociological scrutiny and macro-social policy interventions intended to reduce social inequalities and thus health inequalities. Obesity-related ‘public health’ promotion, driven by epidemiology and other enmeshed practices that straddle the public/private sectors, has thus tended to focus on the individual, rendering them accountable for the management of risks and disease prevention through personal action and ‘healthy lifestyles’. Since the early 1980s, various organisations have legitimated and supported myriad obesity-related initiatives. In addition to multinational corporations that opportunistically profit from obesity concerns amidst the commercialisation of health (Herrick, 2009; Monaghan et al., 2010), key international and national voices include: The World Health Organization (WHO, 1998), British Heart Foundation (BHF, 1999), UK central government (House of Commons, 2001; National Audit Office, 2001), US Surgeon General (USDHHS, 1996, 2001) and the Foresight (2007) report. Collectively, in warning of the poor state of the health of populations, these agencies report the increasing health risks and growing obesity epidemic. Authoritative claims abound, partly as what Monaghan et al. (2010) term ‘obesity epidemic entrepreneurship’ – myriad practices that socially construct fatness as a correctable health problem at collective and individual levels. In summary, epidemiologically ‘informed’ obesity discourse largely focuses on the individual, ultimately rendering them (or, as with children, their parents) responsible for managing health risks, and hence disease prevention, through lifestyles. What are deemed ‘healthy behaviours’ and ‘unhealthy behaviours’ are thus constructed through the language of disease risk factors. In stressing personal and/or parental responsibility for ‘health’, determinants of health are those deemed modifiable and it is this capacity to serve as an explanatory framework for health and disease prevention, not just for the causes of disease, which in conjunction with [a truncated] emphasis on the social, makes a lifestyle approach distinct from other explanatory models used in contemporary medicine. (Hansen and Easthope, 2007: 8) As will be seen in subsequent chapters, this approach may be critiqued on numerous grounds. For example, drawing from writers such as Vaz


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and Bruno (2003), Bethan Evans and Rachel Colls state in Chapter 5 that the focus on lifestyles and statistical correlations between body mass and illnesses at a population level construct ‘patients before their time’, rendering obesity a ‘virtual disease’ since individuals may not actually get sick because of their weight. This construction, they explain, is based on an anticipatory logic of risk that justifies pre-emptive action in policy and a ‘defensive medicine’ that seeks to defuse the ‘obesity time bomb’. We would add that this bellicose construction is curious. If we accept that epidemiological data might have some use – offering at least some ‘pearls’ of wisdom amidst controversy (Davey Smith and Ebrahim, 2002) – then we would reiterate that many large-scale, methodologically rigorous, studies fail to show that obesity poses a serious threat to health while moderate fatness – ‘overweight’ – is consistently associated with increased longevity (Bacon, 2008). Hence, using epidemiology to claim fatness is always and necessarily unhealthy arguably misrepresents the best available evidence. Another criticism, and a central one running through this edited collection, is that epidemiological risk factor data are abstracted from their human social contexts, which, as Davey Smith and Ebrahim (2002) point out, are structured by socio-economic concerns. This difficulty regarding the common uptake of epidemiology limits recognition of how factors beyond ‘structurally indebted lifestyles’ (Scambler, 2002) are much more significant when explaining the social gradient in (ill) health and the disproportionate burden of health problems among the (new) poor, that is, the consistent inverse relationship between social status and morbidity and mortality (e.g. Marmot, 2004). Commonly ignored, yet seriously health-damaging, contextual factors include: being a second-class citizen, or being made to feel like a second-class citizen. Epidemiologically informed ‘lifestyle’ approaches thus obscure how health is an embodied multi-dimensional construct. As a social construct, health also comprises different meanings to different people. Paradoxically, the embodiment of health may also include actions which (in reductionist terms we are warned) could risk biomedical health, for instance, sedentary pleasures and eating calorific food, which are part of ‘a life worth living’ (Monaghan, 2008) for many people in developed nations. Health, after all, includes well-being, which, Evans and Colls (Chapter 5) explain, is ignored in recent UK policy interventions intended to secure future adult health by combating childhood obesity. And, such interventions proceed despite officially expressed concerns that proponents cannot demonstrate they will do more good than harm and other policy rhetoric claiming ‘every child matters’.

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In challenging obesity discourse we are cautious of invoking a reductive critique which would position science itself (or indeed, specifically epidemiology) as wholly liberating or disempowering, much in the same way as we would avoid the traps of simply ‘celebrating’ fatness in contrast to those who would ‘demonize’ it. For example, one might note that in an effort to move beyond an epidemiologically driven public health agenda, the new public health paradigm (see Nettleton, 1996; Petersen and Lupton, 1996) brought about a focus on the environment and the enhancement of people’s life skills for health. Following the Ottawa charter, it sought to highlight the social, political and economic conditions that may lead to health differences. This seems sociologically mindful. Yet, crucially from our perspective, despite ostensibly recasting attention to social structures and inequalities one can observe that much of the associated health policy still focuses on the modification of individual lives. Following the new health paradigm, in several countries, health care systems have placed great emphasis on providing the information and skills for an individual to live a ‘healthier’ life. This is a discourse reflected, more broadly, in health care policy and practice in certain contexts. For instance, Henwood et al. (2003: 590–1) note that in the United Kingdom, health policies emanating from the Department of Health are based on the need for developing more information for patients, which is ‘understood to be a necessary precursor to the development of new “partnership” relationships between health care practitioners and patients that the government is seeking to promote’. Whilst on the one hand, an increasing range of information, services and products are promoted on the basis of enabling consumers to ‘insure against disease or illness’ (Nettleton, 1997: 213), ultimately the onus of change is on the individual, regardless of people’s socially indebted means, abilities, priorities, needs or desires to make changes. In reproducing gender inequalities, women are also targeted by government policy as principal guardians of health within the family (Aphramor, 2005; also, see Moore, 2008). In all of this, the health impact of structural arrangements and inequalities and vital debate on political remedy remain sidelined and some inequalities are even reinforced (also, see Rogers’ (2004) critique of evidence-based medicine and justice, and Chapter 8 in this volume, Aphramor and Gingras). Thus, despite the apparent progressiveness of ‘empowerment’, some recognise informed choice as ‘part of the larger neo-liberal, consumerist discourse and ideology of healthcare’ (Spoel, 2006: 198). An example usefully grounds our critique. The Internet is one domain where debates about health-related information are well rehearsed.


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In their exploration of the Medicalization of Cyberspace, Miah and Rich (2008) note the rapid development of a range of resources emerging in cyberspatial environments. These resources are oriented around ‘healthy lifestyles’ and the prevention of obesity, including but not limited to: online personal trainers, calorie counters, Body Mass Index (BMI) calculators and a proliferation of information about health and diet. Via a ‘prosthetic surveillance’ (Rich and Miah, 2009), collectively these web tools encourage people to see health as individually determined. They encourage people to vigilantly monitor and survey their own bodies and assess these against normative ideals and health risks, similar to those rationalising or ‘McDonaldizing’ (Ritzer, 2004) processes critiqued by Monaghan (2008) when researching a slimming club. The marketing of such material has been made easier by an aestheticisation wherein the toned, taut, streamlined and always gendered body of consumer culture becomes a key resource for the marketing of weight-related products and services (also, see the discussion on feminist body studies below). Thus, in efforts to combat obesity, discourses of health promotion concerned with lifestyle, commercialisation and ‘informational medicine’ (Nettleton, 2004) can sometimes come together and enhance forms of healthism. As can be seen with the above example and elsewhere, the role of social structures and inequalities on the development of obesity (or on morbidity and mortality regardless of body composition and lifestyles) remains under-researched and often ignored or marginalised. Following our reference to Evans and Colls, this criticism not only extends to the re-articulation of obesity discourse in cyberspace or the Internet but also within public policy and other institutions dedicated to tackling the so-called epidemic. Once it is taken for granted that excess calorie intake represents the main threat to the current and future health of populations and individuals, pervasive efforts are directed at reducing calorie consumption and/or increasing calorie expenditure. The scope of intervention in official reports or policy may temporarily stretch beyond personal culpability, for example, to acknowledge the impact of an ‘obesogenic environment’ (Foresight, 2007) but it is not yet fashionable to explore the various antecedent or contingent socio-cultural and socio-economic factors that may impact on health, including metabolic risk, with or without adiposity (Krieger and DaveySmith, 2004). In this sense, obesity discourse has been recontextualised in ways that obfuscate complexities, such that fatness is seen unequivocally to arise from inappropriate eating and exercise behaviours and to cause ill-health. Correspondingly, really important and politicised

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causes of ill-health – which remain beyond the reach or control of any one individual – are largely ignored. Herrick (2009: 52), when critiquing food and drink industry-led ‘obesity prevention programmes’, makes a similar point: fundamental causes of poor health, such as poverty and structural inequalities may be overlooked in favour of more individualised explanations of health status, with solutions proffered in the form of information, and cast in the language of consumer empowerment and choice. We would posit that the formation of obesity discourse in this way not only has implications for social justice and the stigmatisation and commodification of bodies in societies where the gendered body is a ‘vehicle’ for a healthy and perhaps ‘glamorous lifestyle’ (Davis, 1997: 2). It also raises ethical concerns about effective health-related practice, given recent observations that ‘attempts to change individual lifestyles will achieve very little in terms of preventing disease or creating healthier societies’ (Hansen and Easthope, 2007: 35) – or, as happens, making people thinner. Such observations are in addition to the ethical concerns we raised in 2005 in Social Theory & Health, notably how obesity discourse can lead to forms of size discrimination, inequality and ineffective clinical ‘lifestyle’ recommendations, notably dietary approaches to weight-loss. Admittedly, other critical contributors may see the issue somewhat differently, arguing, for example, that ‘lifestyle rather than weight should be the primary target’ of public health programmes (Campos et al., 2006b). However, we see such issues as open for debate and critical engagement in line with a sociologically imaginative approach that views lifestyle as indebted to, and more often eclipsed by, social structures in matters pertaining to health and illness. In complicating and politicising our critique in a global context, we would also flag accumulating evidence demonstrating that ‘unequal societies’ are ‘unhealthy societies’ – an observation that extends to rich countries on different continents. As recently discussed by Wilkinson and Pickett (2009), societies with high levels of income inequality have much higher indicators of ‘health and social problems’ such as: lower life expectancy, illiteracy, imprisonment, homicide and teenage pregnancy. The contrasting pictures of the United States and Japan (high and low income inequality respectively) are a case in point, while Sweden and Ireland follow a similar pattern in Europe with corollary differences in their index of


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health and social problems. In line with such data, which also implicate obesity, the surest way to promote healthier societies is to reduce income inequality rather than obsess about the individual’s putative ‘responsibility’ for their weight/fatness and health. In short, by bringing together a multi-disciplinary collection we not only aim to contribute to the literature on obesity and critical weight studies, but also add to the growing body of writing which addresses the impact of concepts of health and ‘lifestyle’ on contemporary health practices and policy recommendations. This inevitably leads to other relevant debates too, such as how to incorporate biology and material bodies into sociological analyses and thus the uses and limitations of (extreme forms of) social constructionism (e.g. Williams, 2003; Williams et al., 2003). Other obvious areas of contestation include bioethics, where, as with Zylinska’s (2009) recent critique, problems arise in moral philosophy and discussions on enhancement, health and the (gendered) body given the typical emphasis on the singular, individual person who is somehow abstracted from wider socio-political processes. We simply flag these debates here, though they remain relevant in ongoing and future dialogue on the social construction of fatness and the obesity epidemic.

The social construction of fatness: these are not just big words Ideologies constructed around the ‘obesity epidemic’ are far from harmless, however: they allow individuals to be evaluated as ‘bad’ and/or ‘sick’ people; they allow institutional interventions and practices that are damaging to the people these practices affect; they cause widespread anxiety, which is in itself unhealthy; and they influence the relationships and practices within families in ways we would argue are detrimental to the well-being of parents and children and their relationships with each other. (Gard and Wright, 2005: 180) The socially constructed meanings of fatness, medicalised as overweight and obesity, matter in the human social world and thus we invoke what some would call a ‘passionate epistemology’ (Krieger, 2000). In taking such an approach, when debating obesity we would contest the irrationalities – or unintended negative consequences – ethics, and ineffectiveness of obesity discourse as recycled in contexts ranging from the school to the street. These issues, we would assert, implicate everybody

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regardless of whether or not they are overweight or obese (e.g. people at a supposedly ‘healthy’ weight may struggle with food and fat, or experience other ‘weight-related’ problems), though such issues may be especially problematic for people who are seen as fat in daily life. Reasons for this include the reality of sizism or fat oppression (Brown and Rothblum, 1989) and the common desire physically to fit in. Bringing together this collection, then, is no Ivory Tower exercise and, as we will elaborate, is necessary and timely given the ubiquity and power of obesity discourse. One of our recurrent concerns, and something we have been especially sensitised to as social researchers (and, in the case of Lucy, a health professional), is the issue of discriminatory practices and forms of inequality that obesity discourse or ‘ideologies constructed around an “obesity epidemic” ’ (Gard and Wright, 2005: 180) might legitimate. This is not to reduce fatness to social oppression and ignore the fleshy body (similarly, see Williams, 2003, when critiquing the social model of disability); rather, we recognise how oppression is a contingent part of the lived experience of obesity for many people in these ‘epidemic’ times (Monaghan, 2008). While such processes include episodes of enacted stigma and blatant hatred towards people deemed fat (a long-standing concern among female fat activists and sometimes their partners), we are also concerned about ‘civilized oppression’ (Harvey, 1999). This comprises typically subtle, even unwitting, ‘morally inappropriate forms of control’ by people in a position to exercise degrading, belittling and destructive power over others (Harvey, 1999; also, Rogge and Greenwald, 2004). This concept bears a family resemblance to what Bourdieu (2001) terms ‘symbolic violence’ – or communicated violence – in his discussions on masculine domination and education (also, Bourdieu and Passeron, 1977). In large part, this violence is often tacit and accepted in ways that obscure the pervasive operations of power in society (through misrecognition). Symbolic violence is often accepted as legitimate when it encounters and reinforces pre-existing dispositions – in this instance the everyday Western cultural fear and loathing of fatness, or fatphobia. Of course, other contributions could also be usefully drawn from to hone politicised arguments on the degradation of bodies, such as Young (1990) who discusses the various faces of oppression (e.g. economic exploitation, marginalisation, violence and cultural imperialism comprising the designation of certain bodies as abject or disgusting). Let us put this into context with some examples. In August 2008 in the United Kingdom, The Local Government Association argued that parents who allowed their children to eat ‘too much’ – that is, whose


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children were fat and assumed to have become so because of their diet – could be as guilty of neglect as those who did not feed their children at all (see Sherman, 2008, and Chapter 6 in this volume, Rich, Evans and De Pian). This conclusion speaks of pernicious stereotypes, an aspect of oppressive ‘cultural imperialism’ (Young, 1990). Such typifications fuel a logic that is underpinned by faulty premises, leading to extreme measures usually reserved for children suffering from serious physical or mental abuse. In the United Kingdom, some fat children have been placed on the at-risk register amidst stigmatising and emotionally corrosive allegations of parental abuse, though very recently social workers removed two cases from the register when scientists claimed the children’s weight was caused by a ‘newly identified genetic abnormality’ (Henderson, 2009). In the United States, Campos (2004) explores the myriad agendas that influenced the decision to remove a 3-year-old fat girl from her parent’s custody and the harm done, and explains how the court reversed the decision when the controlled diets prescribed did not result in significant weight change. One might argue that with any health issue, there are inevitably some individuals who do not benefit from particular policies and practices. However, strategies like the ones above are a salutary reminder of how current thinking on obesity powerfully shapes interventions, practices and policies in ways that may seriously and negatively impact people’s lives. For this reason, understanding how obesity debates impact on the social construction of fatness, and by extension thinness, entails more than ‘simply’ understanding a ‘health’ condition. Much of the work in this volume reiterates how people’s lives and bodily practices are shaped by these discourses. Indeed, there is a real need to think about people and their health not simply in terms of weight categorised bodies, but, rather, as ‘lived bodies’ (Williams and Bendelow, 1998) who interact, think, feel and sometimes hurt deeply. Work elsewhere in the context of health education has begun to attune more to the embodied affects of obesity discourse amidst concerns that children are ‘becoming abject targets for size discrimination’ (Rich, 2010; also, see Leahy, 2009). In line with such work, it is vitally important to recognise that bodies ‘count’ as emotional as well as material entities, comprising physiologies that may be adversely affected by past and ongoing experiences with social inequalities (Freund, 2006) and ‘biopedagogies’ that mobilise ‘affects of shame, guilt [and] disgust’ (Leahy, 2009: 181). Other literature facilitates theoretically informed research, though not in a blind way. Elsewhere, for example, Monaghan (2008) critically draws from feminisms and strands of fat activism when repudiating

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‘militarised medicine’ or medicalised discourse that is particularly bellicose and would have us wage ‘war on obesity’ for the sake of public health. Among other things, his study draws from and extends critical realist writing that is attuned to various modalities of gendered embodiment, ranging from the normative (size, shape and weight) to the visceral (physiological), pragmatic (the active body) and experiential (emotional) (also, Watson, 2000). While our empirical studies are grounded in qualitative data and concepts are often emergent, in line with an analytically inductive approach that is attuned to the messiness and contingency of the social world, other social scientists provide theoretical thinking that sensitises us to processes such as biopower, ‘bodywork’ and stigma relations and why all of this matters. For example, there is much in the sociology of the body, or embodied sociology, which provides useful theorising on bodies as the source, location and medium of society (Shilling, 2003, 2005). Among other things, Shilling (2005) offers what he terms a ‘corporeal realist’ epistemology that eschews relativistic indifference towards the social and natural worlds and provides space for critical commentary on potentially detrimental practices that may affect human potentiality. To return to Scambler’s (2006) writing, which posits generative mechanisms (such as socioeconomic structures in disorganised capitalism) that have observable effects, our attention is also drawn to the structural antecedents of stigma alongside issues of deviance, culpability, blame and shame. Among some of the salient points he raises for subsequent empirical exploration is the degree to which ‘the “aestheticisation” of the normalabnormal binary’ has added to ‘the culturally disadvantaging charge of ugliness to most types of stigma’ (Scambler, 2006: 286). Fatness, as socially constructed in late modernity (i.e. labelled ugly, corporeally polluting and unwanted), would seem to be a paradigmatic case here and one intimately connected to macro-social concerns such as entitlement to community membership, inclusion/exclusion and ultimately health (Reidpath et al., 2005). Of course, critical studies of bodyweight significantly predate the recent literature on obesity discourse and other potentially relevant writings in the social sciences. Specifically, much has already been written about the relationship between the body, gender and weight. In past decades and continuing to the present, feminist scholarship has sought to reveal the deeply gendered nature of the stigma of fatness in the West, revealing, perhaps famously in the words of Orbach (1978) that ‘fat is a feminist issue’. Although occupying different theoretical positions,


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feminists writing on the cultural preoccupation with body ideals have revealed connections between disordered relationships with the body (particularly eating disorders), the female body and broader discourses of health and beauty (see Bordo, 1993; Seid, 1989; Wolf, 1991). Whilst many of these earlier studies tended to focus primarily on what were seen as medically defined ‘eating disorders’, with such studies accepting and reiterating some core pathologising beliefs on fatness, they also challenged medical readings of the body and weight and addressed broader concerns about processes of medicalisation. Although further connections between body size, shape and the female body continue to form the focus of social critique (Murray, 2008), the recent preoccupation with bodyweight and health has prompted a collection of studies looking more broadly at the obesity epidemic and the social construction of fatness (for a review of some key writings, see Pieterman, 2007). Even special issues of journals or sections of journals are devoted to this; for example, The Sociology of Sport Journal (Vol. 25, No. 1, 2008) and, more recently, Antipode (Vol. 41, No. 5, 2009). Much of this literature critically extends, complements and sometimes questions previous ways of exploring weight issues. Recent research seeks to understand relationships between the social construction of fatness and the female body, but also the implications for a broader range of subjectivities related to class, ethnicity and multiple femininities and masculinities. The social meanings of thinness are also considered insofar as they are held in contradistinction to the discredited obese body. When debating obesity we thus remain concerned, as others have, that ‘the promotion of thinness as healthy can be an equally powerful but negative force because it is sanctioned by medicine and has moral overtones’ (Burns and Garvey, 2004: 561). We would stress here that fatness, thinness, normality and deviance are interconnected and blurred in the world as lived and experienced, similar to other binaries such as mind/body, nature/culture, public/private and biology/society (Williams and Bendelow, 1998). Critical weight studies have begun to reveal how current obesity discourse negatively impacts people’s understanding of their own and other people’s health and bodies, and consequently how it shapes and constrains ‘body management practices’ (Riley et al., 2008). Various authors reveal a strong connection between obesity discourse and disordered eating, dieting and body modification (see Beausoleil, 2009; Burns and Garvey, 2004; Evans et al., 2008; Rich et al., 2004). In cultures where the slim body has become a marker of morality, distinction

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and female beauty, obesity discourse plays no small role in contributing to ‘normative discontent’ and risky weight management practices. What is made clear in this literature is that gendered/gendering messages associated with weight-loss have been perniciously promoted via obesity discourse across various social sites, such that it is difficult to escape the idea that thinness or leanness is intrinsically healthy. The problems with this idea become clear given the steps people may take to maintain or achieve such bodily capital, such as smoking and obsessive relationships with food and exercise. Critical weight studies usefully draw attention to how obesity discourse comes to be recontextualised through policy, media and other institutions and has a consequence on the ways people not only understand their bodies, and other people’s bodies, but how they actively relate to them and shape them. Research has begun to document the expression of obesity discourse within health policy and the school curriculum, including potentially damaging consequences for young people’s (especially girls’ and young women’s) body images and developing sense of self (e.g. Beckett, 2004; Burrows and Wright, 2004; Evans et al., 2008; Leahy, 2009), and how school teachers, GPs and other health practitioners construct and interpret these various definitions. Evans et al. (2008: 17) describe this as a ‘body pedagogy’ associated with an obesity epidemic or ‘any conscious activity taken by one person, organization, or a State, designed to enhance an individual’s understanding of their own and/or others’ corporeality’. This body pedagogy provides social and discursive tools through which individuals and populations come to monitor and survey their own and other bodies, and take action to reduce their own and other people’s bodyweight. Evans et al. (2008) make clear that obesity has become an instructional discourse, such that it has become an increasingly difficult task to address the issue of eating disorders within this terrain (also, Beausoleil, 2009). We would add that addressing the unhealthy ‘costs’ of achieving weight-loss (Burns and Gavey, 2004), body image concerns or the growing problem of eating disorders in young people (Neumark-Sztainer, 2005; Yager and O’Dea, 2005) has become an incredibly difficult charge. Indeed, health practitioners, teachers and parents are left with the unenviable task of having to negotiate and reconcile the different and often contradictory meanings about the body and health (Cliff and Wright, 2010). How, then, might we meaningfully intervene and ethically enhance critical awareness of alternative conceptualisations of bodyweight, health and the relationships between them? These and other issues also emerge in this collection.


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Chapter outline We have sought to cover sufficient ground in this introduction to enable readers to more fully appreciate those critical perspectives advanced by other contributors to Debating Obesity. Following our critique of medicalised discourses on health and individual lifestyles, Chapter 2, by Paul Campos, asks ‘Does Fat Kill?’ Here Campos critically engages the medical and epidemiological evidence that seemingly legitimate obesity discourse. Extending his previous work, notably The Obesity Myth (Campos, 2004) and a point–counterpoint debate in the International Journal of Epidemiology (Campos et al., 2006a, 2006b), Campos maintains that claims about an obesity crisis are strongly influenced by cultural and economic factors that have nothing to do with the actual medical evidence. To this end, he maintains that the health narrative is not built from neutral biomedical facts, but is imbued with cultural meanings and values that are highly contestable. They are also consequential, potentially framing how people relate to themselves and others. Such concerns are taken up empirically in the next two chapters from, respectively, sociologists and feminist social psychologists. Bringing men’s embodied experiences into the debate, Chapter 3, by Lee Monaghan and Michael Hardey, offers an ideal typical framework for exploring ‘bodily sensibilities’ comprising vocabularies of the discredited male body. Such vocabularies, which reproduce a dominant Western cultural aesthetic that discredits fatness and potentially spoils identities, include vulgarised idioms such as ‘fat bastard’ and ‘obesity’ – labels used in diverse contexts, ranging, respectively, from the pub and street to the clinic and public health. Empirically, the authors use qualitative data (mainly ethnographic observations) to explore the significance of language, meaning and interactions in the construction and management of men’s embodied identities thus further redressing the gender bias in social scientific literature. The role of obesity discourse in reproducing and amplifying everyday prejudices is also critiqued. Prejudiced sensibilities are contrasted with a ‘wise’ (Goffman, 1968) approach, a term applied by the authors to, for example, various critical weight scholars and health professionals who challenge stigmatising obesity discourse. Chapter 4, by Irmgard Tischner and Helen Malson, also furthers a gendered engagement with obesity discourse as part of a Foucauldian analysis. Empirically, they use focus group and interview data which largely comprise women’s talk about appearance, appetite, food and

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the gendered dynamic around control/containment and embodied subjectivity. Contributing to discursive psychology and poststructuralist theory on the management, negotiation and gendered politics of femininity, they reveal the fluidity, ambiguity, multiplicity and inter-changeability of women’s subject positions. This, they stress, is within the current obesity terrain wherein ‘the war on obesity’ compounds streamlined definitions of ‘normative femininity’, consolidating women’s fatness as both a public issue and private trouble. Interestingly, they also highlight how larger women in their study sometimes reframed fatness in more positive ways albeit under constraints and at the risk of negating their femininity. The ethical implications of obesity discourse for children are discussed in the next two chapters. This is important given the centrality of childhood, understood as a critical period in the lifecourse, to the social construction of the crisis in space and time. Chapter 5, by Bethan Evans and Rachel Colls, critically explores the implications of ‘collapsing time’ between childhood and adulthood as part of current medicalised and government concerns to defuse the ‘obesity time bomb’. They consider how recent UK policy interventions to monitor schoolchildren’s BMI are justified through pre-emptive logic that allows the dismissal of potential harm to children’s current well-being through a focus on future adult health. Their chapter draws from various disciplines, though it is particularly indebted to geography (specifically children’s geographies, post-medical geographies and the geography of embodiment). Among other things, their work furthers debate by challenging the idea, common in geography, that ‘bodies are merely dots on maps’ to be subjected to spatial analysis in the service of highly problematic (anti-)obesity policy. Of course, schools and associated policies are only part of the broader range of contexts that monitor children’s bodies and their embodied practices. Again, taking childhood and ethics seriously, in Chapter 6 Emma Rich, John Evans and Laura De Pian introduce the concept of the ‘surveillant obesity assemblage’, which encompasses these other sites (e.g. the clinic, family home, cyberspace). Drawing from sociological research (which is UK-based and has been co-ordinated with parallel studies in Australia and New Zealand), Rich and colleagues suggest that obesity surveillance is powerfully constituted by a series of agencies, individuals and technological mediums that are provisionally linked together as an assemblage. This not only reveals the pervasiveness of obesity discourse but also implores us to reconsider issues of agency and resistance as multi-directional in diverse settings. In seeking to develop


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the obesity debate, rather than offer definitive conclusions, their chapter engages ‘broader questions concerning the theorisation of surveillance and resistance’. Following our earlier references to fat activism, Chapter 7, by Charlotte Cooper, charts successive waves of the fat lib movement on both sides of the Atlantic over the past four decades. Her chapter reports on a hitherto largely uncharted movement comprising women who identify as fat, and sometimes their partners who have helped develop fat activist communities such as the National Association to Advance Fat Acceptance (NAAFA). Importantly, Cooper, who is personally committed to fat activism, reveals how strands of fat lib politicise the lived/gendered realities of fatness through various forms of resistance in actual and virtual space. Although not necessarily unified in approach, she shows how collectively fat activism demands a reframing of fat in ways that counter dominant obesity discourse. In so doing, she also provides a powerful template for, among others, health professionals seeking to resist the weight-centred paradigm and develop more humanistic approaches to health. Lucy Aphramor and Jacqui Gingras, in Chapter 8, take this up with reference to dietetics. They recontextualise modes of resistance in formal health care, beginning with their rejection of the term ‘obesity’. Dissatisfied with the current uncritical uptake of obesity claims within health professions, the authors’ pragmatic use of theory presents a compelling case for a radical rethink in line with promoting ethical and evidence-based practice. Having established the need for change, they engage with concerns reiterated elsewhere in this book by exploring the systems and practices that make change difficult for individuals and professions. Throughout their chapter we repeatedly witness the real life limits of exercising ‘personal choice’, both in the difficulty of acting without constraint and the curtailed, though not redundant, implications of individual action on transforming broader defining structures. As indicated, our concern as editors is not only to expand debate but also to do so in a reflexive manner that considers how the debate might be understood and proceed in the future. This concern includes discussing how critical weight studies might be interpreted, and perhaps even misrecognised, by others. Our editorial reflections in Chapter 9, besides summarising and concluding this collection, are intended to anticipate and respond to some of the challenges that critical weight studies encounter. Here we discuss some of the more pertinent issues, troubles and themes that have emerged during our own work when

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seeking to expand the obesity debate and further the development of a credible alternative perspective. For example, we underscore what we see and have always seen as the relevance of health professionals plus the centrality of social justice. Finally, after reflecting on the need to complicate critique and counter misrecognition we highlight some possible future agendas.

Notes 1. Ours is a Western cultural landscape, and our generalisations about people’s understandings of their bodies, and about dominant takes on fatness and obesity are not intended to universalise this particular perspective, but to speak of (parts of), and to, a temporally and culturally situated perspective. 2. Some refer to this emergent area as Critical Obesity Research, while others use the term ‘Fat Studies’. This variance in labels is understandable given the diversity of perspectives and contributors furthering critical thinking on obesity or fatness. We are not prescriptive, but we prefer ‘critical weight studies’ when challenging obesity discourse because: ‘a) the social construction of an obesity epidemic depends on the idea of weight (as a proxy for fatness), b) while biomedical words, such as obesity, are a necessary part of our empirical research we seek to distance our critical analytical approach from pathologising labels that medicalise fatness, c) like obesity, fat is often offensive to people in everyday life (people who might be participants in our ethically informed studies) and d) we are not simply concerned with “the fat body” but rather heterogeneous bodies that do not necessarily fit or place themselves on a fat/thin dichotomy or continuum despite being medically categorised as overweight, obese or even morbidly obese’ (Monaghan et al., 2010: 40). A caveat, when using this label, is that our critique is not simply negated if ‘obesity epidemic entrepreneurs’ use other body measurements when ‘diagnosing’ bodies (e.g. waist to hip ratio). We would respond that our critical attention is directed at discourses which pathologise human bodies that are typically deemed ‘too heavy’ by medicine yet such designations also incorporate other normative dimensions which are often the target of ‘health’ interventions and everyday ‘concern’, such as: body composition, fat distribution, overall size, shape and so forth. The degradation of fatness runs through much of this and so our work has an obvious affinity with Fat Studies, which we consider different from, but related to, critical weight studies because of an overt activist element. As Tomrley and Kaloski Naylor (2009: 12) argue the term ‘fat studies’ ‘has moved beyond any academic discipline [ . . . ] the concerns, politics and intentions span academic and non academic spheres’. They go on to suggest that fat studies ‘as an academic category – overlaps with any non-academic activism, expression or argument’. 3. Epidemiology examines causality as a result of complex interactions and factors – a multi-causal model – to examine a population and individual risk of developing particular diseases such as obesity (see Pearce, 1996). Typically, this is undertaken through the collection of population health and demographic data.


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——— (2005) The Body in Technology, Culture and Society. London: Sage. Smith, S. (1990) Sizism: One of the Last ‘Safe’ Prejudices. The California Now Activist. Online. www.naafa.org/press_room/sizism.html, accessed 6 December 2006. Sobal, J. (1995) The Medicalization and Demedicalization of Obesity. In D. Maurer and J. Sobal (eds) Eating Agendas: Food and Nutrition as Social Problems. New York: Aldine De Gruyter, pp. 67–90. Spoel, P. (2006) Midwifery, Consumerism, and the Ethics of Informed Choice. In P.L. Twohig and V. Kalitzkus (eds) Bordering Biomedicine: Interdisciplinary Perspectives on Health, Illness, and Disease. Amsterdam: Rodopi Publications, pp. 197–214. Throsby, K. (2007) Happy Re-Birthday: Weight Loss Surgery and the ‘New Me’. Body & Society 14 (1): 117–133. Tomrley, C. and Kaloski Naylor, A. (eds) (2009) Fat Studies in the UK. York: Raw Nerve. UK Parliament (2004) House of Commons Health Committee: Obesity. Third Report of Session 2003–2004, volume 1. Ordered by The House of Commons, 10 May 2004. Online. www.publications.parliament.uk/pa/cm200304/ cmselect/cmhealth/23/2302.htm, accessed 8 September 2004. USDHHS (US Department of Health and Human Services) (1996) Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention. ——— (2001) The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Washington, DC: Government Printing Office. Vaz, P. and Bruno, F. (2003) Types of Self-Surveillance: From Abnormality to Individuals ‘At Risk’. Surveillance and Society 1: 272–291. WHO (World Health Organization) (1998) Obesity: Preventing and Managing the Global Epidemic. Geneva: World Health Organization. Walkerdine, V. (2009) Biopedagogies and Beyond. In J. Wright and V. Harwood (eds) Biopolitics and the ‘Obesity Epidemic’: Governing Bodies. New York: Routledge, pp. 199–207. Warin, M., Turner, K., Moore, V. and Davies, M. (2007) Bodies, Mothers and Identities: Rethinking Obesity and the BMI. Sociology of Health & Illness 30 (1): 97–111. Watson, J. (2000) Male Bodies: Health, Culture and Identity. Buckingham: Open University Press. Wilkinson, R. and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Nearly Always Do Better. London: Allen Lane. Williams, S.J. (2003) Beyond Meaning, Discourse and the Empirical World: Critical Realist Reflections on Health. Social Theory & Health 1: 42–71. Williams, S.J. and Bendelow, G. (1998) The Lived Body: Sociological Themes, Embodied Issues. London: Routledge. Williams, S.J., Birke, L. and Bendelow, G. (eds) (2003) Debating Biology: Sociological Reflections on Health, Medicine and Society. London: Routledge. Wolf, N. (1991) The Beauty Myth. New York: Doubleday. Wright, J. and Harwood, V. (2009) Biopolitics and the ‘Obesity Epidemic’: Governing Bodies. New York and Abingdon: Routledge.


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Yager, Z. and O’Dea, J. (2005) The Role of Teachers and Other Educators in the Prevention of Eating Disorders and Child Obesity: What are the Issues? Eating Disorders 13: 261–278. Young, M.I. (1990) Justice and the Politics of Difference. Princeton, NJ: Princeton University Press. Zylinska, J. (2009) Bioethics in the Age of New Media. London: MIT Press.

2 Does Fat Kill? A Critique of the Epidemiological Evidence Paul Campos

The current war on fat is proceeding on the basis of several (usually unstated) assumptions. In particular, the recent explosion of public health interventions across North America, Europe and Asia that address the so-called obesity epidemic are based on the following beliefs, which in turn form the basis of the recent spate of warnings issued by obesity researchers and the public health establishment – warnings which have been repeated countless times in the mass media all across the world: (1) A strong correlation exists between weight and health risk. (2) This correlation reflects a direct causal relationship. People within the narrow range of ‘ideal’ weight are healthier than people who are not, because they avoid the detrimental causal effects of overweight and obesity. (3) Significant long-term weight-loss is a practical goal, and will improve health. (4) The cost–benefit ratio involved in trying to make people thinner justifies using scarce public health funding to pursue this outcome.1 Note that all four of these assertions must be true in order to justify the public health establishment’s war on ‘overweight’ and ‘obesity’. Obviously if the correlation between weight and health turns out to be weak, then making weight a focus of public health policy is unwarranted. Yet even if the correlation is strong, making fat a major public health issue makes sense only if higher than average weight is an actual cause of illhealth, rather than merely a marker for other risk factors. Otherwise, the attempt to produce weight-loss will involve the treatment of a symptom rather than a cause. Still, even if both these conditions are met, making weight-loss a subject of public health remediation will be advisable 36

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only if there is some reliable and relatively safe way of producing that result. Finally, even if all the foregoing can be shown to be the case, spending public health resources on making people thinner, or keeping them thin, is justified only if the relative cost–benefit ratio of doing so is sufficiently positive that it justifies spending scarce resources on such interventions, rather than on other pressing public health needs that will as a consequence remain relatively under-funded (consider that, for example, in the United States (US) context, approximately 46 million Americans have no health insurance of any kind) (US Census Bureau Report, 2004). In fact, the evidence for all four of these propositions is weak to nonexistent. The current ‘fat panic’ (Saguy and Almeling, 2005), and the outburst of public health activity it has inspired, has very little to do with science, and everything to do with the economic and professional interests of obesity researchers, eating disordered thinking and anxieties about class, race and social over-consumption in general. But before we can evaluate the real sources of the moral panic over fat, we need to consider the scientific claims that help fuel it. (1)

A strong correlation exists between weight and health risk.

The validity of this claim depends on the body mass level that is being referenced. In regard to so-called ‘overweight’ (BMI 25–29.9) the claim is completely false; in regard to obesity it is mostly false (on the other hand in reference to underweight, that is, a BMI of less than 18.5, it is clearly true) (Campos, 2004: 10–13). Before turning to the epidemiology of so-called ‘overweight’ and ‘obesity’, we should recognise that the obesity epidemic itself is a statistical artefact of the decision to define overweight and obesity at such low weight levels that even a small increase in average weight in the population will produce tens of millions of newly overweight and obese individuals. When people hear the word ‘obesity’ they tend to conjure up images of enormously fat individuals for whom even basic mobility is compromised. But the vast majority of people who our public health authorities claim weigh too much weigh no more, or only a little more, than the average person in modern Western societies. Biologist Jeffery Friedman offers a useful analogy: Imagine that the average I.Q. was 100 and that five percent of the population had an I.Q. of 140 and were considered to be geniuses. Now let’s say that education improves and the average I.Q. increases

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to 107 and ten percent of the population has an I.Q. of above 140. You could present the data in two ways. You could say that average I.Q. is up seven points or you could say that because of improved education the number of geniuses has doubled. The whole obesity debate is equivalent to drawing conclusions about national education programs by saying that the number of geniuses has doubled. (Cited in Campos et al., 2006: 55) Also, to properly interpret the meaning of the statistical associations between weight and health, we should keep in mind how observational medical studies work. Epidemiologists follow a group of subjects for a certain time, and note what changes occur in the health of the subject population over the course of the study. These studies are observational rather than clinical in that they do not attempt to determine directly the effects of various risk factors on health. Instead, they observe what correlations appear among the study’s subjects in terms of relative risk for dying or developing particular diseases. For example, consider a study that follows 2000 middle-aged people for 15 years, half of whom had the government approved BMI of 18.5–24.9 at their time of entry into the study, and half of whom were obese, that is, they had a BMI of 30 or higher. Suppose that, at the end of the study, 10 out of 1000 people in the former group have died of cardiovascular disease, compared to 15 out of 1000 in the latter group. The relative risk ratio observed between obesity and death from cardiovascular disease in this study would then be 1.50, in that obese people had a relative risk of cardiovascular death that was 50 per cent higher than the referent group made up of supposedly ideal weight subjects. A 50 per cent increase in risk sounds like a lot, but in this (characteristic) example that increased risk consists of one extra death among 200 people over a 15-year time span. And note that such an observation falls far short of proving that this increased risk was caused by the associated characteristic: it merely notes the association. Epidemiologists are usually careful to point out that it is very difficult to draw causal inferences from mere associations, unless those associations are extremely powerful (for example, heavy smokers are 30 times more likely to die of lung cancer than non-smokers) and/or the study controls rigorously for large numbers of potentially confounding variables. (Perhaps the obese subjects in the study above had a higher rate of cardiovascular death because they were on average poorer or more sedentary or had higher rates of dieting and the resultant weight-cycling or were more likely to use diet drugs or were

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discriminated against by health care providers or for some combination of these and other reasons.) With these caveats in mind, let us look at the association between mortality risk and weight. Perhaps the most careful and methodologically rigorous observational study published to date in regard to the association between weight and mortality risk in the American populace appeared in the Journal of the American Medical Association in March of 2005 (Flegal et al., 2005). The authors used three nationally representative cohorts of US adults, who had been followed between 1970 and 1998. Flegal and her colleagues used the government’s 18.5–24.9 normal or ‘ideal’ weight category as their baseline referent group, and compared the relative risk of premature mortality in this group to that of people defined as ‘underweight’ (35 BMI). The authors found that, in the United States as a whole, the lowest mortality risk was in the overweight category. They calculated that, in comparison to people in the overweight category, Americans in the ‘normal weight’ category suffered approximately 86,000 excess deaths per year. In comparison to the normal weight category, people in the moderately obese and very obese categories suffered approximately 112,000 excess deaths per year, with the great majority (82,000) of these excess deaths taking place among the very obese. And, in comparison to the normal weight category, underweight people suffered approximately 34,000 deaths per year (in their analysis, the authors controlled for smoking and pre-existing disease, in anticipation of the common claim that the high mortality rates seen among the underweight are products of smoking and reverse causation, that is, the idea that such people are thin because they are sick rather than vice versa). Consider what these numbers mean. First, Flegal et al.’s (2005) analysis indicates that more Americans who are not overweight or obese die prematurely every year than Americans who are overweight and obese, even though there are more Americans in the latter category than in the former. Second, the risk of premature death associated with obesity was negligible or non-existent until one reached a BMI of 35 (indeed in the study’s most recent data, the relative risk of premature death among the moderately obese – BMI 30–34.9 – was less than 1.00, meaning that it was lower in this group than it was among so-called ‘normal weight’ people). Only 6 per cent of the study’s subjects had a BMI of 35 or higher, indicating that the US government’s claim that approximately 60 per cent of the populace is at increased risk for premature mortality because of their weight is exaggerated by a factor of at least ten. And this

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remains true even if one makes the absurd assumption that 100 per cent of the premature deaths associated with obesity were actually caused by obesity. Third, the risks associated with underweight were very high. Only 2.7 per cent of the study’s subjects were underweight, meaning that the 34,000 annual premature deaths among such persons represents a relative risk that was, in most of the study’s cohorts, actually higher than that found among the very obese (>35 BMI). To put these figures into concrete terms, the authors found that the risk of premature death was higher among women who look like Kate Moss (BMI 15.7) or Gwyneth Paltrow (BMI 16.1) than the combined premature death risk found among average-height (5’4”) women at all weight levels above 203 pounds.2 Fourth, the authors’ data illustrate why the official ‘overweight’ category used by public health agencies around the world is nonsensical: if a certain weight level is associated with the lowest risk of premature death, what does it mean to label such people ‘overweight’? Indeed, if the authors had used only the top third of the so-called ‘normal’ weight category (23.0–24.9 BMI) as their referent group, this would have produced a total of 82,000 annual premature deaths among the newly defined ‘underweight’ (BMI < 23) (Campos et al., 2006). Although Flegal et al.’s (2005) study caused something of a media furore, the only unusual feature of their results was that the media actually paid attention to the fact that a large-scale study had found that there was no risk of excess death associated with ‘overweight’ (quite the contrary), that there was little risk of excess death associated with obesity until one reached extremely high weight levels and that there was a high risk of premature death associated with weight levels just a few pounds below the government’s ‘recommended’ ideal weight (Hellmich, 2005). Far from being unusual, these results are very much in line with what large-scale observational studies of the relationship between weight and mortality risk generally find. For example, the National Health and Nutrition Examination Survey (NHANES) – an ongoing large-scale survey that reflects the composition of the American population as a whole (Durazo-Arvizu et al., 1998) – found essentially the same thing as Flegal et al.’s (2005) study, which employed an updated version of the same data: a very shallow U-shaped curve describing the relationship between BMI and mortality. Significantly increased mortality was only associated with either extreme of BMI: the underweight and the very obese. For the more than 90 per cent of the population outside these extremes, body mass had no significant relationship with increased mortality risk. As the authors noted, ‘the resulting empirical findings from each of four race/sex groups,

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which are representative of the U.S. population, demonstrate a wide range of BMIs consistent with minimum mortality and do not suggest that the optimal BMI is at the lower end of the distribution for any subgroup’. Another compelling illustration of this point is provided by a study undertaken by scientists at the National Center for Health Statistics and Cornell University (Troiano et al., 1996). This study is particularly suggestive because it involved a meta-analysis of dozens of previous studies, involving a total of more than 600,000 subjects with up to a 30-year follow-up, making it, in the words of one scientist, ‘one of the most comprehensive analyses of the relationship between mortality and body weight published to date’ (Gaesser, 2002: 97). This meta-analysis found that among non-smoking white men the lowest mortality rate was found between a BMI of 23 and 29 – a weight range that overlaps with almost all of the government’s definition of ‘overweight’, and which is higher than two-thirds of the government’s recommended weight range. The mortality rate for white men in the supposedly ‘ideal’ weight range of BMI 19–21 was the same as that for those with a BMI of 29–31, most of whom would be categorised as obese. The researchers were sufficiently struck by this to point out that since their analysis of existing studies had found ‘increased mortality at moderately low BMI for white men comparable to that found at extreme overweight, which does not appear to be due to smoking or existing disease’, it followed that ‘attention to the health risks of underweight is needed, and body weight recommendations for optimum longevity need to be considered in light of these risks’ (Gaesser, 2002: 98). The results for non-smoking white women were even more striking: for such women, the authors found that the BMI range correlating with the lowest mortality risk was extremely broad, from around 18–32, meaning a woman of average height could weigh anywhere within an 80-pound weight range without seeing any statistically significant change in her risk for premature death. Dozens of other studies illustrate the same basic point: for the vast majority of people, including the vast majority of people whom public health authorities around the world currently classify as weighing ‘too much’, body mass has little or no association with mortality risk. Given our cultural hysteria about weight, it is important to emphasise that studies such as Flegal et al.’s (2005) do not demonstrate that the ‘overweight’ range is really optimal, and that the current official ideal weight range is really underweight. What such studies show is that tiny variations in relative risk can generate impressive-sounding numbers of premature deaths when applied to very large populations. In some of

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these studies, such as the above, there is a slightly increased risk associated with the so-called ‘normal’ weight range. In others, there is a slightly increased risk associated with the so-called ‘overweight’ range. But the fundamental point is that large-scale studies of the issue feature no socially meaningful variation in mortality risk across a very broad range of weights.3 Yet if the relative risks in Flegal et al.’s (2005) study had been reversed, and ‘overweight’ rather than ‘normal weight’ had been associated with 86,000 excess deaths, we can be confident this would have been presented by many obesity researchers and public health authorities as definitive proof that even being slightly ‘overweight’ is supposedly deadly. Indeed, they have often exploited such trivial variations in relative risk for just this purpose (see, Campos, 2004: 14–17). (2) The correlation between weight and health risk reflects a direct causal relationship. People within the narrow range of ‘ideal’ weight are healthier than people who are not, because they avoid the detrimental causal effects of overweight and obesity. As we have seen, the relationship between weight and mortality risk is, except at statistical extremes, weak or non-existent. While mortality risk is not identical to health risk in general, it is a good proxy for it. (It is true that the heavier than average are at significantly increased risk for some diseases, most notably type 2 diabetes and osteoarthritis, but it is also true that they are at significantly decreased risk for others, including lung cancer, osteoporosis and most of the major respiratory ailments (Campos, 2004; Gaesser, 2002).) But the more fundamental point is that the correlations between increased overall health risk and higher than average weight, weak as they generally are, do not in themselves demonstrate a causal relationship. Before we conclude that epidemiological associations signal such a relationship, we must consider confounding variables that might explain some, most or all of the associated risk between a particular level of body mass and an increased risk of mortality and morbidity, as well as the extent to which nonobservational clinical work has produced a causal explanation for the observed association.4 Although it is almost impossible to discover the fact if one relies on quotations from obesity researchers in the mass media, very little evidence has emerged regarding the question of how exactly either higher than average weight or high percentages of body fat are supposed to cause disease.5 With the exception of osteoarthritis, where increased

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body mass contributes to wear on joints, and a few cancers where oestrogen originating in fat tissue may contribute, causal links between body fat and disease remain hypothetical (Anderson et al., 1996; Hochberg et al., 1995). This is all the more problematic when one considers the host of confounding variables that may account for some or all of whatever increased health risk is observed among the very obese. Factors that may account for associations between high levels of obesity and increased health risk include sedentary lifestyle, poor nutrition, lower socio-economic status, discrimination in the provision of health care, social discrimination generally, weight-loss cycling brought on by chronic dieting and diet drug use, as well as a host of other, largely unmeasured, variables. When one or more of these variables are controlled for in a rigorous fashion, the already weak association between higher body mass and increased mortality and morbidity tends to be greatly attenuated or disappear altogether (Campos, 2004: 25–38). For example, one of the most commonly cited collections of data for the proposition that obesity is a serious health risk comes from the wellknown Framingham study (this is a group of several thousand residents of Framingham, Massachusetts, that have been followed by epidemiologists for more than 50 years). Yet all of the excess mortality associated with obesity in the Framingham cohort can be accounted for by the impact of weight cycling, which is to say by the adverse health impact of dieting. (Almost all dieters weight cycle, and most people who weight cycle are dieters). Obese Framingham residents with stable body weights are not at increased risk (Lissner et al., 1991; also, see Diaz et al., 2005). Indeed, numerous studies suggest that weight cycling increases mortality risk, which is tantamount to saying that the weight-loss industry may to a significant extent be causing the health risks that it claims to be ameliorating (Brownell and Rodin, 1994; Hamm et al., 1989; Iribarren et al., 1995; Lissner et al., 1989). Many common weight-loss treatments generate particularly problematic confounding variables. For example, over-the-counter diet pills used by millions, including phenylpropanoloamine and herbal ephedra, have been linked to heart attack and strokes and recently banned in the United States. In one study, the adjusted odds ratio for stroke in women taking phenylpropanolamine for weight-loss was 16.6 (Kernan et al., 2000), many times higher than the relative risk for stroke associated with a BMI over 30, which in one typical study was 1.29 (indeed, this level of increased risk was not statistically significant) (Walker et al., 1996). And the higher a person’s BMI, the more likely they are to use these and other hazardous weight-loss methods.

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One study found that 22 per cent of weight-loss clinic clients surveyed used phenylpropanoloamine for weight-loss. If only one in 13 obese persons were exposed to over-the-counter diet pills containing phenylpropanolamine, then all of the excess risk associated with obesity could be accounted for by increased diet pill use. No epidemiological study to date has assessed relative mortality risks after taking the known hazards of stimulant diet pills into account (Campos et al., 2006). Aerobic fitness and the activity levels that promote it appear to have a much more profound effect on health than body mass. Steven Blair, who is widely recognised as the world’s leading authority on the relationship between fitness, health risk and weight, has published numerous studies indicating that obese people who maintain a quite moderate level of aerobic and cardiovascular fitness – the sort of fitness level that most people can maintain by the physical activity equivalent to 30 minutes of brisk walking per day – have a far lower mortality rate than thin unfit people and the same mortality rate as thin fit people (Barlow et al., 1995; Blair et al., 1989; Lee et al., 1999; Farrell et al., 2002). This level of fitness among obese people is not, as is often claimed, rare. For example, in Blair’s Aerobics Center Longitudinal Study, which is the oldest and most comprehensive data pool measuring the effects of fitness on health, half of the subjects with a BMI of 30 have been found to be fit, while one-third of those with a BMI of 35 maintain aerobic fitness. Other researchers have obtained similar results. Indeed, the Harvard Alumni Study has found the lowest mortality rates in men who have gained the most weight since college, while also expending at least 2000 calories per week in vigorous physical activities (Paffenbarger et al., 1986). The Behavioral Risk Factor Surveillance System, a large-scale study from the 1990s, found that a lack of physical activity was a much better predictor of cardiovascular disease mortality than BMI (Hahn et al., 1998). And a 2002 study of nearly 10,000 Puerto Rican men found that even modest amounts of physical activity had profound health benefits for men across all weight ranges. This study found that ‘the likelihood of premature death among men who were obese (BMI > 30) did not reach statistical significance, especially after adjusting for other risk factors’, such as sedentary lifestyle (Crespo et al., 2002). A particularly striking illustration of the severe health risks associated with sedentary lifestyle is provided by a 30-year University of Texas study, in which five undergraduate men remained in bed for 20 days, and then had their vital statistics measured. Thirty years later, after participating in a 6-month exercise program, the men were tested again. The results: the five men had better aerobic capacity and cardiovascular

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fitness at age 50 than they had displayed after the 20 days spent in bed as undergraduates. In other words, 20 days of complete inactivity seems to have been worse for their health than 30 years of aging (Winslow, 2002). And while it is true that the fatter a person, the less likely he or she is to be fit, focusing on fatness rather than fitness seems perverse, given that unfit fat people may get fit often without losing weight (by becoming moderately physically active), while, as we shall see, making fat people thin is a different story. Type 2 diabetes provides a particularly compelling example of why it is important to consider confounding variables, rather than merely assuming that fat is the cause of disease, and that therefore producing weight-loss is the appropriate ‘cure’. Unlike most diseases that are blamed on fatness, there actually is a strong correlation between type 2 diabetes and increasing weight. Type 2 diabetes arises among people who become insulin resistant. Insulin transports glucose in the blood to cells. When people become insulin resistant their bodies absorb less glucose, and their pancreases have to produce more insulin. This eventually can lead to a systemic breakdown that produces type 2 diabetes. Research has demonstrated that as much as half of a person’s risk for developing insulin resistance is purely genetic. This ‘thrifty gene hypothesis’, which has been confirmed by molecular genetics, holds that mutations favouring fat storage and the ability to survive famines also confer a significantly increased risk of developing diabetes. Thus, obesity may be an early symptom of diabetes rather than an underlying cause (Neel et al., 1998). More important, intervention studies that attempt to lessen the risk for developing diabetes among the obese appear to offer consistent results: if sedentary people become moderately physically active and eat a lower-fat, lower-sugar diet, they greatly decrease their odds of developing diabetes, even though these interventions typically produce little or no weight-loss. This suggests strongly that, along with genetic predisposition, lifestyle factors, rather than weight, are the key variables in both the development and prevention of type 2 diabetes (Diabetes Prevention Program Research Group, 2002; Lamarche et al., 1992; Tuomilehto et al., 2001). Of course, more sociologically informed studies should also be mentioned here given the degree to which lifestyles are indebted to social structures (e.g. socio-economic status and ethnicity), which appear to be more significant for health than diet or physical (in)activity (see Chapter 1 in this volume). Following the latter point, it is worth recognising that in the United States obese people are far more likely to be poor and members of ethnic

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minority groups than thin people (Mokdad et al., 2003).6 They are thus subject to multiple forms of social discrimination, both from the medical system in particular and society in general. Such discrimination has been shown to have a profound effect on health – indeed, something as relatively straightforward as not having health insurance is a vastly more powerful predictor of risk than body mass – yet epidemiological studies that both attempt to measure the effects of weight on health and control for socio-economic status are rare (Campos et al., 2006). This is yet another compelling reason to be sceptical about the causal significance of those associations that do exist between obesity and increased health risk. In sum, the weak association between body mass and health tends to disappear altogether when factors other than weight are taken into account. Fat active people are healthier than thin sedentary ones, and just as healthy as thin active persons. Dieting, diet drugs, poverty and social discrimination all have profound effects on health risk, and all disproportionately affect the heavier than average. Under such circumstances, trying to make fat people healthier by making them thinner can be analogised to trying to prevent lung cancer by whitening the teeth of smokers. (3) Significant long-term weight loss is a practical goal, and will improve health. In fact, the current demonisation of fat is even more misguided than all the foregoing suggests. Although a program to prevent lung cancer by whitening teeth is nonsensical on its face, it is true that we know how to whiten teeth. What we do not know how to do is how to make fat people thin. This statement is in one sense shocking, even though there are few better-established empirical propositions in the entire field of medicine. Yet the empirically absurd assertion that all, or almost all, people in developed nations could have a BMI of between 18.5 and 24.9 if they tried hard enough is repeated over and over again by researchers and public health authorities, in the face of overwhelming evidence to the contrary.7 It is an apparently unshakeable bit of folk wisdom masquerading as science that, if people simply undertake a regimen of attempting to eat less and exercise more, they will lose significant amounts of weight and keep it off permanently. For most of the past century, medical and public health authorities have been telling people that they can become ‘ideally’ thin by restricting caloric intake and increasing activity levels. Hundreds of millions around the world

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have attempted to follow this advice – and we see the result. As was pointed out nearly 25 years ago by William Bennett and Joel Gurin (1982: 283), ‘the standard “sensible” recommendations to change eating habits and diligently use caloric charts are no more than elaborate folklore, expressions of faith in a world that ought to exist, but in fact does not’. Indeed, if the public health establishment’s advice on this issue was sound, there would be almost no fat people (for example, the US government’s own statistics indicate that around 90 per cent of all obese people diet regularly. In other words, almost all fat Americans are undertaking the cure that obesity researchers and the weight-loss industry have provided for their ‘disease’) (Serdula et al., 1999). The vast majority of people who attempt to lose weight eventually regain all the weight they lost. A significant percentage of them gain back more than they lost: at least a third of such people who have been followed for at least 5 years (Campos, 2004; Garner and Wooley, 1991; Korkeila et al., 1999). Ironically, this suggests that a significant portion of the weight gain observed in the American population, and elsewhere, over the course of the past century is attributable to dieting. Another ironic consequence of the almost complete failure to find effective ‘weapons’ of ‘body mass destruction’ is the remarkable fact that the central premise of the war on fat – that turning so-called overweight and obese people into so-called normal weight individuals will improve their health – remains an untested hypothesis. We simply do not know if significant long-term weight-loss is medically beneficial, because no one has ever been able to produce this result in statistically significant groups of people. It is true that various studies indicate improved health is associated with small amounts of weight-loss, and obesity researchers seize on this fact when they claim that it is beneficial for overweight and obese people to lose even 5 per cent or 10 per cent of their body mass. Yet note that this outcome has been observed only in contexts in which subjects undertake lifestyle changes – specifically, increased activity levels and improved nutrition – that have been shown to have striking health benefits completely independent of whether or not such changes produce any weight-loss. It is particularly striking that intervention studies that find associations between improved health and weight-loss generally record no dose response: in other words, people who lose small amounts of weight, or even gain weight, get as much health benefit from the intervention as those who lose larger amounts (Campos et al., 2006). Data from the recent National Health Interview Survey are typical in this regard. Among overweight and obese men and women, with and

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without type 2 diabetes, those who reported trying to lose weight (but without success) experienced a reduction in mortality rate that was the same as, or greater than, those who reported that they successfully lost weight. In other words, weight-loss itself did not appear to be beneficial. Indeed, in this same study, weight-loss was associated with a mortality hazard ratio of 3.36 (that is, people who lost weight were more than three times more likely to die over the course of the study than people who did not lose weight), and weight cycling with a hazard ratio of 1.83. By contrast, obese people with stable body weights had no increase in mortality (Gregg et al., 2004; Diaz et al., 2005). Similar results were obtained in the Iowa Women’s Health Study and a major American Cancer Society study from the 1990s, which represent the only two large studies to date that have attempted to measure the health effects of intentional weight-loss (French et al., 1999; Pamuk et al., 1993). The failure to demonstrate that weight-loss in itself is medically beneficial is particularly disturbing given the hazards associated with many of the techniques employed by people trying to lose weight. For example, it is estimated that approximately eight million Americans have active diagnosable eating disorders such as anorexia and bulimia (anorexia has the highest fatality rate of any ‘mental illness’), while tens of millions of others engage in episodic eating disordered behaviour (Makino et al., 2004). As we have seen, diet drugs are associated with a host of serious health risks. For instance ephedra, which was recently banned by the Food and Drug Administration (FDA) after, among other things, the deaths of several high-profile athletes who were found to have the stimulant in their blood, was known among college students as ‘legal speed’ (Gugliotta and Amy Shipley, 2003). The story of how fen-phen and its pharmacological cousin Redux ended up getting FDA approval, even though they were known to have serious potential side effects up to and including death, and even though fen-phen produced an average of only 7 pounds of weight-loss in comparison to a placebo, is a classic tale of what happens when administrative agencies are captured by the industries they are supposed to regulate. (At the FDA approval hearings for the drug, obesity researcher Judith Stern, who serves on the board of the American Obesity Association, a drug industry lobbying group that presents itself as a disinterested scientific organisation, opined that any expert who opposed the approval of Redux ‘should be shot’ (Mundy, 2001).) Given that the associations between weight and health are weak or non-existent outside of statistical extremes, that even these associations disappear when confounding variables are considered, that there

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is no method available to produce significant long-term weight-loss in the vast majority of people and that there are still no clinical trials demonstrating the health benefits of long-term weight-loss, how do obesity researchers and public health authorities manage to continue to sell their message that even modest amounts of overweight kill, and that achieving thinness is the key to good health? When confronted with powerful evidence that, except at statistical extremes, weight is a very poor predictor of mortality risk, orthodox obesity researchers fall back on various rhetorical strategies. First, they make methodological objections, the most common of which is that studies fail to control for risks such as pre-existing disease (Liebman, 2005). Second, they make certain marginal concessions. Perhaps, they say, being overweight does not increase one’s mortality risk, but it puts one closer to being obese, which does increase mortality risk.8 Given this, they argue, ‘isn’t it better to be in the normal weight category?’ Third, it is often argued that, in the words of one prominent obesity researcher, ‘even if positive energy imbalance rather than excess adiposity is the cause of some morbidity, the solution will be the same: increased activity and reduced energy in the diet’ (Stevens et al., 2006). Finally, they will talk about ‘quality of life’. Even if mortality risk is not actually increased by being fat, isn’t one’s quality of life improved by not having to employ the medicines, such as statins, that are keeping all these surprisingly tenacious fat people alive for as long, or longer, than the ‘ideal weight’ among us? (Squires, 2005). The responses to these strategies are straightforward. Studies such as the 2005 Flegal article do control, rigorously, for pre-existing disease and smoking. The veritable obsession some prominent obesity researchers seem to have with making picayune and ill-founded methodological objections to studies that contradict their claims about the risks of overweight is all the more striking, given that these researchers remained completely silent about – or indeed were co-authors of – highly publicised studies that were riddled with far worse methodological problems and outright errors, but which appeared to support their point of view (for a specific example, see Campos, 2004: 13–19). The claim that it is better to be ‘normal’ weight than overweight because that puts one farther away from being obese ignores that being normal weight puts one closer to being underweight, which as we have seen is associated with a far higher mortality risk than all but the most extreme levels of obesity. In statistical terms, the average overweight person is perhaps 75 pounds away from being dangerously heavy, while the average normal weight person is perhaps 20 pounds away from being

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dangerously thin. The argument that everyone agrees physical activity and balanced nutrition are good things, and that therefore the disagreement between those who advocate weight-loss via these methods and those who advocate these things for their own sake turn on a semantic quibble ignores the practical effects of the current international obsession with thinness. Specifically, such arguments overlook that becoming more active and adopting a healthy diet do not result in significant weight-loss for most people, and that there are many so-called overweight and obese people who already have healthy lifestyles and therefore do not need ‘treatment’ (conversely, it could be argued that many lean persons have unhealthy lifestyles in need of improvement). And it is even more crucial not to ignore the social reality that many people pursue weight-loss through harmful methods such as smoking, purging, chronic weight cycling, fad diets, diet drug use and weight-loss surgery. Given the demonstrable health damage that such weight-loss practices inflict, it is not merely a matter of semantics whether the public health establishment chooses to focus on lifestyle or weight-loss (Campos et al., 2006). As for ‘quality of life’, it simply is not true that obese people are being kept alive by drugs and other therapies that are comparatively rare among thin people. For example, in Flegal et al.’s (2005) data, 3.5 per cent of the obese subjects were using statins, as opposed to 2 per cent of the ‘normal weight’ subjects. Obviously, excluding all these people from the subject pool would have almost no impact on Flegal et al.’s (2005) observed correlations. (If obesity researchers really want to improve the quality of life of the heavier than average, they could start by dropping claims that millions of perfectly normal and healthy people have a disease simply because their body mass is above an arbitrary definitional line.) In short, both the scholarly work and the public positions of many obesity researchers are riddled with the sort of selective citation of evidence and egregious double standards that we may take for granted when employed by, say, political spin doctors or particularly brazen litigators, but which are supposed to be anathema to genuine science. Examples of this can be found almost at random: for example, a study published recently in the Journal of the American Medical Association (Yan et al., 2006) illustrates this strategy perfectly. A national news article describing the study – probably derived from the press release the authors of such articles helpfully provide the media – is entitled ‘Study Confirms You Can’t Be Fat – And Healthy’. The article goes on to describe the study’s conclusions: obese middle-aged subjects without high blood pressure or high cholesterol at the time of entry into

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the study had a 43 per cent increased risk for coronary heart disease mortality in comparison to normal weight persons, over the course of a 32-year follow-up. The article quotes the study’s lead author: ‘The takehome message would be pay more attention to your weight even if you don’t have an unhealthy risk factor profile yet.’ The article contrasts the study’s findings with what it describes as the ‘controversial’ Flegal et al. 2005 JAMA study, which in a considerable understatement the article describes as ‘suggest[ing] that excess weight might not be as deadly as previously thought’ (Associated Press, 2006). This is disingenuous since the actual study contains the following data: the 43 per cent increase in relative risk for coronary heart disease mortality among obese people was based on a 95 per cent confidence interval stretching from a relative risk of 0.33–6.25. In lay terms, this means the researchers could state with 95 per cent confidence that, in these data, the associated risk between dying from heart disease and obesity lay somewhere between obese people having one-third as much associated risk as normal weight people, and six times as much associated risk. In other words, the 43 per cent increase in relative risk cited by the article fell radically short of having anything like statistical significance. Even more remarkably, the study’s authors assumed, in their methodology and statistical analysis, that diet, physical activity and fitness play no role in health or mortality (Yan et al., 2006). As we have seen, this is the epidemiological equivalent of assuming the Earth is flat – and yet it is a common assumption in studies that claim to find a significant link between body mass and health risk. Two particularly notable examples of this kind of thing – notable because these studies have been cited thousands of times in the media for the proposition that fat kills – are provided by the 1999 JAMA study that supposedly found 300,000 excess deaths were caused every year in the US population by obesity and overweight, and the 2004 JAMA study that raised that impressive figure to 410,000. The 1999 study has the following sentence in its statement of methods: ‘Our calculations assume that all (controlling for age, sex and smoking) excess mortality in obese people is due to their adiposity.’ By this same method, one can prove that wearing clothes that smell of tobacco causes 120,000 lung cancer deaths per year, and that singing Christmas carols significantly increases mortality among turkeys. The 2004 study featured, if anything, even more dubious calculations. Besides containing basic mathematical errors (errors that were brought to the attention of the authors, who included Julie Gerberding, the Director of the CDC, by other researchers within CDC, but which produced no public correction from the agency until

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the media learned of the errors months later) (Wahlberg, 2005), the 2004 study assumed that 410,000 annual deaths were a consequence of sedentary lifestyle and poor nutrition, and that overweight and obesity served as perfect proxies for these risk factors. In other words, they assumed that 100 per cent of overweight and obesity is caused by sedentary lifestyle and poor nutrition; and that no one with a BMI under 25 is sedentary or eats poorly. Even more remarkably, the only citation the authors provided for this assumption was to a study by Steven Blair that stands for almost precisely the opposite proposition. When I asked Blair what he thought about this use of his work, he told me he ‘was astonished to see my work cited in that manner’ (personal communication, 17 April 2004). Yet the most questionable practices of obesity researchers who seek to prove that ‘overweight’ and ‘obesity’ represent a deadly epidemic may go well beyond exaggerating the significance of weak associations and ignoring confounding variables. Indeed, there is evidence to suggest that certain prominent researchers engage in what is known among scientists and statisticians as ‘data trimming’. One particularly invidious form of data trimming involves testing different exclusionary criteria on a subject base until the desired correlations appear, and then using those criteria because they produce the desired outcome. A medical school professor who has studied the obesity literature for more than 20 years described for me what he considers the highly suspicious statistical analyses employed by some obesity researchers (see Campos, 2004: 47–9): I was first clued into this subject in the context of the famous Framingham study. Two reports on the impact of weight from Framingham appeared in JAMA. One showed no impact from overweight and only a slight effect from obesity, but a strong risk associated with underweight. I have a copy of some of raw data tables from the government printing office, and they support this interpretation. The second paper appeared a couple of years later. It showed mortality risk increasing linearly with BMI. Why the differing conclusion? The answer, I believe, lies in a subtle statistic: the number of subjects. The data showing no harmful effect from overweight used all five thousand subjects. The later report used less than half the total number of subjects, and was very fuzzy regarding why it excluded the majority of the data pool. It’s almost as if the authors excluded most of the ‘fat and healthy’ and ‘sick and thin’ subjects, leaving only ‘fat and sick’ and ‘thin and healthy.’

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This professor then went on to critique the methods of two prominent people in the field: [These two researchers] always exclude a large proportion of their study subjects. When they give a reason, it’s usually that the subjects have a particular disease, or they have lost weight in the past ten years. Another favorite is to exclude current smokers, conveniently overlooking the fact that ex-smokers are still at increased risk, and are almost invariably fatter than never smokers. But excluding certain subjects from consideration undermines the ability to generalize the results (anybody remember Statistics 101?). If you exclude everyone who has disease, your conclusions apply only to healthy people, and not to anyone who is ill. If you exclude everyone who has lost weight recently, then your conclusions apply only to weight-stable people. This means that [these two researchers’] weight guidelines, if they apply to anyone, only apply to people who are in perfect health and have a stable weight. The problem is that the guidelines are mainly applied to people who are not healthy, because these are the people coming into the doctor’s office and getting the ‘lose weight or die’ lecture. [Also] the list of diseases used as grounds for exclusion ends up being unique for every paper [these authors publish]. The amount of weight-loss, and the number of years in the study prior to death as a ground for exclusion also vary from report to report. Why does this trouble me? What do I imagine is behind this ‘custom tailoring’ of the data analysis? Well, imagine that your boss has demanded that you return a particular result from the data. You would run many different analyses. ‘Let’s try excluding people with disease X. Is obesity harmful yet? No? Let’s try excluding people with disease Y. Does omitting people who have lost 50 pounds give us our answer? No? Let’s try 25 pounds, or ten.’ By running hundreds of different possible combinations of exclusion criteria, it’s possible to edit your subject base in such a way as to support almost any result. Whatever happened to reporting the results from the group you originally enlisted in the study? In clinical trials, this sort of data trimming would get you in real trouble! Why is it tolerated only for studies of obesity? At the very least, these authors should be required to provide the results from their excluded subjects. Such observations may help explain the curious fact that, even as we are deluged with claims from obesity researchers that fat kills, evidence for that proposition ends up being conspicuously absent from large-scale

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epidemiological studies, and seems to be directly contradicted by the continuously improving overall health and life expectancy of populations all around the developed and developing world, including nations in which supposedly at least half the populace has been dangerously overweight since the middle of the previous century (National Center for Health Statistics 2005). Under such circumstances, and to return to the final proposition listed at the start of this chapter, it seems grossly inefficient for public health agencies to focus on trying to make people thinner, at the potential expense of initiatives that would have a more direct impact on population health regardless of promoting weightloss. Indeed, when fat is inappropriately defined as a killer and the public health establishment seek to win ‘the war on obesity’, various costs are incurred and these are not just financial costs or opportunity costs. In concluding this chapter I would reiterate a final point that is relevant when reading some of the subsequent chapters in this collection. Namely, engaging the ‘current scientific evidence should prompt health professionals and policy makers to consider whether it makes sense to treat body weight as a barometer of public health’ and it should ‘make us pause to consider how propagating the idea of an “obesity epidemic” furthers the political and economic interests of certain groups, while doing immense damage to those whom it blames and stigmatizes’ (Campos et al. 2006: 59).

Notes 1. For an in-depth analysis of these claims, see Campos (2004) and Campos et al. (2006). As scholars from a variety of disciplines have become increasingly critical of the claim that higher than average weight represents a major health risk, some obesity researchers have raised the objection that law professors, political scientists, sociologists, anthropologists and so on have no business criticising their work, because such critics are not medical professionals. The reply to this objection is two-fold. First, critiquing epidemiological studies is a matter primarily of statistical analysis – something in which, ironically, many obesity researchers, unlike most of their academic critics, have little or no formal training. More fundamentally, a central argument made by these critics is that distortions of the medical evidence have produced an inappropriate medicalisation of an issue that is largely cultural, economic and political. In other words, to claim that only obesity researchers should address the extent to which ‘obesity’ ought to be considered a public health issue is to beg the precise question at hand. 2. A 5’4” woman with a BMI of 35 weighs 204 pounds. Paltrow’s BMI is taken from a 23 July 2002, Wall Street Journal story, where her height was given as 5’11” and her weight as 112 pounds. Moss is 5’7” and weighs 95 pounds according to various media reports.

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3. A risk can be statistically meaningful yet socially meaningless. For example, researchers in a particular study might note that so-called ‘overweight’ people between the ages of 30 and 39 have a 10 per cent greater risk of premature death than so-called ‘normal weight’ people, based on a 95 per cent statistical confidence interval (or, as in Flegal et al.’s (2005) study, researchers might note that ‘normal weight’ people were at increased risk in comparison to ‘overweight’ people). This increased risk is socially meaningless, both because such a weak association could be accounted for completely by a wide range of confounding variables, and because a 10 per cent increased risk of premature death is practically meaningless among cohorts that already have an extremely low baseline risk. In other words, 10 per cent more than almost nothing is still almost nothing. 4. Consider this unusually candid quote from obesity researcher Charles Hennekens: ‘Epidemiology is a crude and inexact science . . . we tend to overstate findings, either because we want attention or more grant money’ (cited by Williams, 1995: 1). 5. When the weakness of the epidemiological link between BMI and health risk is pointed out, it is sometimes argued that BMI is an inexact measure of body fat, and that high levels of body fat, rather than high body mass per se, represent the real health risk. Yet when epidemiological studies have compared BMI to per cent body fat as a marker for disease risk, BMI is consistently superior to per cent body fat. This suggests that body build rather than fatness may be the source of some of the risks associated with high BMI (Nakanishi et al., 2000; Spieglman et al., 1992; Warne et al., 1995). Furthermore, some body fat depots, particularly subcutaneous fat on the hips and thighs, may actually provide significant health benefits. Thigh and hip fat in particular have been reported to be associated with lower plasma triglycerides and higher HDL-cholesterol levels (Campos et al., 2006). 6. Furthermore, epidemiological data indicate that the lowest mortality risk for African Americans is found at higher weight levels than among whites, that is, in the middle of the so-called ‘overweight’ range, and that among African American women in particular it is difficult to document any increased risk of mortality associated with even very high levels of obesity (see, for example, Wienpahl et al., 1990). 7. Indeed, some prominent obesity researchers are now suggesting that people ought to try to maintain a BMI of between 18.5 and 21.9. This represents a weight range of 108–127 pounds for an average-height woman (Field et al., 2001; Hellmich, 2004). 8. For example, Professor David Katz of the Yale Medical School made this argument when I debated him on a Minnesota National Public Radio broadcast in March, 2005.

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Mokdad, A.H., Ford, E.S., Bowman, B.A., Dietz, W.H., Vinicor, F., Bales, V.S. and Marks, J.S. (2003) Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, JAMA 289 (1): 76–79. Mundy, A. (2001) Dispensing With the Truth: The Victims, the Drug Companies, and the Dramatic Story Behind the Battle over Fen-phen. St Martin’s Press: New York. Nakanishi, N., Nakamura, K., Suzuki, K., Matsuo, Y. and Tatara, K. (2000) Associations of Body Mass Index and Percentage Body Fat by Bioelectrical Impedance Analysis with Cardiovascular Risk Factors in Japanese Male Office Workers, Industrial Health 38 (3): 273–279. National Center for Health Statistics (2005) Life Expectancy Hits Record High. Gender Gap Narrows. National Center for Health Statistics Fact Sheet, February 28. Online. http://www.cdc.gov/nchs/pressroom/05facts/lifeexpectancy.htm. Neel, J.V., Weder, A.B. and Julius, S. (1998) Type II Diabetes, Essential Hypertension, and Obesity as ‘Syndromes of Impaired Genetic Homeostasis’: The ‘Thrifty Genotype’ Hypothesis Enters the 21st Century, Perspectives on Biological Medicine 42 (1): 44–74. Paffenbarger, R.S. Jr., Hyde, R.T., Wing, A.L. and Hsieh, C.C. (1986) Physical Activity, All-cause Mortality, and Longevity of College Alumni, New England Journal of Medicine 314 (10): 605–613. Pamuk, E.R., Williamson, D.F., Serdula, M.K., Madans, J. and Byers, T.E. (1993). Weight Loss and Subsequent Death in a Cohort of U.S. Adults, Annals of Internal Medicine 119 (7): 744–748. Saguy, A. and Almeling, R. (2005) Fat Panic! The ‘Obesity Epidemic’ as Moral Panic. Paper presented at The Annual Meeting of the American Sociological Association, Philadelphia, August 12. Online. http://www.allacademic.com/meta/ p22928_index.html. Serdula, M.K., Mokdad, A.H., Williamson, D.F., Galuska, D.A., Mendlein, J.M. and Heath, G.W. (1999) Prevalence of Attempting Weight Loss and Strategies for Controlling Weight, JAMA 282 (14): 1353–1358. Spieglman, D., Israel, R.G., Bouchard, C. and Willett, W.C. (1992) Absolute Fat Mass, Percent Body Fat, and Body Fat Distribution: Which is the Real Determinant of Blood Pressure and Serum Glucose?, American Journal of Clinical Nutrition 55 (6): 1033–1044. Squires, S. (2005) Middle Ground on BMI, Washington Post, May 17. Stevens, J., McClain, J.E. and Truesdale, K.P. (2006) Commentary: Obesity Claims and Controversies, International Journal of Epidemiology 35 (1): 77–78. Tuomilehto, J., Lindstrom, J., Eriksson, J.G., Valle, T.T., Hamalainen, H., Ilanne-Parikka, P., Keinanen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., Salminen, V., Aunola, S., Cepaitis, I., Moltchanov, V., Hakumaki, M., Mannelin, M., Martikkala, V., Sundvall, J. and Uusitupa, M. (2001) Prevention of Type II Diabetes Mellitus by Changes in Lifestyle Among Subjects With Impaired Glucose Tolerance, New England Journal of Medicine 344 (18): 1343–1350. Troiano, R.P., Frongillo, E.A. Jr., Sobal, J. and Levitsky, D.A. (1996) The Relationship Between Body Weight and Mortality: A Quantitative Analysis of Combined Information from Existing Studies, International Journal of Obesity Related Metabolic Disorders 20 (1): 63–75. U.S. Census Bureau. (2004) Income, Poverty, and Health Insurance Coverage in the United States: 2004, Online. www.census.gov/prod/2005pubs/p60-229.pdf.

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Wahlberg, D. (2005) CDC Apologizes for Mixed Messages On Obesity, AtlantaJournal Constitution, June 3, at 1A. Walker, S., Rimm, E.B., Ascherio, A., Kawachi, I., Stampfer, M.J. and Willett, W.C. (1996) Body Size and Body Fat Distribution as Predictors of Stroke Among U.S. Men, American Journal of Epidemiology 144 (12): 1143–1150. Warne, D.K., Charles, M.A., Hanson, R.L., Jacobsson, L.T., McCance, D.R., Knowler, W.C. and Pettitt, D.J. (1995) Comparison of Body Size Measurements as Predictors of NIDDM in Pima Indians, Diabetes Care 18 (4): 435–439. Wienpahl, J., Ragland, D.R. and Sidney, S. (1990) Body Mass Index and 15-Year Mortality in a Cohort of Black Men and Women, Clinical Epidemiology 43 (9): 949–960. Williams, L. (1995) Stalking the Elusive Healthy Diet. In Scientific Studies, Seeking the Truth in a Vast Gray Area, New York Times, October 11, at C1. Winslow, R. (2002) Study Shows Even Moderate Exercise Can Reverse Effects of Aging by Years, Wall Street Journal, May 8. Yan, L.L., Daviglus, M.L., Liu, K., Stamler, J., Wang, R., Pirzada, A., Garside, D.B., Dyer, A.R., Van Horn, L., Liao, Y., Fries, J.F. and Greenland, P. (2006) Midlife Body Mass Index and Hospitalization and Mortality in Older Age, JAMA 295 (2): 190–198.

3 Bodily Sensibility: Vocabularies of the Discredited Male Body Lee F. Monaghan and Michael Hardey

Warning! The following may shock middle-class sensibilities When discussing the embarrassing and emasculating topic of ‘man breasts’, Longhurst (2005) draws attention to the abjection of fat men as ugly, despised, fearful and grotesque. Referring to the film Goldmember, starring Mike Myers as Austin Powers, Longhurst (2005: 175) mentions Fat Bastard who ‘has huge, rounded hairy shoulders, a large belly and ample womanly breasts’. Rather than reserved, Fat Bastard exhibits considerable bravado with sayings (spoken with a Scottish accent) like ‘I’m dead sexy!’ (Longhurst, 2005: 175). For British men, the ‘fat bastard’ label may also be publicly worn as a badge of pride, rather than shame, or at least admitted to as a part of their identity. The following ethnographic extract refers to this and other vulgarised idioms through which men, who may be medically defined as ‘obese’, construct ‘acceptable’ identities: I was drinking with Mac and Jimbo, working-class Scottish fellas in their forties. Mac said he’s called ‘Big Mac’ at his ‘local boozer’ adding, ‘obviously, not because I’m big like, but because I’m a fat bastard’. He then quipped: ‘I’m not like you Jimbo. I admit I’m a fat bastard’. Jimbo, matter-of-factly, replied: ‘Okay, I’m a fat bastard. But if anybody called me a fat CUNT I’d do that to them!’ Jimbo, with a mad glare, then pretended to slit his throat with his index finger. Mac explained that this gesture is often used in a light-hearted way among friends in Scotland. (LM’s field diary) 60

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In this chapter, we consider such bodily sensibilities, vocabularies and the socio-cultural conditions under which men, like Mac and Jimbo, engage in gendered identity work. Such work may be considered salient in a society where ‘bodies are in’ (Frank, 1991) and fatness is routinely constructed as a ‘physical stigma’ that ‘spoils identities’ (Goffman, 1963). This, we would stress, is amidst public health warnings about a global obesity epidemic (WHO, 1998) that reportedly affects most men in developed nations, and other widely circulated representations of ‘normative male embodiment’ (Watson, 2000) comprising toned, athletically muscular or lean physiques. Such an undertaking extends the obesity debate beyond a reductionist biomedical approach and furthers social scientific knowledge. There is currently a general neglect of men’s bodies, fatness and weight issues in the social scientific literature (Bell and McNaughton, 2007; though, see Monaghan, 2005a, for example). This neglect is unfortunate because the socio-cultural meanings, if not physicality, of men’s bodies are being authoritatively reshaped or sanctioned by biomedicine in ways that render fatness especially stigmatising. Representations of ‘appropriate’ masculinity increasingly incorporate health-concerns or ‘healthism’ (Crawford, 1980), based on biomedical criteria as manifest in the Body Mass Index (BMI, kg/m2 ) and waist circumference measure (i.e. between the lowest rib and the iliac crest). These measures offer a (crude) proxy of visceral and total body fat without recourse to costly imaging or densitometry techniques to visualise the distribution of fat. Anthropometric measures have prompted a debate about the application of any one or combination of measures as indicators of excessive visceral fat that allow for bodily differences shaped by ethnicity, age and so forth (e.g. Ardern et al., 2003). Yet, what is seldom debated is how public health concerns about an obesity crisis – ‘informed’ by ‘scientific’ measurements of objectified bodies, rather than an understanding of lived/gendered bodies – prejudicially construct a putative problem that may amplify the stigma of obesity and further discredit embodied identities. This, we would add, is despite an ostensible concern in public health with stigma – a problem often misleadingly located ‘in’ fat people and which should be remedied through weight-loss (also, see Aphramor and Gingras, Chapter 8 in this volume). Medicalised and government-backed concerns about the obesity crisis, routinely evidenced by insensitive or sizist depictions of men’s fatness (e.g. Schauss, 2006; also, see the front cover of the National Audit Office’s 2001 report), are inseparable from the larger society and culture. Following the Fat Bastard reference, this larger context includes popular

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culture with its depictions of ‘fat’ people as grotesque. Media images of such bodies have proliferated amidst disproportionate coverage of an obesity epidemic (Marsh, 2004, Monaghan et al. 2010). Magazines and broadcast media that cultivate a male audience do so in ways that reinforce the aesthetic of the ‘fit’ male body and promote individual acts of consumption that apparently make such an ideal achievable (Crawshaw, 2007). Many television programmes in Britain and elsewhere valorise the reformation of such bodies through adherence to a healthy lifestyle. At a cultural level, the aestheticisation and promotion of ‘fit’ male bodies as fleshy advertisements of the self draws men’s attention to the body as central to masculine identity (Wernick, 1991). The general emphasis on bodies and lifestyles, and the centrality of the body to identity in late modernity, is considered within sociological theory (e.g. Shilling, 2003). Such literature draws attention to what has been called a ‘somatic society’ (Turner, 1996) where, to follow Bourdieu (1984), bodies have meaning in terms of cultural capital that is amassed through perceived adherence to ‘healthy choices’ (notably, diet and exercise). Bodies are important markers of social difference and distinction and, as such, fatness is a potential liability. Under these conditions, ‘fat bodies’ – regardless of their actual (in)actions – may be prejudicially equated with breaking biomedical and social ‘rules’. They risk being labelled as deviants in need of treatment or reform. Men who encounter and/or feel this stigma are obliged to signal their ‘social fitness’ through compliance or else account for their bodies (Monaghan, 2008). Certainly, as evidenced above, men who accept they are fat may not necessarily strive to be slim, or try to embody an aesthetic ideal. Rather, they may construct a situationally fitting identity in order to distance themselves from the discrediting (emasculating) qualities commonly associated with fatness and ‘conform to hegemonic masculine values’ (Robertson, 2007: 122). Extending an analysis presented elsewhere (Monaghan, 2008), we consider how lived male bodies construct socially ‘acceptable’ identities in their interactions with other people and a larger sizist society where war has been declared on obesity. As will be seen, these identities are constructed despite, or rather because of, the undesirable qualities that their real or imagined fatness represents to others (as captured in discrediting labels like ‘obesity’). Our examples are centred on gendered vocabularies that reproduce as well as challenge normative expectations to lose weight/fat – expectations that are not only continually reproduced in popular culture but also a ‘health sector’ that has ‘increasingly contributed to the cultural definition of the “ideal” lean body’ (O’Hara and Gregg, 2006: 260). Our analysis lends support to the sociological


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claim that the body has become an important (identity) project in late modernity but also shows how fraught with difficulties this project is for larger men who are subject to increasing biomedical and social ideals that are constructed around rationalised/normative embodiment. First, before outlining the research and elaborating upon our typology of bodily sensibility, we consider the historically transmitted conditions under which ‘fat’ male bodies are constituted and the current degradation of fatness is amplified.

Reinventing and amplifying the bodily aesthetic Masculinities and (in)appropriate male bodies, which are social relational constructions (Connell, 2005), are continuously emergent and reinvented in light of scientific, social-economic and cultural change. Rarely invisible, large ‘fat’ male bodies and associated appetites have continually ‘stood out’ and have been celebrated as well as demonised. Besides positive images of men’s fatness and feasting during the medieval European carnival (Bakhtin, 1965), fat men were warmly captured in the nineteenth century novel and especially in Dickens’s depiction of characters like Pickwick. ‘Pickwick was a genial sphere “another sun” ’ (McMaster, 1983) who was counterpoised to his comparatively thin companions and through feasting was able to glimpse the pleasurable possibilities open to the emergent middle-class. More contemporaneously, and in critiquing the disciplining of female bodies in a field of gendered inequality, Bordo (1993: 108) states: ‘Men are supposed to have hearty, even voracious appetites’ which, through the consumption of red meat (also, see Sobal, 2005) and calorific foods, are believed to create a ‘natural’ masculine body. What amounts to the relative normalisation of ‘fat men’ runs through more recent work in Fat Studies where it is stated obese women are seen, even by doctors writing in twentieth century medical journals, as ‘most offensive and dangerous’ and denigrated as an ‘aesthetic affront’ to society (Murray, 2008: 2, emphasis in original). Relative to many Western women, there may be greater acceptance, or promotion, of men’s ‘bodily bigness’ and ‘love of food’. Nonetheless, the imbrications of gender, class, bodies, consumption and other social factors (e.g. anxieties about national fitness) have meant that ‘fat men’ and their real or imagined dietary habits have been and continue to be discredited. Note, for instance, satirical socialist cartoons where corpulent men were portrayed as ‘fat cats’ metaphorically ‘feeding’ off the surplus created by the working-class, or abject depictions of white middle-class

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‘Tubby Hubbies’ in early Cold War Canada (McPhail, 2009). Also, consider how the social, scientific and political concerns of the Enlightenment gave rise to the obese figure of George Cheyne (1673–1743), a doctor in England. Reportedly weighing well over 400 pounds, Cheyne described his ‘putrefied overgrown Body from Luxury and perpetual Laziness’ (Cheyne, cited in Guerrini, 2000: 135). In her biography of Cheyne, Guerrini notes, ‘to be fat was not only aesthetically and medically undesirable, it was morally reprehensible’ (2000: 135). Fatness was then a constant risk for the ‘intellectual and sensitive man’ who had neither the supposed disposition of the female body nor the physicality of the labouring classes. Other fat men similarly stand out in history. William Banting, who was a coffin maker to the British royal family and whose only qualification was a fat body, wrote the first recognisably modern diet book in the late 1800s. Unable to ‘stoop to untie my shoe’, Banting eventually followed a regime similar to the Atkins diet, which he published in his ‘Letter on Corpulence, addressed to the Public’ (1896 [2005]). In the preface, Banting writes, ‘of all the parasites that affect humanity I do not know of, nor can I imagine, any more distressing than that of obesity’ (p. 1). More contemporaneously, obesity scientists and their allies have continued to draw from, consolidate and amplify the sizist view that fatness (overweight, obesity or even morbid obesity) is pathological and, in line with ruggedly masculinist rhetoric, should be combated (also Murray, 2008). This institutional degradation, which is part of what Evans et al. (2008) term ‘obesity discourse’ (also, see the introduction to this volume), is seemingly justified at a population level given widely reported links between increasing body mass, various morbidities (e.g. type 2 diabetes, liver disease) and excess mortality (Campbell and Haslam, 2004; WHO, 1998; for a critical reading of the epidemiological evidence, see Campos in Chapter 2 of this volume). While the idea of childhood obesity features prominently in obesity discourse and provides considerable ammunition for ‘obesity crusaders’ (Basham, et al., 2006), or ‘obesity epidemic entrepreneurs’ (Monaghan et al., 2010), men’s fatness is also closely scrutinised: men are claimed to be more at risk than women from the physiological harms of obesity, typically stored in the abdominal region, and are more likely than women to be classed as ‘excessively’ heavy (MHF, 2005). Although highly contestable (Campos, 2004; Evans et al., 2008; Monaghan, 2005b), the biomedical ramifications attributed to overweight and obesity are well publicised. They have also ‘informed’ claims from one US Surgeon General that obesity is a serious public health hazard that is ‘more threatening than


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weapons of mass destruction’ (Carmona, 2003). This public health educator also called obesity ‘the terror within’, further legitimating the view that fatness is totally unacceptable and should be aggressively fought or tackled regardless of the possible effects of such claims on people’s health and well-being (O’Hara and Gregg, 2006). These symbolically violent claims, disseminated and amplified through the mass media, have provoked considerable activity within public health. Consequent predictions about the potentially massive increased demand on secondary health care resources have generated concern amongst policy makers (e.g. UK Parliament, 2004). Correspondingly, in addition to diagnosing the putative problem, policy makers – in association with ‘experts’ and others – seek to devise and implement ‘effective’ solutions (which, we would add, promise more than they deliver). Strategies include modifying the nature of the city and architecture under the guise of ‘health towns’ (DoH, 2008). Some schools have also introduced the weighing of children and calculating their BMI as part of a national monitoring programme (DoH, 2006, also, see Evans and Colls, Chapter 5 in this volume). ‘Weight’ has therefore become a public issue for everyone regardless of class, age or gender (though this may be especially troublesome for people who are seen as fat in everyday life). While the parallel with tobacco use in terms of health education and promotion has some veracity, ‘combating obesity’ is more complex and for men involves a foregrounding of dietary choice, physical labour or exercise, bodily form and consumption patterns that in the past have been buried under patriarchal relations and robust masculinity. This foregrounding is worked out in everyday life, including bodyto-body interactions that are inseparable from ‘tacit body knowledges’ that negatively conflate fatness with pathology and a devalued inner self (Murray, 2008). In the clinical encounter, BMI and waist measurement approaches classify men according to biomedical criteria that supposedly ‘reveal’ risks associated with their bodily form and assumed behaviours. Once identified as a ‘health risk’ the clinical expectation is that the ‘overweight’ or ‘obese’ body will be challenged by lifestyle change that typically includes diet and exercise. Of course, following our references to obesity science and parliamentary reports, this prescribed remedial work is officially legitimated as governments seek to help tackle the putative crisis. In the United Kingdom and elsewhere, health policy is reconfigured around assumptions about individual responsibility for health. This fits with what Crawford (1980) calls ‘healthism’ – a form of medicalisation where lifestyles are assumed to prevent disease. Following Petersen and Lupton (1996), this is part of the distinctly

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middle-class and de-politicising obligation for the ‘entrepreneurial self’ to work on their body as part of ‘the new public health’. For example, the White Paper, Choosing Health: Making Healthy Choices Easier (DoH, 2004), outlines the nationwide strategy to improve health and depicts the consumer/citizen as constantly vigilante about his or her health and responsible for making appropriate choices (Hughes, 2004). The paper recognises that this model of consumer responsibility demands a degree of state intervention in the food industry and elsewhere so that individuals have the information upon which to make choices. In other words, the link between health, as part of consumption and as marketable commodity, is highlighted in order to promote lifestyle change and risk avoidance. And, it perhaps comes as little surprise that women are urged within government-backed public health promotion to assume a direct role in getting ‘their men’ to make healthy dietary choices (see Aphramor, 2005). In short, women are obligated not only to work on their own bodies (Murray, 2008) – gendered action which is largely related to pervasive Western beauty ideals and institutional rewards (Kwan and Trautner, 2009) – but also actively assist others in this ‘health’ project. Health promotion and the commercial marketing of the body and body maintenance increasingly reflect and reinforce each other so that it becomes difficult to separate ‘health’ from ‘body image’ (Glassner, 1995). Gender is implicated in this in various ways, and extends beyond ideas of female beauty, state expectations that women should ‘help’ their male kin lose weight, or masculinist militarised metaphors that have run through medicine since the nineteenth century and recur within obesity discourse (Monaghan, 2008). For example, the image of the fit male body taps into the myth of masculinity and ‘the male body as symbolic of sex and power’ (Barthel, 1992: 149). Such ideals are represented more in the media than in reality but, through commodification and medicalisation of all aspects of men’s lives, most are thought to be able to aspire to some approximation of the lean and fit body. Such representations provide a bridge from an individual problem to a public issue. Extending beyond the historically circumscribed and middle-class life worlds of George Cheyne and William Banting, such definitional practices and associated interests reinvent and amplify a powerful bodily aesthetic that discredits men’s, women’s and children’s fatness on an unprecedented scale. In reinventing the aesthetic, magazines, television series and newspapers commonly expose ‘unhealthy’ foods, especially ‘ready meals’ and fast-food that are assumed to manifest in the materiality of the body.


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In response, the food industry has quickly turned biomedical concerns about fat, salt and additive levels into opportunities to sell ‘healthy’ foods. Such foods – marketed as ‘natural’, ‘low fat’, ‘vitamin enriched’ or ‘organic’ – tap into an evolving consumer market. The diet industry also provides diverse ways to ‘read’ foods by decoding the perceived or imagined bodily impacts of various products. In order to circumvent the potential fat-inducing properties of different foods, consumers must invest time and money into making the ‘correct’ dietary choices. In this apparently rich information environment, fat individuals appear to be ‘weak’ in that they have been unable or unwilling to make ‘correct’ healthy choices when confronted with dietary, leisure and lifestyle opportunities. Again, this includes men who are seen as fat and who may seek self-improvement as part of a ‘body project’ (Shilling, 2003). While a ‘don’t care’ rhetoric is associated with hegemonic masculinity and embodied health practices (Robertson, 2007: 122), men are not immune from such concerns. Indeed, some commentators claim that men in Western societies are in ‘crisis’ and are contributing to the growing popularity of self-help books (e.g. Clare, 2000) and typically ‘feminine’ bodywork, such as cosmetic surgery (Atkinson, 2008).

The research Most data for this larger project on men and the war on obesity were generated during in-depth interviews with men who might have been medically classed as overweight or obese (N = 37), and a 9-month slimming club ethnography in Northeast England (see Monaghan, 2008). However, for the purposes of this chapter, and for reasons explained below, other data sources are mainly used here to engage everyday vulgarised idioms. In providing some background to the larger study, the mean age of the interview sample was 43, most men were white and from a working-class background. All but one man presented as heterosexual. An understanding of gay male cultures and the meanings of gay men’s ‘bigness’ or fatness was obtained through virtual ethnography, and such methods also enabled Lee to obtain insights of other ‘fat accepting’ groups such as the self-identified gluttons. Although these groups are explored elsewhere (Monaghan, 2005a), we will make passing reference to some of these insights below in order to ground our analysis. With regards to the offline interview sample, most men would have been medically classed as overweight or obese based on selfreported weight and height, though the methodological concern was

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to understand men rather than measure them. We acknowledge that in today’s multidisciplinary research environment some readers might feel that interviewees should have been weighed and measured. This expectation might also be compounded since we make reference to the possible biomedical classification of men, who were seen by themselves and others as fat in everyday life, as ‘obese’ (an aesthetic evaluation rather than simply a measured one). Nonetheless, we are cognisant of the politics of such ‘scientific’ action and would point readers not only to critical weight studies that challenge this (as in other contributions to this volume) but also criticism of how disciplines like anthropology measured bodies in a way that historically served and reproduced oppressive ideologies and colonial interests (Synnott and Howes, 1992). Analogously, weighing and measuring men amidst public health concerns about an obesity epidemic, while personally relevant for dieters, could be viewed as the insidious exercise of bio-power over subjugated bodies by ‘surveillance medicine’ (Armstrong, 1995). Other data were also generated. As indicated at the start of this chapter, observations were recorded while participating in informal situations that were not intentionally geared towards research. The public house is a recurrent example. Indeed, in Britain weight issues are very much part of the fabric of everyday life; talk about weight, like talk about the weather, is commonplace. These serendipitous data, comprising ‘thick descriptions’ of social interactions and everyday conversations usefully capture the potentially offensive meanings of fatness in a way that was not always possible given the situational constraints and proprieties of more formal research methods; notably, a face-toface audio-recorded interview with a university researcher associated with the middle-class habitus. Lee wrote up these additional data, from the ‘underbelly’ of social life, in a field diary. Informed consent was obtained whenever this was practical. As will be seen below, such data, which have been rendered anonymous through the use of pseudonyms, provide grounded glimpses into ways of orienting to and labelling fat male embodiment and the relational construction of masculine identities in contexts of every day and night life. It is worth stressing that data emerging from these contexts are important because they are removed from the proprieties of more formal researcher–respondent interactions, they pertain to real-world masculinities-in-action (or rather interaction in naturalistic settings) and they help redress complaints in social studies of men’s health concerning an absence of knowledge that is grounded in men’s (context-dependent) experiences (Robertson, 2007).


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Data were imported as text files into a software package that facilitates qualitative data analysis, Atlas.ti (Muhr, 1997). Data were indexed, enabling a systematic approach to a thematic analysis (e.g. all references to stigma were categorised with an identifying code and readily accessible as part of a grounded theory study which, we would add, does not bar the use of existing theories). In the remainder of this chapter we draw on these data to illustrate ideal typical ways of orienting to the bodily aesthetic, vocabularies of the discredited male body and men’s identity work.

A bodily sensibility: Keeping up appearances? Bernard, in his fifties, gave me his phone number at the slimming club after agreeing to meet with me next week for an interview. When I jotted down his number he repeated his name, but added: ‘you can put down fat bastard if you want’. Slightly embarrassed but also curious, I asked: ‘what is it about fat bastard? Other men sometimes call themselves that’. He said: ‘Well, it’s male bravado I think. Some people take offence at it. I was always called it. It was my name, and I didn’t take offence. I think it’s down to where you were brought up, the area you come from.’ (LM’s slimming club field diary) Brad: The only thing, overweight looking about us really is my sides. And the bits on my stomach. But you can’t really tell unless I’ve got my top off, and then my dad says like ‘you’ve got a bit of a paunch on you there’ or my mam and her friend will say stuff . . . . And my mates [very quietly] call each other fat bastards. (Interview with 16-year-old student who wanted to lose weight) The bodily aesthetic is a broad continuum that increasingly maps outlying too ‘thin’ or ‘fat’ bodies. It is embedded and constructed within the contours of ‘somatic society’ (Turner, 1996), which is stratified according to divisions such as gender, class, age, ethnicity and sexuality. As noted, this aesthetic is reproduced, rationalised and amplified through bioscience, medical practice, state policy, the media and everyday routines of consumption mediated by the market. Following Brad and Bernard, the aesthetic is also reproduced through micro-social interactions with significant others, such as family and friends who may feel entitled to evaluate, pass comment on, label and even ridicule those who are

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deemed fat. Although there may well be a discrepancy between self and other people’s evaluations of what constitutes a fat body (certainly, there is a general clash of perspective between biomedical and men’s everyday definitions of ‘appropriate’ weight-for-height) (Monaghan, 2007), the visual impact of fatness is especially important here since bodies that are seen as too fat are not only open to quantification by experts but also public assessment and disparagement. In short, bodies that are seen as fat are typically categorised and associated with ‘wrong’ choices, unhealthy behaviours and so forth. There is a powerful combination of biomedical claims that point to the cost of overweight and obesity to the individual and society (e.g. in addressing chronic illness) and public(ised) assumptions about deficient lifestyles and bodies. Consequently, shared beliefs about fatness give rise to stereotypes and reflect and reinforce the bodily aesthetic. These stereotypes are not simply free-floating beliefs or expectations about individuals or groups. They are consequential, potentially embarrassing and shameful social constructions that are formulated within and mediated by the ‘habitus’ comprising embodied, class-related dispositions (Bourdieu, 1984). As indicated by Brad’s quiet admission, which points to stigma, and Bernard’s working-class masculine bravado, these constructions shape how people are perceived, represented, treated and (self-)positioned on hierarchies of moral worth and systems of symbolic exchange. These stereotypes have become sufficiently pervasive that they form part of what Murray (2008) terms ‘tacit body knowledges’ or what Giddens (1984) calls ‘practical consciousness knowledge’. Building on Giddens’ structuration theory, Turner (2002) argues this can be seen as ‘the stock of knowledge that one implicitly uses to act in situations and to interpret the actions of others. It is this knowledgeability that is constantly used, but rarely articulated, to interpret events’ (p. 531). People draw on this knowledge when they interpret their own conduct and that of others in everyday interaction, and when they evaluate bodies as either supportive or transgressive of the gender order and (middleclass) healthist prescriptions. Dominant evaluations of men’s fatness not only run counter to hegemonic ideas about rationality, responsibility and control (Connell, 2005) but also the visual or normative embodiment of an ‘appropriate’ male form (Watson, 2000). However, it should be stressed that such monitoring of conduct and bodies may be done tacitly so that it is only given expression through ‘discursive consciousness’ that demarks ‘the difference between what can be said and what is characteristically simply done’ (Giddens, 1984: 3). To follow Garfinkel (1967), practical consciousness involves the ‘folk’ methods


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of everyday interaction that guide and interpret action, but which are rarely articulated. The construct of the fat body, in a field of power where plural masculinities are ongoing practical accomplishments (Connell, 2005), may therefore be resident at both levels of consciousness and may invoke actions that help give meaning to and consolidate an individual’s sense of ‘normality’ or belonging by constituting the ‘other’. The category ‘fat man’ is a social phenomenon and process consisting of labelling, stereotyping and the possible discrediting of embodied gendered identities. In short, within contemporary Western culture, to identify somebody as fat, and one who appears not to have reformed through altering health and consumer behaviours, is to label them undesirably different. This infringement creates a disparity between what Goffman (1963) terms ‘virtual’ (assumed) identities or social stereotypes and ‘actual’ (real) identities that are reflected on human actions (p. 3). Such discrepancies in social identities may result in stigma or otherwise discredit individuals as outside the social norms. Gendered labels such as ‘fat bastard’ are indicative of deviation and, depending upon social context, may outcast men who threaten established bodily images. Watson (2000: 83) similarly notes how ‘male stereotypes such as “the slob” and “the couch potato” ’ stigmatise men who are said to be ‘a real mess’. These labels and stereotypes reinforce the notion that ‘fat men’ are deviant, though some labels may be more pernicious (emasculating) than others. This was evidenced in the introduction with Jimbo’s reaction to the possibility of being called a ‘fat cunt’ (which is the antithesis of all that is appropriately and respectably masculine: soft, wet, fleshy and perhaps malodorous). Of course, following Mac’s and Bernard’s talk, labels that could spoil identities may also be re-signified. Similar processes are observed among fat activists, who assert that they are proud of their fatness (e.g. Cooper, 1998; also, see Cooper Chapter 7 in this volume) and who urge other fat people to call themselves ‘fatso’ in an attempt to turn fat hatred back on itself (Wann, 1998). With regards to some British men’s seemingly proud declarations that they are ‘fat bastards’, it should of course be recognised that such talk is geared to specific situations and the politics of masculine identity rather than, as with committed activists, broader social change and civil rights. It is also worth adding that, within vulgarised idioms, ‘bastard’ is compatible with the social construction of admirable working-class British masculinities (e.g. ‘he is a hard bastard’ or ‘good-looking bastard’) (Monaghan, 2008: 24). Either way, whether discredited or credited, men who are seen as fat may have little choice

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but to reflexively and discursively engage the aesthetic. To inhabit a male body that is seen as fat in contemporary Western culture, and could be labelled or (mis-)represented as such in the interaction order, is always to be open to discursive practices that challenge a man’s sense of normality and masculinity. We argue that men who risk stigmatisation because of the social meanings ascribed to the size, shape, weight or composition of their bodies, typically develop a knowledgeability and utilise vocabularies that enable them to construct situationally ‘fitting’ identities. They do not do this in isolation but in relation to other people and a medicalised and consumer society where war has been declared on obesity. This is the contemporary context for a ‘bodily sensibility’ comprising individual knowledgeability, feelings and discursive practices that shape social (inter-)actions. This sensibility, inseparable from a larger emotional nexus and economy wherein some male bodies matter more than others, not only shapes the actions of those labelled ‘fat’ or ‘obese’ but also those who may be in a position to shape or impose such labels. This sensibility is presented in a typology (Table 3.1). The horizontal dimension reflects an orientation to fat identity; for example, the degree to which a body may be considered fat (overweight, obese or even morbidly obese) by oneself and/or other people. The vertical axis represents a continuum stretching from a resistance to the aesthetic to its reproduction. This gives rise to four ideals types, or logical rather than ‘desirable’ mental constructs: ‘the proud’, ‘the wise’, ‘the stigmatised’ and ‘the prejudiced’. This typology, which provides a heuristic and means of engaging the messy empirical world, structures the remainder of our chapter. As an ideal typical model, this should be viewed with necessary caveats. For example, in reality, men may be deeply ambivalent when ‘proudly’ identifying as ‘fat bastards’ and feel stigmatised when others, ‘the prejudiced’, impose this or other discrediting labels on them. It should also be noted that what is considered ‘fat’ is a contingent social judgement, and while those in public health overwhelmingly use an inclusive definition based on BMI, those who might be stigmatised by such definitions may Table 3.1

A typology of fat bodily sensibility

Resist the aesthetic Reproduce the aesthetic

Considered ‘fat’

Not considered ‘fat’

‘The Proud’ ‘The Stigmatised’

‘The Wise’ ‘The Prejudiced’


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not actually consider themselves fat or obese. Moreover, they may join the collective degradation of fatness, in line with their definitions of and stereotypes about ‘obesity’ and belief that they are not ‘really’ fat. What we have here, then, are perspectives more so than actual individuals (also, Goffman 1963) which, as recently explained in the sociology of health and illness, must also be understood through a politicised lens that critiques social structures (Scambler, 2009).

The proud It was Saturday night and four young men were drinking in the pub together. A football match was being screened and spirits were high. Three of the men loudly identified each other and themselves as fat and joked about it. There was some ambivalence but also subsequent declarations of pride. Two of them bantered together: ‘You’re a fat bastard you are,’ ‘Well I’m not as fat a bastard as you!’ This continued for some time, with one of them bringing an athletically muscular doorman into the conversation: ‘You’ve got big shoulders!’ Another in the group, hearing this, tensed his body and then looked dismayed: ‘Nope, I’m still a fat bastard’. All the men were friendly and none apparently took offence: ‘We know we’re fat; we’re proud of it!’ Friendship seemed to neutralise any potential sting. One of them said to me: ‘We’ve known each other for years. We all come from the same village. This is what we’re like when we go out drinking together’. (LM’s field diary) As an ideal type, ‘the proud’ resist the bodily aesthetic by defining it as an acceptable, if not central, part of their identity. The negative interpretations attached to the fat male body are inverted so that the biomedically classified ‘unhealthy’ becomes ‘healthy’, the socially defined ‘unacceptable’ becomes ‘acceptable’ and so forth. In the realm of fiction, Pickwick would have been situated in this category. He acknowledged his size and incorporated it into his identity in that it is impossible to imagine Pickwick as thin. The carnivalesque is also noteworthy and it has a literary heritage at least as old as Chaucer. And, as noted at the start of this chapter, Fat Bastard, in Goldmember, is portrayed as morbidly obese and grotesque but is proud (e.g. claiming he is sexy) (Longhurst, 2005). Going from fiction and ideal types to the lived reality of men’s fatness, there are obvious manifestations of ‘the proud’ in various contexts. Such men typically interact with like-minded others, whether in situations

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of bodily co-presence or virtually through the Internet, and they are mutually supportive. Gay male subcultures have been noted, though there are also heterosexual men in fat acceptance organisations in the United States. Such men, at least in terms of their public ‘presentations of self’ (Goffman, 1959), identify as Big Handsome Men whose romantic appeal is not diminished by their fatness (Monaghan, 2005a). Other groups include men who proudly call themselves ‘gluttons’ and celebrate the pleasures of consumption and fatness as a reaction to the aesthetic and bourgeois notions of responsible risk management. For them, fatness and behaviours associated with fatness are justified, rather than excused. After engaging in an e-mail exchange with one contact, Adam, and asking him whether he had heard of the ‘Phat Bastard’ clothing label, available in Britain, he told me that he had not but there was a ‘Phat Farm’ brand in the United States and ‘if they weren’t so expensive, I’d love a Phat Farm T-shirt just to advertise and draw attention to my fatness’. However, similar to the ambivalences noted in the above field diary extract, this was also something of a contradictory move, rather than a simple declaration of pride, with Adam adding: ‘I like doing that to myself, kind of self-deprecating, or pointing out I am fat before they do kind of thing, cause I enjoy my fatness.’ On one level, this parallels the interactional moves of people with physical impairments who seek to put others at ease by explicitly acknowledging their visible difference albeit without them declaring they enjoy their impairment (Shakespeare, 1999). As indicated then, men who identify as fat and perhaps gluttonous may be ambivalent. Mac, quoted earlier, identified himself as a ‘fat bastard’ when stating other men in ‘the boozer’ called him ‘big’ and he was simply matter-of-fact, rather than proud. His definition was nonetheless benign. When jokingly implying that Jimbo was also a ‘fat bastard’ who was in denial about this, Mac did not mean to cause offence (as recognised by Jimbo and his subsequent ‘fat acceptance’). In short, Jimbo concurred with Mac, with both men effectively rejecting the bodily aesthetic and associated sensibility that denigrate fatness as shameful. This took the form of a simple admission, a case of ‘yeah, so what?’ However, while ‘bastard’ was incorporated into Jimbo’s identity, other expletives were not. The issue there, of course, was not the potential offensiveness of being called ‘fat’ though the aesthetic would have amplified the emasculating ‘cunt’ that conflicted with his identity as a tough Scotsman who should be treated with respect. Elsewhere, Jimbo told me that his workmates on a building site called him a ‘fat bastard’, though one man also called him a ‘fat cunt’ when he thought Jimbo was out of earshot. Jimbo was the foreman and, in exercising his authority, decided to dismiss this


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man (who we would squarely place in the prejudiced category – see the next section). In short, what we call the proud is a positive orientation to the otherwise discrediting bodily aesthetic and fat identity. During a subsequent interaction with friends and their wives (two women who publicly struggled with their weight), Mac jokingly encouraged Jimbo to adopt a ‘fat mind’, rather than a ‘thin mind’, and admit he was, like Mac, a ‘fat bastard’. This light-hearted exchange caused much laughter in the group and, while potentially offensive, was tempered by Mac’s point that men look acceptable when carrying extra weight provided they also have big shoulders. Friendship, social context and the physicality of the male body (relative distribution of fatness, and gendered evaluations of size and shape) all mediated the fat bastard label so that Mac could, with impunity, loudly and proudly declare his adoption of a fat identity and the need for his friend to take a similarly defiant stance in relation to the bodily aesthetic. Of course, and in finishing this section, the fact that we are dealing with an ideal type should be underscored. This is clearly captured in the ethnographic extract that opens our discussion on the proud and which was recorded in a highly carnivalesque context: the pub on a Saturday night, during a screened football match. Although one of the young men stated ‘we know we’re fat, we’re proud of it’ there was movement between this category and that of the stigmatised. Celebration and solidarity was apparent, but for one man in particular there was a movement from the declared ‘proud’ category when encountering another, more masculine, body shape (a muscular doorman who had big shoulders). Another man in this group, who was called a fat bastard by his friend, also sought immediately to minimise its salience by pointing to his friend’s fatness: ‘I’m not as fat a bastard as you!’ The lived reality of men’s fatness, identities and sensibilities is complex, contradictory and contingent. The above also corresponds with Berger’s (1963: 178–9) observation, made about ethnic minorities’ reactions to racism, that pride may be ‘hollow’ for people seeking to reverse ‘negative identity assignments’.

The prejudiced A woman at today’s research seminar expressed an interest in my work. After I mentioned I was writing something on men and dieting, and I’d send her copies of my work as and when it was published, she said: ‘I’ll show it to my husband. He should go on a diet’. I remarked

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that men often told me their wives or family encouraged them to diet, by, for example, suggesting they had ‘a bit of a tummy’. She replied bluntly: ‘I tell him he’s a fat bastard!’ (LM’s field diary) ‘The prejudiced’ do not identify as fat and they actively endorse the bodily aesthetic in relation to others whom they consider inappropriately fat. Their own weight/fat is not thematic in the interaction though this does not negate the possibility that they may be medically labelled ‘overweight’ or ‘obese’, or the possibility that they were ‘fat’ in the past but had since lost that weight and feel qualified to instruct others to do the same (e.g. Fumento, 1997, in Gard and Wright, 2005: 145–8). In short, the prejudiced maintain that ‘fat people’ should comply with the embodied obligation to lose weight and perhaps even be told this directly. Admittedly, as a perspective and mode of perception, it could be asserted that this process, similar to the misreading of racial differences in the eighteenth century, ‘is less an effect of conscious prejudice, than it is of historically and culturally specific tacit body knowledges’ (Murray, 2008: 33, emphasis added). Furthermore, there are obviously ‘supportive’ health professionals who seek to mitigate patient responsibility for obesity and lament about societal blame (e.g. obesity is a ‘disease’ in an ‘abnormal’ environment). Nonetheless, there is a pervasive ideology of individual responsibility, which means people who are labelled ‘obese’ (and who remain so) are commonly assumed to have made and seemingly keep making the ‘wrong choices’, that is, they are slothful and gluttonous. In societies where health maintenance is widely considered an individual’s responsibility, it is too easy to view adults with fat bodies as being responsible for their plight. As Goffman (1963) notes, under such conditions prejudicial responses (whether consciously intended or not) become exaggerated and can contribute to the stigma felt by others. The consumption of media valorising men’s lean and athletic physiques (see Crawshaw, 2007) also helps to reaffirm the sense of bodily appropriateness through which the prejudiced confirm their ‘normality’ or even sense of moral ‘superiority’. The above extract reproduces one woman’s talk about how she disparaged her husband, in line with her expectation that he should diet and what she assumed was a piece of social research that would support that body project. Whether her evaluation and misunderstanding was ‘informed’ by a prejudicial ‘concern’ for his health or something else (e.g. some women may wish to avoid ‘courtesy stigma’, that is, stigma by association (Goffman, 1963)), she endorsed the aesthetic in relation to another person. And, as observed elsewhere, such intolerance from


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various people and sources (wives, doctors, the public, the media) may trigger dieting among men or figure in their accounts about going on a weight-loss diet (Monaghan, 2008, especially Chapter 3). As stated by one man from the slimming club, Al, who sought to lose weight mainly because he routinely encountered stigma in public from people who ‘automatically think you’re a glutton or lazy fat bastard’: ‘you’re an easy target if you’re fat. There’s lots of prejudice and nasty people’ (cited in Monaghan, 2008: 95). What we term ‘the prejudiced’ is an ideal typical perspective and practice that provides the conditions of possibility for other types of sensibility, that is, the stigmatised, as explored in the next section. When discussing the prejudiced – which was also broached empirically in the previous section with reference to Jimbo’s workmates – our attention transcends everyday face-to-face interaction and research participants’ narratives. While empirical attention could be focused on, for instance, the ridiculing of fat people in songs and videos on the popular broadcast site, YouTube, or online discussion boards directed at a medical audience (Monaghan, 2010a, 2010b), what we have in mind here are broader public health discourses that legitimate fat fighting as an embodied obligation. Focusing upon these is necessary because it could be argued ‘the dire predictions and sheer intensity of “obesity talk” has more to do with preconceived moral and ideological beliefs about fatness than a sober assessment of existing evidence’ (Gard and Wright, 2005: 3; emphasis added). Authoritative calls to ‘combat obesity’ or defuse a ‘health time bomb’ (UK Parliament, 2004: 8) are seemingly based on certain science showing ‘fat is a killer’ but, as indicated earlier, such claims cannot be taken at face value (Campos, 2004; also, Campos, Chapter 2 in this volume). Of course, such preconceptions and pervasive definitions, routinely circulated with authority, may nonetheless be real in their effects. Those whom Basham et al. (2006) identify as ‘obesity crusaders’ engage with and create science in ways that, whether intended or not, perpetuate anti-fat prejudice. Claims within government policy documents, which cite think-tank reports declaring ‘we are facing a public health problem that the experts have told us is comparable with climate change in both its scale and its complexity’, further legitimate concerns about a crisis and, by implication, the view that many people are failing in their ‘duties’ as citizens (DoH, 2008: 3). This moral opprobrium occurs despite a de-personalised and seemingly mitigating focus on what is termed ‘the obesogenic environment’ (WHO, 1998), since the putative causes and consequences of the ‘epidemic’ (and prescribed solutions) are inseparable from individual bodies come neo-liberal consumers. Within the rhetoric of ‘the war on obesity’ such people should

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become active participants, rather than passive targets. And, as with real war, such definitions may amplify pre-existing societal prejudices and cruelties (Monaghan, 2008). ‘Obesity crusaders’ or alarmists would thus, despite their own subjective dispositions and possible vocabularies of motive (e.g. appeals to health care), be typified as ‘prejudiced’ on our analytical schema. However, in differentiating between and going beyond Basham et al.’s (2006) critique of ‘obesity crusaders’, we would include various types of ‘obesity epidemic entrepreneur’ or, more accurately, modes of entrepreneurship (Monaghan et al., 2010) which fits with our critique of sizist definitional practices rather than criticisms of actual individuals who may very well have good intentions. Such practices work through the social structure, or networks of relations and figurations, to include micro-social interactions and embodied social relationships. Dependent upon enterprise, and analogous with Becker’s (1963) ‘moral entrepreneur’, obesity epidemic entrepreneurs’ practices construct fatness as a correctable health problem. Entrepreneurship not only includes the moralising/ discrediting activities of obesity scientists and governments but also anti-obesity organisations (e.g. charities that receive considerable funding from Big Pharma), journalists, celebrities, clinicians, fitness instructors and slimming club leaders. The man in the slimming club come ‘entrepreneurial self’ (Petersen and Lupton, 1996) similarly engages in the social construction of fatness as a correctable problem. However, while he may certainly be prejudiced towards others who are considered ‘too heavy’, he would be categorised as ‘the stigmatised’ on our typology since fatness is an unwanted part of his identity just as it is for other men who may not consider themselves fat but who feel they are inappropriately labelled as such by other people.

The stigmatised I was out drinking on Saturday night and met up with a few guys I know. They’re in their twenties and a couple of them are avid football fans. One of them, John, is ‘mad for’ Manchester United. Under the influence of a few beers, and while walking from one club to another, they started a football chant: ‘He’s fat, he’s Scouse, he’s gonna rob your house, he’s Wayne Rooney!’ Thinking about ‘vocabularies of the discredited male body’ I asked John about the ‘who ate all the pies’ chant and ‘what’s all that about?’ John and his friend didn’t explain. Rather, and oblivious to whoever may be listening, they took the opportunity to chant this out loud: ‘Who ate all the pies? Who ate all the pies? You fat bastard! You fat bastard! You ate


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all the pies!’ As we walked around the corner they chanted this a second time within earshot of a stocky-looking man. He turned around and looked annoyed: ‘Hey, I’m a bodybuilder and powerlifter. I’m not fat!’ The chant was not directed at him, but he defined the situation as real and it was real in its consequences. John and his friend tried to appease him but he was unconvinced and, with macho posturing on both sides, physical violence almost ensued. Thankfully, though, it was avoided as we walked away. (LM’s field diary) Whether through direct interaction with the prejudiced, or their own internalisation of fatphobia, ‘the stigmatised’ reproduce the aesthetic and it forms an unwanted part of their identity. Some indication of this was provided when discussing the ambivalences of fat male embodiment and the prejudiced. Importantly, because the stigma of obesity potentially exerts an ‘unbearable weight’ (Bordo, 1993), and weightgain could also be gradual and imperceptible, an individual may not necessarily regard themselves as ‘fat’ until they are subjected to ‘shocking’ social processes and labelling that identifies them as such. This could occur in the clinic (labelled ‘obese’) or the street (labelled ‘fat bastard’). A glimpse in a shop window or a photograph could also trigger a ‘realisation’ that one’s body is ‘inappropriately’ fat, with the ‘owner’ of that body feeling that they are ugly or unacceptable (see Monaghan, 2008). Such processes of identification, or even misidentification, and degradation are captured in the above symbolically, if not physically, violent interaction. As far as the anonymous man was concerned, he was being offensively labelled as ‘somebody who was physically out of shape, gluttonous and deserving of public ridicule’. In Goffman’s (1963) sense, this man momentarily suffered a ‘spoilt identity’ that ‘discredited’ him even though his perceived labellers were not intentionally treating him as fat and unworthy of ritual courtesy and respect. Unfortunately, he felt he was being singled out and humiliated. More broadly, a parallel process of misidentification (misrecognition) and degradation also occurs in public health discourses and the clinic. This is because the standard measure of overweight and obesity, the BMI, does not measure fatness. Indeed, it classes muscular people as too heavy or fat with some men interviewed during this research, who were not bodybuilders, complaining about such labelling from their doctors. It is also worth adding that dietary choices cannot be inferred from weight, or inferred from reported weight-gain in the population, amidst uncertain, contradictory and equivocal scientific evidence (Basham et al., 2006; Keith et al., 2006).

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Even so, amidst pervasive prejudice and a sense of crisis, the stage has been set for a stigmatising power play and forms of strategic interaction that may be more or less protective of masculine identities and sensibilities. Here, men who risk stigma may employ ‘remedial activity’ in relation to their ‘deviant’ and unwanted bodily form as seen through their own eyes and/or the eyes of others. To follow Goffman (1959), in the face of a potentially discrediting interaction an individual stands ‘ready when called on to provide relief of various sorts’ for others (p. 183). What for the proud might be a chance for calibration or the assertion of fat identity is for the stigmatised a call to avoid embarrassment. Some of this also compares to the public apology. As Goffman (1971) explains when discussing ‘remedial work’, there is a ‘splitting of the self into a blameworthy part and a part that stands back and sympathizes with the blame giving, and, by implication, is worthy of being brought back into the fold’ (p. 113). Hence, rather than being proud (like the shameless ‘fat bastard’ or politicised fat activist), he joins the degradation ceremony. Such processes emerged in the mixed-sex slimming club, with Bernard (a ‘big loser’ who was previously ‘proud’ of his deviant social identity but who had since lost a lot of weight), disparagingly calling himself a ‘fat bastard’ who still had three stone (42 pounds) to shed (Monaghan, 2008: 59). Alternatively, the stigmatised may employ strategies to mitigate or avoid situations where they are open to negative labels (Degher and Hughes, 1999). And, as seen above, some men may claim they are muscular, rather than fat, in response to the aesthetic. Of course, the stigmatised may also take action to address the fat body by following medical advice, changing their lifestyle or employing other (typically ineffective and risky) remedies. This creates an alignment between ‘the prejudiced’ and ‘the stigmatised’, though this alignment is challenged by those we term ‘the wise’ and who are critical of the aesthetic and its amplification.

The wise The war on fat is an outrage to values – of equality, of tolerance, of fairness, and indeed of fundamental decency toward those who are different. (Campos, 2004: xvii) Those who are ‘wise’ are familiar with and sensitive to those seen to have fat or obese bodies, but they are not open to these labels themselves (Goffman, 1963). In terms of our typology, the wise, similar to the


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proud, reject the aesthetic and processes that amplify this (e.g. through consumer culture, medical practice, the new public health and the war on fat). Reflecting on the original notion of ‘the wise’ among ‘homosexuals’ in a context of homophobia and discrimination, Goffman describes ‘wise’ people as ‘normal but whose special situation has made them intimately privy to the secret life of the stigmatized individual and sympathetic with it’ (1963: 41). For Goffman, the wise are one of two sets of people from whom the stigmatised ‘can expect some support’, the other being ‘the own’ or ‘those who share his stigma and by virtue of this are defined and define themselves as his own kind’ (1963: 40–1). We would make clear, with reference to our typology, that the ‘support’ offered by the stigmatised sometimes consists of weight-loss advice and, as with ‘sympathetic’ clinicians endorsing weight-loss, this does not fit with our definition of ‘wise’ because it reproduces rather than resists the aesthetic. Although friends and family may be prejudiced and enact stigma (as noted earlier with reference to Brad and the woman at a research seminar), the wise could include people at close relational distance who claim to know the ‘real’ person ‘inside’ an otherwise discredited body. During interviewing and the slimming club ethnography, wives and daughters of men struggling with ‘weight problems’ sometimes acted in a way that could be typified as wise albeit in a larger gender order where female body dissatisfaction is normative (Bordo, 1993; O’Hara and Gregg, 2006) (hence, in terms of their felt identify, some of these women might be typified as the own rather than the wise even if objectively slim). For instance, when interacting with the researcher these women sometimes minimised the salience of men’s fatness as a physical stigma or underscored their man’s embodied qualities which, independent of weight-loss efforts, made him a good person rather than an irresponsible social pariah. And, in highlighting the degree to which our table is an ideal typical model (and the contingency of labels and lived bodies that could be identified as fat), there is a sense in which many research participants were wise even when personally identifying with ‘weight problems’. This is because men often rejected the word ‘obesity’ as stigmatising and they did not identify as ‘obese’ (defined by them as ‘extremely fat’) – an empirical observation that goes beyond the flesh and easily makes sense when noting Cohen et al.’s (2005: 154) comment that ‘even in the clinical setting, “obesity” is often imbued with value judgments and biases that associate overweight (sic) not only with poorer health but also poorer character and lack of education’. Understandably and wisely then, men often rejected the medicalised aesthetic

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even if they were carrying some unwanted weight or fat. Moreover, they often thought biomedical definitions of ‘overweight’ and ‘obesity’ based on BMI were ridiculous and laughable (Monaghan, 2007) (similarly, see Evans and Colls, Chapter 5 in this volume, on anti-obesity policy as a ‘grotesque discourse’ that is ‘ridiculous’ and incites laughter). Following our reference to critical weight studies, the wise may also include academics and practitioners who critique obesity science and fat fighting campaigns. Unlike proud fat activists (Cooper, 1998), fatness is not presented as a personal resource or integral component of their identity when mounting such a challenge (though their thinness may be seen by other people to privilege their critical contributions amidst pervasive and taken-for-granted anti-fat prejudice). For example, although exceptional, there are slim dietitians who are extremely critical (and, we would say, wise) but who are not visibly fat and who would not be medically classed as overweight or obese (e.g. Aphramor, 2006). Nonetheless, the wise may include those who publicly admit they were fat in the past and, to follow Goffman (1963: 31), were part of ‘the own’ but who subsequently ‘reformed’ their fat body (an obvious reason for their weight-loss is that they felt stigmatised, rather than proud). For example, Paul Campos, an influential critical weight scholar, is one such person who could be positioned in the wise category. After describing ‘the war on fat’ as an outrage to social values, Campos informs his readers that he transformed his ‘obese’ body into ‘someone who currently maintains what our public health establishment mischaracterize as an “ideal” weight’ (Campos, 2004: xxvi). He then explains how his previously fat body was a resource when writing The Obesity Myth. In line with Goffman’s (1963) description of the stigmatised who ‘pass’ as ‘normal’, Campos (2004: xxvi) describes himself as ‘a fat person hiding inside a thin body’ and sees ‘distinct advantages’ in this: ‘Who, after all, can describe a prison more accurately than one of its inmates?’ More sociologically, however, and following Berger (1963), we would add that society is ‘in’ the person and ‘prisoners’ may also busily keep walls intact – an imperfect analogy, as Berger himself acknowledges when subsequently describing society as a ‘puppet theatre’ and ‘tragi-comedy’, albeit one that is populated by conscious agents who are ‘entrapped by our social nature’ and ‘co-operation’ (pp. 140–1). Contributions from ‘wise’ critical weight scholars, even if well referenced and ethically informed, are frequently ignored and even attacked by ‘the prejudiced’. Nonetheless, we would maintain that such contributions have implications for public health and clinical practice and are important, just as men’s everyday understandings of health are


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important for health practitioners when seeking to take an informed approach (see Robertson, 2007). Following the reference to Aphramor (2006), a dietitian in the British National Health Service, the wise include practitioners and others who resist the weight-centred approach to health (also, Aphramor, 2005). As part of a series of critical papers on ‘the obesity debate’ in Social Theory & Health, Aphramor (2005) challenges clinical recommendations to lose weight. Citing supporting literature, she maintains that such advice is unethical and clinically unsound amidst extremely high failure rates, well-documented risks and the absence of informed consent (something which could result in patient litigation). Instead, Aphramor, along with a Canadian dietitian (Aphramor and Gingras, 2007), subscribe to an alternative clinical paradigm as an antidote to sizism: Health At Every Size (HAES) (also, Bacon, 2006; Gaesser, 2002; Robison, 2005). Although subjugated by prejudicial obesity discourse (and hamstrung by associated limitations in available research funding), Aphramor and Gingras explain in Chapter 8 of this volume that HAES is a more compassionate, ethical and effective approach to health and ‘weight problems’. It includes promoting nutritious diets and moderate physical activity for those seeking to improve their biomedical health (or metabolic fitness) without being sidetracked by numbers on the weighing scales, tape measure or BMI. Hence, it is also relevant for people at a putatively ‘healthy’ weight who experience health problems that are commonly attributed to obesity (e.g. cardiovascular disease). The vested interests of the prejudiced are also challenged, including the weight-loss industry and others engaged in obesity epidemic entrepreneurship. Finally, as per Aphramor and Gingras’ more recent developmental work on what they term ‘Health in Every Respect’, there is recognition of how social structural inequalities seriously impact health in ways that go beyond individual ‘choices’ and behaviour (similarly, see Marmot, 2004). Critical contributors to US health promotion literature similarly underscore more macro-social considerations and the harms associated with the current public health focus on obesity, or what Cohen et al. (2005) term ‘the O word’ (also, see O’Hara and Gregg, 2006, with reference to the Australian context).

Conclusion A motive for writing this chapter was a desire to recognise and take seriously how men might interpret and respond to a masculine bodily aesthetic in the wake of the putative obesity epidemic that reportedly affects most men in Western nations. This aesthetic, legitimated

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through discourses of health and risk management, is also shaped by popular representations of lean, toned and hard male bodies and their antithesis: the grotesque, ‘morbidly obese’ (sic) body. The aesthetic is overwhelmingly about normative male embodiment – the size, weight and appearance of the physique – which may be differentiated from visceral embodiment (Watson, 2000). The aesthetic, which has the potential to spoil identities through felt and enacted stigma, is often reproduced but also resisted in various contexts, ranging from the pub to the clinic. Analytically, we critiqued the aesthetic and the conditions under which it is articulated and embodied thus contributing to a new wave of studies that challenge obesity discourse. When exploring this public issue and sometimes-private trouble empirically it was necessary for us to report the modes of expression that men negotiate and use to position themselves in relation to masculine bodily ideals, labelling and possible stigmatisation. What the ‘wise’ reader might think of as vulgarised idioms are in common currency in the everyday lives of many men, though, understandably, they may not necessarily be articulated among people who risk being stigmatised as obese given situational proprieties (including those associated with ethical social research or a perceived middle-class audience). These idioms – also residing at the tacit level of ‘practical consciousness’ (Giddens, 1984) and ‘experiential embodiment’ (Watson, 2000), and which emerge in everyday interaction and the ‘underbelly’ of social life – are the product of a culture where masculinity is thought to proceed from men’s bodies (Connell, 2005). This is within a gender order where size, strength and forbearance have long been associated with hard physical labour and classed constructions of manliness. To be a ‘fat bastard’, at least for those we defined as ‘proud’, is to transcend any scientific definition of ‘obesity’ and to accept, if not relish, the role. The role also taps into a heritage where fictional characters like Pickwick were popular icons of what it was to be male. Labels such as cuddly, tubby and plump that have been applied to such men have less prominence in the lexicography of terms of endearment today. The term ‘fat bastard’ is aggressive and assertive, reflecting and resisting the cultural disparagement of fatness that has been overlaid by notions of stupidity, laziness, weakness and a failure as vigilant citizen. The label ‘fat bastard’ forms part of a vocabulary that particularly taps into British working-class masculinities where to be ‘hard’ is to be male while ‘bastard’ marks an otherness from middle-class, biomedical and state expectations about the good consumer/citizen. In connecting with other studies of masculinities and health, there is resonance here with


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Robertson’s (2007) qualitative research in Northwest England. Referring to men’s engagement with health care, rather than vulgarised idioms per se, he states ‘men frequently and publicly use (rhetorical and/or actual) resistance to health advice as a way of demonstrating masculinity’ (Robertson, 2007: 122) albeit without abandoning the idea that they are personally responsible for making ‘healthy lifestyle choices’ and thus are in control and independent, as per hegemonic masculine values. The typology we have presented is an ideal typical attempt to understand the complex cultural milieu that men, who are viewed as fat in everyday life, must navigate. We argue that the sensibilities adopted by the stigmatised, the prejudiced, the proud and the wise, reflect and/or provide ways of managing everyday life and the stigma of what medicine calls obesity. This is in a healthist culture where larger men have increasingly to explain or account for themselves if they are to construct ‘acceptable’ identities and resist subordination on gendered hierarchies (which are also intertwined with systems of exploitation and hierarchies based on class, age and so on). The need for such words reflects the power of the bodily aesthetic in contemporary Western culture, ‘tacit body knowledges’ (Murray, 2008) and the entrepreneurship that amplifies this evaluative schema throughout the social body with potentially detrimental effects on public health (Cohen et al., 2005; O’Hara and Gregg, 2006). A significant problem here is that medical and public health analyses of ‘risky’ bodies and lifestyles are inseparable from a larger assemblage or de-politicising obesity discourse, as well as embodied dispositions and political economic structures, which mark and potentially shame and blame individuals. This, we would stress, is a culture wherein commercial interests are capturing and driving the obesity agenda through the further commodification of health and standardised bodies that supposedly signify health. Within this embodied system of symbolic interactions, exchange, value and inscribed worth(lessness), the role of socio-economic structures – which have a measurable impact on morbidity and mortality (Marmot, 2004) – unfortunately appears less significant than individual consumer led choices and normative embodiment. Hence, the conditions will remain, at least for the foreseeable future, for what we have called a bodily sensibility and vocabularies of the discredited body. In the interests of public health and a more equitable society, we would reject the aesthetic and the authoritative definitional practices and structured interests that reinvent and amplify this. It is, of course, up to others to decide whether such thinking fits with their definition of wise.

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Acknowledgements An earlier version of this paper was published in Critical Public Health (2009), 19 (3–4): 341–62. The ESRC (grant number: RES-000-22-0784) provided funds for most of this research. Our thanks go to the ESRC as well as Robert Hollands and Gary Pritchard, for their help with this project. Finally, our thanks go to research participants who (whether intentionally or not) provided us with grounded insights into their bodily sensibilities.

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National Audit Office (2001) Tackling Obesity in England. London: The Stationary Office. O’Hara, L. and Gregg, J. (2006) The War on Obesity: A Social Determinant of Health. Health Promotion Journal of Australia 17: 260–3. Petersen, A. and Lupton, D. (1996) The New Public Health: Health and Self in the Age of Risk. London: Sage. Robison, J. (2005) Editorial: Health at Every Size: Antidote for the ‘Obesity Epidemic’. Health at Every Size Journal 19 (1): 3–10. Robertson, S. (2007) Understanding Men and Health: Masculinities, Identity and WellBeing. Maidenhead: Open University Press. Scambler, G. (2009) Review Article: Health-Related Stigma. Sociology of Health & Illness 31 (3): 441–55. Schauss, A. (2006) Obesity: Why are Men Getting Pregnant? California: Basic Health Publications. Shakespeare, T. (1999) Joking a Part. Body & Society 5 (4): 47–52. Shilling, C. (2003) The Body and Social Theory (2nd edn). London: Sage. Sobal, J. (2005) Men, Meat and Marriage. Food and Foodways 13: 135–58. Synnott, A. and Howes, D. (1992) From Measurement to Meaning: Anthropologies of the Body. Anthropos 87 (1–3): 146–66. Turner, B.S. (1996) The Body & Society (2nd edn). London: Sage. Turner, J. H. (2002) The Structure of Sociological Theory (6th edn.) California: Wadsworth. UK Parliament (2004) House of Commons Health Committee: Obesity. Third Report of Session 2003–4, volume 1. Ordered by The House of Commons, 10 May 2004. Online. www.publications.parliament.uk/pa/cm200304/ cmselect/cmhealth/23/2302.htm, accessed 8 September 2004. Wann, M. (1998) FAT!SO? Because You Don’t Have to Apologize For Your Size! Berkeley, CA: Ten Speed Press. Watson, J. (2000) Male Bodies: Health, Culture and Identity. Buckingham: Open University Press. Wernick, A. (1991) Promotional Culture: Advertising, Ideology and Symbolic Expression. London: Sage. World Health Organization (WHO) (1998) Obesity: Preventing and Managing the Global Epidemic. Geneva: World Health Organization.

4 ‘You Can’t Be Supersized?’ Exploring Femininities, Body Size and Control within the Obesity Terrain Irmgard Tischner and Helen Malson

In an atmosphere of neo-liberalism and healthism (Crawford, 1980), the war on obesity targets both genders (Monaghan, 2008). Such is the pervasiveness of obesity discourse that very few escape its evaluative gaze. All adults are to a large extent held responsible for their own health and well-being, and health is equated with body size by health professionals, the media and the general public alike (e.g. Department of Health, 2008; also see LeBesco and Braziel, 2001). As outlined in Chapter 1, dominant obesity discourse, and ‘epidemic psychology’ (Strong, 1990) with which it is associated, construct ‘fat’ as unhealthy and slimness and weight-loss as inherently good. Whilst such ideas are contested in critical weight studies (see Campos, Chapter 2 in this volume), the conflation of ‘being healthy’ with ‘losing weight or maintaining a low bodyweight’, recycled as discursive ‘truth’, is omnipresent and goes largely unquestioned within Western cultures. Both men and women who are seen as fat in everyday life risk being discredited by obesity discourse and its associated ‘concerns’. It is imperative then to recognise that these discursive effects can cause serious harms. These not only include probable stigma, discrimination and spoilt identities for ‘large’ individuals (e.g. Murray, 2005; Throsby, 2007) but also potential detrimental effects on the physical and mental health of individuals of any size. The equation ‘only slim = healthy’ can facilitate the rationalisation of ‘bulimic’ behaviours like purging as ‘healthy’ (Burns and Gavey, 2008) and generally contributes to many people having disturbed relationships with food and eating (e.g. Lupton, 1996; Orbach, 2006a). These harms are socially distributed according to various axes of 90

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power, including sexuality, ethnicity, age and profession (Probyn, 2008, 2009). One highly significant axis of power distribution is gender and, despite the pervasiveness of obesity discourse, we argue that gender equality within this medicalised and aestheticised terrain is still as elusive as in other areas of society. Generally speaking, women’s and men’s bodies and identities, their femininities and masculinities, are produced and regulated in qualitatively different ways and inscribed with different meanings. Women, particularly within Western cultures, have historically and currently been subject to considerably greater ‘pressure’ than men to conform to gendered body ideals particularly, since the 1960s, to slimness as a key signifier of ideal ‘femininity’ (e.g. Bordo, 1993; Smith, 1990). Whilst pressure on men to conform to particular body ideals is also increasing (e.g. Bell and McNaughton, 2007; Gill, 2008), the ideal masculine body is socially constructed as tall, strong, muscular and lean (Frith and Gleeson, 2004; Monaghan, 2007). A male body that is sizeable, and even technically overweight or obese based upon BMI, is at least entitled to occupy its space (Connell, 1987; Morgan, 1993, cited by Monaghan, 2007). Moreover, bodily appearance and hence bodyweight and shape is also less prominent in hegemonic constructions of masculinity-in-action than it is in typically more passive constructions of emphasised or ‘normative’ femininity (Smith, 1990). This gendering of how appearance figures in constructions of sexed/gendered identities can be understood in the discursive context of Cartesian dualism and the culturally entrenched, hierarchical binaries of mind/body, man/woman, culture/nature, rational/irrational (Malson, 1998). Whilst we cannot treat women as one homogeneous group, with women’s subjectivities being inflected by class, ethnicity, age and other cultural forces (Butler, 1999; Probyn, 2009), in Western cultures these Cartesian discourses add to the ways in which femininities are produced and constituted in terms of bodily appearance and consequently the intense production and regulation of women through their bodies. The constructions of ‘body fat’ and of ‘female bodies’ converge on ‘fat’ women’s bodies in as much as both ‘fat’ and women’s bodies are construed as uncontained, uncontrolled and dangerous to a Western patriarchal order (Grosz, 1994). That the female body has been and still is repeatedly constructed in Western cultures as inherently uncontrolled and thus in need of control has been noted by a number of writers and, as Grosz (1994: 203) maintains, the ‘metaphorics of uncontrollability’, common in ‘literary and cultural representations of women’, are constituted in terms of women’s

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bodily functions. This applies particularly to processes around sexuality such as menstruation and pregnancy, where themes of uncontrollability (in the form of menstrual blood flow) and undefined boundaries (in pregnancy) are signified: Can it be that in the West, in our time, the female body has been constructed not only as a lack or absence but with more complexity, as a leaking, uncontrollable, seeping liquid; as formless flow; a viscosity, entrapping, secreting; as lacking not so much or simply the phallus but self-containment – not a cracked or porous vessel, like a leaking ship, but a formlessness that engulfs all form, a disorder that threatens all order? (Grosz, 1994: 203) Thus, whatever its size or shape, according to this reading the female body per se is constituted as formless, uncontained and lacking control; as threatening to cultural (patriarchal) order and thus requiring containment. ‘Fat’ on female bodies, we would maintain, compounds (rather than initiates) this construction. Contemporary Western discourses of femininity and beauty in which the (heteronormatively) attractive woman is construed as small and slender have similarly been analysed as both reactions to and expressions of women’s relative lack of power and status in contemporary Western cultures (e.g. Chernin, 1983; Lawrence, 1979; Orbach, 1993); as gendered ‘ideals’ which stamp ‘control’ on a female body that is culturally constituted as uncontrolled (Bordo, 1993; Malson, 1998); and as a requirement which effectively incapacitates women from taking a more powerful role within society through what Wolf, for example, calls the ‘Professional Beauty Qualification’ (e.g. Wolf, 1991). In short, women may be constrained and disadvantaged by the additional energies and other resources they may be persuaded to expend on ‘maintaining’ their bodies, a drain on resources which equates to inequality. It is not through a ‘sovereign power’ of men (or any other group) or through its lacking in women, but through the discursive constitution of what a woman/man should be and look like (which in turn is inflected with issues of class, sexuality, age and ethnicity) that women are ultimately disadvantaged. Murray (2008) has recently articulated similar concerns in The ‘Fat’ Female Body. Incorporating reference to her own experiences of fatness, she states that fat women are constituted as an ‘aesthetic affront’ to society (even in twentieth century medical journals), adding: ‘what underpins the current “panic” over “obesity” in contemporary


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Western culture is a moral anxiety about the preservation of fixed gender identities and normative female sexuality and embodiment’ (pp. 2–3). This is not to say that men are under no pressure to work on themselves and their bodies as signifiers of personhood and masculine identity, and, indeed, many men may endeavour to negate aspects of their physicality that could be construed as woman-like (e.g. man breasts) whether directly by altering the flesh (diet, exercise, surgery) or indirectly through aggressive bravado (Monaghan and Hardey, Chapter 3 in this volume). Furthermore, there is a more general sense in which late modern citizens should engage in body work regardless of their own sex-specific corporeality. Valuing the individual, autonomous, selfimproving and self-regulating individual is a characteristic of neo-liberal societies, where we – men and women – are ‘obliged to be free’ (Rose, 1996: 17) to ‘choose’ the ‘right’ actions ‘for understanding and improving ourselves in relation to that which is true, permitted, and desirable’ (Rose, 1996: 153). The actions we ‘choose’, for example, choosing how much and what we eat – can be understood in terms of what Foucault termed technologies of the self: [T]echnologies of the self, which permit individuals to effect by their own means, or with the help of others, a certain number of operations on their own bodies and souls, thoughts, conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality. (Foucault, 1997: 225) In relation to health and health management in Western nations, the ‘cultural realities’ of what is true, permitted and desirable are constituted within medical discourses, which converge with contemporary discourses of consumer culture and aesthetics in classifying bodies as normal or pathological, healthy or unhealthy. These discourses, employed in, for example, governmental ‘health campaigns’ like the ‘Change for Life’ initiative in the UK (Department of Health, 2004; 2008) are utilized in turn in promoting products and services from fitness studios to supermarkets (e.g. http://www.change-4-life.org/worcester/) all promising to help us make the ‘right’ choices for a ‘healthy’ life. Our argument is then not that men somehow escape the regulatory power of this ubiquitous neo-liberal technology of a healthy self – or what Rich and colleagues (Chapter 6, this volume), term as ‘surveillant obesity assemblage’ – but that the operations of healthism are inevitably gendered, playing out sometimes quite differently in the interstices of the discourses in which

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health and gender are constituted. Our aim in this chapter is therefore to explore some of the significances of the ways in which fat bodies are also always-already gendered bodies, grounding this exploration in qualitative data and a Foucauldian discourse analysis of women’s and men’s talk about ‘fat women’ and (un)controllable femininities.

The research and analysis The analysis presented here is drawn from a three-year study into the experience of ‘being large’. In total, 24 women and five men were interviewed individually and in focus groups. The following is based on data collected during one focus group with men and one focus group with women, as well as individual interviews with women and men. The recordings of these conversations were transcribed verbatim1 and anonymised with pseudonyms. We have taken out the interviewer’s non-verbal interjections from the quotes to aid readability for the purpose of this chapter only. The data were discursively analysed, using a broadly Foucauldian approach. There are many versions of discourse analysis, with varying degrees of emphasis on an investigation of micro-interactions (under investigation of interpretative repertoires) at one end and a focus on broader discursive practices and potential political critique at the other end of the scale. These two ends of a scale are frequently termed ‘discursive psychology’ (DP) and ‘Foucauldian discourse analysis’ (FDA), respectively (Willig, 2008). Both discursive approaches are grounded in the post-structuralist notion that language does not reflect or transparently represent social reality, but that dynamic and ever changing versions of social reality are constructed through language (Gergen, 2009). They consider discourses as inconsistent and variable, and as constructed in social interaction as well as constructive of objects, subjects and realities. However, whilst DP focuses and locates this construction within discrete events of interaction, within which versions of the world are actively created between the respective individuals involved (Wiggins and Potter, 2008), FDA turns its focus onto which discourses are available to individuals within certain societal, cultural and political contexts (Parker, 1997; Wiggins and Potter, 2008). For Foucault, discourses are historically and culturally located, dynamic webs of statements, which are interrelated with other statements (Foucault, 1989/1972). Within these discursive fields knowledges and realities are constructed, and the types of discourses available determine what can be said (and by whom), and what types of objects,


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subjects, realities and ways of being are constructed (Parker, 1992). Foucault closely links knowledge with power which he sees as joined in discourse. Knowledges, or ‘regimes of truth’, are constituted in discourse, which in turn creates fields of possibilities – of acting, being and knowing. There is a reciprocal relationship between power and knowledge, and this power/knowledge transcends all aspects of life (Hollway, 1989; Malson, 1998). The subject in post-structuralist theory is constituted and regulated in discourse, and through dynamic and ‘power-infused processes of embodied subjectification’ (Papadopoulos, 2008: 143). This means that whilst the availability of certain discourses produce particular possibilities of ‘doing’ and ‘being’, subjectivities are not only imposed and either accepted or rejected but produced and reproduced through embodied experiences within these fields of possibilities (Papadopoulos, 2008; Smith, 1990). In FDA we thus investigate not only what discourses are available and deployed by individuals but also look at what Parker calls ‘the micro-level’, that is how these discourses are used and how subjectivities are produced within them, in order to be ‘able to identify the ways in which processes of ideology and power find their way into the little stories of everyday life’ (Parker, 1997: 293) and our embodied subjectivities. The discourses FDA examines are not to be understood as the discrete statements by individual participants that discursive psychology analyses. They occur or exist through the articulation of statements and the relations between a number of statements but no direct interaction between speakers is necessary or, as Foucault (1989/1972) puts it, the respective authors of the statements need not be aware of the relations between his and other author’s statements, neither do the authors need to know each other, or even be aware of each others’ existence. As such the pieces of discourse we investigate will always only be a fragment of the discursive field they belong to and the relations that form the discursive field are always shifting and dynamic, and as such always only provisional, never fixed (Foucault, 1989/1972). The aim is to locate statements within discursive fields and explore their relations with other statements, the knowledges, regimes of truth and power-relations that are constituted within their discursive fields and consequently what subject positions and ways of being are constructed and made available within them (Malson, 1998; Malson et al., 2006). There is no agreed one way of doing Foucauldian discourse analysis, and we would therefore like to briefly outline the steps taken in the analysis presented in this chapter: By reading and re-reading the

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transcripts we familiarised ourselves with the data and dominant themes were identified. These overriding themes, for example ‘gender’, were further analysed by marking and copying out all the pieces of text in the data that referred to it. Coding categories in respect of the construction of objects/subjects within the text were identified and transcript extracts copied and pasted into extract collations per object/subject. One collation of extracts was pulled together for each of the following: construction of gender differences; women (e.g. in talk about women’s position in society, restrictions on women’s lives and choices, and so on); large women; femininities (as in the performance of being a woman, e.g. what signifies being and feeling feminine); men; large men and masculinities. A category labelled ‘miscellaneous’ contained all extracts that offered an additional aspect of gender, something that was not entirely covered by the other coding categories mentioned above (one example is Erika’s talk about supportive women friends, where she draws on discourses of female friendships). Within these data-collations, we identified sub-themes on the object/subjects constructed, discourses employed and the construction of meaning within them. These subthemes, meanings and discourses were drawn together in a table of constructs, including some of the interview/focus group extracts which our interpretation was based on. An important part of discourse analysis is the application of one’s data to existing literature and theory, in order to locate it within discursive fields (see above) or as Parker puts it to ‘soak what you have {text-inprocess, in the form of interview transcripts} in this resource’ (Parker, 2005: 98). Literature used here includes works by Susan Bordo (1993; 1998/1990), Sandra Lee Bartky (1988; 1990), Elizabeth Grosz (1994) and others, as well as writings of Michele Foucault (e.g. 1977; 1988; 1991). Having decided what sub-themes should be analysed in detail, the information collated in the table was thus pulled together and analysed in relation to existing literature and theory. In our analysis, we are not concerned with, for example, any generalisable differences in men’s and women’s views but, rather, with how ‘fat women’ are discursively constituted (in both women’s and men’s talk) and with the gendered constructions of embodied ‘fat’, control, dieting and empowerment. In the following, we focus on the convergence of constructions of ‘fat’ and ‘femininity’ on ‘fat women’s bodies’ and with the ways in which constructions of ‘female fat’ are articulated. Drawing on accounts from both men and women – and focusing on the themes of appearance, the ‘uncontrolled female body’, woman as body, eating and dieting and finally empowerment – we explore how this gendering


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of ‘fat’ plays out in accounts of living as a fat person and, particularly, as a fat woman.

Appearance As argued elsewhere (Tischner and Malson, 2008), in/visibility plays a central part in the dynamic construction of ‘fat’ women’s subjectivities. This was articulated during the focus group discussions: Erika: And I do, I do find as well when uhm (.) even the really close circle of friends that I got in {city}, really, really supportive women of similar age and things, I’m, I am always very careful what I eat when I’m with them (.)/hmm/(.) because I don’t want to be seen to overeat/several: yeah/by them. (Women’s focus group) Even within the close circle of ‘really supportive women’, Erika construes herself as watchful of what she is eating in order not to be seen to be eating too much (similarly, see Murray, 2008). Of course not all ‘large’ women will be as careful and concerned as Erika about how they are seen. Significantly, however, awareness of one’s appearance, of being seen and ‘read’ from one’s appearance and visible actions in ways that might be stigmatising, was described in the women’s focus group as a general concern not only of ‘fat’ women but of all women: Erika: yeah (. .) it, what would be interesting would be whether the size, you know, 10s and 11, 12s in this world, how often they feel attractive, or whether they think, ‘oh my bum looks big in this, or my . . . ’, you know = Debbie: = they do actually, I’ve got a friend /Erika = it’s people’s perceptions/ she’s a size 8 and she, she says ‘oh, my bum’s really big’/{quiet laughter}/ and I was like ‘yeah, right, o.k.’/{laughter}/and then she, she asked me to go for coffee one day and I went ‘couldn’t possibly walk down the corridor with you, your bum is far too big’/={collective laughter}/and she felt really upset, and I’m like ‘uh, irony?’/{collective laughter}/so, yeah, I, I think whatever size you are, you, you hate certain lumps and bumps about yourself. (Women’s focus group) Deya: I have had all these problems with uhm other people’s perceptions of how I should look and that’s all it is, really, it’s not about you

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as a person at all. I mean how you are inside your head is nothing to do with how you look/I: no/but, the world today, society today (.) they just look at the outside, uhm a and that’s what you (are) judged on, you know, and so we’ve all become, (we all sort of from) the inside looking out constantly inspecting our (.) you know, chassis, like a car or something (emphasis added). (Interview) Thus, women in general are constructed here as concerned about their appearance and how their bodies will be judged by others and in this context are constituted as vigilantly self-critical of their own bodies and/or body-parts: ‘whatever size you are, you, you hate certain lumps and bumps about yourself’ and in ‘society today’ we are all ‘constantly inspecting our, you know, chassis’ (a tellingly masculinist metaphor that underscores how gendered bodies are socially constructed and experienced under a masculinist gaze). Indeed, the women in our study often constructed their bodies more like a collection of body parts to be assessed – ‘lumps and bumps’ and bums – than as integrated wholes. ‘My bum looks big in this’ is frequently presented as a ubiquitous refrain of women, and we encounter it in jokes, the media and day-to-day talk. It is received with the collective laughter of recognition by the women in the focus group, as something that is very familiar. This ubiquitous concern with physical appearance and the production of the body as a collection of body parts requiring improvement is part of what Shilling (2003) calls the ‘body project’, the lifelong endeavour to perfect the body. In this context, lifelong ‘overweight’ is construed as something necessitating a lifelong commitment to weight-loss and institutionally sanctioned control – as articulated in the following accounts from the women’s focus group: Laura: I went to a dietitian when I was 7/hmm/because I was picked up by the health screening at school as being overweight, and (.) that was the beginning. Dietitian when I was 7 and diets (.) ever since (.). (Women’s focus group) Debbie: I was a size 16 going to comprehensive school, and look, [ . . . ] I think, crikey, size 16, I’d love to be a size 16 but, looking back I felt enormous going to school/yeah/and I was the biggest girl in the school. (Women’s focus group)


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The women participants here construe their lives as constant battles with their weight, starting at an early age. These battles, which are, of course, mandated and legitimated by ‘the war on obesity’ as well as a ‘fashion-beauty complex’ (Bartky, 1990; also, see Monaghan, 2008) are fought on the grounds of both health and appearance. And in both discursive terrains ‘large’ women are positioned as in need of improvement. ‘Fat’ is culturally constructed as ugly (Malson, 1998), and being thin, albeit nowadays also ‘toned and slightly muscly’ (Arthurs and Grimshaw, 1999), is generally considered beautiful or ‘ideal’ for Western women. At the same time, discourses of beauty have dovetailed in recent years with discourses of health (Arthurs and Grimshaw, 1999; Malson, 2008) such that through the near interchangeability of ‘health’ and ‘beauty’, beauty ‘on the outside’ is read as health ‘on the inside’ (e.g. Malson, 2008; Markula et al., 2008). And, within a neo-liberal context, health (on the inside) is constituted as a matter of individual responsibility where everybody – men and women – is held responsible for their own health and deemed able to change health through ‘health behaviours’ (Rose, 1996). Whilst the production and maintenance of a healthy body is now constructed as a lifelong project for all, the lifelong project of appearance ‘enhancement’ remains distinctly feminised, even whilst it is also increasingly aimed at men (Gill, 2008). Women become actively engaged in ‘doing femininity’ through working on their bodies (cf. Smith, 1990; Ussher, 1997), which become ‘body projects’ of subjectivity, regulated through a nexus of discourses of heteronormative beauty, health and femininity. For Dorothy Smith (1990), women’s work on their bodies is part of the complex relations and discourses that ‘define’ and produce femininity. The recent convergence and conflation of ‘health’ (that is, a particular version of health, constituted through weight rather than other indices of the physical body) with ‘beauty’ and ‘femininity’ can be seen as further consolidating the regulation of women’s lives as lifelong body projects. The above accounts can also be seen as drawing on the discourse of Cartesian dualism in which the body is constructed as a separate, inferior entity to the mind, which needs to be controlled by the mind (Bordo, 1993). Drawing on these discourses, in the above excerpts, women are constituted as critical observers of their own bodies such that the scrutinising subject/mind is separated from the body constituted as an object of her critical gaze (see also Blood, 2005) and, as we have outlined above, in need of control and containment.

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The gendering dynamics of body size The containment of the female body in contemporary Western culture and its apparent threat to cultural/patriarchal order is (in part) achieved through the construction of the ‘ideal’ woman as slim (Bordo, 1993) – a body that is ornamental, streamlined and expressive rather than instrumental and capable of exceeding its own limits. This culturally constructed and constraining equation of normative ‘femininity’ with slim/small bodies – objectified-bodies-in-the-world, more so than embodied-subjects-that-physically-work-in-and-on-the-world – is articulated in the following excerpts from the women’s focus group where, one could argue, emphasis was given to our primary instrument for acting on and changing the world (i.e. the hands) as well as women’s fashions (thus connecting back to our section on appearance): Debbie: I feel less feminine (.) because of my size (. .) Judy: I can’t say I have ever felt feminine = Debbie: = then I also have my father’s large hands rather than my mother’s small hands, so (.) [ . . . ] I feel, the bigger I’ve been, the less feminine I’ve, I’ve felt. [...] Laura: In a lot of shops you do now also get a petite range/hmm/for small and short people/yeah/I’m torn between the two because I’m not very tall/{laughter} [ . . . ] Erika: But isn’t petite such a (. .) [ . . . ] connotations/{group comments}/are nicer connotations than plus/yeah {laughter}/your petite is one end and plus is the other. (Women’s focus group) In the above excerpts, large bodies, or indeed just large body parts like hands, are associated implicitly or by default with men and masculinity. Being small in height in itself is not enough: femininity is construed here as ‘petite’, as small in every sense and every direction – something that is also observed in Monaghan’s (2008) study where men sometimes justified their ‘bigness’ through appeals to embodied masculinity (‘being more of a man’) in contrast to women who were normatively positioned as ideally ‘petite and small’ (p. 48). Laura jokes that she is torn between the plus and petite women’s clothes sections of shops as she is ‘not very tall’. Through the laughter in the group this dilemma is


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constituted as a joke. Despite the fact that she is ‘not very tall’, as a ‘fat’ woman, Laura would not call herself petite in earnest, which, in contrast to ‘plus size’, is positively construed. ‘Your petite is one end and plus is the other’ (Erika). The ‘plus size’ conjures up images of adding on more, of too much, of excess. In addition to connotations of excess appetite as well as excess body, the excess signified by ‘plus size’ resonates too with the construction, outlined above, of woman as excessive, expansive and uncontrollable, in need of containment (Grosz, 1994). In the excerpts above, Debbie, Laura and Erika articulate their disqualification from this petite feminine ‘perfection’: their ‘plus size’ bodies signifying not an ‘ideal’ diminutive and contained femininity but an ‘improper’ excess of flesh (and perhaps appetite) on a body that, in being female, is already constituted as an excessive and uncontrolled liability (see also Ussher, 1991). The thin woman’s body, then, signifies the ‘ideal’ feminine woman, which, at the same time also signifies the inferiority of women in a patriarchal society – a body, and thus person, one (man) does not have to take seriously, and need not feel threatened by (Bordo, 1993; Malson, 1998; Wolf, 1991). Normative femininity is constructed as, and signified through, smallness, fragility, emotionality and frivolity, all characteristics that are constructed as inferior to men’s rational and unemotional mode of operation (Malson, 1998). Sarah Crawley (2002), in her very entertaining ‘autoethnographic rant on dresses, boats and butchness’, argues that women’s bodies are also socially constructed as less able than men’s bodies. This construction of the idealised, that is small, female body, as being not as capable as a man’s body was also evident in our data. In contrast to the constructions of the ‘fat’ woman as lacking control and therefore ‘being no good’ for a job, discussed above, here her size was construed as working for her in respect to gaining respect in the (male-dominated) workplace. As can be seen, however, this entailed negating her femininity in order to ‘pass’ in a domain where instrumental rational action, and getting ‘one’s hands dirty’, took precedence over other forms of gender validation: Lucy: I worked for quite a long time, well for 19 years for {communications company}, and 13 of those years I spent as an engineer (.) uhm, I was the second woman in {city} to become (.) an engineer (.) uhm, the girl before me was slim, blonde and (.) the guys used to do everything for her (.) whereas I was (.) not as overweight as I am now but I was still overweight, and, hence, I (.) more rapidly became accepted because I was seen as being possibly stronger (.) and more

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able to do the job than being a delicate thing/general murmur/I mean one of the guys that I was, an out and out, uh, not quite a misogynist but going that way (.) one day at tea break sat down and said, well, yeah, well you, Lucy, you’re just one of the lads (. .) and I actually th- (. .) took that as quite a compliment/(inaud)/in that I’ve been accepted as being just me/yeah/ (Women’s focus group) Similar to the above quotes where ‘largeness’ was construed as nonfeminine here again being overweight is produced as signifying nonfemininity, however, this time not in an entirely problematic way. The above extract positions Lucy as ‘one of the lads’, as a non-feminine woman within society, generally, and one could say thereby disqualifies her from femininity as conventionally defined in terms of appearance comprising a streamlined physicality (and other aspects of the body, such as blonde hair). However, in contrast to the earlier positioning of ‘fat’ women, Lucy here also constructs her ‘overweight’ as enabling her to gain respect in a male-dominated work environment. By not being ‘slim’ and ‘blonde’ (and typically woman-like) she is being considered an equal who can hold her own like the other ‘lads’ she works besides. Dorothy Smith (1990) uses the phrase ‘fatness as a repudiation of the local organization of femininity’ (p. 183) to describe the way in which being ‘fat’ can free women from the ‘doctrines of femininity’ (p. 171). These doctrines of femininity, that is the socially constructed notions of what makes a woman, are being distributed and reinforced through the discourses of femininity within the mass media and day-to-day talk, but also through women’s compliance with them. Women gain ‘membership’ in the discourses of femininity, through the adoption of the practices and appearances prescribed within the doctrines. The images women thereby create are being ‘read’ by others – often in terms of the above discussed signifiers of femininity, that is thin/small, emotional, frail, caring for others, passive, and so forth and in relation to the male-dominated workplace as possibly less able or ‘incompetent’ (e.g. Nicolson, 2002; Orbach, 2006b; Smith, 1990): When they lose weight, that is, begin to look like a perfect female, they find themselves being treated frivolously by their male colleagues. When women are thin, they are treated frivolously: thinsexy-incompetent worker. (Orbach, 2006: 22; original emphasis)


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Some women may thus intentionally break the interpretative circle and avoid the doctrines of femininity in order to avoid the thin/feminine/incompetent complex (Crawley, 2002). We are not suggesting that women intentionally become ‘fat’ in order to succeed in the world of engineering or other male-dominated work environments, and the dynamic constructions of women within the discursive fields of the workplace and capabilities remain problematic. Whilst some ‘large’ women (who are seen to be like men or ‘lads’) are positioned as competent and respected members of a predominantly male work-force within discourses of embodied masculinities and femininities in the above excerpt, the discourses equating normative femininity with less capability, irrationality, lack of self-control and so forth stay in place. These discourses were also evident in talk about food, eating and dieting in our study.

Women’s diets, food and freedom: From personal troubles to a public issue As numerous commentators have observed, and as briefly outlined above, Western culture places very high value on self-discipline and the size of one’s body is seen as a signifier of a person’s self-control (e.g. Lupton, 1996; Rose, 1996). The gendered body is not only personal in such a terrain, but also very public. Women, in particular, may be evaluated by others and themselves and seek to construct their embodied identities in relation to these dominant and highly publicised discourses. This is reflected in constructions of (feminine/feminising) fat as signifying an absence of control, with self-control construed as dieting or not eating: Judy: you cannot buy a woman’s magazine now, without it offering you a diet on the front page, to make you feel as if, if you’re a woman you gotta be on a diet, if you’re fat you gotta be on a diet/hmm/and you cannot get away from it, wherever you move. (Women’s focus group) In the above quote dieting is construed (in magazines) as a woman’s and a ‘fat’ person’s duty, with a personally experienced trouble becoming a public issue (Mills, 1970/1959) as manifest through ubiquitous obesity discourse. This imperative not to eat in order to lose weight is continuously constructed in discourses of health, discourses of femininity and indeed in the common narratives we come across on a daily

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basis2 as reflected in the excerpts below. As can be seen and in accord with recent observations in critical weight studies (Evans et al., 2008; Monaghan, 2008), medical practice and medicalisation are also very much implicated in such talk, thought and action – a commonly recycled and potentially injurious obesity discourse that cannot be divorced from gender and which is imbued with militarised metaphors that are also part of everyday parlance (e.g. ‘battling’ with one’s weight): Sue: I think it’s it it’s again, it’s a judgemental thing I mean partly in the in the medical services now it’s such a big issue that, you know, if you cross the, dare to cross the door for anything, even if it’s just a vaccination for a holiday, you know they will be uh, you know you are not gonna not gonna get out without getting on the scales, you know, and it’s uhm (. .) it’s, it’s frustrating because, you know, you can’t lead your ordinary life because this, the fact that you are, you know you got a weight problem, will get in the way. (Interview) Jemima: I did once say to somebody they made made a comment about eehm needing to needing to lose weight and I said oh yes I know it’s such it’s it is such a battle. ‘Well all you’ve got to do is stop eating isn’t it?’ I looked and I went o.k. thank you for your helpful advice. Well and they were they were big as well and eehm it was a it was a chap actually and he was going on and on and on about me needing to lose weight and I’m like well excuse me but have you actually looked at yourself? I mean I don’t normally because I know how hurtful it is but I was just getting so in . . . that he felt I I that he could comment about me. (Interview) The socially accepted norms of ‘perfection’, of health and beauty, are constructed, circulated and maintained through the above-mentioned discourses in texts, images, talk and action. As such our practices, our technologies of the self, are regulated in and through discourses. As articulated in the excerpts above, there is no getting away from the discourses of health and beauty that construct women as ‘ideally’ always dieting and dieting/not eating as a feminised3 practice. This normalisation of women’s dieting (see also Orbach, 1993) was constructed in the men’s focus group as a counterproductive and harmful social pressure which ‘must be a great deal worse’ for women, a view


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that is also expressed by men who have participated in other studies (Monaghan, forthcoming): Rich: I think that sort of diet thing is, must be, must be, I cannot say it is, but I, but I would imagine it must be a great deal worse {for women}/I: hmm/In my view it must be a great deal worse (.) I: In what way? Rich: All the social pressure to, to, to not eat uhm (.) which is basically, I mean, the whole way through, it’s an unhealthy thing because what it ends up doing is, [ . . . ] you tend to eat more and more privately/Don: mhm/(.) which means it’s actually doing the opposite/ Don: mhm/you know the social pressure is actually having the opposite effect to what (.) you would imagine the social pressure would. You’d think the social pressure would, would depress somebody’s eating when act-, in fact it’s pushing the eating into a private place where it can actually be (.) uhm (.) more, you know, they could be eating more, and more unsuitably, because uhm, because what you eat in private tends to be (.) you know portable (inaud) tasty foods tend to be much worse for you. (Men’s focus group) Thus, Rich suggests that ‘the diet thing’ is ‘a great deal worse’ for women than men and goes on to construe this as counterproductive by drawing on everyday understandings of criminal(ised) practices such as drugtaking, which he presents as ‘pushed . . . into a private place’, resulting in ‘over-indulgence’. Significantly while Rich articulates a ‘womanfriendly’ account that is critical of ‘the diet thing’ his argument is also premised on a assumed ‘unsuitable-ness’ of the ‘eating more’ that he suggests women do in private spaces. Representations of women eating in secret have also been analysed by Bordo (1993) in her work on advertisements for food products. Women, she suggests, are generally depicted eating publicly only in a restrained way, but as indulging in food once hidden away behind ‘do not disturb signs’. Thus, Bordo claims that ‘female eating is virtually always represented as private, secretive, illicit’ (p. 129) and links this also to Victorian times, when women were instructed that it was not appropriate for them to show unrestrained appetite: The representation of unrestrained appetite as inappropriate for women, the depiction of female eating as a private, transgressive act,

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make restriction and denial of hunger central features of the construction of femininity and set up the compensatory binge as a virtual inevitability. (Bordo, 1993: 192) This dynamic in the construction of ‘eating what one wants’ for women as something that was wrongly pushed ‘underground’ by society’s disapproval on the one hand, and as problematic on the other hand, was also evident in the following excerpts. Here, again, unrestrained eating was construed as an act of freedom and rebellion yet, at the same time, as a problem, as trouble: Judy: I don’t think I was really fat until I, after I’d had the children, but the real problem started when I left my husband and I was allowed to do what I wanted to do for the first time in my life (. .) I can eat when I want, and eat what I want, whenever I want (.) Debbie: The same thing happened to me when my mother died. I went from (. .) not, only having chocolate on the weekends or whatever and then mum died and I could have chocolate every night of the week if I wanted to, so I did/yeah/and I’ve grown 10 stone within (.) 3 years/yeah/ (Women’s focus group) Linda: I wouldn’t eat a pudding {when eating out with mum} because I would, mum would frown upon that, uhm, I probably wouldn’t have starters, I probably just have a main course and it probably would be salad {laughter} Laura: Trouble is, you then go home afterwards = {laughter} = and you make up for it/several: oh yeah/because it’s that reaction, it’s like ‘now I can have what I want to have’/yeah, it is isn’t it/(. .). (Women’s focus group) In these excerpts, the women represent themselves as grasping some freedom in eating what they want. Having been controlled by others in their eating habits for a long time once they can eat what they want they will. The controlling is here not constructed as general social pressure but as happening within family structures, with the women (apart from Judy) positioning themselves as rebelling against maternal (or sometimes a husband’s) disapproval. Lupton (1996) describes how young adults, when moving out from home, enjoy the new-gained


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power over what they could and could not eat, and similar discourses of shifts in power relations are at work here. From being disempowered by husband or mother, women construe themselves as then enjoying self-determination in relation to food as soon as they can. However, this freedom of eating, this rebellion, is still enacted behind closed doors, done in hiding, and still constructed as something that is ‘trouble’. Whilst positioning themselves as rebels within discourses of familial and patriarchal control, the dominant and stigmatising discourse of the ‘fat’ overeater is held in place within these articulations. The simplistic conflation of the stereotypical ‘obese’ body with gluttony and/or the eating of ‘bad’ food within these discourses is contested by some fat activists (e.g. Cooper, 1998) as well as writers from other disciplines (e.g. Jutel, 2005; Keith et al., 2006; Murray, 2005), and the identity struggle it imposes on ‘fat’ individuals is reflected in our research data. In Laura’s comment, confirmed in the collective laughter of recognition it receives, there is a dynamic tension between, on the one hand, finally getting the food one wants but, on the other hand, construing this as a rebellion against a seemingly appropriate or necessary (maternal/patriarchal) control. As such the women here position themselves as troubled rebels, who may be ‘wrong’ for indulging their appetites.

Empowering women’s ‘fat’?: Strategies for managing potentially spoilt gendered identities Being ‘fat’ was not always construed as wholly negative, however, although positive aspects may entail other drawbacks for women, for example a negation of normative femininity, as discussed above in the context of male-dominated workplaces. Within the discourses articulated in our study, ‘large’ bodies were constituted as empowering in various circumscribed ways. As mentioned above, the construction of embodied masculinities and femininities is mediated by issues of class, sexuality, professions and subcultural aspects; in relation to (sub)cultural aspects of embodied ‘fat’ masculinities Monaghan (2008), for example, has provided a detailed discussion with reference to men’s accounts. In our focus group, size was also construed as potentially empowering for women albeit, as seen in the following focus group excerpt, with reference to modes of comportment that are equated with masculinity (violence and conflict management). What readers may also observe in this extract, and in connecting back to some of our previous analysis, is evidence of ongoing identity problems for some of these

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women vis-à-vis dominant discourses that equate valued femininity with physical appearance: Erika: But it’s also partly how we feel about ourselves, though, isn’t it, how we/Laura: yeah/project ourselves (.) and how (.) ‘cause I, I think occasionally being big has actually helped me, where, for example, I used to work in an FE college, in the library there, and we, we had a huge fight break out in the middle of the library, so I just stood in the middle and, ‘right, you go there, you go there’ (.) big (.) you know, and, and, they had to take notice of you, uhm, no doubt if I had been much smaller but still with a loud voice, may be I could have done it, but the fact that I was physically big gave me, empowered me to enable me to do that (.) so I think it, it’s partly how we feel about ourselves as well/hmm/because how often do any of us feel really, really attractive? (. .) {quiet laughter}. (Women’s focus group) In the above account, being ‘large’ is associated with strength and with not being ‘messed around’, a small benefit, one might say, given (a) normative idealisations of valued femininity which women often measure themselves against and (b) the larger symbolic assault on people who are routinely discredited as inappropriately fat or obese within interpersonal interactions, public health campaigns and the current war on obesity. Erika construes being ‘physically big’ as empowering and enabling, drawing on a discourse of liberal individualism to construe empowerment as a product of ‘how we feel about ourselves’ – a feeling that comprised ambivalence and contradiction and was publicly shared following Laura’s emphasis on ‘we’. Nonetheless, in seeking to manage spoiled identities and stigma (Goffman, 1968), being seen and heard as a ‘fat’ woman was also construed as empowering in other places and in ways that did not necessarily entail negating their femininity as conventionally defined (e.g. being fashion conscious or engaging in dance). Also, some of the participants in our research who identified as fat found it empowering to see larger individuals achieving in areas that are socially constructed as reserved for ‘slim’ people (e.g. running). Eileen spoke about wearing shorts in public, for example, and Charlotte talked about her dancing and orienteering friends: Eileen: I mean I personally haven’t got a problem with wearing things like shorts /I: mm/ um, but I’m, I’ve got big friends and I’ve got


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friends that wouldn’t wear sleeveless tops [ . . . ] and I’ve even had people stop me in the street and say oh I’ve always wanted to wear shorts, I just wanted to say ‘oh God you’ve just made my day seeing you in a pair of shorts’. (Interview) Charlotte: I guess I do carry these internalised notions of what a ‘fat’ person can do and it’s important to me to be around people that that kind of buck those notions like (.) my friend {name} is a dancer she’s just an incredible dancer/I: Hmm/and you know, uh and not just like (.) a {laughing} crappy dancer, she’s like a da, a prop, a proper professional dancer and she’s fat and my friend {name} in Norway does orienteering and, you know, she runs around in the woods with a map and she’s my size, and you know I find that (.) just amazing and kind of really nourishing to be around people like that. (Interview) Visibility and being seen has long been associated with the ‘male gaze’ (e.g. Coward, 1984) and surveillance (Foucault, 1977). However, as Foucault (1977) argues, power is productive as well as constraining. As detailed in work elsewhere (Tischner and Malson, 2008), being visible as a ‘fat’ woman and watched by others takes on a different significance here, as it is constructed by both Eileen and Charlotte above as having a productive rather than constraining power. There is in these accounts a similar emphasis on the visibility of women’s large bodies but the powerrelations that are constituted in Eileen’s and Charlotte’s accounts are normalising of bigger women’s bodies and enabling rather than excluding and disabling. In addition, the positive effects of being seen and seeing other ‘large’ individuals are not only constructed on a one-to-one basis with one person learning from one other. They are constructed at a social as well as an individual level – as leading to a normalisation of the visibility of, and perhaps subsequently improved acceptance of ‘large’ people.

Conclusions One of the major themes discussed in this chapter has been the gendered dynamic around control. The constructions of ‘fat’ and femininity converge on the ‘large’ woman’s body, in as much as her body in terms of both its size and its gender is made to signify a lack of self-control, self-containment and thus as threatening to (patriarchal) order (except,

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perhaps, in the context of some male-dominated work environments, as discussed above). This threat then becomes contained through a positioning of ‘large’ women within discourses of health, femininity and beauty as in need of improvement to be achieved through a ‘body project’ of self-scrutiny and a lifelong battle with her bodyweight. The current atmosphere of healthism, the ever-intensifying ‘war on obesity’ and the conflation of health and beauty thus produce an evermore restrictive prescription of available ‘body projects’. The ‘obesity debate’, in our view as feminist social psychologists, thus needs to be expanded beyond its rather limited and limiting horizons to explore these complex gendered discursive interactions and the various ways they may produce and regulate the embodied lived experiences and identities of women of all sizes. In connecting with other feminist literature we would add that this is with an awareness of many Western women’s often already troubled relationships with their bodies, food and dieting. We would stress that women are not passive dupes within these complex discursive systems and dynamics of power, however, but position themselves as active agents within these projects of body, health and femininity. They may simultaneously accept and reject the subject positions of, for example, the ‘troubled’ eater on the one hand and rebel on the other hand, in their accounts of eating with other people and in private. There is an ambiguity between taking control over their eating by eating in private, and at the same time construing this private eating as problematic. In all of these, there are also tensions and ambivalences with regards to the negotiation of stigmatising identities and stereotypes that would position fat people as gluttonous and out-of-control. ‘Large’ bodies were not only construed as problematic but also as empowering at times. However, as observed, the negation of negativity also often entailed the negation of normative femininity with becoming empowered also meaning becoming more ‘masculine’ in places (e.g. becoming ‘one of the lads’ or forceful and potentially violent). At other times, our respondents’ discourses ‘fitted’ with ideals of femininity in a way that was subjectively experienced as empowering by them (e.g. with reference to fashions and professional dancing). Whilst we have focused our analyses in this chapter on a gendering of ‘fat’ which, we have suggested, often disadvantages (fat) women, we have also sought to illustrate how women who participated in our study offered accounts that moved beyond and resisted the reductionist and truncated terms of dominant obesity discourse so that fat bodies figured as empowered, strong, enabling and able to engage in activities (e.g. orienteering) that are often socially constructed as reserved for slim people. Increasing the


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visibility of ‘fat’ individuals engaged in such activities was constructed as normalising of the ‘fat’ body and as such as validating and potentially aiding the social acceptance of fat. The latter may be difficult for obesity epidemic alarmists to accept. However, considering the social construction of health and well-being, for the individual ‘large’ person there are potential benefits to be derived from the discursive expansion and diversification of acceptable body shapes and sizes vis-à-vis embodied identities, relationships and health practices. Some of these themes are taken up in subsequent chapters, such as Charlotte Cooper’s account of fact activism (Chapter 7) and Lucy Aphramor and Jacque Gingras’ chapter on dietetics and Health in Every Respect (Chapter 8).

Notes 1. The following transcription conventions were used: {laughing/laughter} spoken whilst laughing {} passages (e.g. names) anonymised by researcher or additional explanations that are not part of the original interview [ . . . ] denotes were small sections of the transcript have been cut out (.) (. .) ( . . . ) pauses – more points denote longer pauses () inaudible or unclear passages, so the accuracy of the transcription is not guaranteed do – Italics denote words/phrases that were emphasised/stressed by the interviewee // – interjections = denote beginning and end of overlapping speech or if there was no break between the to speakers’ utterances (↓) denotes a drop in volume in the word/phrase following the symbol. 2. On a recent trip to Munich, the first author was reminded of this socially constructed female duty to watch one’s calorie intake and to choose diet drinks (and foods) by an air hostess: When offered a drink, Irmgard asked for a can of coke, and was promptly presented with a can of Diet Coke. She responded to the offer by saying: ‘Could I have “proper” coke, please?’ The air hostess, pointing to the red non-diet coke can on her trolley, with an incredulous tone in her voice asked: ‘This one?’ and after Irmgard’s confirmation added: ‘It’s just that ladies don’t ask for diet coke, but always mean it’. It seems that diet coke is construed as the standard for ‘ladies’. 3. For excellent discussions of the implications of this construction of dieting as feminine for ‘fat’ men, please see Stearns (1997) and Monaghan (2008).

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Goffman, E. (1968). Stigma: Notes on the Management of Spoiled Identity. London: Penguin. Grosz, E. A. (1994). Volatile Bodies: Toward a Corporeal Feminism. Bloomington, IN: Indiana University Press. Hollway, W. (1989). Subjectivity and Method in Psychology. London: Sage. Jutel, A. (2005) Weighing Health: The Moral Burden of Obesity. Social Semiotics, 15(2): 113–125. Keith, S. W., Redden, D. T., Katzmarzyk, P. T., Boggiano, M. M., Hanlon, E. C., Benca, R. M., Ruden, D., Pietrobelli, A., Barger, J. L., Fontaine, K. R., Wang, C., Aronne, L. J., Wright, S. M., Baskin, M., Dhurandhar, N. V., Lijoi, M. C., DeLuca, M., Westfall, A. O. and Allison, D. B. (2006) Putative contributors to the secular increase in obesity: exploring the roads less traveled. International Journal of Obesity, 30: 1585–1594. Lawrence, M. (1979) Anorexia Nervosa: The Control Paradox. Women’s Studies International Quarterly, 2, 93–101. LeBesco, K. and Braziel, J. E. (2001) Editors’ Introduction. In: J. E. Braziel and K. LeBesco (eds), Bodies Out of Bounds: Fatness and Transgression. Berkeley, London: University of California Press, pp. 1–15. Lupton, D. (1996). Food, the Body and the Self. London: Sage. Malson, H. (1998). The Thin Woman: Feminism, Post-structuralism and the Social Psychology of Anorexia Nervosa. New York and London: Routledge. ——— (2008). Deconstructing Un/healthy Body-weight and Weight Management. In S. Riley, M. Burns, H. Frith, S. Wiggins and P. Markula (eds), Critical Bodies – Representations, Identities and Practices of Weight and Body Management. Basingstoke: Palgrave Macmillan, pp. 27–42. Malson, H., Schmidt, U. and Humfress, H. (2006). Between Paternalism and Neo-liberal Regulation: Producing Motivated Clients of Psychotherapy. Critical Psychology, 18: 107–135. Markula, P., Burns, M. and Riley, S. (2008). Introducing Critical Bodies: Representations, Identities and Practices of Weight and Body Management. In: S. Riley, M. Burns, H. Frith, S. Wiggins and P. Markula (eds), Critical Bodies – Representations, Identities and Practices of Weight and Body Management. Basingstoke: Palgrave Macmillan, pp. 27–42. Monaghan, L. F. (2007). Body Mass Index, Masculinities and Moral Worth: Men’s Critical Understandings of Appropriate Weight-for-height. Sociology of Health & Illness, 29(4): 584–609. ——— (2008). Men and the War on Obesity: A Sociological Study. Oxon and New York: Routledge. ——— (forthcoming). Men on Women: Doing Gender through Weight-related Talk (provisional title). Morgan, D. (1993) You Too Can Have a Body Like Mine: Reflections on the Male Body and Masculinities. In: S. Scott and D. Morgan (eds), Body Matters: Essays on the Sociology of the Body. London: The Falmer Press. Murray, S. (2005). (Un/Be)coming Out? Rethinking Fat Politics. Social Semiotics, 15(2): 154–163. ——— (2008). The ‘Fat’ Female Body. Basingstoke: Palgrave Macmillan. Nicolson, P. (2002). Having it All? Choices for Today’s Superwoman. Chichester: J. Wiley. Orbach, S. (1993). Hunger Strike – The Anorectic’s Struggle as a Metaphor for our Age (New edn). London: Penguin.

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——— (2006a) Commentary: There is a Public Health Crisis –It’s Not Fat on the Body but Fat in the Mind and the Fat of Profits. International Journal of Epidemiology, 35(1): 67–69. ——— (2006b) Fat is a Feminist Issue: The Anti-diet Guide; Fat is a Feminist Issue II: Conquering Compulsive Eating (New edn). London: Arrow. Papadopoulos, D. (2008) In the Ruins of Representation: Identity, Individuality, Subjectification. British Journal of Social Psychology, 47(1): 139–165. Parker, I. (1992) Discourse Dynamics. Critical Analysis for Social and Individual Psychology. London: Routledge. ——— (1997) Discursive Psychology. In D. Fox, and I. Prilleltensky (eds), Critical Psychology: An Introduction. London: Sage, pp. 284–298. ——— (2005) QualitativePpsychology: Introducing Radical Research. Maidenhead: Open University Press. Probyn, E. (2008) Silences Behind the Mantra: Critiquing Feminist Fat. Feminism & Psychology, 18(3): 401–404. ——— (2009) Fat, Feelings, Bodies: A Critical Approach to Obesity. In: H. Malson and M. Burns (eds), Critical Feminist Approaches to Eating Dis/orders. London: Psychology Press, pp. 113–123. Rose, N. (1996) Inventing our Selves: Psychology, Power, and Personhood. Cambridge and New York, NY: Cambridge University Press. Smith, D. E. (1990) Texts, Facts, and Femininity: Exploring the Relations of Ruling. London: Routledge. Stearns, P. N. (1997) Fat History – Bodies and Beauty in the Modern West. New York and London: New York University Press. Strong, P. (1990) Epidemic Psychology: A Model. Sociology of Health & Illness, 12(3): 249–259. Throsby, K. (2007) ‘How Could You Let Yourself Get Like That?’: Stories of the Origins of Obesity in Accounts of Weight Loss Surgery. Social Science & Medicine, 65: 1561–1571. Tischner, I. and Malson, H. (2008) Exploring the Politics of Women’s In/visible ‘Large’ Bodies. Feminism & Psychology, 18(2): 260–267. Ussher, J. M. (1997) Fantasies of Femininity – Reframing the Boundaries of Sex. London: Penguin. Wiggins, S. and Potter, J. (2008) Discursive Psychology. In: C. Willig and W. Stainton Rogers (eds), The SAGE Handbook of Qualitative Research in Pychology. Los Angeles, California, and London: Sage, pp. 73–90. Willig, C. (2008) Introducing Qualitative Research in Psychology – Adventures in Theory and Method (2nd edn). Maidenhead: Open University Press. Wolf, N. (1991) The Beauty Myth. London: Vintage.

5 Doing More Good than Harm? The Absent Presence of Children’s Bodies in (Anti-)Obesity Policy Bethan Evans and Rachel Colls

Introduction The growth of overweight and obesity in the population of our country – particularly amongst children – is a major concern. It is a health time bomb with the potential to explode over the next three decades . . . . Unless this time bomb is defused the consequences for the population’s health, the costs to the NHS and losses to the economy will be disastrous. (Annual Report of the Chief Medical Officer, DH, 2002: 44)

The current moral panic about fatness in the United Kingdom (as in many other countries) has resulted in the ongoing development of numerous initiatives implemented in an attempt to defuse the so-called ‘obesity time bomb’. As the quote above illustrates, concern about the potential future implications of existing bodyweight/mass is heightened in UK policy discourse when it is focused on children and young people and resultant policy initiatives have in the main aimed to control and regulate children’s (potentially) obese bodies over and above adults’ (see also HOC, 2004; DH, 2008). Building on the critique of the so-called ‘obesity epidemic’ developed in earlier chapters, here we question both the justifications for and the implications of the focus on children in UK anti-obesity policy.1 We do so with reference to recent work across the social sciences, which has questioned how socially constructed ideas about childhood mean that children are increasingly central to political attempts to predict and govern the future in ways which may have unintended consequences for children’s well-being in the here-and-now. 115

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In particular, we draw on work which interrogates the anticipatory logics underpinning both dominant constructions of childhood within policy action which attempts to ameliorate future problems (Ruddick, 2006) and the political economies through which childhood is constructed as a period of investment for the future (Katz, 2008). In this chapter we use this theoretical work to interrogate the role of, and implications for, children’s bodies in anti-obesity policy which attempts to prevent obese futures. We do so through analysing the development of one particular anti-obesity intervention: the National Child Measurement Programme (NCMP) first rolled out in the United Kingdom in 2005–2006 (see DH, 2006 for details). This forms part of our ongoing critical engagement with this policy and builds on work published elsewhere (Evans and Colls, 2009) in which we question the power afforded the BMI (Body Mass Index) in obesity policy and the multiple materialities and spatialities of the BMI. In this chapter we expand from this discussion to further interrogate the ways in which children’s bodies are imbued with the capacity to reveal the state of future adult bodies and the implications of this for children’s well-being. Our discussion in this chapter is rooted in the politics of critical weight studies which, similar to fat activism and the Health At Every Size (HAES) movement, assert that the relationship between fatness and health is more complex than that which is written into anti-obesity policy (see Aphramor, 2005; Gard and Wright, 2005 for an overview). As such, we aim to highlight the ways in which simplistic understandings of fatness and embodiment may be damaging to people of all sizes (for example, see Evans et al., 2004). Following Evans et al. (2002) our analysis of the NCMP is therefore motivated by a concern that this intervention has the potential to act not as ‘an ameliorative, “corrective” or intervention agency, a potential “cure” to disorder, . . . [but] as a set of processes which may, themselves, have a problematic, damaging and “disordering” effect on . . . people’s lives’ (Evans et al., 2002: 199). Like geography, referred to by some as a ‘magpie discipline’ (Kearns and Moon, 2002), critical weight studies brings together scholars from multiple disciplinary, empirical and theoretical perspectives. As such, our analysis is informed by theoretical work from a range of (sub)disciplines including sociology (Boero, 2007; Gard and Wright, 2005), education (Evans et al., 2005, 2008), science studies (Vaz and Bruno, 2003) and geography (specifically children’s geographies and post-medical geographies) (Colls and Evans, 2008, 2009; Evans, 2004, 2006a, 2006b; Evans and Colls, 2009; Horton and Kraftl, 2006a, 2006b; Katz, 2008; Ruddick, 2006). Work from (and across) these disciplines

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has been instrumental in critiquing the taken-for-granted assumptions underlying dominant medical ‘truths’ which claim the power to define, and the ability to know, bodies often beyond or contrary to individuals’ embodied experiences (Evans and Colls, 2009). Moreover, such work continues to be of vital importance in the critique of the institutionalised fatphobia materialised in anti-obesity policy (Evans, 2003; Evans et al., 2003; Evans et al., 2004; Evans et al., 2008). This chapter contributes to this growing body of work by drawing together, and expanding on, key arguments from work presented elsewhere (Evans, 2006a; Evans and Colls, 2009) in order to question anti-obesity policy. Our discussion is divided into four sections. First, we provide some context regarding geographical work on obesity and children’s bodies in ‘Geographies of childhood and obesity’. Secondly, in ‘Big fat truths and lies’, we then outline theoretical arguments about the production of ‘truths’ in obesity discourse through the combination of medical2 and moral knowledges. While we share the editors’ concerns about oversimplified tendencies within obesity debates to trade in the rhetoric of truth and lies (see Chapter 9 in this volume), we argue that obesity discourse may be considered a ‘grotesque discourse’ (Foucault, 2003; see also Ruddick, 2006) and we use this theoretically informed position to critique what are often assumed to be unequivocal ‘truths’ driving anti-obesity policy. We illustrate this discussion through analysis of the 2004 House of Commons Health Select Committee Report on obesity (HOC, 2004) which contained the initial proposal for a comprehensive BMI surveillance programme eventually implemented in the form of the NCMP. Thirdly, we outline the ‘Background to the NCMP’, by detailing the various stages of its development and the ways in which the debate surrounding its implementation reveals some of the uncertainties about its ability to function as an ameliorative device. In the fourth section, ‘Producing healthy adults: Justifying the NCMP’, we then interrogate the justifications for the NCMP. Here we draw on work which questions the temporalities of both obesity as a disease and children’s bodies within conventional Western medicine to argue that the focus on children in anti-obesity policy is symptomatic of what Ruddick (2006) has identified as a shift in Western policy from a concern about children’s current well-being to a concern about the future dangers they embody. Here, Foucault’s discussion of the ‘collapsing of time’ between childhood and adulthood in criminal psychiatry provides a useful analogy for understanding children’s experiences of, and rights within, public health programmes in relation to (childhood) obesity in the United Kingdom. We illustrate this discussion through an analysis

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of the process through which the NCMP was developed in order to question the assumptions about child embodiment driving the justification of the programme. Finally, we conclude by asking ‘what role is there for children within such politics?’

Geographies of childhood and obesity Historically, geographical approaches to health and well-being have been driven by positivist spatial science, aiming to document spatial variations in disease prevalence, health inequalities and/or health care provision. There is a lasting legacy of this approach to the relationship between health and place in geographical engagements with obesity. Geographers have, for instance, been central to the production of what we refer to as ‘fat maps’ – maps which label countries, regions or cities as more or less obese/fat (see, for example, Moon et al., 2007). Research in this area has gained momentum in recent years with the increasing use of Geographic Information Systems (GIS) technologies and such work underpins the recent policy turn towards ‘obesogenic environments’ in the search for the ‘cause’ of obesity (see Foresight, 2007). Yet, the reliance on data based on problematic bodily measures has meant that such work has tended to reproduce inconsistent and contested medical categories as ‘empirical’ certainties. Consequently, as part of a suspect dividing practice, such work has acted to fix bodies within particular boundaries as problematic (or not), simultaneously homogenising populations on the basis of geographical location. The renewed focus on ‘the environment’ in obesity discourse has also therefore acted as an ‘imperative for geographers to question the politics of fatness, critically interrogating the drivers for, and implications of, the increasingly stringent, often knee-jerk policies which unilaterally define certain bodies and places as fat and problematic’ (Colls and Evans, 2009: 1012). This more critical approach is situated within post-medical geographies which, following Parr (2002), engage with bodies as ‘more than dots on maps’ (p. 243) and with medical discourses in a critical capacity. This approach involves thinking about the mutually constitutive relationship between places, spaces and bodies (Grosz, 1999; Nast and Pile, 1998) and demonstrates that readings and experiences of bodies, health and illness (in this case obesity) cannot be divorced from the social, cultural, historic, economic and political contexts in which they are produced. These more critical geographies of obesity therefore have the potential to contribute to critical weight studies more broadly through questioning the spatialities of obesity discourse. Some examples


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of geographical work in this area include that which questions: the cultural and moral situatedness of obesity policy (Evans, 2006a); the political economies through which obesity knowledge is (re)produced (Guthman and DuPuis, 2006);3 the political and geographic specificities driving historical obesity ‘epidemics’ (McPhail, 2009); the simultaneous (re)production of particular bodies and spaces as obese (Evans and Colls, 2009); the movement of obesity knowledges and practices between and through different spaces by the multiple actors deemed ‘responsible’ for obesity (Colls and Evans, 2008); and the material and embodied experiences of those considered obese and/or involved in anti-obesity interventions across various spatial contexts such as schools, shopping centres and so on (Colls, 2006; Evans, 2006b; Evans and Colls, 2009). These geographies of obesity contribute to the growing critique of dominant obesity knowledge through providing examples of the spatio-temporal situatedness of anti-obesity discourse and practice. For example, Clare Herrick’s analysis of social marketing campaigns surrounding obesity demonstrates that ‘public health discourses rely on a set of clearly defined, proven and accepted aetiological and epidemiological causal relationships, which, in the case of obesity, are not only deeply uncertain, but the object of intense political and commercial conflicts’ (Herrick, 2007: 100). Likewise, McPhail’s (2009) analysis of archival sources from the early cold war in Canada illustrates that concern about obesity is not, as is commonly suggested, a recent phenomenon. Moreover, this work reveals that concern about obesity at this time, in Canada, focused mainly on white male obesity, was a product of concerns about both the fitness of the nation in a time of impending war, and the breakdown of the nuclear family following women’s increased involvement in paid work. Clearly, as these examples illustrate, obesity cannot be considered a neutral, universal, biological or medical ‘problem’, but the figuring of fatness as problematic is inherently tied to the political, economic, social and cultural context within which it is produced.4 Similarly, work in children’s geographies has questioned the assumed universality of the categories ‘child’, youth and adult (see Evans, 2008). Rooted in (and contributing to) the body of work collectively referred to as the New Social Studies of Childhood (NSSC) (Holloway and Valentine, 2000a), geographers have highlighted the spatio-temporal specificity of dominant Western constructions of childhood as innocent, free, lacking in responsibility, frivolous, playful and so on. Work here has demonstrated the problematic application of this notion of

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childhood internationally with reference to both international policy (see Skelton, 2007 on the United Nations Convention of Rights for the Child) and specific empirical examples (see Cheney, 2005 on the rehabilitation of child soldiers in Uganda). Of specific relevance for this chapter is the recent growth in geographical work on children and embodiment (see, for example, Colls and Evans, 2008; Evans, 2006b; Horton and Kraftl, 2006a, 2006b; and a special issue of Children’s Geographies edited by Colls and Hörschelmann, 2009). Building on the NSSC this work has demonstrated how the construction of childhood as ‘the literal embodiment of change over time’ (James, 2000: 23) has underpinned multiple historical and contemporary interventions which have attempted to cure a range of social ills through disciplining children’s bodies. As Gagen (2000) argues, with reference to the regulation of gendered bodies through the reform of children’s playgrounds in early twentieth century America, ‘as individuals in their most malleable state, children were popularly conceptualised as members of the population most capable of catalysing change’ (p. 600). Moreover, Katz (2008) argues that in order to fully understand the implications of such conceptualisations of childhood for historical and contemporary children’s everyday experiences, one must situate them within the political economies from which they stem. Writing from the USA, she argues that numerous crises of childhood are manifestations of a broader ontological insecurity associated with multiple anxieties about the (political-economic, geopolitical and environmental) future. These anxieties, she argues, are increasingly managed through interventions which attempt to control the future through controlling children in the present. Thus, Katz writes ‘the deep anxieties and ontological insecurity provoked by contemporary political economic, geopolitical, and environmental conditions are increasingly channelled into the production and reproduction of certain modes of framing childhood and thus materialized in the bodies and historical geographies of particular children’ (2008: 15). Countering such conceptualisations of childhood, children’s geographers have asserted the importance of recognising children as agents, have challenged a staged approach to the lifecourse and have argued that embodiment should be seen as a continual, ongoing process not movement along a fixed trajectory towards a predicted end point. Thus, as Horton and Kraftl (2006b) state, ‘one does not necessarily grow up or out of certain bodily capacities, or styles, or comportments, or tendencies. Instead, these inflect our attempts to go on – to cope, to make the best of things – in different ways, in different situations. There is


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no sense of progression, procession or development, at least not towards any point’ (p. 271 emphasis in original). Although such work clearly has its roots in the NSSC, recent work, particularly that by Ruddick (2006, 2007), has begun to highlight some potentially damaging side effects of asserting children’s agency. Rather than generating an alternative understanding of childhood, Ruddick’s work demonstrates that assertions of children’s agency work alongside existing constructions of childhood (as innocent, lacking responsibility and so on) to the result that when children’s agency is recognised, they simultaneously lose the protection afforded them as children (the example Ruddick uses is the increase in the frequency of children being tried as adults in the US criminal justice system; see also Cheney, 2005, regarding the difficulty for Western charities of simultaneously seeing child soldiers as victims and perpetrators of war). Moreover, this work has shown such constructions of childhood place limitations on the way children are positioned in debates about responsibility (see Colls and Evans, 2008) and on children’s participation in policy development (see Mayall, 2006). Our analysis in the remainder of this chapter builds on Ruddick’s (2006) discussion, similarly utilising Foucault’s (2003) analysis of the role of childhood in the establishment of clinical psychiatry to interrogate the position of childhood within contemporary policy. With children at the centre of obesity policy interventions in the United Kingdom, this work indicates that questions need to be asked about the ways in which children are present within this policy (e.g. as children or as future adults) since this will have important implications for children’s rights and responsibilities.

Big fat truths and lies As in many other countries, obesity is high on the agenda in both policy and media reporting in the United Kingdom, constituting the main means by which fatness enters public debate. Obesity is frequently referred to as an epidemic, or a disease, although the basis for its classification as such is contested as it is neither an illness in its own right – rather a measure of body size which has been correlated with some illnesses and so is considered a ‘risk factor’ – and is not contagious, usually a pre-requisite for being considered an epidemic disease (for further discussion see Campos et al., 2006; Evans and Colls, 2009; Gard and Wright, 2005). As others in this book have argued, the obesity epidemic can therefore, to a large extent, be considered a socially constructed epidemic, which is spread through policy and media reporting. As such,

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it has been referred to both as a ‘postmodern epidemic’ (similar to epidemics of youth violence or drug use), characterised by ‘a rapid spread of fear and calls for vigilance’ (Boero, 2007: 43), and as a ‘media epidemic’ (Campos et al., 2006), demonstrating that the rapid rise in the perception of obesity as a problem is more reflective of a rapid rise in media reporting on obesity than a rise in obesity prevalence (for example, according to Campos et al., 2006, in the USA, in 1980, there were 62 newspaper articles published on obesity, rising astonishingly to over 6500 in 2004). This entanglement of media, policy and medical knowledges, as others have noted (see Evans et al., 2008; Herrick, 2007; Rich and Miah, 2009), means that the ‘truths’ about obesity, although presented as ‘scientific fact’, are inevitably several steps removed from ‘scientific’ research – which is itself rooted in socio-cultural assumptions about fatness (Gard and Wright, 2005). Analogies can be drawn here between the combination of medical and non-medical knowledges in the production of obesity ‘truths’ and Foucault’s description of the combination of medical and lay (legal) knowledges in criminal psychiatry, ‘brought about only by means of the reactivation of . . . elementary categories of morality’ (Foucault, 2003: 35). Similarly, Boero (2007) argues that the production of obesity ‘truths’ involves the processing of scientific knowledge through a ‘cultural black box’ within which ‘preexisting, yet largely unexamined cultural understandings of fatness form the plinth of representations of scientific debate or agreement about weight’ (p. 51). Through this process, Boero (2007) argues that medical knowledges undergo significant re-interpretation and simplification based on everyday assumptions, moralities and ‘common senses’ relating to health and body size. Thus, we are left with a situation where the ‘Uncertainties, ambiguities and conflicts of knowledge inherent in the primary research field [bio-medical science] are often obfuscated and very difficult to see in the “obesity discourse” once it enters the public domain in the form of official reports’ (Evans, 2003: 88). To illustrate this further, we want to turn here to a range of examples of the ways in which obesity discourse relies on elementary moralities through analysis of the HOC (2004) report into obesity. Elsewhere Evans (2006a) discusses in more detail the social and cultural discourses about embodiment evident in this document, and whilst we will not go into detail here, it is important to summarise this in order to contextualise the NCMP since this is the report which included the initial suggestion that such a monitoring programme may be beneficial to tackle the ‘problem’ of obesity. Below, we therefore present five (by no means all) examples from the HOC (2004) report of the influence of cultural


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ideals of body maintenance and Christian notions of sin on anti-obesity policy. These moral discourses form the means for the translation of contested knowledge into simple, scientific truths about obese bodies and although we separate these out here, they are (as with modes of ‘obesity epidemic entrepreneurship’ highlighted by Monaghan and Hardey in Chapter 3 in this volume) clearly inextricably intertwined and mutually constitutive of ‘obesity’ as problematic. Firstly, the report relies on a division between good and bad (bodies, citizens, foods and activities) in order to assert fatness as a universal problem (see Evans, 2004, 2006a). It does this through evoking Christian notions of sin, for example, questioning (as a subheading within the report) whether the main cause of obesity is ‘gluttony or sloth’ (p. 23). This is further expounded through the frequent implication that obesity is due to individual irresponsibility; that obese individuals should feel guilt and remorse; and that obese individuals are irresponsible citizens draining national resources. For example, the report states that ‘the average person is remorselessly getting heavier’ (p. 104), makes frequent reference to the cost of ‘obesity’ to the national economy and goes as far as to state that ‘obesity’ ‘will bring levels of sickness . . . making a publicly funded health service unsustainable’ (p. 7). Secondly, the report asserts the fundamental and universal dangers of fatness through the use of hyperbolic language to generate fear (Evans, 2010; also see ÓTuathail, 2003 for discussion of similar strategies in the production of fear surrounding the war on terror). Thus, a range of moralities are evoked and produced through the presentation of ‘obesity’ as an ‘epidemic’ bringing with it inevitable and impending doom. The graphic descriptions through which fear is evoked simultaneously produce a sense of disgust at the bodies of a future ‘obese’ nation. For example, the report states that ‘with quite astonishing rapidity, an epidemic of obesity has swept over England’ (HOC, 2004: 7) and ‘should the gloomier scenarios relating to obesity turn out to be true, the sight of amputees will become much more familiar in the streets of Britain. There will be many more blind people . . . [and] this will be the first generation where children die before their parents as a consequence of childhood obesity’ (p. 9). Thirdly, drawing on ideas of fatness as grotesque, the report builds on the dualistic moralities and the fear of fatness outlined in the first two points above, to construct ‘obesity’ and ‘overweight’ as inherently abnormal. It does this, for example, through asserting that a view of ‘overweight’ as anything other than abnormal is a dangerous consequence of rising ‘obesity’ rates: ‘So rapid has been the rise in obesity that there is a danger it will overtake the population to the extent that

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what used to be considered “overweight” starts to become “normal” ’ (HOC, 2004: 8). Fourthly, building on the construction of obesity as a result of individual irresponsibility or sin, the report presents obesity as a result of laziness, inaction, a lack of control or incorrect bodily maintenance in numerous ways. Not least, it does this by implying that everyone is, without correct attention, inevitably getting fatter. To this end, it frequently conflates ‘overweight’ and ‘obesity’, including those who are ‘overweight’ in the reporting of statistics on obesity (thereby also inflating the figures), and states that ‘society is getting fatter, not just those who are already fat’ (HOC, 2004: 13). Finally, the cumulative effect of this approach to fatness is the implication that fat people are to blame for their fatness and are fundamentally flawed subjects. To this end, the report implies that the stigma associated with fatness, and the associated mental health problems and prejudices faced by those who are labelled or who consider themselves fat, is the fault of the individual themselves. It does this, for example, through suggesting that the solution to school-based bullying of fat children may be to support these children to lose weight and to deal with this stigma (rather than challenge those doing the bullying). This is exemplified in the following suggestion made by one contributor to the report (which thankfully was not accepted): ‘it might be helpful if more stigma [was] attached to obesity so that people made more effort to lose excess weight’ (HOC, 2004: 104). What analysis of the HOC (2004) document makes clear is that obesity policy cannot be extracted from wider social and moral understandings of fatness (Gard and Wright, 2005). Drawing on Foucault (2003), we can understand the inclusion of social and moral readings of fatness as fundamental to the production of the universal truths about obesity which are necessary to push forward policy action. With reference to the role of elementary moralities in the development of criminal psychiatry, Foucault (2003) argues that truths produced through the combination of medical and lay knowledges gain power derived from neither one of the knowledges itself, but from the moralities evoked in their combination. This power, the ‘power of normalization’ (Foucault, 2003: 42), is thus concerned with ‘the control of the abnormal individual, rather than . . . the control of crime or illness’ (Foucault, 2003: 42). Since obesity policy is concerned with instilling in all individuals the necessity of maintaining a ‘normal’ bodyweight, we may similarly consider obesity policy a technique of normalisation. According to Ruddick (2006), fundamental to Foucault’s argument is recognition of the role of grotesque or ubuesque (Foucault, 2003: 11)


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discourses in the development of normalisation techniques. A grotesque discourse, according to Foucault, has the power to kill, in that it has ‘the power to determine, directly or indirectly, a decision of justice that ultimately concerns a person’s freedom or detention, or, if it comes to it . . . life and death’ (Foucault, 2003: 6); it is a discourse of truth since grotesque discourses have power derived from being ‘discourses with a scientific status’ (Foucault, 2003: 6); and it is a discourse which provokes incredulous, nervous or shocked laughter, a laughter which, as Ruddick (2006) explains, ‘signals that something has gone awry, that there is an application of an arbitrary sovereignty, that the discourse mobilised to produce truth claims does not conform even to its own rules’ (p. 55). Obesity discourse, we would argue, therefore constitutes a grotesque discourse since it fits the above three characteristics in the following ways: Firstly, it has power over life and death through its ability to shape individuals’ understandings of their own life chances by defining them as ‘ill’ or ‘diseased’ – in some cases morbidly so. It does this without reference to any experienced ill-health but purely on the basis of body size (for further discussion see Evans and Colls, 2009). Moreover, this is materialised in policy which may act to have very real implications for an individual’s right to access life saving, or life improving, medical care in situations where access to treatment is universally prohibited for those above a designated body mass. Secondly, obesity discourse constitutes a discourse of truth since (as is evident in the examples from the HOC report) it claims scientific authenticity yet remains reliant on what Foucault describes as a ‘childish discourse . . . completely governed by fear and moralization [which therefore] can only be derisory’ (Foucault, 2003: 35). Finally, the juxtaposition of the reliance on fear and morality whilst claiming scientific truth means obesity discourse is one which provokes laughter. As Foucault explains, laughter is provoked since this makes the discourse ridiculous.5 The claims to scientific objectivity are undermined at the very moment that they are called upon, since truths are spoken by ‘a scientist’ through ‘a childish discourse that disqualifies him as a scientist at the very moment he is appealed to as a scientist . . . [the] discourse of fear . . . makes him ridiculous as soon as he speaks’ (p. 36; also, see Monaghan, 2007a on the irrationalities of obesity discourse). Whilst the conflation of medical and moral knowledges makes obesity discourse ridiculous, it is also fundamental to the continued assertion that fatness poses a universal threat since it is this which allows for the inadequacies in obesity knowledge to remain unacknowledged (Evans and Colls, 2009). Understanding obesity discourse as a grotesque

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discourse is therefore important in revealing the inconsistencies in obesity knowledge which are lost through assertions of scientific truth (Monaghan, 2007a). For example, the focus of UK obesity policy on children is frequently justified as necessary since childhood body mass is assumed to directly determine adult body mass and health. This is accepted as an absolute ‘truth’ in obesity policy, to the extent that the House of Commons report on obesity stated that ‘Most overweight or obese children become overweight or obese adults; overweight and obese adults are more likely to bring up overweight or obese children’ (HOC, 2004: 7). However, this claim to a universal, deterministic link hides complexity and uncertainty in the underlying research. Whilst it is likely that there is also research which supports the HOC claims, research published in the British Medical Journal (BMJ) in 2001 reported that: There is a widespread popular belief that adult fatness begins in childhood . . . . Current concerns about rising rates of overweight in children also hinge on the assumption that fat children are more likely to become fat adults. Our data [produced through longitudinal research in NE England] suggest a far less deterministic situation. There was . . . no net increase in adult disease risk for overweight children or teenagers. (Wright et al., 2001: 323) On this basis, the BMJ published the following statement: ‘One of the Urban myths of parenting is that chubby children bloom into dumpy adults’ (Abbasi, 2001: 1314). Yet there is no acknowledgment in the HOC report (as in most policy documents) that the universality of these claims is contested and so such claims continue to drive policy and justify the overwhelming focus of anti-obesity interventions on children.

Background to the National Child Monitoring Programme In order to explore this further, the remainder of this chapter focuses on the NCMP BMI monitoring programme carried out in primary schools in the United Kingdom. Before discussing this in relation to the models of childhood which dominate Western policy and medical interventions in the next section, we will firstly present some background about the NCMP because the stages of its development are fundamental to our


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subsequent critique (for more detailed discussion of the experiences of those involved in the practical implementation of this programme see Evans and Colls, 2009). The NCMP developed from a suggestion made in the HOC (2004) report, that ‘throughout their time at school, children should have their Body Mass Index measured annually at school . . . . The results should be sent home in confidence to their parents, together with, where appropriate, advice on lifestyle, follow-up, and referral to more specialised services’ (p. 95). This suggested intervention constitutes an obesity screening programme since the suggestion involves action being taken as a result of the test (action being the reporting of the child’s BMI and advice based on it back to parents). Because it constituted a screening programme, it therefore required approval from the National Screening Committee (NSC) before implementation could progress. NSC guidelines judge a proposed programme in relation to the potential harm and good caused by the intervention, requiring that any test must identify ‘those individuals who are more likely to be helped than harmed by further tests or treatments to reduce the risk of a disease or its complications. [In short,] . . . the benefit from the screening programme should outweigh the physical and psychological harm’ (DH, 2006: 22–23, emphasis added). The inquiry by the NSC into BMI monitoring raised several concerns about the proposed programme (see Box 5.1). Consequently, the NSC blocked the implementation of an obesity screening programme on the basis that ‘screening for childhood obesity could not guarantee to do more good than harm’ (DH, 2006: 23). The concerns raised by the NSC reveal some of the uncertainties inherent in defining and diagnosing ‘obesity’, and in linking obesity to health (Campos et al., 2006; Gard and Wright, 2005; Monaghan, 2007a, Oliver, 2006; Ross, 2005). These uncertainties are usually absent from policy representations of obesity. In response to the lack of NSC approval, proponents of the programme removed the feedback and intervention element in order that it may be classified not as screening, but as population monitoring (DH, 2006; Evans and Colls, 2009).6 This ensured that the programme could proceed without requiring NSC approval. Most recently, the programme has been revised again, with the feedback stage reinstated, this time bypassing the NSC by including the revision within the much larger Health and Social Care Bill, introduced to Parliament on Thursday 15 November 2007 (see DH, 2007).

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Box 5.1

NSC findings (DH, 2006: 22–23)

a. There is insufficient evidence to support the effectiveness of any interventions for obesity in individuals identified through screening and who are not otherwise concerned [about their weight] b. There is no agreed cut-off point that can be consistently linked to increased morbidity and mortality in children c. The psychological effects of drawing attention to height and weight are not fully known d. Interventions to encourage physical activity and healthy eating have benefits wider than those which might be measured by BMI

Numerous concerns have been raised that the NSC’s fears about the psychological effects of measurement have been overlooked in the roll-out of the programme. Empirical work with children and adults involved in the NCMP (Evans and Colls, 2009) has shown that the potential for harm to children’s well-being, as a result of their involvement (recognised by the NSC), is very real and that key ethical questions need to be asked about why the programme is continuing. Moreover, this work has demonstrated that due to the inadequacies of the BMI as a measure of health and well-being (Campos et al., 2006; Monaghan, 2007a; Ross, 2005), especially in childhood (Foresight, 2007), the continuation of the programme (and the addition of feedback to parents) can only function to ensure that ‘children (and parents) remain in a state of anxiety about the possibility of their (or their children’s) bodies being revealed to be abnormal’ (Evans and Colls, 2009: 1077).

Producing healthy adults: Justifying the NCMP Public health engagements with children’s bodies have long been characterised by methods of surveillance adopted to allay fears that ‘without correct monitoring, children would put their inevitable instincts to inappropriate use’ (Gagen, 2000: 605). Obesity policy places particular emphasis on children and young people, based on the assertion that interventions to prevent and/or treat childhood obesity are ‘more important than adults, as habits set down in childhood are likely to form the pattern for the rest of a person’s life’ (HOC, 2004: 94). This justification


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is clearly rooted in a particular understanding of embodiment which draws on developmental models, influential in shaping medical engagements with children’s bodies. Such engagements are characterised by the surveillance and monitoring of children’s physical development clearly reproduced in the monitoring of BMI which for children is then compared to a normal curve on a percentile growth chart. Through such interventions, as Armstrong (1983: 63) states, ‘Knowledge of the child . . . [is] expressed as a single and individual growth trajectory constructed by joining the points marked on a percentile growth chart . . . a constant normalizing gaze exercised by a new medical discipline over the growth and development of all children’. There is clear evidence here of the importance of dominant Western models of childhood which see children as becomings (Holloway and Valentine, 2000b). Such an understanding of embodiment fails to recognise that ‘the body is always in motion’ (Harrison, 2000: 503), ‘bodies are always in flux; always ongoing; never still’ (Horton and Kraftl, 2006a: 77). Instead, children’s bodies are fixed on a straight line or trajectory towards adulthood which is itself fixed as ‘a clear and knowable destination’ (Lee, 2001: 7). Mayall (1996) argues that UK social policies are embedded within such models of childhood. Thus, he asserts that within such policies children constitute ‘non-persons proceeding through an ordered sequence of stages . . . . The health, education and welfare complex works to achieve normalcy through observation, measurement and testing’ (p. 54). The NCMP clearly exemplifies such a policy, evident in its form as a surveillance programme, and in justifications for its implementation (see Box 5.2). Similar to Katz’s (2008) and Ruddick’s (2006) arguments, children are justified as the targets of the NCMP, not through a concern for their well-being as children but in an attempt to secure the health of the future nation. Thus, the first justification (shown in Box 5.2) implies that all children are inevitably gaining weight, the second that any weight gain or associated behaviours undertaken during childhood will inevitably lead to adulthood ill-health, and the third that knowledge of children’s BMI has the capacity to reveal and prevent future childhood and adulthood ill-health. Mayall (1996: 145) proposes that within social policy ‘children inhabit triple personhood, they are persons now, are in process towards another version of personhood, and are too the persons they will become’. There are clear differences between the NSC and proponents of the NCMP regarding which of these persons are held as most important. Children are present within justifications from the NCMP in a much more limited way than within the NSC’s evaluation of the

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Box 5.2 Justifications for the NCMP ‘Not only would this system identify children who are already overweight or obese, but it could target those at the top end of the “normal” range of BMI to prevent further weight gain’ (HOC, 2004: 95). ‘People’s patterns of behaviour are often set early in life and influence their health throughout their lives. Infancy, childhood and young adulthood are critical stages in the development of habits that will affect people’s health in later years’ (DH, 2004: 41). If BMI monitoring had happened earlier ‘then maybe we wouldn’t have been in the mess that we are in now because people would have been able to observe the insidious increment of weight over that period of time’ (Chairman, CGF, 2005: 7).

proposed screening programme. As outlined above, the NSC’s judgement that BMI screening ‘could not guarantee to do more good than harm’ was based on analysis of the potential good and harm caused to children’s well-being now. Thus, the NSC highlighted as problematic the limitations in the use of BMI for the diagnosis of ill-health during childhood and that knowledge of BMI is incidental to any interventions which may be made to improve children’s health (see Box 5.1).7 This is fundamentally different to proponents of the NCMP who assert that the programme is justifiable due to the benefits to the health of the future adult population. This misalignment in terms of who the programme should protect/benefit is crucial to understanding why concerns for children’s well-being were seemingly dismissed in the continuation of the programme despite NSC concerns. Contrary to the NSC, children are absent presences within justifications for the NCMP, present only as indicators of the bodies they will become. Thus, assertions of longterm improvements to the health of the (future adult) population easily override any concerns about negative consequences caused by such interventions to individual children here-and-now. Here, Ruddick’s (2006) use of Foucault (2003) to explore a shift in the position of childhood within Western institutional cultures is valuable for understanding the focus on the future in childhood obesity policy. Ruddick presents a range of examples from juvenile crime cases in the United States which assume direct causality between childhood acts and


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adulthood criminality. Such assumptions, Ruddick argues, are premised on ‘anticipatory logics’, which echo Foucault’s discussion of the significance of childhood in criminal psychiatry. Foucault (2003) notes a historical shift in the role of psychiatric testimony in court proceedings, from one premised on establishing the state of mind of the accused at the time of the crime, to one based on establishing whether the defendant is capable of committing such a crime using evidence of behaviour or personality during childhood. As a result of this shift, Foucault argues that childhood became the central focus for criminal psychiatry because it constitutes evidence of the possibility of future guilt. The aim, according to Foucault, ‘is to show how the individual already resembles his crime before he has committed it’. Hence, it is ‘a matter of establishing continuity with childhood, or rather of immobilizing life around childhood’ (Foucault, 2003: 301). Similarly, according to Ruddick, within youth criminal justice policy in the United States ‘the imagined time frame between puerile act and serious offence is constrained to the point of collapse; the smallest transgression is acted upon as if the criminal act is immanent’ (Ruddick, 2006: 56). Ruddick gives an example of the arrest of a young boy for drawing a picture of a knife – an act seen to predict future violent behaviour and therefore to require pre-emptive rehabilitation. Clear parallels can be drawn here with obesity policy. For example, the first two justifications for the NCMP shown in Box 5.2 demonstrate that the smallest transgression is taken to indicate the need for intervention (in the first justification, being at the higher end of the ‘normal’ weight range is seen as problematic, and in the second justification childhood behaviours are seen as direct predictors of adulthood behaviours). Likewise, behaviours thought to contribute to weight gain (not even weight gain itself) are seen as signifying inevitable future ill-health and therefore requiring pre-emptive action. Such pre-emptive logics drive, for example, calls for the implementation of legal measures to ensure that children are not able to consume certain foods within schools. We are therefore faced with a situation where the former education minister, Ruth Kelly, in 2006 stated that those who allow certain foods into schools will be ‘open to the same sanctions as anyone else who breaks the law’ (Ruth Kelly, quoted in BBC 2006).8

Conclusion: Every child matters? Childhood obesity is seen as problematic predominantly because it is assumed to cause inevitable adult ill-health (HOC, 2004). The drawing

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of direct lines between child and adult bodies is one of many obesity ‘truths’ underpinning obesity policy which fail to adequately reflect the research on which they are based (Evans, 2003). Understanding obesity discourse as a ‘grotesque discourse’ (Foucault, 2003; Ruddick, 2006) and anti-obesity policy as a technique of ‘normalisation’ (Foucault, 2003) provides a means to understand the importance of social, cultural and moral contexts in the production of such ‘truths’ (Gard and Wright, 2005). In addition to these moral discourses, the focus on children in anti-obesity policy makes evident that such policy must be contextualised within the wider shift in Western policy and practice from a concern with the here-and-now to a concern with the future, a future understood with reference to immanent risks mitigated through anticipatory action. Thus, as Nowotny (1994: 52) identifies, ‘with the mounting pressure that solutions to impending, recognizable problems have to be found now . . . . The future of our children is no longer interpreted in individual terms – as the desire for social advancement and well-being – but as a question of collective survival’. In medicine and public health, this shift to a focus on the future is evident through the classification of otherwise healthy individuals as diseased on the basis of risk factors (which may or may not result in ill-health) (Vaz and Bruno, 2003). Methods, such as genetic testing and statistical correlations at population level which associate certain ‘lifestyles’ or bodily forms with illnesses, have allowed the creation of a category of ‘pre-symptomatic’ persons or ‘patients before their time’ (Jacob, 1998: 102, cited in Vaz and Bruno, 2003: 274). Obesity exemplifies such diseases because, although referred to as a disease, it may be diagnosed in someone who is fit and healthy and who may never suffer any symptoms of ill-health as a result of their ‘obesity’ (Gard and Wright, 2005). Obesity is one of a growing number of ‘virtual diseases’ (Vaz and Bruno, 2003: 280) rooted in the identification of risks, often despite limited knowledge of the biological mechanism linking them to ill-health. Risk based pre-emptive action in health policy and also other pre-emptive politics (such as the war against terrorism – see Anderson, 2010) relies not on the establishment of direct causality, instead ‘in order to justify pre-emptive action, a risk must be constructed as highly probable, as pressing and as concerning everyone . . . transforming every individual into a virtual victim’ (Vaz and Bruno, 2003: 284). Thus, preemptive action against obesity is justified through assertions that it is society that is getting fatter, not just the obese (HOC, 2004), logics also evident in the justifications for the NCMP shown in Box 5.2. Moreover,


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‘virtual diseases’ such as obesity rely on the temporal gap between onset of risk factor and onset (or not) of symptoms. This gap allows for preemptive action and ‘the idea of a defensive medicine thrives in this temporal distance’ (Vaz and Bruno, 2003: 286) – its success is seen as a function of the size of this temporal gap with early intervention leading to increased success. The focus on children and young people in obesity policy is motivated (in part) by the drive to identify those who are pre-symptomatic at the largest temporal gap possible. This is evident in the increasingly younger ages at which children are being targeted in obesity policy to the extent that it is now frequently suggested that once a child is born it is too late to act (BBC, 2001). Moreover, this is evident in the first justification for the NCMP shown in Box 5.2 which not only sees childhood obesity as a pre-symptom for adulthood ill-health but sees being at the top end of the ‘normal’ weight range as a pre-symptom of future obesity. Central to critiquing the focus on children in anti-obesity policy is an interrogation of the temporalities which dominate conventional Western medicine and drive particular forms of bodily knowledge which see children’s bodies as adults-in-the-making. Such temporalities allow assertions that children’s bodies are problematic in their capacity to shape the future. What is less frequently acknowledged and far from a driver of national interventions on obesity is that being defined as ‘obese’, or simply drawing attention to body size within the current state-sanctioned fatphobic culture, may have immediate negative effects on a child’s well-being in the here-and-now (Evans and Colls, 2009; Evans et al., 2004; 2008). Thus, in the case of the NCMP, concerns about the negative impacts of the intervention on children’s well-being now were dismissed with reference to the possible benefits to the adults they may become. The focus on children in obesity policy is clearly driven by anticipatory logics which underpin pre-emptive policy action. Pre-emptive public health policy bears similarities to what Nowotny (1994) describes as the disappearance of the future, replaced by an ‘extended present’ (p. 8), whereby ‘the future mapped out in linear terms draws dangerously close to the present, filled with conditional negatives’ (pp. 49–50). However, in the case of pre-emptive action focused on children, we would argue that, rather than the future, it is the present which disappears – the future collapses in on the present allowing for children’s everyday experiences to be overlooked in pursuit of a ‘healthy’ future adult population. According to Ruddick (2006: 65), there has been a

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recent broad shift in discourse about children’s rights ‘from an approach founded on their best interest to one focused on the social dangers they pose’. As such, it seems salient to recognise the potential implications of linear temporalities on policy relating to children. A raft of policies in the United Kingdom claim to act in the child’s best interest and assert that every child matters. Whilst some policies clearly do just this, it is important to question in what way children are present – in what way do they matter – does every child matter or every future adult? Moreover, with the continued drive to control fatness being targeted at children, it is important to continue to question both the ‘truths’ underpinning anti-obesity policy and the potential implications for children’s well-being.

Notes 1. By ‘anti-obesity’ policies we mean those policies developed with the intention of preventing individuals’ bodies from being of a size classified as ‘obese’. 2. We use the term ‘medical knowledge’ here to refer to those knowledges which claim a ‘scientific’, ‘objective’ authority separate from any social, cultural or moral values about different bodies. We would argue that such objectivity is not possible, but recognise the power inherent in this claim. 3. There has been some critique of work which questions the structural inequalities which produce different spatial distributions of obesity (as suggested by Guthman and DuPuis, 2006) since this work remains reliant on the classification of bodies according to problematic measurements, and reproduces simplistic assumptions about the relationship between food consumption, body size and health (Monaghan, 2008). However, dismissal of this approach completely would be to ignore valid concerns about malnutrition and health inequalities. A possible solution may be to address these concerns through a HAES approach in order to ask pertinent questions about every(sized)body’s access to nutritional food, health care and so on, rather than focusing on body size. 4. For further examples see the special edition of Antipode 41 (5) on critical geographies of fat/bigness/corpulence edited by Colls and Evans (2009). 5. In fact, respondents in Monaghan’s (2007b) research on men’s understandings of BMI frequently referred to it as ‘ridiculous’. 6. Concerns about the cost of implementation also meant that under the revised programme children are not measured annually, but twice – once on entry to primary school (age 5) and once before they leave (age 11). 7. For example, children’s access to a nutritious diet and to exercise facilities may be improved without knowledge of their BMI and the benefits to their health may be seen even if there is no reduction in BMI. 8. See also Monaghan et al. (2010) on ‘enforcers/administrators’, a subtype of ‘obesity epidemic entrepreneur’ who are already implicated in the social construction of fatness as a correctable problem.


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Rich, E. and Miah, A. (2009) A. Prosthetic Surveillance: The Medical Governance of Healthy Bodies in Cyberspace. Surveillance and Society 6 (2): 163–177. Ross, B. (2005) Fat or Fiction: Weighing the Obesity Epidemic. In Gard, M. and Wright, J. (eds) The Obesity Epidemic: Science, Morality and Ideology. London: Routledge. Ruddick, S. (2006) Abnormal, the ‘New Normal’, and Destabilizing Discourses of Rights. Public Culture 18: 53–78. ——— (2007) At the Horizons of the Subject: Neo-liberalism, Neo-conservatism and the Rights of the Child. Part One: From ‘Knowing’ Fetus to ‘Confused’ Child. Gender, Place and Culture 14: 513–527. Skelton, T. (2007) Children, Young People, UNICEF and Participation. Children’s Geographies 5 (1): 165–181. Vaz, P. and Bruno, F. (2003) Types of Self-Surveillance: from Abnormality to Individuals ‘At Risk’. Surveillance and Society 1: 272–291. Wright, C.M., Parker, L., Lamont, D., and Craft, A.W. (2001) Implications of Childhood Obesity for Adult Health: Findings from Thousand Families Cohort Study. British Medical Journal 323: 1280–1284.

6 Children’s Bodies, Surveillance and the Obesity Crisis Emma Rich, John Evans and Laura De Pian

Introduction Fat children ‘should be taken from parents’ to curb obesity epidemic. (The Times, 18 August 2008) Lyon (2002: 1) suggests that whilst work in the field of surveillance studies is broad and diverse, ‘what they have in common is that, for whatever reason, people and populations are under scrutiny’. Increasing amounts of intervention into people’s lives in a quest to monitor and regulate their diets, health, body size and shape is one way in which people have fallen prey to increasing levels of surveillance in society. As evidenced in previous chapters, the construction of obesity as a ‘health crisis’ has further propagated what Armstrong (1995) refers to as ‘Surveillance Medicine’: Surveillance Medicine requires the dissolution of the distinct clinical categories of healthy and ill as it attempts to bring everyone within its network of visibility. Therefore one of the earliest expressions of Surveillance Medicine – and a vital precondition for its continuing proliferation – was the problematisation of the normal. (Armstrong, 1995: 395) On the one hand, individuals are being prescribed ways to behave, with shifts in legislation and policy concerning health and obesity, leading to the deployment of a range of technologies of medical surveillance which monitor and regulate people’s lifestyles. As Armstrong observes, ‘Surveillance Medicine turns increasingly to an extracorporeal space – often represented by the notion of “lifestyle” – to identify the precursors 139

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of future illness’ (Armstrong, 1995: 401). At the same time, individuals are expected to engage in practices of self-surveillance through vigilantly adhering to health imperatives. Whilst both child and adult populations are subject to these forms of surveillance, the inflection towards children perhaps raises substantial ethical questions which warrant further exploration. Particularly since in Gard’s (2007) view, the construction of childhood obesity as an unbounded crisis has made it easier to talk about such intervention in the lives of even younger children in ever more drastic ways. So drastic it seems, that as per the media headline above, it has become conceivable that a child might be removed from their parents care because of obesity. As outlined in previous chapters, moral panic related to obesity continues to drive the call for intervening at earlier stages in people’s lives, legitimising forms of surveillance in its wake. Attention of this kind has increasingly been directed towards children and young people, as a population defined as most ‘at risk’ of being affected by the ‘obesity crisis’ and most amenable to change (DH, 2008a). Associated initiatives and practices to combat obesity are becoming radically interventionist, ranging from adaptations to school health and physical education policy, to calls for obese children to be removed from their families and placed into social care. As well as an increase in the volume of policies promising to reduce childhood obesity rates, there has been a trend towards the use of technologies which subject the body to the process of ‘informatization and digitization’ (Van der Ploeg, 2002: 59). Increasingly, quasi-medical surveillance techniques are being utilised to collect ‘body data’ (Lyon, 2001) to monitor, survey and regulate young people’s bodies (particularly weight) and lifestyles in a variety of contexts. One might argue the utilisation of these techniques to address an ‘obesity epidemic’ reflects a broader shift towards modes of social governance within socio-technological societies that ‘redefine bodies in terms of, or even as, information’ (Van der Ploeg, 2002: 64). The focus on ‘body data’ (Lyon, 2001) behoves us to look more closely at how surveillance is enacted against a backdrop of socio-technological cultures which actively shape our understandings of the body, identity and health (see Aas, 2006; Harraway, 1991; Miah and Rich, 2008) and more specifically obesity. For example, how do children’s bodies function within these surveillant practices, and how are we to understand concepts such as resistance in this terrain? In examining the propensity towards the collection of information about children’s bodies, in the final section of the chapter, we thus attempt to revisit broader questions

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concerning the theorisation of surveillance and resistance to develop the obesity debate. In doing so, our intention is to draw out a number of issues to stimulate further discussion, rather than offer any conclusive commentary.

Research project Although we draw attention here to various social contexts, including the home and the use of surveillance technologies in that setting, we also draw on more systematically generated data. More specifically, we use insights from a recent 2-year study funded by the Economic and Social Research Council (ESRC RES-000-22-2003) involving an established research team at Loughborough University (Dr Emma Rich, Professor John Evans and Laura De Pian). The study has investigated how health imperatives and associated curriculum initiatives are operationalised within and across a range of schools located in England, while collaborating and collating its findings with parallel studies pursued in Australia by Professor Jan Wright, Dr Valerie Harwood, Dr Ken Cliff (funded by the Australian Research Council (ARC)) and Dr Lisette Burrows and Jaleh McCormack in New Zealand. The methodology was designed to explore empirically the relationships between demographic ‘resources’ (socio-cultural capital) born of age, gender, class, ethnicity and (forms of) schooling; sites and sources of influence on ‘body knowledge’, and individuals’ relationships to their embodied selves. Although the research involved a combination of quantitative and qualitative data derived from some 1176 questionnaires administered to pupils aged 9–16 years, in eight schools in middle England, the United Kingdom, and qualitative data drawn from interviews with 90 pupils and 19 staff (see De Pian et al., 2008), this chapter draws only on qualitative data.

Theorising the dispersion of obesity surveillance As part of the project of monitoring and intervention in childhood obesity in the United Kingdom and other Western countries, an increasing range of technologies have been employed within a variety of contexts to retrieve body data from children. New technologies have even led to children routinely collecting data on their own bodies. For example, in later parts of this chapter we discuss the development of digital technologies such as ‘health based’ games for video consoles like Nintendo’s Wii fit through which children collate and monitor body data. In other

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contexts, children are subjected to practices through which it is near on impossible or difficult for them to resist or opt out of measurement. Early intervention via the implementation of health-related policies and initiatives in schools and wider community settings has been identified as the key to tackling obesity, not only in the United Kingdom but worldwide (DH, 2004, 2005, 2008a, 2008b) as well. The UK government, for example, has targeted children across an age-range of 4–18 years in its drive for better health. As part of a National Child Measurement Programme (DH, 2008a: 1) children in Reception (age 4–5) and Year 6 (age 10–11) are now weighed and measured during the school year ‘to inform local planning and delivery of services for children; and gather population-level surveillance data to allow analysis of trends in growth patterns and obesity’. Such imperatives have shaped a number of policies that have been implemented in schools across the United Kingdom, prescribing (and in some cases restricting) the lifestyle choices young people should make in order to avoid becoming overweight or obese. As mentioned, the majority of these imperatives concern diet and physical activity, which, if improved, is believed will not just halt, but reverse the rise in childhood obesity – a government target set for 2020 (DH, 2008a). A developing body of work has begun to reveal the disciplinary and regulative effects that obesity discourse may have upon children’s subjectivities, particularly in terms of a developing sense of embodiment (e.g. Beckett, 2004; Burrows and Wright, 2004, 2007; Evans et al., 2008; Rich et al., 2004). Much of this work has alluded to the disciplinary nature of health discourses within contexts of learning, revealing what Wright and Harwood (2009) describe as ‘biopedagogies’. Within formal and informal curricular of UK schools, children now routinely experience a range of procedures which involve the collation of data on their bodies, and the monitoring of their lifestyles, in part to meet these government targets. These include but are not limited to; biometric fingerprint screening technologies to record, monitor and in some cases restrict school lunch choices; regular weighing and calculating of child’s Body Mass Index (BMI) classification; pedometers to record the number of steps a child takes; skinfold measurements; heart rate monitors; and lunch box inspections. However, school is not the only context in which young people’s bodies are routinely monitored and regulated. Surveillance instruments are deployed in a range of contemporary social contexts in order to keep track of the body as it moves in and across a variety of settings. The dispersion of these mechanisms across an ever increasing range of contexts leads to an almost insidious affirmation across populations of the duty to care for one’s body.


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As Armstrong (1995: 400) suggests ‘the ultimate triumph of Surveillance Medicine would be its internalization by all the population’. As technologies used to undertake surveillance have become more widespread and advanced, theorisations of surveillance have also developed. Following Haggerty and Ericson (2000: 607–608), rather than ‘stretch Foucault’s concepts beyond recognition so that they might better fit current developments, we draw from a different set of analytical tools’ to explore the contemporary contexts within which young people encounter body surveillance. Like other authors seeking to explore the ‘messiness that characterizes contemporary attempts to govern’ (Leahy, 2009: 174) health behaviours within education, we fiind the concept of assemblage offers much potential (see Leahy, 2009; Rich, forthcoming). Leahy’s (2009) recent work within health education offers a compelling explanation of how ‘school based health education can be understood as a governmental assemblage in and out of itself with complex linkages and connections to other assemblages’. Elsewhere, Rich (forthcoming) draws on Haggerty and Ericson’s surveillant assemblage to examine these school-based assemblages in terms of their surveillant properties. Building on the work of Gilles Deleuze and Félix Guattari (1985), Haggerty and Ericson (2000) suggest that we are ‘witnessing a convergence of what were once discrete surveillance systems to the point that we can now speak of an emerging surveillant assemblage’ which standardizes the capture of flesh/information flows of the human body. It is not so much immediately concerned with the direct physical relocation of the human body (although this may be an ultimate consequence), but with transforming the body into pure information, such that it can be rendered more mobile and comparable. (Haggerty and Erikson, 2000: 613) Read through these conceptual lenses, rather than seeing surveillance as undertaken via a centralised gaze, surveillant assemblages act like rhizome plants, which ‘grow across a series of interconnected roots which throw up shoots in different locations’ (Haggerty and Ericson, 2000: 615). In this way, assemblages of obesity interface with various technologies, contexts and media forms to produce surveillant practices. Elsewhere (Rich, forthcoming) we have examined this process specifically in terms of school-based surveillance. In this chapter, we draw on this theoretical framework to explore how young people’s bodies are tracked across a variety of settings which operate as an interdependent assemblage. In this sense, one can examine how surveillance

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practices associated with obesity function through an assemblage which ‘comprise discrete flows of an essentially limitless range of other phenomena such as people, signs, chemicals, knowledge and institutions’ (ibid., 608). This assemblage of various media, institution and agents acts as the ‘provisional linkages of elements, fragments, flows, of disparate status and substance’ (Grosz, 1994: 167). As Rich and Miah discuss (2009), health discourses are articulated through a complex process, including a ‘negotiation of values within popular culture’. No longer confined to medical and health contexts, they argue that health promotion messages are a prominent feature of various media and cultural artefacts. The imperative towards surveillance of one’s own and others’ bodies is a message now conveyed within a number of ‘bioethical media events’ (see Miah and Rich, 2009). Television programmes such as Jamie Oliver’s School Dinners (in the UK), You are what you eat and docu-films like Morgan Spurlock’s Super Size Me are part of the cultural landscape of ‘edutainment’ (Dijck, 2006) which inform young people’s understandings of what it means to be the healthy citizen. Elsewhere, family life has also been targeted by government campaigns as an appropriate social context through which to surveil and change the lifestyles of young people. One notable example of this is the UK government’s most recent multi million pound health initiative, ‘Change 4 life’, launched in January 2009 as ‘a society wide movement’ (DH, 2008b): Change4life helps families eat well, move more and live longer [ . . . ] The campaign aims to inspire a societal movement in which everyone who has an interest in preventing obesity, be they Government, business, healthcare professionals, charities, schools, families or individuals, can play their part. (DH, 2008b) This campaign began by targeting young families with children aged 5–11 years, but soon after targeted parents of 1–4 year olds (Early years) and new parents with babies (Start4life). Additionally, young people are increasingly viewed as vehicles through which ‘healthy’ eating messages are transmitted to those actors deemed ‘most responsible’ (Colls and Evans, 2008: 628) for food consumption choices, that is, parents. In this way it is hoped that health education targeting young people will have a wider impact than on children’s health alone – improving the health of families and by extension, communities. The deployment of surveillance mechanisms and imperatives across the increasingly diverse range


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of social sites means that it is possible ‘to keep track of the body movement across various spaces and at differing temporal spaces as it attempts to capture the human body’ (Zureik, 2002: 40).

Mapping children’s bodies As outlined above, children encounter a range of surveillant practices in campaigns towards ‘healthy schools’ in the United Kingdom. Most notably, the National Child Measuring Programme (NCMP) was first rolled out in 2005–2006 (see DH, 2006) which legislates that every year children in Reception (4–5 years) and Year 6 (10–11 years old) are weighed and measured in school. In an effort to make the body more ‘mobile and comparable’ (Haggerty and Erikson, 2000: 613) the collection of BMI data was also rolled out as a monitoring programme in 2006, so that likely future trends or changes in obesity patterns of young people could be monitored. In November 2007 (under the Health and Social Care Bill), legislative changes were made to NCMP whereby all parents of children in Reception and Year 6 who take part in the NCMP will receive their child’s results accompanied, where deemed appropriate, by advice on lifestyle or referral to other services. These techniques might thus be considered part of an obesity surveillant assemblage which enable the ‘creation of spaces of comparison where flows can be rendered alike and centres of appropriation where these flows can be captured’ (Haggerty and Ericson, 2000: 608). Participants in our research study talked at length about their experiences of surveillance instruments such as weighing or fingerprint screening to monitor food purchases, across a variety of social settings, such as schools, doctors, home or through the Internet. Across these social sites, children’s bodies come to be understood as ‘hybrid’ (Haggerty and Ericson, 2000) constructions. Food choices, activity levels and weight are variously monitored and recorded as discrete observations and then ‘reassembled’ and ‘abstracted’ (Haggerty and Ericson, 2000: 611) into a statement about the person. Participants in our research reported being subject to different forms of surveillance to keep track of their weight and dietary practices across different spaces from family environments through to various spaces across the school setting. Sunil: My dad takes me to his surgery to measure me every 6 months I think, I think something like that, just whenever dad says I need to be measured.

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Interviewer: So does your dad keep a record of it then? Sunil: Probably on his health stick in his drawer, just to see how we are. Information about Sunil’s body is recorded in these different spaces, stretching the capacity to track Sunil’s body ‘across various spaces and at different temporal spaces’ (Zureik, 2002: 40) from the medical surgery to his family home. Within school settings, students reported surveillance techniques across the various socio-cultural and geographical spaces of the school. Canteens, for example, were spaces where food choices were monitored with some schools employing biometric technologies to record such data. As recognised by some children themselves, this was exercised in a field of power/knowledge comprising and reproducing generational inequalities that were also sometimes scrutinised (also, see our later discussion on resistance): It’s a thumb print. Parents can find out what you’re eating at lunch. (Elsie, Year 7) I think they should have the child’s permission as well as the parents’. (Katherine, Year 9) Since when has a parent needed a child’s permission? (Bob, Year 9) In other cases, the school extended the capacity to monitor children’s movement both in and outside of school settings by giving children themselves equipment such as pedometers to record information: Katy: In my old school we were given one. Interviewer: Do you know why you were given a pedometer? Katy: Because we were told that you’re supposed to walk so many steps a day. Many of our participants were routinely weighed in schools, either as part of the formal curriculum or through school health practices: I mean when the school nursing service came in to weigh and measure the children but they took the view that they were going to weigh and measure all children they didn’t highlight, they didn’t ask


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us to say who do you think is overweight, they just said we’re going to weigh and measure them all. (Teacher) These pedagogical spaces operate through processes designed to ‘capture flows’ and involve introducing ‘breaks and divisions into otherwise free flowing phenomena’ (Haggerty and Ericson, 2000: 608). As these informational flows are captured and abstracted into particular categories (such as BMI classifications), meanings are assembled around particular bodies. The child who is categorised as ‘overweight’ or ‘obese’ becomes one of a list of other categories through which we come to monitor the ‘precariously normal’ or more specifically ‘a way of seeing a potentially hazardous normal childhood’ (Armstrong, 1995: 396). Indeed so hazardous is this construction that there have been recent cases of fat children being taken into care because of presumed risks associated with obesity. Thus surveillant mechanisms associated with weight categorise particular bodies and this effort to ‘monitor precarious normality delineates a new temporalised risk identity’ (Armstrong, 1995: 403). On the basis of weighing a certain amount a body (which may be healthy) may become ‘overweight’, ‘lazy’ or ‘risky’ and thus a ‘complex rhizomatic flow of multiplicities reduced to a single grid of social strata’ (Malins, 2004: 86). These categorisations may provoke particular responses or behaviours if one is to demonstrate being the dutiful, healthy individual. As one participant recalls: Well I just see how much weight I’m putting on and if I’ve put on quite a lot I do more sporting activities and I eat salad and more healthy things. (Lewis, Year 5) Techniques such as BMI weighing involve the translation of the collection of body data ‘into information patterns’ (Aas, 2006: 154) in which crude body data is being utilised as a way to understand bodies relative to what are seen as ‘normal populations’: If there is one image that captures the nature of the machinery of observation that surrounded the child in those early decades of the twentieth century, it might well be the height and weight growth chart. Such charts contain a series of gently curving lines, each one representing growth trajectory of a population of children. Each line marked the ‘normal’ experience of a child who started his or her development at the beginning of the line. (Armstrong, 1995: 396)

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In this process, children’s bodies, and the complex mediations which come to bear upon their weight and health, are simply and literally ‘disembedded and lifted out into new levels of abstraction’ (Haggerty and Ericson, 2000: 154). Young people’s food choices, activity levels and weight are variously monitored and recorded by both themselves and others as discrete observations, which are ‘reassembled’ and ‘abstracted’ (Haggerty and Ericson, 2000: 611) into categories which differentiate ‘abnormal’ (at risk) populations (such as a school) and individuals from others: in other words, these surveillant practices obfuscate classed, gendered, ethnic, social, somatic experiences of the person, which clearly mediate and constitute conditions of health and which cannot be explained via simple categorisations such as BMI. In doing so body data collation and analysis ‘reduces the complexity and chaos of an everchanging multiplicity of bodily flux to discrete categories of meaning and constancy’ (Malins, 2004: 86). As a consequence, for many of the participants in our research study, rather than understanding complex mediations of the relationship between one’s weight and health, bodies were read through simple energy in–energy out equations: Yeah, I weighed myself like three weeks ago, I do like loads of exercise and then like a week or two weeks after I weigh myself to see how much I’ve lost and then I like get a present or something if I’ve lost weight, if I’ve put on weight I get told off. (Amit, Year 11) Understanding health as ultimately their own responsibility (Armstrong, 1995) young people themselves made use of these surveillance tools: Yeah I’ve used it [pedometer] before just to see how much steps you’ve done and how much calories you can burn by doing that much steps. (Anil, Year 8) For Anil, the pedometer not only captures flows of information to help him understand his health, but it is also read through a lens in which it is ultimately about how one demonstrates one’s self-control and health through wilful effort to ‘burn’ calories. Surveillance thus plays no small role in the way in which bodies are made meaningful in these assemblages. Anil comes to understand the use of the pedometer through a Cartesian notion of subjectivity and body which ‘regards the body in terms of metaphors that construe it as an instrument, a tool, or a machine at the disposal of consciousness, a vessel occupied by


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an animating, wilful subjectivity’ (Grosz, 1994: 8). This assemblage thus brings together individuals, institutions, machines and broader knowledge about obesity in a process where the child’s body and health is made meaningful: Henry (Year 8): I’ve got a pedometer on my bike and so I sometimes have a look at that. Interviewer: Why do you use that? Henry: Cause I just want to know how many calories I’ve burnt so that I know if I’ve got a good balance – if I’m working off enough calories. Interviewer: OK, and why would you choose to look at that? Henry: I don’t know, I don’t really want to be obese. For Henry, the pedometer is important precisely because of the broader knowledge about ‘risk’ infused in obesity discourse. Primarily, this discourse regards the obese body as one which is acted upon in a particular way, requires disciplining and is thus the outcome of particular ‘psychical intentions’ (Grosz, 1994: 9). The Cartesian dualism underpinning these methods of surveillance is therefore significant in terms of how the body is constructed as a ‘source of truth’ (Ball, 2005) revealing whether one has exercised control and responsibility over their body. Teachers in our research also talked of utilising techniques such as BMI weighing classifications. In assessing, labelling and categorising pupils’ bodies, parents and teachers draw upon an assemblage in which knowledge of obesity is constructed through various institutions and relations, such as media and medicine: Sarah (Head of Personal Development): Yeah, I’ve got two boys in my form . . . Jim (Head of PE): I was going to mention something about that. Sarah: . . . who do diaries with me at the moment – one of them particularly whose family aren’t particularly big, you know, came directly and said I am concerned and they spoke with Jim I think about that, so we suggested a food diary and we’re going to look at that. They can talk to our school nurse as well and we can maybe devise, to look at exercise – they both do a fair amount of exercise.

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Such practices are forms of ‘somatic surveillance’ described by Monahan and Wall (2007: 162) as a process through which: body-monitoring systems translate corporeal information into data, relay this bodily data across information networks, and allow for the intervention of feedback mechanisms upon bodies. In other words, they lend themselves to surveillance functions. As they note, the crucial point is that in processes such as weighing, the monitoring of bodies turns into surveillance when forms of ‘sociotechnical feedback’ occur. For Jim and Sarah, this involved direct intervention into the lives of the two boys whose bodies were being classified as ‘at risk’ when read through this assemblage. The young people we interviewed also talked about this process of feedback: For people who have higher than average BMIs or lower then she’ll [matron] give you advice on say what sporty clubs you can do for those people. (Tina, Year 11) Both teacher and students’ accounts thus revealed how surveillant techniques were drawn upon to ascertain those individuals who might be ‘at risk’, and involves what Lyon (2002) refers to as ‘phenetic fix’, a trend to ‘capture by data triggered by human bodies’ (weight) and to ‘use these abstractions to place people in new social classes of income attributes, habits, preferences, or offences, in order to influence, manage, or control them’ (Lyon, 2002: 3). In this sense, assumptions may be made about a child’s BMI which may bear no relation to their actual lifestyle or health, or take into account the complex mediations which impact weight. Instead, it is assumed that children who record a BMI category of overweight are the product of an imbalanced energy equation, caused by either being inactive or eating too much and in need of ‘advice’ or ‘intervention’: Yeah, the boys were weighed and that’s all that happened and that was something that I inherited but it was testing for testing sake, I can think of one specific example of a boy that was grossly overweight for his age and I spoke with him personally and we got him to speak as well with the school matron about his size because it was causing problems and it was certainly causing problems for him. (Martin, Teacher)


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To see if, well if you’ve put on loads of weight she [matron] might say that you‘ve put on loads of weight and you need to do something. (Sally, Year 8) As Malins (2004: 100) observes ‘by doing away with (or, more accurately, ignoring) the force of bodily relations, they support the production of subjects who understand and identify themselves in relation to the terms of these knowledges’. For example, Rachel, a Year 11 girl in our research, describes how simple classifications such as ‘weight’ were particularly meaningful to young people in terms of how they made sense of their own and others’ bodies: Well with matron herself I don’t mind it, it’s when you get out of the medical roomy place and everyone goes ‘oh I’ve lost two kilograms blah blah blah blah’ and you’re thinking ‘oh, I’ve gained five’ [ . . . ] It’s just when you go outside and everyone wants to know and everyone wants to compare – it gets a bit too competitive. Within these assemblages, health exists on a ‘scale’ rather than an absolute category which can be achieved and instead becomes an almost limitless condition in which one can always lose a bit more weight, or eat a little less: The tactics of the new Surveillance Medicine, on the other hand, have been pathologisation and vigilance. The techniques of health promotion recognize that health no longer exists in a strict binary relationship to illness, rather health and illness belong to an ordinal scale in which the healthy can become healthier, and health can co-exist with illness. (Armstrong, 1995: 400) This tendency towards the comparison of body data is not only significant at the level of individual interaction, but also in terms of the broader trends to compare populations, such as the use of BMI statistics to compare the levels of obesity in different countries (see Halse, 2009), or average BMI of a school. This information forms the basis of ‘mapping’ procedures which pinpoint those deemed most at risk, and thus where intervention should be focused. For example, in the United Kingdom in August 2008 Dr Foster Research produced the well-publicised (Independent, 28 August 2008) ‘UK fat map’ identifying geographical

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hotspots where obesity levels were particularly high within the United Kingdom. The map and accompanying report were compiled using data from GP practices, including a register of patients with a BMI of 30 or over. Within these assemblages, it is hardly surprising that our participants come to know themselves as either fat or thin, healthy or unhealthy, failing or morally right; through dichotomies that abolish ‘multiplicities and variation’ (Malins, 2004: 100). This raises a number of ethical questions as to how ‘data’ of this kind are used in ways which enable highly negative and consequential judgements to be made and speak to broader concerns about social governance and inclusion through ‘categorization and social ordering’ (Zureik, 2002: 39). For example, in August 2008, in the United Kingdom, The Local Government Association, which represents more than 400 councils in England and Wales suggested that ‘fat’ children should be classed as examples of ‘parental neglect’ (see Sherman, 2008). Such concerns were raised on the basis of projections of obesity figures, with David Rogers, the Local Government Association’s public health spokesman, stating that: by 2012 an estimated million children would be obese and by 2025 about a quarter of all boys would be grossly overweight [ . . . ] Councils would step in to deal with an undernourished and neglected child, so should a case with a morbidly obese child be different? (Sherman, 2008)

Prosthetic surveillance within an obesity assemblage Obesity surveillance is not limited to the forms described above, nor is it simply imposed onto individuals. In addition to the forms of surveillance which children may be subjected to, there is also a range of technologies which children use of their own volition to ‘read’ their bodies. Indeed, surveillant assemblages associated with obesity are pervasive and effective precisely because they extend well beyond formal institutions and instead reside ‘at the intersection of various media that can be connected for diverse purposes’ (Haggerty and Ericson, 2002: 609). Conceptually, the assemblage provides a means through which to understand the connections with new media, technology and the increasing tendency towards the monitoring of children’s bodies via digital consumer culture which turn the body into information. Elsewhere, Miah and Rich (2008) have noted the emergence of a ‘medicalized cyberspace’, within which the convergence of health discourse with


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digital consumer culture has resulted in the infiltration of surveillance techniques of the body into private leisure spaces. Indeed, as Rich and Miah (2009) observe, many children themselves are collating body data with ‘the advent of a range of digital platforms that merge entertainment with the regulation of the body’ such as health games online, or games played on consoles such as Nintendo’s Wii Fit or My Health Coach. As one participant comments: If you look at new gadgets like the Nintendo Wii that’s like helping you like exercise a lot more. (James, Year 9) Within cyberspace, children are now utilising weight charts, calorie calculators and target heart rate calculators, all of which enable users to undertake their own health screening in order to monitor their bodies in relation to risks associated with obesity: They do calculations in maths so I think they [children] sometimes pick up on this, if you click onto boots the chemists’ web-site, you can check your BMI no problem. (Pamela, food and textiles teacher) you can even check on the Internet they say that he doesn’t really eat that much [Christiano Ronaldo] but when he does eat a lot he eats mostly healthy and good foods. (Sayid, Year 6) sometimes like on the Internet there could be things about healthy eating. (Elise, Year 7) Websites associated with physical activity behaviours, for example, typically provide BMI and exercise level counters as methods of assessment (see Evers et al., 2003: 66). Users enter data about their body, such as physical activity patterns, diets, weights, height and so on, which are then reassembled into classifications of health categories and risk indicators. These digital tools further expand the temporal spaces in which body data on children and young people are captured. The Nintendo Wii, mentioned above and discussed recurrently by children, is perhaps one of the most popular examples of this. This games console can detect

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movements of the player via wireless controllers, designed to mimic the real life movements of particular activities: Yeah, but they even brought out these computer games like with Wii. It’s meant to be so you can exercise when you do it because you do the sports. They’re not as good as real exercise but they’re better than sitting in front of the TV. (David, Year 8) A recent development for this console is Wii fit which offers an integrated balance board peripheral device that weighs the user, gauges fitness and balance and monitors BMI. Weight monitoring tools, nutrition games and virtual environments, such as Nintendo Wii fit, provide a means through which to regulate prosthetic bodies. ‘Digital’ environments such as these bring corporeal measurements of BMI, fitness and so on into virtual settings as a prostheses of physical selves. Thus, Rich and Miah (2009) suggest that this form of surveillance not only regulates physical bodies in real time, but via prosthetic surveillance regulates and defines bodies that are simultaneously hyper text and flesh. This games console thus gives a BMI measurement offering categories such as ‘overweight’, with players then offered training programmes designed to improve their results. Surveillant technologies such as Wii fit are examples par excellence of the way in which bodies are abstracted within the surveillance assemblage: First it is broken down by being abstracted from its territorial setting. It is then reassembled in different settings through a series of data flows. The result is a decorporealized body a ‘data double’ of pure virtuality. (Haggerty and Ericson, 2000: 611) Within Wii fit, one’s weight is recorded via the balance board, turned into information in the form of a BMI category and represented on screen. The user even constructs a visual image (avatar) designed to represent their prosthetic self in cyberspace. The data double represents a particular medicalised identity infused with technology (see Haraway, 1991; Hayles, 1999; Miah and Rich, 2008). In these cyberspaces, children’s bodies are not read through their territorial settings; that is, their embodied and contextual histories and complexities such as their gendered, classed, cultural or ethnic localities which may bear upon their weight–health relationship. Instead, to


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use Haggerty and Ericson’s (2000) expression, they are made sense of through ‘abstracted’ and ‘reassembled’ categorisations based purely on body data. Thus, leisure spaces, school sites, popular culture, official policy and so on converge and interlink in ways which make obesity discourse an almost boundless ‘surveillant assemblage’ (Haggerty and Ericson, 2000). Within this process, a disparate range of individuals are authorised to undertake the surveillance of others’ bodies. We are reminded, here, of Haggerty and Ericson’s point that ‘the surveillant assemblage cannot be dismantled by prohibiting a particularly unpalatable technology’ (Haggerty and Ericson, 2000: 609).

When the body speaks up: Reading resistance and mediation in the surveillant obesity assemblage In this final section, we raise questions about the intersections between young people’s bodies, technology and how they engage with, or resist, processes of abstraction. If techniques of surveillance ‘informationize’ (Van der Ploeg, 2002) and ‘prostheticise’ (Rich and Miah, 2009) children’s bodies, how are we to make sense of how young people (and perhaps others) mediate and resist obesity discourse? Whilst any assemblage involves a complex series of connections across a range of machines, people, institutions, knowledges and so on, this is not to suggest an ever present gaze or surveillance which is simply internalised by children. In the complexity of the assemblage, spaces may arise for the agency of the body to be announced, and resistances occur. Dislocations can arise, for example, between ‘sacred’ (state sanctioned ‘scientific’) health knowledge/s and ‘profane’ knowledge/s integral to an individual’s lived experience given by their culture and class (see Evans et al., 2008; Perhamus, 2008). A surveillant assemblage therefore offers no guarantee that state-sanctioned preferred behaviours (for example, relating to food or exercise levels) are adhered to. In this sense, whilst children’s bodies may be drawn into assemblages which stratify and organise them in the practices associated with new health imperatives in schools, so too, they may develop what Deleuze and Guattari (1985) call ‘lines of movement’ which move away from the particular surveillance assemblages which seek to organise them. However, we also need to be cautious of limiting ourselves to reading resistance only as a deliberate and intentional practice. Politicised writings by feminists concerned with the body, alongside the Health

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At Every Size movement (HAES), provide an official corpus of critical weight scholars, who articulate a deliberate response and resistance to current obesity discourse. Others may be less organised (e.g. the parents or pupils who refused to subscribe to Jamie Oliver’s school dinners) but no less resolute in their opposition to state-sanctioned ideas of how they should eat. On other occasions, resistance may even occur as an unintended or unforeseen outcome of the presence of particular surveillance technologies. Given this prospect, we need to better understand how the corporeal, institutional, virtual and technological interact within the sort of surveillant mechanisms described above. Whenever the lived experiences of gender, class and ethnicity, alongside somatic and corporeal sensations and sensibilities, impact on a child’s weight, tensions may surface during moments of surveillance to reveal the frailty and inadequacies of these technologies in capturing ‘health’, as Hannah comments: I don’t know really. I don’t really think there’s a perfect size, because we’re all different. We’re all different heights, and different bodies and people, like if you’re Hispanic, you have different tendencies to like if you’re Indian, if you’re British, if you’re African. (Hannah, Year 11) These moments of resistance might be read through various theoretical lenses. For example, Bernstein (2000: 32) pointed out that in the flow of discourse (recontextualisation) between sites of practices, such as translation of government policies into school policy/initiatives, ‘there is a space in which ideology can play’. Furthermore, the interpretive activity of children is subject not only to developing ‘socio-cognitive resources’ but also corporeal resources (Evans et al., 2009), especially as their bodies’ corporeality meets with socio-technological practices. In other words, if we are to understand how obesity surveillance is experienced by those it targets, then we need a more complex reading of how these technologies are always inevitably mediated for individuals through their material (flesh and blood, sentient, thinking and feeling) bodies, their actions and those of their peers, parents/guardians and other adults. Indeed, there has been renewed interest in the corporeality of the body, its somatic impetus (Evans et al., 2009), which may help to reveal how ‘the body retains its own impetus – an impetus for forming assemblages which allow desire to flow in different directions, producing new possibilities and potentials. Revolutionary becomings’ (Malins, 2004: 86).


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The orientation towards the collection of body data to combat childhood obesity not only reinstates the body as a central focus of sociological study but also challenges its ontological status since biology, body, technology and culture are caught up in a complicated series of flows within the obesity assemblage. Negotiating the difficult terrain of avoiding biological essentialism, whilst at the same time rejecting the view that the body is a blank subversive canvas, totally inscribed through culture, has remained a perennial concern for sociologists, philosophers and feminist scholars as they have endeavoured to address the tensions at the nexus between body and mind and body and culture (see Braidotti, 2002; Grosz, 1994; Hayles, 1999; Shilling, 2005). Bodies are inscribed socially through disciplinary practices concerned with health and normalisation, but they also embody affective, cognitive and somatically mediated meanings. The meanings inscribed are based on the presence of a particular body, and its attributions within social context: including the geographies of space (occupation of space of one’s body), time (within the current obesity epidemic) and location (social location, e.g. gender). However, as Zembylas (2008: 4) notes ‘human beings have universal corporeal potential’ and many of the young people in our research talk about this potential during periods of growth and maturation: But overall I’m happy with it, because obviously we’ve changed a lot since we were seven years old and I can still see myself changing in the future as well so I’m just going along with it and think it’s my body and it’ll grow into itself. Sometimes I just think ‘oh my days – what do I look like?’ and some days I think ‘yeah, I’m happy with this’. I never actually think I don’t like my body. (Rachel, Year 11) Time and again, the young people in our study talked about their fast changing, sometimes awkward and contradictory, less than ‘perfect’ bodies that were measured and abstracted in myriad settings. It is the unstable and ever changing nature of their bodies which brought forth unintended moments of resistance to obesity surveillance: With matron herself if she says ‘you’ve put on two kilograms’ I won’t be that bothered because I just think it’s my body changing or ok maybe I ate loads this lunchtime. (Rachel, Year 11)

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Following Ball (2005) we therefore suggest that at the embodied intersections between body and technology and body and culture, one may find more nuanced forms of resistance which challenge some of the moralised truth claims embedded in obesity discourse: The questioning of the extent to which the body can be pinpointed as a source of truth, because it is constantly reconstituted and inherently unstable, is the starting point for challenging biotechnologies that specifically locate the body as a site of ultimate truth or authenticity about the person. (Ball, 2005: 101) This raises fundamental questions about what happens at the intersections between the body and these surveillant technologies, and their refraction in the responses of those children who experience them. Such relations have been brought more obviously into question through the emergence of technologies in cyberspace that measure body data. These spaces construct a particular ontology of the body as materiality and flesh, but also as a prosthetic representation, captured in cyberspace as a flow of information within the surveillance assemblage. There are moments where rather than being silenced, the embodied and embedded histories of young people act as a sort of embodied sensibility, whereby it confronts the ‘reliability’ of these technologies and their truth claims. By way of example, in May 2008, British media (Daily Mail, 2008) published concerns raised by parents whose child was labelled ‘fat’ by the Nintendo Wii Fit games console. The stepfather of the 10-year old-girl commented: ‘She is a perfectly healthy, 4ft 9in tall 10-yearold who swims, dances and weighs only six stone’. In response to this, Nintendo issued the following official statement: Nintendo would like to apologise to any customers offended by the in-game terminology used to classify a player’s current BMI status, as part of the BMI measurement system integrated into Wii Fit. Wii Fit is still capable of measuring the BMI for people aged between two and 20 but the resulting figures may not be entirely accurate for younger age groups due to varying levels of development. In this example, the sensibility (see Monaghan and Hardey, Chapter 3 in this volume) of the active body, of what the child knows and feels through and in their own bodies, confronts the legitimacy of the


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surveillant technology. The child’s engagement with physical activity and their own reading of their embodied and embedded history confronts the abstracting of their body data (weight) into some alternative subjectivity (fat), highlighting the problems with a surveillance system which decontextualises or erases their somatic, affective, embodied histories. As Green (1999: 29) observes, surveillance strategies are ‘often deployed as strategies of social dominance, but do not automatically determine response. Individual agents have the capacity to formulate individual responses’ (Green, 1999: 29). In the case above, the individual response of the child and parents involves the recognition of the irreducibility of the body, and the limitations of using surveillance technologies which endeavour to ‘capture’ a temporal prostheticised body. Indeed one is reminded of Haggerty and Ericson’s (2000) assertion that some forms of surveillance can be productive. Their ‘rhizomatic’ nature has ‘transformed hierarchies of observation, and allows for the scrutiny of the powerful by both institutions and the general population’ (Haggerty and Ericson, 2000: 617–618), resulting in what they refer to as a synopticism rather than just a panoptican. In this case, this rhizomatic flow operates in such a way that a powerful consumer company, Nintendo, responded to its consumers with an apology. Here, the use of BMI monitoring reveals to both the child, the parent and later the public the contradictions inherent in obesity discourse, namely that one’s weight and BMI do not confirm the body as a source of ‘authenticity and truth’ (Ball, 2005). Nor may it be an accurate conduit to relay complex information about an individual’s physical activity level, dietary habits or state of health. Recognising the uncertainty of the body is in this way an important aspect of expanding the obesity debate, where the heterogeneity of the body captures the imperfect nature of surveillance mechanisms, revealing moments of resistance. This is not to celebrate or condemn the use of such technologies as BMI measurements or Wii fit but rather to attend to the ‘interpretations of the affordances of the artefact: the possibilities for action that it offers’ (Hutchby, 2001: 449: cited in Zureik, 2002). The oversimplification of tools such as BMI highlight their own unreliability when read through these young people’s lives, and the complexities, contradictions and uncertainties they experience in relation to weight and health. As Shilling (2008: 1) observes ‘bodily change sometimes occurs as a result of consciously formulated actions undertaken in situations of considerable autonomy, but it also happens frequently in circumstances over which individuals have little control’.

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Conclusion Our modest exploration of surveillance of children through obesity discourse is not theoretically novel, but does indicate the need for more sophisticated engagements of surveillance of young people’s bodies. As Ball (2005: 94) comments: a politicization of the constitutive instability of the body is needed to augment a practical and analytical understanding of how resistance to surveillance practices might be conceptualized. In this sense, by expanding our understanding of how obesity surveillance operates, rather than examining discrete practices, institutions or agencies, we have attempted to explore the way in which obesity surveillance is ‘driven by the desire to bring systems together, to combine practices and technologies and integrate them into a larger whole’ (Haggerty and Ericson, 2000: 611). We have suggested that the embodied and localised histories of individuals may surface in moments of surveillance, revealing their importance in understanding complex conditions such as weight and health. Overcoming the ‘profound somatophobia’ (Grosz, 1994: 5) and fatphobia which plague research on the body and obesity, and rediscovering the body’s efficacy, seems crucial in documenting these complexities. By bringing the relationship between mind–body, body–technology, weight–health relations to the fore, we may better reveal how problematic it is for surveillance techniques to gloss over vital complexities of weight/fat and instead read the body as ‘truthful’ through simple quasi-medical measurements. Surveillance practices gathering body data of children therefore raise a number of ethical questions about how these techniques are operationalised and the ramifications of misuse of these data. The tendency to reduce the body to an articulation of some ‘truth’ which forms the basis of decisions about a child’s health, or whether a child should be taken away from its parents and placed into care, implores us to reconsider not only anti-obesity monitoring strategies, but also the conceptual strategies through which we understand current surveillance of young people’s bodies. This chapter has hopefully gone some way towards encouraging such an approach, drawing from and promoting theoretical, politicised and empirical understandings about power, children, technology, embodiment and fatness.


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7 Fat Lib: How Fat Activism Expands the Obesity Debate Charlotte Cooper

‘Nothing About Us Without Us!’ is a slogan that was popularised by disability rights activists and has been since taken up by other socially marginalised groups, for example transgendered people. It is a slogan that could easily apply to those seeking to create social change within fatphobic systems and discourses that dehumanise fat people. Such systems make us abstracted and absent, passive or pitiful sites for intervention. Yet where fat people are ironically ignored in statutory initiatives designed to ‘tackle obesity’, fat activism makes us very much present, it enables us to develop a voice, a sense of self, agency and collective power, and it awakens us to self-determination. It creates new possibilities not just for fat people but also for anyone with an interest in fatness. To most people the idea of linking the words ‘fat’ and ‘activist’ is plainly ludicrous, activism presumes a dynamic engagement with public life, a concept far removed from the couch potato stereotypes associated with fat people. But, as we shall see, fat activism has a diverse history that is at least four decades long. This movement is largely undocumented, with a modest associated literature. Thus, in this chapter, I will draw upon my own personal history as an activist within various fat communities.

Who am I to speak about this? My own history with fat activism began as a child in the 1970s when my mother, a nurse, placed me on a number of weight-loss projects and diets which started when I was about 7 years old and continued until just after her death in 1986. I grew up with cultural fantasies about the value of weight-loss and thinness inside my home, amongst my 164

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peers and in the wider culture. As a teenager I developed an interest in feminism, rock’n’roll and transgressive queer literature (e.g. Acker, 1984; Burroughs, 1977). It was through these lenses that I encountered early writings on fat liberation (Schoenfielder and Wieser, 1983) and began to think of my own fatness as part of an outlaw identity, by which I mean rebellious, freaky, fun-loving, anti-assimilationist and proud of it. I have been involved with numerous episodes of fat activism and related activities over the past 20 years in the United Kingdom and United States. Past, current and ongoing activities include: writing for various audiences (e.g. as a journalist, web editor and blogger); making zines (homemade publications, usually produced for fun and not profit); performing (e.g. as a member of a band, The 123s, or doing spoken word); acting as an invited speaker in universities and elsewhere (e.g. at the British Film Institute, as the keynote at NOLOSE); completing an MA, and publishing my dissertation as Fat and Proud (Cooper, 1998); organising a support group; founding a girl gang; making films; networking; attending protests, conferences, dances and sex parties; talking to my friends; training as a counsellor; speaking up; and more. Perhaps my activities reflect the diverse possibilities for fat activism. Lately I have embarked upon a PhD at the University of Limerick. My activism has been a means of validating fat identity, generating fat culture and community, instigating a creative critical response to dominant obesity discourse, having fun with interesting people and, in punk tradition, of ‘fucking shit up’ (Sinker, 2007: 91).

Who are the fat activists? As a fat activist I am one of many. It would be foolish to assume that fat activism is a unified movement. For example, there are debates within the movement about creating boundaries around fat activist identities (Cooper, 2009a) that exclude Fat Admirers, people, usually men, who have a sexual preference for fat partners, usually women (Goode and Preissler, 1983), or people who are actively seeking to lose weight. There is a heavy bias towards Stateside activism because much of the literature, documentation and organisation is based there. As with many attempts to create social change, the history of fat liberation is peppered with infighting, although this could be read equally as a sign of healthy debate and a pluralistic approach to social change. In addition, readers should not assume a continuity between the events mentioned below since it is common for activists to be unaware of fat liberation history, itself unsurprising when one considers how little is documented.

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It is difficult to answer the questions of who can be a fat activist and who is included because they presume a stable membership of a single community that is clearly delineated. Whilst there are some organisations that have management boards, for example the National Association to Advance Fat Acceptance (NAAFA, and formerly The National Association to Aid Fat Americans), much activism takes place in an ad hoc manner amongst friends and extended groups of acquaintances, and around many intersections. It is possible that there are common assumptions within these groups about what a fat activist might be, this is more likely than an official constitutional commitment, but this subjective phenomenon has been under-researched. Additionally, it might be that initiatives that were founded within communities that already had a tradition of creating exclusive space, for example lesbian separatism, might be more interested in creating similar spaces within fat community, where members and non-members are distinguished from one another, again, this is under-researched. Some organisations, for example NOLOSE, refer to allies, but I suspect that this strategy relates more to the problems of creating an integrated, trans-friendly space, that might one day be open to cisgendered men too, in an organisation that was founded in more separatist queer communities, than an intention to create distinctions between different-sized people; delegates of all sizes attend that conference. I am reluctant to make definitive statements about who is inside and who is outside, nor would I want this somewhat arrogant responsibility. I believe that people should be free to define themselves as they wish. Moreover, a definitive statement would be purely speculative, since there is little documentation about fat activism in general and none that I can think of that makes explicit the requirements for membership.

Definitions Like Murray (2008) I reject the notion that fat is an empirical fact, hence I make no attempt here to delineate between who is and who is not fat and leave readers to make such decisions for themselves based on their own ontologies and subjectivities. Murray critiques essentialist identities within fat activism, which universalise fatness and fail to take into account differences and conditions. As she rightly points out, fat identities ‘are always contingent and multiple’ (p. 88). I use a broad and eclectic definition of ‘activism’, which I take to mean intentional actions that seek to bring about change (Cooper, 1998). Can one be an activist without intention? I would argue that the intention

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need not necessarily come from oneself, but could be read by others, for example through the adoption of a historical figure whose actions may not have been regarded as activist within their own period, but could be seen as such in later years. I am unwilling to demarcate what is and what is not activism because of the danger of reinforcing binary positions or marking myself out as an arbiter of such positions, instead I approach activism as something conditional and complex. I also consider fat activism to be an evolving entity, or rather a series of entities, which are sometimes interwoven and sometimes estranged from each other. Evans et al. (2008) show how obesity discourse has been created through institutional and medicalised facts and pedagogy. Yet obesity discourse is not just handed down and authoritarian, it is also experienced through everyday relations, so I would define it further as ‘a limited cluster of approaches and theories which support the most popular ways of understanding obesity’. Such popular understandings may have cultural variations. These frameworks for understanding obesity are so ubiquitous that they come to be recognised as truths or commonsense, yet they form a discourse. Here fatness and fat people are contextualised as pitiful and/or many of the following: lacking in moral fibre, diseased, potentially diseased, greedy and lazy, not just ugly but disgusting, pathetic, underclass, worthless, a repulsive joke, a problem that needs to be treated and prevented. See Simmons (1994), Brownell and Battle Horgen (2004), McKeith (2005), Spurlock (2006) and Butland et al. (2007) for examples of this dominant obesity discourse. Much of the obesity literature and its accompanying discourse has strong roots in medicine, which is why it is sometimes referred to as ‘a biomedical model of obesity’ (see Aphramor, 2005; Aphramor and Gingras, Chapter 8 in this volume; Sobal, 1995). However, medicalisation is not the only way in which obesity discourse has been formed, it is also maintained by other related power structures (Cooper, 1998) and stakeholders including: drugs companies, food producers and retailers, satellite medical and diet industries, government policy makers, advertising and media and fashion industries. In addition, in her work on stigmatised people, Everett asserts: ‘Social structures that should protect either turn a blind eye or actually participate in discriminatory acts, leaving people feeling abused and abandoned’ (2006: 51). A number of scholars note how fatphobia is created through forms of intersectionality, for example Chernin (1983) and Freespirit (1983) suggest that fat hatred is formed or influenced by other forces of oppression, for example, misogyny, ageism or fear of disability.

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It is the dominant obesity discourse outlined above that most fat activists seek to challenge, because it is argued it can lead to stigma, stereotyping, discrimination, self-hatred and a sense of helplessness in fat people. From a medical sociology perspective, Reidpath et al. (2005) demonstrate that these inequalities can have a direct impact on health and social inclusion. The dominant discourse provides a basis for inappropriate interventions that can deplete our quality of life and embolden stakeholders to prescribe more problematic treatments. A growing body of work (Austin, 1999; Schoenfielder and Wieser, 1983; Sobal and Maurer, 1999a, 1999b) has revealed how this can lead to processes of alienation of fat people from each other, and from allies in the wider society, and crush the possibility of meaningful community or resistance.

Earlier history The earliest documented examples of fat activism span the years 1967 to roughly 1989. I have pulled out five examples from this period: The FatIn, Fat Power, NAAFA, The Fat Underground and the London Fat Women’s Group. I have pieced together the information below from magazine articles and first person accounts because, as far as I am aware, there are as yet no research studies or larger bodies of literature upon which to draw. I have chosen these early examples of activism because of their relevance to me as an activist; I consider Fat Power, NAAFA and The Fat Underground to be the founding bodies for fat activism. The Fat-In The first ever documented example of fat activism took place when New York radio personality Steve Post convened a Fat-In at Sheep Meadow in Central Park in June 1967. Other members of staff at WBAI, Post’s station, had already organised various public gatherings (Land, 1997), and the Be-In was a popular cultural event, part of the late 1960s hippie zeitgeist. According to Sports Illustrated 500 participants carried: banners reading ‘Fat Power’ and ‘Buddha Was Fat’. Some wore buttons with the message ‘Take a Fat Girl to Dinner’ or ‘Help Cure Emaciation’. They burned a pile of diet books and a photograph of Twiggy and offered each other fattening foods brought especially for the occasion. (Anonymous, 1967: 12)

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Post, described as 210-pound 5’11”, told reporters that the Fat-In’s purpose ‘was to protest discrimination against the fat’. The Fat-In broke new ground, but is considered little more than a publicity stunt by William Fabrey of NAAFA who spoke to Post about the event in 1982. I asked if I could include some of his comments about the event in this chapter and Fabrey consented, remarking: At the time, it was commonplace to seize on any outrageous topic and hold a sit-in, as you point out. Reporters would be sure to show up. It was an attempt to put radio station WBAI before the public. Participants sometimes barely knew what they were protesting – it was the ‘camp’ thing to do. I heard that Post himself was a compulsive dieter for years after that. Nonetheless, the event was noteworthy on its own merits. But it had no steam behind it. (Fabrey, 2009, personal correspondence) Whether or not the Fat-In was an activist event is debateable. In itself it was clearly a weak statement for fat rights, but it was also an ambiguous event that took place within a cultural landscape where nothing like it had come before. Perhaps observers such as Lew Louderback, Fabrey and others projected what they wanted onto it, and sparked their own ideas and activism from the event. The Fat-In may have been more a product of whimsy and marketing than political grit, but it nevertheless created a postmodernist spectacle that could be seen as a precursor to, for example The Fat Underground’s eulogy to Mama Cass, and The Chubsters, who I shall discuss later. Fat Power Llewellyn (Lew) Louderback described himself to me as a hack writer living in Staten Island whose titles include genre pieces such as Pretty Boy, Baby Face – I Love You (1969) and Operation: Moon Rocket (1968). I have been in communication with Louderback since 2008 through letters, phone calls and a visit to his home in New York. I explained my intentions to him about this chapter and he consented to allow me to reproduce his words here. Five months after the Fat-In, Louderback published a piece in The Saturday Evening Post entitled ‘More People Should be FAT’ (1967), he recalls: My motivation for writing the piece was my outrage at the kind of life my wife [Ann] had been forced to live as a fat woman. (She died four years ago. Of lung cancer, of course, since she was a

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follower of the ‘reach for a smoke instead of a sweet’ school of weight control.) (Louderback, 2008a, personal correspondence) The article led to a meeting with Fabrey and also a book deal, which resulted in Fat Power (1970). Louderback remembered that Fat Power was written very quickly and drew upon previous clinical work by Bruch (1957) as well as Stunkard and Burt (1967). Louderback was assisted by Fabrey and his wife, he explains: Ann did a lot of the research, incidentally, she was working for an ad agency. Her job was editing, proof-reading and getting everything just right on these ads. Terrible pharmaceutical ads. But she had access through the company to all kinds of magazines that she could get articles from. (Louderback, 2008b, personal correspondence) Written in his zingy, pulpy style, Louderback’s prose is distinctly prefeminist, it exhibits a naïve understanding of race and class, and has a heteronormative slant that fixes this work very much within its time and place. However, the book is also astonishingly current, nearly four decades after its publication, and it remains a pioneering if little-known incitement for change. Louderback makes a compelling demand for civil rights for fat people. He argues that anti-fat prejudice is fostered by the media and indirectly provides healthy profits for medical, fashion and diet industries. He draws upon fat history and culture, considers diet culture, medical discrimination, challenges health truisms and offers practical suggestions for living fat. According to Louderback, the book was not successful. He explained that he was offered a publicity interview on the hugely popular Johnny Carson Show, a late night television talk show, but turned it down when he discovered that the producers’ intentions were to lampoon him. Fabrey describes the tension between the book’s aims and the reality of commercial publishing: It was a miracle that [Fat Power] was published at all. The original publisher. Meredith Press, who had the manuscript sold it, with a batch of others, to Hawthorn Books, I believe, and Hawthorn treated it like an orphan. Only one editor at the original publisher believed in it, and in Lew, and he or she left the company. Hawthorn’s attitude, according to Lew, was ‘Well, all right, I suppose we have to publish it,

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but a limited press run, no budget for publicity, and keep the pages to a minimum’. What saddened me most was that [Louderback] didn’t save the original manuscript, before all the cuts, and especially the footnotes, and that wasn’t the publisher’s fault. (Fabrey, 2008, personal correspondence) Fat Power was the first book written for a popular audience that offered a coherent critique of the biomedical model of obesity and spelled out a manifesto for rights and recognition for fat people. Louderback, like many activists, channelled personal experiences into political work and, like other writers who take a critical stance on obesity (for example, Freespirit, 1983) was forced to negotiate a hostile media and choose between public humiliation and obscurity. Perhaps it is this and the lack of reference notes which has caused the book to be little-known today, although it influenced fat activists at the time. NAAFA bought copies of Fat Power to sell in its bookshop and Louderback effectively left the movement. NAAFA Fabrey, like Louderback, had been sickened by the fatphobia directed towards his first wife Joyce, and wanted to take action. Upon reading Louderback’s Saturday Evening Post article Fabrey believed that he had found a kindred spirit and set about seeking reprints to distribute himself. This led to a meeting that included the Fabreys and the Louderbacks, who resolved to establish an organisation. On 13 June 1969 NAAFA’s Constitution and Bylaws were signed by a group of nine people headed by Fabrey who was designated founder (Fabrey, 2001). NAAFA began with an agenda for social change, Fabrey explains: I wanted to make the world a safer and more pleasant place for persons of size, and for them to like themselves better, and lastly, and less important, for nobody to tell me what my taste should be. (2008, personal communication) He added that the early days of the organisation were a struggle. He was politically inexperienced, the group was attempting to develop radical new ideas within a fragmented board, amongst a membership who appeared depressed, directionless and without hope. When the board decided to expand its social function and develop a dating service it was not only Louderback who left but also more politically astute factions who went on to form The Fat Underground in the early 1970s.

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NAAFA continues today and organises conventions and get-togethers. The organisation has local groups in the United States, and special interest support groups, including, for example, those that examine the intersections between fat identity and mental health professionals, the military, parenting and care-giving to fat children, sleep apnea and weight-loss surgery. The organisation has a large membership when compared to other fat activist groups, and its social function remains popular. Yet it is somewhat beleaguered, uneven and criticised (Harding, 2007) for its conventional and conservative approach, and for the high level involvement of Fat Admirers. The tension continues between those who seek friends and lovers and social support/networks, and those who want a stronger focus on public life and policy. However, NAAFA helped provide a legacy in an ongoing emphasis on language, especially the use of ‘fat’ which was deemed preferable to the medicalised ‘obese’ and words to express various features of fat experience, including although not limited to: supersized, fat admirer, fat acceptance. NAAFA established an autonomous political organisation by and for fat people and their allies, and offered what Kathleen LeBesco calls ‘possibilities of organizing around conflicted identities’ (2004: 10). Fabrey reflects further: What I actually helped to achieve was a more responsive fashion industry, and a subculture of people who accept themselves, and those who admire them. My being an ‘FA’ (a term I helped coin) feels a little more mainstream, sort of, than it ever was, but there are still hateful people who will still put me down because of it, and lots of fatphobia out there, as always. But now there is a whole movement to deal with it. I helped to give it a kick-start, although it took about 30 years longer than expected. (2008, personal communication) The Fat Underground The Fat Underground was part of a radical feminist therapy collective which used a social model for mental health and provided a space for women to redefine themselves and take personal and political action against their oppression. They used a similar concept of oppression as that developed by Freire (1970) which entailed recognising the validity of their own experience and using it as a pedogological basis through which to educate their peers and their oppressors. Their existence exemplifies the close relationship between feminism and fat activism in the earlier part of the movement. In 1972, a group, including Freespirit

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and Fishman, approached the Radical Psychiatry Center in Berkeley to train as radical therapists where they used their work as a platform for fat activism. In 1973, they established a chapter, or a local group, of NAAFA in Los Angeles, however Freespirit remarked: ‘It was like the Black Panthers working with the NAACP’, she says of the old factions within NAAFA. ‘Their idea of activism was to go to the Cerebral Palsy Foundation and do volunteer work so that people would say that fat people are nice. Ours was to demonstrate – break into a university lecture hall at UCLA during a class on behaviour modification (for weight loss) and take over the classroom’. (Relly, 1998) Fishman adds: Our confrontational stance eventually drew the attention of NAAFA’s main office. Although some of the leadership privately applauded us, officially we were told to tone down our delivery, and also to be more circumspect about our feminist ideology, which most NAAFA members were not yet ready for. (Fishman, 1998) The group eventually struck out on their own. They established themselves at The Women’s Center and had a mission: The Fat Underground confronts the double oppression of fat women in society through our nutritional, psychological and politically radical analyses of our condition which dispute all present myths about fat. Through media appearances, consciousness raising and informative written materials we provide a support group for fat women who are not dieting and we provide outreach to those who wish to politically align themselves with their fat sisters. (The Fat Underground, 1975) To achieve this, the group published a manifesto and position papers on the inefficacy of dieting, discrimination at work, eating, health, psychiatry, sexism, eating disorders, public furniture, medical power, stereotypes and humour. They published some of their work in Spanish as well as English, and made media appearances. The position papers were based on their own research at medical libraries after Lynn MabelLois (now Lynn McAfee), who had access to a medical library, shared

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her research skills with the group. Thus, they were able to quote primary sources and establish a scientific rationale for fat liberation which was needed in order to counter anti-fat claims and create a dialogue with medical professionals in a language they would understand. The group continued to hold retreats and to use radical therapy as a means of developing positive fat identities. They established coalitions, for example a relationship with the Women’s Studies department at California State University led to members testifying before the California State Board of Medical Quality Assurance in 1975 about amphetamine prescription for weight-loss. The Fat Underground’s most well-known action was the eulogy they held for the fat singer Mama Cass Elliott, in August 1974 at a Women’s Equality Day, mere weeks after she died. Media stories circulated that she had choked to death on a ham sandwich but The Fat Underground recognised that Elliott had been dieting at the time of her death and that this could have contributed to her fatal heart attack. The group presented a symbolic funeral procession; McAfee spoke of Elliott’s inspiration and accused the medical establishment of murdering her and of committing genocide against fat women through their promotion of weight-loss at any cost. Unlike previous events this action attracted media interest and created a visual and known example of what fat activism could look like. In November 1983, core member Reanne Fagan died of breast cancer, the group disintegrated and then reformed as The New Haven Fat Liberation Front. This group published the influential anthology Shadow On a Tightrope (Schoenfielder and Wieser, 1983), inspired other groups to form, and member Karen Scott-Jones (now Stimson) went on to found Largesse, an online archive of fat activist materials that includes the Fat Underground position papers and manifesto (available at: http://www. eskimo.com/∼largesse/Archives/). The Fat Underground synthesised aspects of Fat Power and NAAFA, most notably in their manifesto-writing, function as a support group, diverse activities and research. What differentiates them is that they allied themselves with other radical movements and sought coalitions with them, engaged with direct action and civil disobedience and presented themselves assertively and without apology (Fishman, 1998). They challenged directly dominant obesity discourses of the 1970s and 1980s, as well as now, which conceptualise fat people as without agency, stupid, tragic and disorganised, and, I would maintain, they set the standard for politically aware activism.

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The London Fat Women’s Group Perhaps influenced by The Fat Underground and its associated groups in the United States, The London Fat Women’s Group was the first fat activist group in the United Kingdom. The group demonstrated that fat activism is not just a phenomenon of the United States and that a Fat Underground style organisation could be successful elsewhere. The London Fat Women’s Group was active in the United Kingdom sometime between 1985 and 1989. Explicitly feminist, members Tina Jenkins and Heather Smith, alongside writer and oral historian Margot Farnham, published articles about fat in Spare Rib (1987) and Trouble & Strife (1988, 1989), two feminist magazines published in the United Kingdom. They distributed Shadow on a Tightrope in Britain, and later went on to make a BBC Open Space documentary, Fat Women Here to Stay (1989), in which they challenged the media and diet industry, and talked about fat oppression. This programme is remarkable because it is a rare occasion in which fat activist voices were heard in a mass broadcast, unmediated by weight-loss rhetoric, or weight-loss proponents brought in to provide a ‘balanced’ view by reiterating dominant discourses. In 1989, the group hosted The London Fat Women’s Conference, which attracted much prurient press attention and possibly heralded the end of the group.

Threads and themes I have noted some of the ways that each of the early individual organisations and interventions described above challenged obesity discourse. Now I will consider some emergent and interconnected themes that have gone on to dominate the fat liberation movement, ranging from health to academic and post-modernist/structuralist activism. Health Whilst fat activists are critical of how proponents of obesity discourse apply and interpret data regarding fat and health, there is little evidence to suggest that fat activists reject science itself. Indeed, there is a hunger for data which contests common sense scientific claims about obesity, and a need for scientifically informed decision-making about fat, risk and health, which are compromised in the current climate. As Gard (2009) points out, this can be problematic because it adopts the positivist values of science without critiquing science itself. However, in

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order to explore the discrepancy between lived experience and official accounts of obesity, earlier activists had been obliged to undertake creative research in order to uncover scientific and medical evidence about the health risks of fat, and of problems regarding weight-loss. By the 1980s, work by Wooley and Wooley (1979), Schwarz (1986), Ernsberger and Haskew (1987) and Brown and Rothblum (1989), for example, was used by activists to develop the canon of available literature upon which they were building a critically informed case for fat and health, itself a socially constructed process that cannot be reduced to biology and incorporates well-being. More recently, post-millennial anti-obesity rhetoric and policy (The World Health Organization, 2004), which compounds the problems of living fat in a fatphobic culture, has led to an organised and vocal resistance by health professionals and researchers (for example, Aphramor, 2005; Bacon, 2005; Robison, 2005) seeking to incorporate Health At Every Size (HAES) principles into their work (Association for Size Diversity and Health, ASDAH, 2008). Popular writers such as Sandy Swarc (2003), Paul Campos (2006) and Gina Kolata (2007) are also addressing the junk science inherent in obesity discourse, and unpacking unreliable evidence about fat and health long held to be sacrosanct by the medical establishment (see Campos, Chapter 3 in this volume). Although aspects of Orbach’s earlier work are problematic (Cooper, 1998) Fat Is A Feminist Issue (1978) used psychodynamic theory to popularise ideas that dieting and body hatred are oppressive and that body dysmorphia and eating disorders are the result of a misogynistic society. The book’s influence cannot be understated, particularly on popular feminist and academic work around eating disorders, body image and cultural studies, for example Wolf (1990) and Bordo (1993). The book’s non-diet approach to healthy living was further developed by Polivy and Herman (1983), Roth (1983), Ogden (1992) and, later in the United Kingdom, Mary Evans Young, a management trainer and counsellor, under the name Dietbreakers. Young’s many achievements in the early 1990s included getting an Early Day Motion read in Parliament condemning dieting, establishing International No Diet Day, presenting a BBC Open Space documentary (1992) and publishing a self-help book (Evans Young, 1995). In 1994, she also attempted to introduce The HUGS Programme, an early HAES eating plan from Canada, as a franchise, albeit with limited success. During the mid-1980s, activists established practical grassroots community health projects designed to make wellness accessible to people of all sizes, such as Roberts (1985) and the comedy dance troupe The Roly Polies (1986), who published their own humorous fat fitness book. Later,

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Pat Lyons and Deborah Burgard, two fat sportswomen from The Bay Area, took a more in-depth biopsychosocial view of fat health with their book, Great Shape (1990). This work demonstrated simple exercises and discussed the benefits of movement within a context that acknowledged the psychological, social, political and physical barriers that prevent fat people from taking part in such activities, including a feminist perspective of women’s relationship to sport. In that respect, they were attuned to the sociological view that lifestyles associated with health, illness and risk are themselves indebted to social structures. The work recognised possibilities for community-building around exercise, with community solidarity itself fostering positive health over and above physical activity, and celebrated inspiring individuals. Lyons and Burgard presented ideas for tailoring exercise to individuals’ needs, and listed resources for relevant clothing and equipment, including a section for people who wanted or needed to sew their own. Whether or not they were directly influenced by Great Shape, a number of ventures appeared, particularly within the strong fat activist community of the Bay Area, which reflected the book’s values. Examples of these include Making Waves, a weekly fat swim at the Albany High School Pool in Berkeley, which stipulated that participants must be women weighing 200 pounds or more; Haddon and DeMarco’s home exercise video series Yoga For Round Bodies (1996), featured adapted Hatha sequences; and an increasing numbers of fitness instructors, such as Jennifer Portnick, pushed a size acceptance agenda in their work. A shorter-lived project in the United Kingdom during the early 1990s was Fat And Fit Group Health Action in Newcastle Upon Tyne. This publicly funded initiative took a fat liberation approach, and was hoped to be a pilot for further projects, but was eventually discontinued. Health is likely to remain a central part of an agenda for fat liberation, and understandably so under present social conditions where fatness is fallaciously pathologised as a chronic disease called ‘obesity’. In summary, fat activist approaches to fat health encompass the generation of new data and methodologies for understanding and measuring fat and health, as well as critical interpretations of existing research evidence; a critique of diet culture and weight-loss industries; and the pioneering work of Lyons and Burgard, which influenced grassroots fat-friendly health projects and transformed theory into practical strategies. HAES could be regarded as the result of a number of alliances between these positions, uniting activists, researchers and practitioners. However, these alliances have sometimes been uneasy, as seen in Marchessault et al. (2007) who show the varying degrees by which their

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sample of Canadian dietitians have been able to adopt HAES principles. Their study may illustrate the stresses between HAES theory and the reality of professional identities in practice, incorporating old and newer ways of working, as well as the possibility that HAES itself is constructed in varying ways within various contexts.

Community Local support and activist groups mushroomed during the 1990s and, while their membership was undoubtedly small relative to people seeking to lose weight, it is possible that their supportive nature arose to provide an alternative to weight-loss groups. Group functions included consciousness-raising, sharing experience, finding collective power and voice, validating fat experience and providing community and hope for participants. Most groups of this period were based in the United States. Bond van Formaat in The Netherlands and Allegro Fortissimo in France are notable exceptions and still in existence today. The International Size Acceptance Association attempted to widen the geographical scope for activism but the network is small. An example of such an endeavour was a second Fat Women’s Group in the United Kingdom, which I started in 1992. Until 1995, a small and changeable group met at the London Women’s Centre in Wild Court to talk about our lives as fat women. We went on to publish a newsletter, Fat News, which we distributed to approximately 100 subscribers around the country, and we distributed copies of Shadow on a Tightrope (Schoenfielder and Wieser, 1983). The group later became SIZE: The National Size Acceptance Network. They produced an art show under the leadership of Diana Pollard, but failed to maintain momentum. Most of these groups were not maintained in the long term. Shelley Bovey (1989), one of the key figures of the United Kingdom size acceptance movement in the early 1990s, attended Slimming World incognito and published a diet book (Bovey, 2001). A year later she spoke about ‘an encroaching neo-fascism’ within the size acceptance movement ‘that said you must be proud to be fat’ (Brooks, 2002). Murray (2005) also discusses her struggle to adopt a positive fat activist identity and, in her subsequent book, what she sees as the difficulties of fat politics (Murray, 2008). These concerns partly explain the difficulties for sustainable organising amongst marginalised people with ‘spoiled identities’ (Goffman, 1963), including men who are typically regarded as more self accepting of their fatness (Wolf, 1990), who act in an unforgiving social and political climate. The problematic nature of group organising

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recalls the early struggles within NAAFA and highlights the remarkable longevity of the Fat Underground and achievements of The London Fat Women’s Group.

Lobbying Fat activism exists through organisations such as the Council on Size and Weight Discrimination, home to former Fat Underground activist Lynn McAfee; The Healthy Weight Network and Healthy Weight Journal (subsequently published 2004–2007 as Health At Every Size); The Association for the Health Enrichment of Large People (AHELP), which expired in 2000 and was replaced by ASDAH; and The Body Image Taskforce expanded on the tactical approach instigated by Louderback, NAAFA and The Fat Underground. These groups confidently approached power structures invested in the biomedical model of obesity; for example, McAfee attended meetings of the Federal Trade Commission in the United States and the National Institutes of Health as a lobbyist and testified on problems associated with weight-loss prescription drugs at Federal Drug Administration hearings. Meanwhile, diversity lawyer Solovay (2000) was instrumental in getting height and weight anti-discrimination legislation introduced in San Francisco in 2000 in which local businesses and agencies are required to ‘eliminate body size discrimination from their programs and policies’ (p. 246). Such actions adopt a Social Model (Oliver, 1990) which, although contested by some within the disability rights movement (Shakespeare, 2006), suggests positive social change can happen for fat people by addressing inequalities in structural power rather than by changing the individual to fit. They expand the possibilities of thinking about fatness by demonstrating that fat people have agency and collective political power to resist obesity discourse on a broader base of issues than just health. Modelling activism on other social justice movements can, I would assert, offer not just a template for understanding fat oppression, but a way of addressing it.

Fashion The United Kingdom witnessed a growth spurt in larger-size clothing retailers in the 1990s as businesses began to recognise the existence of a niche market of fat consumers. Fat people started demanding better services, and the term ‘plus size’ began to appear. Most visibly, a number of high street shops introduced specialist ranges, such as H&M and

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Etam. Evans Outsizes dropped part of its name, which had been seen as stigmatising, re-launched as simply Evans, and had a marketing strategy that was brought closer in line with other fashion brands owned by The Burton Group, later Arcadia, possibly to make shopping less of a punitive and shaming experience for fat people, and thus more profitable. Smaller, independent retailers began to appear in this period. Pretty Big magazine documented many of these businesses, particularly those that traded in regional cities. There were also businesses, like William Fabrey’s Amplestuff Catalogue, which sold specialist products in the United States to fat people. Pretty Big and two other mainstream magazines, Extra Special which was superseded by Yes!, and Evans’ own shortlived magazine, Encore, suggest the importance of affiliate businesses, the then nascent fat fashion press, in normalising, contextualising and promoting the plus-size fashion industry. These developments raise questions about the relationship between business, consumer culture and fat liberation, and stretch the notion of fat activism as an intentional act for social change. Greater consumer choice had a positive effect on the fat women who could afford to participate and whose bodies fitted the still limited plus-size selection available. As shopping became more pleasurable and accessible, the fat women reflected in plus-size fashion magazines appeared unapologetic, able to consider themselves as equal citizens with equal consumer rights, adept at using fashion for self-expression and positive body image. As a mass movement the growth of fat fashion was problematic. LeBesco (2004) rightly points out that there was no critical engagement with capitalism and globalisation, of discourses around beauty and appearance, or the questionable nature of a liberation movement based on the ability to buy. However, some fat activists outside the mainstream do address these issues. Amanda Piasecki founded Fatshionista, an online LiveJournal Community in 2004 as a resource that would be devoted to the intersections of fat fashion and politics. The group has grown to over 4000 members and has affiliated communities. The Fat Girl Flea in New York City is an occasional, volunteer-run, fundraising, large-sized clothes jumble sale for NOLOSE, the organisation for fat queer women and their allies. It attracts approximately 500 visitors of diverse backgrounds, and is held at The Lesbian, Gay, Bisexual & Transgender Community Center. Flea participants are encouraged to share stories and clothes and get involved with the event’s social functions. The Flea exposes an archaeology of fat fashion. Digging through the stacks of clothes gives a clear picture of what the fashion industry has decided is appropriate garb for fat bodies,

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but here these rules are subverted, people squeeze into clothes of the ‘wrong’ size, they make things their own and play dressing-up for the fun of it. This, I would maintain, empowers an underclass of people with a pernicious heritage of self-hatred to experiment with kinder and more affirming ways of experiencing fatness. The Flea addresses American consumerism and environmentalism and profits enable low-income delegates to attend NOLOSE conferences.

Performance Schechner (2002) identifies seven interlocking functions of performance: to entertain; to make something that is beautiful; to mark or change identity; to make or foster community; to heal; to teach, persuade or convince; to deal with the sacred and/or demonic. Bertholt Brecht’s Epic Theatre (1964) and Augusto Boal’s Theatre of The Oppressed (1985) recognise performance as a political tool for marginalised people. Fat oppression, although multi-dimensional, is often experienced by fat people through hostile looks and stares from strangers (Cooper, 1998). Performance makes private bodies public and enables fat people to create alternate readings of fat and to return the gaze. It is little surprise that performance is a thriving area for fat activism through groups like Fat Lip Reader’s Theatre, or The Padded Lillies, an occasional synchronised swimming troupe, who send up the fixed smiles of the genre, make use of a vintage Hollywood aesthetic, yet whose physicality is both ironic and sincere. Pretty, Porky and Pissed Off, and The Fat Femme Mafia also perform with a mixture of knowingness and pop-culture awareness, as does stand up comedian Kelli Dunham, whilst The Fat Bottom Revue, Heather MacAllister’s professional fat burlesque group, added a playful yet frank eroticism. Community and performance intermingle in these groups, as with Fat Girl Speaks, an irregular cabaret event in Portland, Oregon, which plays to audiences of 800 or more, and Marina Wolf Ahmad’s Big Moves, a dance company which offers choreography commissions, a touring revue, performing ensembles and workshops. Performance intersects with popular discourses around the need for fat role models to counterbalance negative media portrayals. The mainstream entertainer Dawn French fulfils this role, for example, as does singer Beth Ditto, who is outspoken, queer, working class, feminist and politicised. But role modelling can be problematic, as shown by actress and talk show host Ricki Lake and singer Carnie Wilson. Once

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acclaimed as fat activists, Lake embarked on a series of publicised diet and weight regain cycles, citing child sexual abuse as the reason she had been fat, and Wilson spoke about her self-hatred and broadcast her gastric bypass surgery live online. Role models may be given special status but they also live in the world as fat and are subject to the same pressures as other fat people. Whilst there is a hunger for inspirational fat role models, the ambivalence and disappointment when such a person fails to live up to what might be unreasonably high expectations echo Murray (2008) and her critique of simplistic binaries within activism, which suggest that one moves in a linear fashion from abject to heroic. As Murray points out, fat embodiment is always contextual, complex and contingent.

Media Creating independent media that more accurately reflect fat people’s lives and concerns, instead of being subject to a misrepresentative mainstream media, is part of fat activism’s ongoing commitment to structural change. This echoes punk activist Jello Biafra’s (1987) slogan: ‘Don’t hate the media, become the media’. Alice Ansfield’s Radiance was a mass-circulation, mainstream women’s magazine published in the Bay Area from 1984–2000. Radiance carried fashion advertisements and features like its British counterparts, but had a more overt connection to the fat liberation movement and a stronger community focus. Elsewhere, photographers Edison and Notkin (1994) and the novelist and poet Stinson (1994, 1996), alongside numerous other artists, published depictions of fat people, mainly women, that questioned dominant anti-fat discourses. Accessible publishing technology also made possible an explosion in fat-zine culture. Titles such as FaT GiRL, Fat!So? by Marilyn Wann, Lee Kennedy’s cartoon series, and Nomy Lamm’s I’m So Fucking Beautiful started to expand ideas about fat identity. Sometimes community built up around zines, for example GirlFrenzy hosted a No Diet Day celebration, and the apa-zine Living Large consisted of reflections and ongoing conversations between contributors. The paper-based fat media of the last decade has given way to a massive outpouring of fat activism in new media, particularly via Web 2.0 platforms such as blogs and social networking websites. Early listservs such as fatdykes, Soc.support.fat-acceptance and Alt.support.bigfolks helped to define ‘new communities of fat people’. More recently activists, such as Paul McAleer and his Big Fat Blog, have branched

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out into real world activism; his Coalition of Fat Rights Activists hosts Think Tanks, is documenting the legal position of fat people in the United States and is targeting the media’s use of headless fatties (Cooper, 2007). Others are using already existing online resources to promote fat activism, such as Nash (2007) on YouTube; Blog Carnivals, where a principal organiser curates posts on a given subject; various fat resources lists based on wiki technology; groups, such as Fat Studies on Yahoo; Just As Beautiful, a traditional fat fashion magazine that is distributed as a PDF attachment via email; ad hoc protest groups on FaceBook; or Femme-Cast, a downloadable podcast. Academia The emerging field of Fat Studies marks a critical engagement with dominant obesity discourse within academia. As with health professionals working with HAES, Fat Studies encourages producers of knowledge around fat to be reflexive and question taken-for-granted models in order to broaden the possibilities for fat discourse. While sociological theories of the body have been criticised for erasing the body itself (Williams and Bendelow, 1998), Fat Studies reinstates the physical experience of being fat beyond medicalisation (see, for example, Harjunen’s, 2003 work on fat as a liminal experience). Unlike academic individuals and organisations which uphold a biomedical approach to obesity, such as, for example, Liverpool Obesity Research Network at the University of Liverpool, contributors to this literature are willing to engage with activism, hence this chapter, they occupy a position that is interdisciplinary and explicit in its desire for social justice. At the time of writing, Fat Studies exists through a series of books, for example Solovay and Rothblum (2009), Tomrley and Kaloski (2009); events such as The Popular Culture Association gathering, Fat and The Academy, Resisting Treatment, Fat Studies UK and Bodies of Evidence: Fat Across Disciplines; and online discussion spaces, such as Fat Studies and Fat Studies UK. Post-modern or post-structuralist activism Where previous examples of fat activism were concerned with structural change and social justice, there is a new strand in development that does not prioritise these goals. The Bikini Kill lyric ‘Your whole fucking culture alienates me’ (Hanna, 1993) appears on a poster at Unskinny Bop, the fat-friendly queer dance club in London, and typifies this new approach, which relates to Bornstein’s (1994) rejection of an either/or

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dichotomy. Bornstein writes about false gender binaries, but her argument is also relevant to fat activism where obesity discourse sets up false binaries between healthy/unhealthy, valid/invalid, worthy/unworthy and so on. Bornstein argues that gender outlaws do not need to be defined by the dominant cultural lens, and can reject the boundaries enforced upon them by creating more meaningful definitions. Within this approach, fat activism is playful, subversive, multilayered, creative and confident because there is nothing to prove to obesity stakeholders. Mischief, fun and anarchic spectacle become the incentives for activism instead. For example, when my old university’s student wellness department hosted an Obesity Awareness Week I responded by making a zine called Fat Stuff, photocopying it in secret at work, and distributing it with my girlfriend Kay Hyatt around the campus and in the leaves of selected library books. The zine contained a critique of Obesity Awareness Week, a list of alternative resources that students might find in the university’s library and local suggestions for fat activism that readers could undertake instead of worrying about their weight. In a similarly prankish and irreverent vein Kimberly Brittingham made a dummy self-help book cover for Fat Is Contagious: How Sitting Next to a Fat Person Can make YOU Fat (2007), sat close to people on the New York subway and documented their reactions online. A more complex example of post-modern or post-structuralist activism is The Chubsters. This semi-fictitious girl gang, which I started in 2004, is postmodern in that it is ambiguous, uses a multitude of methods, defies concrete definitions and ‘cannot be defined in any objective totalising way’ (Hall et al., 2003: 147) and refutes a modernist linear sense of progress; and post-structuralist in that it is contingent and contextual (Hyde et al., 2004). Although structural change in favour of fat people would be welcomed by Chubsters, it is regarded as unlikely to happen, thus the group’s activism is cheerfully nihilistic. The Chubsters blurs the line between truth and falsehood, by creating real life events and encouraging real people to participate, yet also promoting an imaginary parallel world based on myth, lies, jokes and pop culture. It creates an alternative reality where fat people are self-aggrandising, belligerent, tough, obstructive, resistant and highly organised. The gang seeks to embrace freakhood and turn upside down fat people’s anxiety that we are all those hateful things touted in the dominant model, our stereotype threat. The Chubsters is a channel for the rage and frustration that many fat people feel in response to fatphobia played as a deadpan gag; where fat people are usually considered an embodiment of safe, affable jollity, The Chubsters’ humour is aggressive, angry and unnerving.

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The group is intentionally mixed. Being fat, female or a fat activist is not a prerequisite for joining. Malevolent attention is directed not at thinner or average-sized people, but towards fatphobic industries and individuals, called Narrow Fucks in Chubsterspeak, because they are narrow of mind.

New possibilities In many ways fat people are still struggling for the same rights and recognition that Louderback outlined over 40 years ago, much activism relates directly to Fat Power. By spelling out a manifesto for change so thoroughly, Louderback’s visionary work created a broad fat activist agenda. The initiatives that the earliest activists established managed to expand fat experience far beyond the limitations of a biomedical model or the obesity discourse that still dominates popular knowledge about fat. The neo-liberal construction of ‘obesogenic’ is currently being touted as a more compassionate view of fatness, but Kirkland (2008) exposes its underlying fatphobia, and with this in mind I would suggest that activism offers a more thorough unpacking of obesity rhetoric than new mutations of older, problematic ideas. Moreover, the sprawling richness and diversity of fat history and culture cannot be circumscribed by a reductive calories in/energy out explanation for obesity, it demonstrates that there is astonishing value in fat identity and experience which would be lost if the drive to eradicate obesity is successful. This is not to say that fat activism itself is beyond critique. Murray (2008) rejects dominant obesity discourse but she also rejects what she sees as dominant fat activist discourse. She argues that at the heart of ‘fat pride politics’ is ‘the liberal humanist belief in individualism, and the staunch belief that possibilities for change lie within the individual’ (p. 5). Murray is clearly alienated from the kinds of North American fat activist ideologies she writes about, specifically that offered by Marilyn Wann, which she regards as reductive though politically strategic. Murray contends that Wann’s feel-good approach fails people, and that creating one’s own fat liberation identity, as proposed by Wann, is a ‘fundamental impossibility’ (p. 6), because fat identity is constructed within systems from which one cannot absent oneself. Murray calls for a more complex consideration of fat identity that engages ‘with the idea that bodies are not simply self-authoring, but are already in a system of exchange’ (p. 88). I accept Murray’s critiques of a certain kind of activism, but I am concerned that she is basing her criticisms on the work of a small faction

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within what I have shown here to be a diverse movement. The liberal humanist belief in individualism is enshrined in the US constitution (Solovay, 2000) so it is understandable that activists in that country, who are dominant in the field, would also reflect these values. However, they should not be assumed to speak for all, and the problematic nature of liberal humanist individualism could reflect problems within the movement related to American cultural imperialism rather than a deeper malaise within activism (Cooper, 2009b). Throughout her work Murray also maintains that activism is a useful response to medicalised fatphobia, but she does not detail how this might be so. In addition, Murray refers to herself as someone who constantly resists her own flesh (4), she criticises Fat!So? for leaving little space for the kind of ambivalence she feels about her own body. Given this, perhaps, like many people, Murray rejects the idea that self-accepting fat embodiment, by people who are within the system of exchanges she cites, could be anything but a charade. Meanwhile, fat activism cannot be regarded as only of relevance to fat people. Engaging with fat activism requires that people of all body sizes recognise fat people’s agency and humanity, which in itself undermines dominant obesity discourses. Such discourses affect people of all sizes. Robison et al. (2007) argue that the arbitrary nature of Body Mass Index (BMI) categories produce populations of ‘deviant’ weight classifications in people of ‘normal’ size and the British government’s Change4Life (2009) weight-loss campaign includes thinner normative-sized people in its target population because it seeks to prevent obesity. Put simply, even if they have managed so far to avoid the creeping private perniciousness of body anxiety, thinner people cannot afford to ignore these public debates, they too are implicated. Finally, traditional fat activist interventions seek changes in power, but there are also new kinds of fat culture forming that disengage from obesity discourse and exist on their own terms. As well as empowering people to speak up, offering a critical view and possibilities for advocacy, they are creating new ways of relating to fat which go beyond the notion of a singular discourse and introduce the possibility of many debates, models and paradigms.

Acknowledgements I offer enormous thanks to Lew Louderback, to whom this chapter is dedicated.

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Reidpath, D.D., Chan, K.Y., Gifford, S.M., and Allotey, P. (2005) ‘He Hath the French Pox’: Stigma, Social Value and Social Exclusion, Sociology of Health & Illness, 27(4): 468–489. Relly, J.E. (1998) The Big Issue, Online. http://www.tucsonweekly.com/tw/10-0198/feat.htm, accessed 26 August 2008. Roberts, N. (1985) Breaking All the Rules: Looking Good and Feeling Great No Matter What Your Size. London: Pengiun. Robison, J. (2005) Health at Every Size: Toward a New Paradigm of Weight and Health, Online. http://www.medscape.com/viewarticle/506299, accessed 26 August 2008. Robison, J., Putnam, K., and McKibbin, L. (2007) Health at Every Size: A Compassionate, Effective Approach for Helping Individuals With Weight-Related Concerns – Part I, American Association of Occupational Health Nurses Journal, 55(4): 143–150. Roth, G. (1983) Feeding The Hungry Heart. New York: New American Library/ Signet. Schechner, R. (2002) Performance Studies: An Introduction. London: Routledge. Schoenfielder, L. and Wieser, B. (1983) Shadow On A Tightrope: Writings By Women on Fat Oppression. San Francisco, CA: Aunt Lute. Schwarz, H. (1986) Never Satisfied: A Cultural History of Diets, Fantasies and Fat. New York: The Free Press. Shakespeare, T. (2006) Disability Rights and Wrongs. London: Routledge. Simmons, R. (1994) Never Give Up: Inspirations, Reflections, Stories of Hope. New York: Warner Books. Sinker, D. (2007) We Owe You Nothing: Punk Planet – The Collected Interviews. New York: Akashic Books. Smith, H. (1989) Creating a Politics of Appearance, Trouble & Strife, 16. Sobal, J. (1995) The Medicalisation and Demedicalisation of Obesity. In Maurer, D. and Sobal, J. (eds), Eating Agendas: Food and Nutrition as Social Problems. New York: Aldine de Gruyter, pp. 67–90. Sobal, J. and Maurer, D. (1999a) Weighty Issues: Fatness and Thinness as Social Problems. New Jersey: Aldine Transaction. ——— (1999b) Interpreting Weight: The Social Management of Fatness and Thinness. New Jersey: Aldine Transaction. Solovay, S. (2000) Tipping The Scales of Justice: Fighting Weight-Based Discrimination. New York: Prometheus Books. Solovay, S. and Rothblum, E. (2009) The Fat Studies Reader. New York: New York University Press. Spurlock, M. (2006) Don’t Eat This Book: Fast Food and the Supersizing of America. New York: Penguin. Stinson, S. (1994) Fat Girl Dances with Rocks. New York: Spinsters Ink. ——— (1996) Martha Moody. London: The Women’s Press. Stunkard, A. and Burt V. (1967) Obesity and the Body Image: II. Age at Onset of Disturbances in the Body Image, American Journal of Psychiatry, 123: 1443–1447. Swarc, S. (2003) Dying to Be Thin, Online. http://www.tcsdaily.com/article.aspx? id=072203E 22 July 506299, accessed 26 August 2008. Tomrley, C. and Kaloski, A. (2009) Fat Studies UK. York: Raw Nerve Books.

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8 Helping People Change: Promoting Politicised Practice in the Health Care Professions Lucy Aphramor and Jacqui Gingras

There is no such thing as obesity While this is an obviously contentious statement, we take this as the starting point for our analysis and efforts to expand the currently truncated obesity debate beyond its medicalised and reductionist focus on disease, risk and pathology. In saying that there is no such thing as obesity we don’t mean to imply that no one is fat. What we are saying is that the term ‘obesity’ – and more especially its assumed precursor ‘overweight’ with which it is often conflated – as currently used in the clinical and academic worlds with which we are familiar has little medical salience. For a very high percentage of populations reputedly in the grip of an ‘obesity epidemic’ (the United Kingdom, the United States and Canada for example) fatness and/or heavy bodyweight (taken as indicating overweight or obesity) do/does not, as is popularly promulgated, reliably indicate a person’s metabolic risk, except at extremes of the weight spectrum. By metabolic risk we refer to the metabolic dysregulation arising from a range of lifecourse experiences that can predispose people to diabetes, hypertension and cardiovascular disease. Belief in obesity (and overweight) couples weight and high metabolic risk as intrinsically related variables and thereby perpetuates what we, in our role as health professionals and critical weight scholars, view as a harmful conglomerate of inappropriate interventions premised on equally harmful ideological drivers. Nutrition professionals have, on the whole (but with spirited exceptions (Bacon, 2008; Gingras, 2005; Ikeda, 1995)), eagerly run with the make-believe of obesity discourse. By describing some of the broad mechanisms by which dietetics seamlessly accepts, integrates and inculcates fashionable anti-fat sentiments and prejudices 192

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we hope to interrupt this phenomenon and promote different, more politicised, effective and compassionate ways of thinking and acting in the real world. Implicit in our diagnosis of fat-prejudice among practitioners is the assertion that the application of the scientific method favoured by dietetics must be seriously flawed. To be more explicit, we maintain that despite its allegiance to a positivistic creed of objectivity, the preoccupation with weight management in dietetics is a function not primarily of scientific truth but of oppressive contemporary mores that value leanness over fatness. In this reading overweight is no more a pathological condition requiring medical intervention than was ‘draptemania’ – a medical diagnosis given to slaves with an urge to flee the plantations (Littlewood and Lipsedge, 1997). We think within the times and tides of our social and intellectual milieu, the category obesity is a dangerous fabrication of our fatphobic culture – a ‘persuasive fiction’ (Strathern, 1987: 251), if you will. This construct has, on the one hand, given us the ticking time bomb of ‘headless fatties’ (Cooper, 2008) duped into slothful stupor by technology and dooming us all to environmental destruction (White, 2008). On the other hand, prejudice and neglect have prevented due consideration of very fat people as a group with distinct medical requirements: research into appropriate anaesthetic use for very fat people is a notable gap, though there are recently revised practice guidelines in the UK (Reynolds, 2007). The rhetorical strategies that have manufactured belief in obesity, and in the obesity epidemic, concentrate resources on advising people how to become/stay thin. In this they streamline with neo-liberal policies that occlude social realities (Guthman and DuPois, 2006) and simultaneously shore up sizist models of health. The primary cause of increased metabolic risk, an ostensible target of anti-obesity policy, is not people’s ‘freely chosen’ eating and exercise habits but is rooted in political systems that disadvantage. It is not that obesity mythology or many proponents of obesity discourse are unaware of relationships between inequalities, fatness and health. But the political bearing of data is defused in unproductive and unimaginative interpretations proffered within the tight constraints of the energy balance perspective. In this model, the primary goal of intervention is to achieve and maintain an idealised bodyweight so energy consumed (as food and drink) and energy expended in activity set the parameters of enquiry. The obesity world also recognises size-oppression – a UK Department of Health campaign (DH, 2006) lists social stigma and isolation as ‘disrupting and irritating’ conditions arising from being fat. The difficulty with their reading, however, is that the ‘stigma of

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obesity’ is clearly located in fat people, for being fat, and the remedy is weight-loss, not equal rights alongside challenges to pervasive prejudice. Indeed, some government-backed health reports actually lament about stigma before enacting it, as in the Irish Task Force Report (2005). In giving the thumbs up to assimilation, these official reports sanction (disablist) oppression; in remaining silent about manifest discriminatory attitudes they perniciously invalidate the daily grind of experiencing fat ‘intolerance and insensitivity: in a word sizism’ (Joanisse and Synnott, 1999: 49, cited by Monaghan, 2008), which, as with other forms of discrimination, has its own health risks. So it becomes obvious that for progressing socially just policies and, more specifically, for designing relevant nutritional public health strategies, we must first acknowledge the reach, consequences and legacy of sizism. Current conceptualisations in public health enmesh bodyweight, and therefore fatness, with nutritional rhetoric. We are not suggesting that the high priority given to changing individual nutritional health behaviours is necessarily an ideal model either for improving the health of fat people or for managing metabolic risk in the population. However, given its symbolic currency as an organising motif for the majority of assumptions about fatness and fat people it has a profound impact on people’s sense of self and on their health. Addressing sizism in nutritional discourse ultimately entails dietitians abandoning their need for, and belief in, value-free science. There are examples from other disciplines. Littlewood and Lipsedge (1997) present a thorough critique of racism in psychiatry, one that illuminates the relevance of the historical and social sources of professional takes on mental health. The authors’ aim is to encourage ‘a self-reflexive practice which examines its own prejudices, ideology and will to power, which is aware of the ironies and contradictions in its own formation, and which is prepared to challenge them (p. 310). The fact that in the 14 years between editions the authors note “little of substance has been achieved” indicates the urgent need for the nutrition professions to begin self-reflexive theorising that treats their sizism seriously. Monaghan and Hardey’s work on bodily sensibility (Chapter 3 in this volume) and clinicians’ attitudes to clinician size (Monaghan, 2010a, 2010b), together with Gingras’ exploration of dietitians’ professional socialisation (Gingras, 2009a), further highlight the need for contemplation and action. Without labouring the point, we do want to impress that thinness does not confer immunity from the debilitating effects of fatphobia, even when someone simultaneously gains from the ‘thinness privilege’ (Bordo, 1993). Some of the ways in which fatphobia is experienced


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include scanty attention to dietary quality in thin people (Hooper, 2001), the spurious rationale presumably being that if someone is thin it follows they have sound nutritional habits. Obstetricians have warned of the damaging effects of these sizist assumptions in failing to identify eating distress among pregnant women (Murphy and Morgan, 2006). Again, on an individual level, body dissatisfaction in people of a medically idealised weight is widespread with particular expressions influenced by gender, class and age, for example (Kurth and Ellert, 2008). At a policy level, sizist attitudes translate into policies that divert attention and resources from developing more meaningful, less harmful, strategies to promote equitable health care. In this chapter, we want to encourage others to leave obesity and its generative principle, sizism, behind. Drawing from everyday practice considerations (critical appraisal, ethics and evidence-based medicine) we identify where dietetic bodyweight management practices arise from a sizist ideology. We then sketch out an alternative narrative (to that offered by the obesity world) for promoting health and preventing non-communicable diseases currently treated as if they are linked to fatness/heavy bodyweight (e.g. hypertension, coronary heart disease). Notwithstanding a recognition of the powerful vested interests and constraints that mitigate against alternative ways of thinking and acting, we also argue for the urgent need to own our complicity and complacency and, albeit belatedly, commit to a radical and strategic overhaul of professional theory and approach. Addressed specifically to dietitians and nutritionists as people, students, educators, researchers and practitioners, our hope is that our contribution proves useful in stimulating debate among a wider audience.

Clinical ethics In this section, we outline the ethical implications of recommending weight-loss. We focus on weight-loss advice in the primary and secondary prevention of coronary heart disease (CHD) by way of example. Our case concentrates on day-to-day practice recommendations only so that it is immediately relevant to clinical decision-making. The question we wish to consider is whether dietary weight management advice is ethical. This means that, paradoxically, we have largely side-stepped the interrelated question of whether any relationship exists between weight/BMI and CHD in the first place. Dietetic discourse on the topic (Thomas and Bishop, 2007) presents this correlation as a self-evident scientific truth. Indeed, the assumption that being fat increases one’s

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risk of CHD (and losing weight is healthful) forms the raison d’être of weight-management recommendations which state that adults should maintain an idealised BMI to prevent CHD and adults with existing CHD who have a BMI greater than 25 should lose weight. Yet, as with other assumed certainties about associations between fatness and disease risk, a more accurate representation of the scientific position would indicate considerable doubt and debate about the validity of the evidence underpinning this advice, a position amplified by other authors in this publication (Campos, Chapter 2 in this volume). The bioethical framework we refer to applies to all dietetic treatments. Within its parameters practitioners are bound to honour beneficence, nonmaleficence, veracity, fidelity, justice and a caring response. We will briefly introduce the terms and use their reach to contextualise our claim that dietetics operates from a sizist ideology. At its simplest level beneficence can be understood as the requirement for effecting some good and/or reducing/avoiding harm. Nonmaleficence is the requirement to do no harm and is expanded on in a British Dietetic Association professional consensus statement (Grace et al., 2008) as the need ‘To carefully consider the important principle of “first do no harm” and to avoid any potential negative consequences of treatment’ (p. 7). The requirement for nonmaleficence again rules out weight-centred treatment approaches. Holm (2007) in a paper on ethics commissioned by the high profile Foresight programme on obesity in the United Kingdom (Foresight, 2007) wrote we can justifiably claim that it is difficult to promote one body shape as good without implying that other shapes are bad, and it is unclear whether it is possible to prevent people from linking bad (sic) body shape to personal and moral badness. (Holm, 2007: 210) Another condition of ethical treatment is that where research on treatment outcomes exists there must be valid evidence of its effectiveness. There are dietetic guidelines produced from a systematic review of the evidence on food and nutrition in the secondary prevention of cardiovascular disease. These guidelines meet all the requirements of evidence-based medicine – authors were qualified dietitians following recognised methodology using evidence from systematic reviews of randomised controlled trials. The guidelines found no treatment benefit for weight-loss interventions (Mead et al., 2006). Further, current research (Willenheimer, 2006) indicates adverse outcomes from intentional


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weight-loss post-myocardial infarction. These findings are hardly surprising given that weight-loss behaviour is ineffective: the most consistent outcome of weight-loss behaviour at 2 years is weight-gain (Ikeda et al., 1999; Jain, 2005; Mann et al., 2007) and frequently weight cycling, which is strongly linked to increased cardiac mortality (BNF, 1999). Yet weight-loss is still touted as a cardioprotective intervention, even by dietitians who contributed to the systematic review that found no evidence for its effectiveness. Here, sizism leads to the rejection of bona fide evidence in favour of illogical choices that reflect its ideals. This inconsistency between evidence and practice also has a bearing on the ethical principles of veracity and fidelity. The stipulation for veracity refers to the requirement for truth-telling. In the practice setting this translates into the dietitian’s obligations to provide full and accurate information in a manner that does not mislead by intent, omission or bias (Anon, 1999; BDA, 2008; HPC, 2008). As, according to the evidence base, it is inaccurate to propose weight-loss behaviour as a necessary or beneficial intervention, dietitians advocating weight reduction could be said to fall foul of this requirement. The related ethical element of fidelity involves faithfulness to norms of moral principles. This requirement presents a similarly hazardous ethical situation for the dietitian who endorses weight reduction. Purtilo (2005) describes fidelity as meeting the patient’s reasonable expectations: the patient expects the practitioner to treat them with respect, to be competent, to adhere to professional standards (including code of ethics and legal duties) and to act in good faith with regard to honouring the integrity of the therapeutic relationship including fulfilling written and verbal agreements (p. 69). In practice, veracity and fidelity require that treatment is evidence based, that is, based on up-to-date scientifically valid data, or, where no such data exist, on sound clinical judgement from a suitably qualified practitioner. They require that relevant information is fully, clearly and honestly communicated to patients and that informed consent is obtained and recorded prior to treatment. The process of obtaining informed consent involves telling the client of the likelihood of success, any risks and alternatives regarding the proposed treatment. The British Dietetic Association (2002) advises the dietitian to seek written consent in case of treatment that involves significant risks or side effects, or failing that, to record the fact of verbal consent. Standard dietetic texts and professional statements routinely omit full information on the documented risks and harms of weight-loss behaviour/reliance on a weight-centred paradigm approach at individual and policy level (BDA, 2008; Thomas and Bishop, 2007).

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Our own experience, including asking current dietetic students what was required of them on placement, tells us that colleagues advocating weight-loss are insufficiently conversant with the risks of weight-loss behaviour (Aphramor, 2005; Robison et al., 2007) and any alternatives (Bacon et al., 2005) to engage in informed consent and that recording of consent and informing of risk simply does not happen with weight-loss. The picture is not one of isolated instances of forgetfulness, substandard teaching or aberrant practitioners but of sizism. It arises from an institutional myopia that characterises weight-loss as, ideally healthful and at worst, a largely benign experiment. This is not to imply that attention to informed consent makes unnecessary and harmful treatment acceptable. Rather it highlights the arbitrary nature of ethical decision-making when up against a powerful and unarticulated ideology. This ideology means that the standardised procedure for weight-loss is taught and prescribed over and over while remaining curiously, and alarmingly, untouched by client health outcomes, ethical deliberation or intellectual inquiry. The principles of veracity and fidelity are further elaborated by dietetic organisations in their professional statements. The British Dietetic Association’s Code of Professional Conduct (2008) describes the following in a section on services to clients (p. 11): Dietitians have a threefold responsibility to ensure that the intervention is necessary and appropriate to: a.

b.

c.

the service user; to make sure that expectations are not raised that cannot be fulfilled, and not to waste time and resources treating service users for whom the treatment will not be or has ceased to be beneficial. themselves as dietitians; by treating a service user who does not require such treatment. It is morally wrong to give treatment when it is not required or when referral to another agency is necessary, or more appropriate. their employer; whether self-employed or employed through a health trust, private hospital or industrial concern, it is ethically wrong to waste time and money by treating service users unnecessarily.

The Code of Conduct requires dietitians to ascertain if treatment is appropriate and describes three categories of contentious referrals. First, where treatment may be actively harmful, second, where treatment is


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unnecessary and third where there is request for a treatment that would be of dubious benefit (Section 2.1.6). It is recommended that where treatment would be actively harmful ‘It would be courteous in these circumstances and beneficial to the service user to discuss the matter with the medical practitioner and suggest an alternative course of management based on the dietetic assessment’ (p. 12). And if, despite this action, repeated requests are made for treatment that ‘cannot be justified in terms of possible benefits or available resources’ a more formal approach by a dietetic service manager is advised (p. 12). To recap, weight-loss is commonly justified as a necessary means to improve cardiovascular risk factors. However, there is a wealth of study data that demonstrate that improvements in indicators typed as weightdependent, such as blood pressure and high density (HDL) cholesterol levels, for example, are favourably influenced by dietary modification and/or increased physical activity levels (plus other non-diet/activity factors) independent of weight-loss. As we have noted, change in dietary composition (without weight-loss) improves outcomes in CHD (Mead et al., 2006), a finding more recently corroborated in the international Lipgene study (O’Connell, 2008). Work by the exercise physiologist Steven Blair is commonly cited to support health benefits of fitness/improved fitness that again occur independently of weight-loss (Blair and Church, 2004). These two examples are drawn from an expanding literature that teases out the impact of non-weight variables on metabolic risk (and the role of ideology and politico-economic factors in shoring up obesity discourse). Although there is much that is still uncertain, a closer look at the evidence reveals that weight-loss is not in fact a necessary treatment for improvement in health outcomes. The practitioner would thus be well advised to revisit their clinical justification for weight-loss with a healthy scepticism to avoid misleading the patient, and referrer, on treatment rationale and prevent them from unwittingly imposing unnecessary, unethical treatment. Veracity and fidelity embrace the ethical principle of a caring response which in turn is strongly linked to the principle of justice. Purtilo (2005) identifies three types of justice that are especially pertinent to health care ethics, namely, distributive, compensatory and procedural. In brief, distributive justice concerns the fair allocation of resources such that outcomes are equitable; compensatory justice to resource provision when someone is wronged or injured; procedural justice pays attention to making sure processes are fair (Purtilo, 2005). Kirkland (2009) explores the question of justice within a rights discourse (in North America) putting health and anti-discrimination

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together. Bringing fatness and rights jointly into the frame brings potential for transformation: ‘Political possibilities are opened up through the introduction of new vocabularies, senses of entitlement, social practices, and opportunities for solidarity, cultural discourses and accounts of personhood’ (Kirkland, 2009). In emphasising beneficence, nonmaleficence, veracity, fidelity, justice and a caring response we offer a radically reformed mindset through which to engage each other, not only regarding fatness, but as an imbuement of any interpersonal practice encounter. Sizist assumptions prevail whenever a dietitian recommends weightloss as a cardioprotective measure (and, given it is ineffective and has harmful side-effects, as a primary goal for treating any other condition). Sizism clouds serious engagement with the ethical dimensions of treatment and prevents practical application of the best available evidence. In other words, and with real life consequences, the dietitian fails to meet her professional obligations towards the client. A far more appropriate response, and one in keeping with professional regulations, would be to inform the referrer that weight-loss interventions are actively harmful, clinically unnecessary and ineffective. The alternative, we would maintain, is to promote an effective, evidence-based treatment approach, Health At Every Size, or HAES.

HAES in practice Within a HAES approach, the therapeutic work focuses on helping someone work towards sustaining healthful and pleasurable eating, realistic enjoyable activity, recognition of and resilience to size prejudice and improved psychological well-being. With a weight-centred approach, thin cardiac patients are likely to receive advice that prioritises dietary quality (although being thin may also prevent patients from being referred for specialist advice, see Hooper, 2001) while their fat counterparts receive non-evidence based advice that prioritises weight-loss (Hooper, 2001). The ethical implications concerning justice and equitable treatment are stark as outlined in the previous section. This is not to suggest being thin protects the patient from fatphobia, but that the inequities in treatment plans prevent ethical care for all. Promoting HAES requires that we are able to recognise the active legacy of weight-centred interventions. How must it feel for the cardiac patient, who attends with every expectation of being told how to lose/manage weight, only to be confronted with HAES? How do we help people repair low body and/or social esteem, or deal with pressure


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from the medical referrer, family and friends to lose weight in the aftermath of a heart attack? How might a chronic dieter – and their loved ones – respond to non weight-centred goals? Leaving our belief in obesity behind will require us to compassionately and truthfully help clients challenge prevailing beliefs about weight, health and embodiment that our own profession has been complicit in constructing and is energetically invested in propagating. In its challenge to sizist stereotypes HAES enables the dietitian to convey respect for people of all shapes and sizes. Imagery and text advocating HAES acts as a forceful foil for highlighting oppressive aspects of the practice and paraphernalia of conventional nutritional interventions. Using HAES, all patients receive equitable treatment and (to an extent) evidence-based advice. In addition, it demonstrates to patients and colleagues that another (health-centred) discourse is available to confront the dominant (weight-centred) hegemony. Outcome measures (using self-report feedback, standard methodology or validated tools), where needed, can include quality of life scores, symptom management, clinical variables such as blood pressure, triglycerides and HDL and low density (LDL) cholesterol, change in dietary quality (such as omega 3 intake), weight stability, reduction in dieting behaviours and attitudes, change in psychological variables such as depression, hope, coping self-efficacy, relational resilience, social esteem and body satisfaction. HAES can be readily theorised as a cardioprotective intervention. A systematic review by cardiac dietitians found no evidence to support weight-loss as improving cardiac health post-MI but there was good evidence to suggest healthful eating would improve outcomes (Mead et al., 2006). A HAES approach has been used successfully in individuals and groups improving clinical measures of cardiovascular risk (Bacon et al., 2005; Lyons and Miller, 1999; Wardlaw, 2005). HAES also helps prevent the lipid abnormalities of weight cycling which are associated with detrimental changes in HDL cholesterol of a magnitude that is known to be associated with an increased risk of cardiac events (Olson et al., 2000). That said, as compared to traditional weight management, there is unfortunately a relatively limited amount of HAES research to draw on. This does not invalidate or weaken our assertion of the merits of HAES. First, there is no evidence that traditional weight management approaches are effective in the long term, there is ample evidence of ineffectiveness and of adverse effect. As such, the approach is actively harmful and the dietitian has an ethical duty to decline to perform the intervention and to challenge its continued use by others. Second,

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there is evidence that HAES is effective in the long term, there is no evidence of ineffectiveness and there is no evidence of adverse effect. (We would argue that concerns about public health needing consistent messages linked to the contention that teaching HAES is confusing patients and practitioners alike points up the need to manage the shift towards consistent accurate, therapeutically valuable messages, and to plug gaps in practitioners’ critical thinking skills, rather than demonstrating that HAES has adverse effect.) HAES has not attracted the same amount of research interest/funding as weight-loss interventions but it does not then follow that HAES cannot be recommended within the stipulations of evidence-based dietetics/medicine which requires ‘the conscientious, explicit and judicious use of current best evidence when making decisions about the care of individual patients’ (Gray and Gray, 2002: 1236). The fact that HAES remains a ‘subjugated discourse’ (Foucault, 1980) overshadowed by the familiar fable of weight-loss is a result of a complex set of socially, culturally, economically and historically transmitted conditions and interests that discredit fatness, amplified in the current ‘obesity epidemic’ rhetoric, and which reproduce and serve as a vehicle for sizism. Within this milieu, when practitioners want to pursue research in HAES it can be near impossible to secure funding and difficult to find mainstream partners or get published (Bacon, 2008) even as ‘healthy weight’ remains a priority for research funding. So too, despite the urgent need for alternative dietetic approaches to body management practices, HAES barely gets a look in. HAES is known to, but not endorsed as a preferred approach by, dietetic associations in Canada and North America. It is not referred to as a treatment option at all in the United Kingdom (BDA, 2008) where there is extremely limited awareness of the existence, let alone significance, of HAES. Aside from clear implications for client welfare this absence has a bearing on dietitians’ fitness to practice – the BDA Code of Professional Conduct (2008), for example, in a section on treatment of dubious benefit, makes clear that individual dietitians are responsible for keeping abreast of research, evaluation and innovations in approaches to treatment.

Institutional sizism A woman is hating her body. Behind all that is written about fat stands that reality, a truth too easy to forget (Dickenson, 1983: 37). We have also to reconcile the fact of clinical guidelines and expert groups recommending weight-loss for its cardioprotective rewards


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despite evidence on the ineffectiveness of weight-loss and indeed evidence of harm (Lau et al., 2007). This contradiction is made possible because of sizism. Acceptance of sizist ideology creates a culture in which data that support its principles are accepted as self-evidently accurate and readily circulate without meaningful scrutiny. In the example that follows, we illustrate how misleading claims are endorsed as trustworthy at the highest level and despite mechanisms to ensure adequate consultation with specialists in the field. To clarify our aims, it is not our intention to point fingers by singling out organisations for blame. Nonetheless, we do hold firmly to the need for professional (individual and organisational) accountability and recognise a responsibility proportionate to power exercised. Similar to Campos (2004: xvii) who describes ‘the war on fat’ as ‘an outrage to values’, we view the exercise of sizism in the medical arena as indicative of a systematic ethical failure. The misrepresentation of the science on weight/health behaviours and health outcomes is not a one-off misquotation or confused understanding of sophisticated statistical calculations but rather a broad-brush misappropriation of data. An exemplar of shabby science at one level, it has implications for professional accountability and credibility at another. However, we would also ask the reader to bear in mind that the organisations we name by way of example are not distinguished by their reliance on bad science: as we write, any document that purports to have solid evidence of the health benefits of long-term weight-loss is similarly misleading. A number of respected associations endorse or rely upon the booklet Your Weight, Your Health produced by the Department of Health (UK) to support recommendations for weight-loss. The British Association of Cardiac Rehabilitation (BACR), for example, reference the booklet in their most recent clinical guidelines. Your Weight, Your Health cites three papers to support the health benefits of losing 5–10 per cent of bodyweight through lifestyle changes. But not one of the papers is fit for purpose. The first paper, by Van Gaal et al. (1997), reports on a number of studies investigating weight change in relation to cardiovascular risk factors. It is not a systematic review of the evidence nor does it contain any systematic reviews. In fact, the parameters of the trials included (e.g. n = 9; 10 weeks duration) clearly render it unsuitable to support the claims made for it in Your Weight, Your Health and therefore BACR. Indeed the original authors qualify their statements throughout: ‘the possible effects of exercise were difficult to determine’ (p. S6); ‘it cannot be proven that weight loss per se is the most important trigger of the reduced mortality’ (p. S8); ‘data on the effects of weight-loss

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on Lp(a) are scarce and contradictory. Further studies are needed’ (p. S7). The second paper cited, by Goldstein (2005), again summarises other papers to present claims for the benefits of weight-loss to health, specifically non-insulin-dependent diabetes, hypertension and cardiovascular risk factors. Data on weight-loss in people with non-insulin-dependent diabetes, for instance, include studies that lasted for only 4 weeks, which involved drug treatment, relaxation and proprietary very low calorie diets. Clearly, it is a misrepresentation of the facts to imply this paper substantiates claims for health benefits of dieting. The third paper (Knowler et al., 2002) cited reports on a trial involving over 3000 people and an average follow-up of 2.8 years which involved weight-loss as one outcome measure. However, as participants were encouraged to undertake 150 minutes of physical activity per week, with a mean achievement of 227 minutes (Mann et al., 2007) it is not possible to draw any conclusions about the independent effects of weight-loss on health from this study which means it is used incorrectly in Your Weight, Your Health. Further, there was a 16 lesson curriculum delivered on a one-to-one basis for 24 weeks supported by additional individual and group sessions: we will explore the relevance of this later. Again, the authors themselves do not assert that their research demonstrates that weight-loss is beneficial. Rather, they clarify that the study was not designed to test the relative contribution of dietary modification, exercise or weight change (they omit social support) on diabetes (and therefore also cardiovascular) risk and that the effects of each variable remains to be determined. Throwing over our allegiance to the energy balance model is not the well-intentioned fantasy of misguided radicals. In taking the reader through the logic under-pinning our recommendations we have demonstrated the irrational nature of a continued belief in obesity discourse (Aphramor and Gingras, 2008), much in line with a ‘sociologically imaginative’ approach that is also attentive to the embodied irrationalities or unintended consequences of slimming as lived and experienced (Monaghan, 2007).

Health in every respect Evidence-based medicine (EBM) heads the roll-call of dietetic good practice with its promise of objectively tested effective treatment. We deployed it earlier to dismantle some of the myths or ‘fat fabrications’ (Evans et al., 2008) around weight reduction thereby exposing


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sizism. Using this familiar tool we showed that the profession’s ostensible commitment to evidence-based medicine, designed to protect against discriminatory practices, is consistently overridden by sizist ideology. We also recognise how a professional tendency to reify the value of EBM, so that it escapes critique, brings its own problems. Rogers’ (2004) analysis of EBM and justice examines some of the pitfalls. EBM can add to inequalities because it serves an individualistic conceptualisation of health and, much in line with the individualisation of risks in late modernity and obesity discourse (see Evans et al., 2008: 143–144), this diverts research resources away from other relevant factors such as structural, social and cultural influences (also, Chapter 1 in this volume): Instead of looking at ways to prevent ill health and ameliorate disadvantage, we are directed towards a system of health care that is very good at delivering highly sophisticated, and often expensive, individual treatments to those who are able to access them. This leaves those with the greatest burden of ill health disenfranchised, as there is little relevant research, poor access to treatments, and attention is directed away from activities that might have a much greater impact on health. (Rogers, 2004: 144) There are other hazards. Rogers (2004) reports on a WHO publication in which the need for EBM was a strong theme. Among the possible interventions for tackling ‘underweight’, micronutrient supplementation and fortification were listed. Rogers continues: ‘This evidence based advice almost beggars belief: if people are underweight and undernourished, surely they need food rather than micronutrient supplementation?’ (2004: 145). Her concern that food is excluded from consideration because of a lack of supporting EBM trials echoes similar disquiet from other authors about exclusion (Schuftan, 2003). In so far as EBM constructs a non-relational understanding of health, it intrinsically conflicts with politically conscious health care. New health inequalities research is illuminating the intertwined (embodied) pathways between socio-economic position, structural processes and lifecourse influences determining health status (Graham, 2002; Krieger and Davey-Smith, 2004). These re-readings favour a more socially integrated view of health and concomitant benefits for dietetic theorising are discussed elsewhere (Aphramor and Gingras, 2009). In contrast, when research is undertaken in this individualistic model, hypotheses

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about so-called lifestyle factors and metabolic risk, core concerns of the obesity world, are predominantly framed in terms of eating and exercise habits (and their effect on weight). Thus Knowler et al. (2002), mentioned earlier, reported on weight change, exercise and dietary modification as factors pertinent to the study outcomes. Despite quite considerable levels of social contact for participants in the form of individual consultations and programme groups, this aspect of the study was not deemed relevant to the discussion. Yet there is evidence that people’s experience of social trust and social networks influences metabolic risk (Kawachi and Kennedy, 1997; Kawachi et al., 1997), with recent contributions to social theorising on health also taking seriously the impact of society on the physical body (including neurohormonal activity in response to stress and inequality) (Freund, 2006; Krieger and Davey-Smith, 2004). Going beyond our specific criticism of Knowler et al. (2002), we would state that understanding health in embodied, relational and thus social terms also throws into relief the impact of shame and stigma, reproduced (if not always intentionally) through institutional sizism. Writing over two decades ago, and no doubt ever more salient given alarming/alarmist concerns about an ‘obesity epidemic’, Mayer (1983: 30) recognised that ‘the [health] miseries which currently distinguish fat people from slim people are artefacts produced by a climate of ridicule and persecution in which fat people’s nutritional and other needs are generally denied’. The link she identifies between the quality of social relations and its impact on health status is backed by more recent research. Brunner (1997) and Marmot and Wilkinson (2001), for example, explore the evidence for non-material pathways that result in health inequalities through an influence on psychosocial well-being. They list control, anxiety, depression, insecurity, stressful life events and poor social networks, low self-esteem and fatalism as some of the candidate stressors in adult life that contribute to psychosocial adversity. These experiences arise from discrimination and oppression and size discrimination in and beyond health care is no exception. Countering the charge that an emphasis on psychosocial variables ignores material conditions which structure experience and can lead to a regressive political agenda, Marmot and Wilkinson (2001: 1235) hold that: to show that social structure . . . [has] painful psychosocial effects is the very opposite of victim blaming. Indeed, the denial of these connections exposes the individual to blame.


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In light of such research and politically attuned theorising, we would maintain that any approach to managing metabolic risk that denies the embodied reality of discrimination and oppression is inimical to equitable health care. Where do we go from here? Health in Every Respect is an approach that embeds HAES and is fully committed to its insights and philosophy as far as they go. It is work in progress that seeks to take a next step in progressing relevant nutritional interventions by challenging the healthism and individualism that characterises, and influences client expectations in, much clinical dietary health promotion work. We have argued elsewhere (Aphramor and Gingras, 2008) that a key danger of the ‘energy balance mindset’ is that it constricts the range of variables brought into question when intervening to manage metabolic risk and blinds us to harms perpetrated in pursuit of thinness. Health in Every Respect recognises that an emphasis on personal behaviours for managing metabolic risk misrepresents current evidence. Dietetic explanations of the role of ‘lifestyle’ in CHD, for example, tend to over-amplify the significance of diet and exercise and ignore the proportionately more important role of other significant variables from low decision latitude at work (Chandola et al., 2006) to poverty, loneliness (Hawkley et al., 2003; Marmot and Wilkinson, 2001), lack of sense of belonging and poor living conditions (Marmot and Wilkinson, 2005). One aim of the perspective we are calling Health in Every Respect is to consider causal factors that fall outside the conventional catchment area of EBM. We suggest that re-orienting dietetic public health discourse and development to further Health in Every Respect would bring the impact of socio-political and economic factors on health into closer view and with this, a greater potential for politicised action. This new consciousness may also be expected to help practitioners find ways of integrating ecological concerns into teaching and practice, work that is not without precedent (Bacon, 2005; Kleffel, 1991) or opposition (Gussow, 1999).

Embracing shame We have outlined pressing ethical reasons for practitioners to reject weight-loss interventions when interacting with and seeking to improve the health of their patients/clients (on the issue of challenging weightloss interventions as directed at health professionals, see Monaghan, 2010a, 2010b). So, our next question is, why has dietetics not stopped to engage with these tensions? What is it about the shift in focus from endorsing nutritional interventions that prioritise weight management

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for patients with a BMI>25 to endorsing nutritional interventions that prioritise cardioprotective diets that is so threatening? Both authors have previously suggested a role for shame in holding back the profession, and individual practitioners, from meaningful engagement with the health disaster of weight-centred interventions. This is, of course, something different than the shame associated with being labelled ‘obese’, as experienced among fatter patients as well as clinicians, which we challenge. As Gingras (2006: 203) acknowledged, ‘When we come to understand that the evidence is stating we are likely doing harm when we promote weight loss, we may encounter our shame at the mundane violence we have enacted in the name of health promotion’, pointing out that ‘When healthcare professionals commit to HAES, they embrace anti-oppressive practices’. For Aphramor such shifting ‘would conceivably require a period of shame-work by organizations as they realize the extent to which they have unintentionally been complicit in perpetuating bias’ (Aphramor, 2005: 332). A brief lesson from history is salutary. Davidoff (2002) describes how, in the 1960s, the results from a large randomised controlled study by the University Group Diabetes Program (UGDP) revealed that the use of tolbutamide, one of the only drugs available at the time to control blood sugar, was associated with a significant increase in mortality rate in patients who developed myocardial infarctions. Instead of reacting to these new data with changed approaches to prescribing diabetes medication, some physicians reacted with hostility, doubt and litigation towards the scientists and their methods. Over the course of time, it was revealed that the reason for this particular response was the physicians’ own feelings of shame and how a change in treatment approach would influence the perception patients had of those physicians. Indeed, it is arguable that shame is the universal ‘dark side’ of improvement (Davidoff, 2002). As such, ‘the experience of shame helps to explain why improvement – which ought to be a “no-brainer” – is generally such a slow and difficult process’ (Rogers as quoted in Davidoff, 2002). Our focus here is on how an understanding of practitioners’ shame can be helpful in moving towards inclusive health care. (We are not suggesting that fat people should feel shame). We believe it is for those of us who have contributed, volitionally or otherwise, to people feeling shamed for their size to commit to reverse the lock-step of size discrimination and turn the mirror on ourselves and our professions in much the same way as racism, sexism and heterosexism are being disrupted (Lorde, 1984). This is one aspect of the emotional underbelly of practice. An underbelly because the highly scientised agenda headed up by EBM’s


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impossible promise of effective predictable health care outcomes leaves little room to explore or make sense of the human side of our therapeutic encounters as embodied, thinking and feeling practitioners. There is relevant research from other health care professionals that can be drawn on to suggest research directions for dietetics. For example, many dietitians fit attributes linked with burnout in a patriarchal medical hierarchy, such as female gender (Sprang et al., 2007), and characteristics such as ‘needing approval, perfectionism, having difficulty asking for help, and feeling very responsible for clients’ (Seibert, 2005: 36). Research into (dietetic) professional socialisation helps elucidate the ways that structure and agency contribute to job stress and strain (Gingras, 2009b; Kirk et al., 2000). In addition they are working with vulnerable individuals with psychological or emotional pain and lacking a system of clinical supervision that exists in other fields (Kirk et al., 2000). In these conditions, burnout is hardly surprising. Like shame, burnout can be cast as a problem arising from dietetics’ focus on developing as a technical project, a primary identification that has left professional selfreflection, and research on emotional aspects of nutritional care-giving, lagging in its wake (Gingras, 2009). Current nutritional discourse teaches both that chronic disease prevention and treatment rely heavily on nutrition knowledge and that incidence of diabetes, heart disease and diet-related cancers is increasing globally. A logical conclusion is that current practice and knowledge regarding food and nutrition may not be enough to prevent and/or treat nutrition-related chronic diseases. When we acknowledge that diets do not work, we challenge the foundation on which dietitians’ identity is based, and upset the bearings, on which dietetic accomplishment is achieved. Moreover, dietitians increasingly find themselves working with terminally ill patients with HIV/AIDS and cancer, and in paediatrics as well as with patients struggling with a wide range of mental health issues. Often, patients bring these unavoidably entangled issues to the dietetic encounter, which can be incredibly stressful for the uninitiated dietitian who has typically been trained in the empirical, or technical, aspects of reductionist nutritional science. If practitioners have not addressed the complexity of practice issues, including the degree to which their work has an impact on patient care, they may struggle with the type of work they find themselves doing and question their suitability for that work. In their study examining job satisfaction, Kirk et al. (2000: 317) found that dietitians are commonly ‘confronted with issues that they do not feel psychologically able to manage’. Devine and colleagues (2004: 489) found that ‘[s]ome experienced [dietitians] had left

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prior jobs with individual counselling responsibilities because it was just too difficult for them to reconcile the job realities with their practice ideals and expectations’. As Devine and colleagues (2004: 791) suggest: ‘The daily challenges of practice make some professionals question whether it is possible to play the roles they [dietitians] envisioned and for which they entered the profession.’ Given the conflicting and contingent messages relating to the relationship between food/nutrition and non-communicable diseases such as diabetes, cardiovascular disease and some cancers, not to mention the gargantuan mistake about obesity, dietitians are at high risk for both role conflict and role ambiguity. Role conflict, which arises as the result of an incongruity or incompatibility of expectations communicated about a role and the actual expectations of that role, and role ambiguity, or the need for certainty and predictability amidst a highly contingent and ever-changing work environment, are strongly associated with the experience of burnout (Sprang et al., 2007). As in medicine, ‘these grim realities suggest the need for primary prevention efforts in [health profession] school curriculums and residency programs. Inadequate [health care professional] preparation could lead to disrupted expectations or even ongoing cognitive dissonance regarding practice situations’ (Sprang et al., 2007: 274–275). There is work to be done. Some of this work is already underway in relation to identifying and addressing disordered eating among dietetic students and opening dialogue about eating distress and diagnosed eating disorders among dietetics practitioners (Houston et al., 2008). This is a hugely significant and welcome turn in dietetics’ research gaze. It is a painful irony that this call to action co-exists with dietetics’ unquestioning obedience to a sizist paradigm. This orientation renders practitioners powerful players as ‘the prejudiced’ (as explained by Monaghan and Hardey, Chapter 3 in this volume) in upholding values that work to increase disordered eating patterns and in which thin–ideal internalisation is vehemently supported. For example, in a recent editorial discussing a questionnaire study of Canadian dietitians’ views and practices of obesity and weight management, Stephen (2004: 501) suggested that ‘one of the most worrying results was that less than half the dietitians felt that they should be role models, and should maintain their own body mass index (BMI) between 20 and 25’. A letter in response, written on behalf of an organisation representing British dietitians working in weight management, critiques some of the details of the editorial but leaves the central premise intact, giving a characteristic wide berth to the facts of weight-loss being risky and ineffective (Ross, 2005). Other


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health professions have argued that a commitment to historicised selfreflexive critique is vital for generating insights relevant to current and future practice (Warelow and Edward, 2007). We suggest the study of dietetics’ historical and contemporary relationship with body weight management practices would shed light on what a productive context for prevention and recovery in disordered eating might look like. We are facing the challenge of changing approaches and ideologies regarding obesity. Ironic as it is, professionals that support change in their patients’ behaviour and thinking may be pre-contemplative regarding their own change process. But given the growing literature on the ineffectiveness of endorsing nutritional interventions that prioritise weight management, we must shift our attention to the alarmingly slow pace of change and begin to dwell deeply on the factors that prevent professionals from doing their ‘fat work’ differently. Just to be clear, we are critiquing practitioners’ stance on body management practices – where the ethical option entails abandoning adherence to a weightcentred paradigm – and not practitioners’ own bodyweight or eating histories. Change can be threatening; it can be far less daunting to meet failure with efforts to try harder within an existing paradigm than it is to face the need to scrap a faulty routine and start afresh, and quite possibly alone, relying on a suppressed knowledge kept furtively fomenting in the professional margins. In this vein, maintaining the status quo is the safer, far more acceptable course of action. How are we equipped to face the losses (of familiarity, of predictability, of comfort) incurred when transitioning from a weight-centred framework to a health-centred one? Where do professionals learn to cope with transitions? What are the implications for our professional selves when we wish to change, but the risks are too great and we continue to maintain the status quo at great cost to our psyche? These questions are the purview of transition management, an area of study more common in the corporate boardroom than the classroom or the health care professional’s work place. As dietetic theorists have become more aware of the inertia, they have turned our attention to theories of transition and have learned that letting go of old patterns and approaches is what people resist, not the change itself. What prevents professionals from letting go of the old ways? Gustafson et al. (1992, as quoted by Plsek and Wilson, 2001) remind us that ‘for systems to change they generally require tension for change’ (p. 748). Tension for change must not be confused with tension about change. Tension for change is a dynamic, constructive process that is accomplished here

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by acknowledging peoples’ personal views about the issue of fatness and affirming the risks inherent in doing our work differently. The subjective losses that might be experienced in moving towards a health-centred paradigm include loss of perceived professional competence, the loss of distance or detachment from the Other (our patients, clients, consumers or colleagues), or the loss of the white-cloaked certainty that shrouds our reliance on energy balance. We have failed to speak openly about the effect of these losses on our professional identity. We do not know what entirely this process would look like in the end, but we do believe strongly that such acknowledgement requires an unwavering compassion and caring; a commitment to the Other that likely brought us to do our healing work in the first place.

Conclusion How then can the contemporary practitioner, think, and do, dietetics differently? One possible aspect of our necessary healing work exemplified by Ikeda (1995) is to speak truth to, and about, the party line: After twenty-five years as a registered dietitian, I am familiar with my profession’s ‘party line’: that large people can lose weight if they permanently alter their lifestyle, that all they need to do is eat a lowfat, low-calorie diet and exercise every day for the rest of their lives. That if they persist long enough, and try hard enough, it will happen. My response is, ‘Bullshit,’ and I’m brave enough to say it out loud in front of my colleagues, which makes me a renegade. Cowden and Singh’s (2009) paper examining the contemporary state of intellectual activity within social work is a further source of inspiration. It brings us full-circle back to the problems of neo-liberalism. Critically, the passage quoted below (referring to Edward Said’s 1993 Reith Lectures making general points about public intellectuals) can help to contextualise the genesis of dietetic stasis and the attraction of formulaic anti-obesity treatment: his comments impinge directly on our discussion to the extent that he is concerned to challenge a definition of ‘professionalism’ which is in an overall sense concerned with making the intellectual self as non-controversial and marketable as possible; and as presentable as possible to those in power. He sees a generalised pressure on intellectuals in the contemporary period to be ‘competent specialists – not


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rocking the boat, not straying outside the accepted paradigms or limits’. (Said, 1996: 74) The authors go on to reassure that of course there is nothing wrong with ‘competence’ or ‘specialisation’ per se. The trouble is when these notions so severely curtail permitted fields of intellectual enquiry that broader issues of social justice get forgotten. After Said, they urge a ‘critical scepticism’ in which ‘the intellectual should be someone who “refuses easy formulas” and should never be simply a technician’ (1996: 69). These intellectuals collectively re-imagine responses to the unexamined everyday practices that sustain health disparities, and their vision was recently formally emulated from within dietetics with the establishment of a critical dietetics movement (Aphramor et al., 2009).

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9 Conclusion: Reflections on and Developing Critical Weight Studies Lee F. Monaghan, Emma Rich and Lucy Aphramor

Preceding chapters raise complex and important scientific, ethical and moral concerns about obesity discourse. Such studies challenge received medicalised ‘truths’ about weight or fatness in late modernity, pervasive rhetoric concerning a cataclysmic ‘epidemic’, the alleged causes and consequences of this ‘crisis’ and the efficacy and safety of proposed solutions. As seen, contributors raise concerns about the scientific foundation of obesity discourse and the negative unintended consequences, or irrationalities, of seeking to ‘cure’ or ‘prevent’ obesity as an individualised health problem in contexts such as schools, slimming clubs, clinics and beyond. As explained in Chapter 1, this collection has emerged, in part, from our shared unease with how certain disciplines, institutions and organisations have been authoritatively making and reacting to alarming, if not alarmist, claims about an obesity crisis. This extends our previous writings on the obesity debate and efforts to develop critical weight studies. Although we have embraced a ‘passionate epistemology’ (Krieger, 2000), none of this is motivated by an unreasoned expectation that things will change if critical knowledge is more widely circulated since, among things, there are powerful structural, political economic, psychological and embodied constraints against alternative approaches (Monaghan, 2008). The emotions of health care should also be flagged here, specifically the ‘underbelly’ of shame discussed by Aphramor and Gingras in the preceding chapter on dietetics. Nonetheless, a necessary, if not sufficient, condition when seeking to influence and perhaps change institutional practice and research agenda is to more widely debate such issues. This, we feel, is the task and promise of critical weight studies. Drawing from a range of disciplines and communities, contributors have identified and explored various impacts and outcomes of obesity 219

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discourse. In offering observations and taking up some of the issues and challenges raised in the contributing chapters, our intention in this final chapter is not to arrive at some finite conclusions on obesity, or even the obesity debate. Rather, we hope to stimulate further discussion among a range of parties on the nature of health knowledge and dialogue, particularly regarding bodyweight management practices and the broader social context of health(care), and ultimately offer some contribution to a change in research direction and clinical/public health practices. For our own part, we have deliberately included a range of inter-disciplinary yet ‘sociologically imaginative’ (Mills, 1970) contributions that could promote alternative and more socially just ways of relating to weight/fatness. This, we would reiterate, is with an eye on broader constraints on such thinking and action, such as ‘epidemic psychology’ (Strong, 1990) and ‘healthism’ (Crawford, 1980), or neo-liberal ideologies of personal responsibility for risk, body and health management in societies where the body is a vehicle of the self and an ongoing ‘identity project’ (Shilling, 2003). Such reflexivity is necessary not least given the highly emotive and controversial nature of this public issue and private trouble. We are well aware that this is a ‘potential minefield’ (Monaghan, 2008) where (latent) interests and myriad emotions infuse debate and the various positions people are willing and able to take and sustain (on the role of emotions specifically in social theory, see Williams, 2001, and in the obesity debate, see Fraser et al. 2010). Also, in remaining cognisant of shifting thinking in academia, our intention has not been to provide a collection of papers that simply deconstruct discourse or invite contrary thinking. Nor do we wish to engage in a dialogue that simply trades in claims and counter-claims about the scientific evidence or facts on fatness or obesity (important as that may be). Rather, our work has emerged out of a concern to ask more searching questions about, among other things, the nature of knowledge and its uptake or rejection, the possibilities for various epistemic communities to engage this issue in different ways and the avenues for moving the debate forward in ways attuned to the body–society nexus and humanistic concerns. Critically, and realistically, we view the discussions in these pages as re-presenting and analysing a substantive and politicised issue that is highly consequential for how people collectively live and relate to one another as embodied, thinking and feeling, actors in the social world. We concede that some people might read this work and assume that it is infused with biases of an approach that is anti-medicine and science, a possible misrecognition given our engagement with, among others, fat activists. Young (1990: 116) observes that when challenges

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are mounted against supposedly neutral assumptions and policies, especially challenges mounted by oppressed groups, ‘their claims are heard as those of biased, selfish interests that deviate from the impartial general interest’. The incredulity often surrounding politicised accounts of fatness provides an empirical referent to Young’s (1990) statement and associated critique of impartiality as ideology. Yet, while we would, as critical weight scholars, question the neutrality of science (science and medicine mediate social relationships in a socio-historical context) many of the authors in this collection argue instead for better science, to address that which is uncertain, and indeed understand the social distribution and determinants of health and illness (e.g. Acheson, 1998; Marmot, 2004). Of course, given our emphasis on politics and by also including a fat activist’s contribution (Cooper, Chapter 7), we concede that this may alienate some whose professional identity and perhaps livelihood are strongly linked to tackling obesity. However, it makes no sense to exclude fat activists from these debates. Furthermore, as explained by contributors to critical public health, the distinction between the activist and health professional cannot be easily sustained and defended (Green and Labonté, 2008). We tread lightly on a potential minefield but we also do this with forethought and a shared hope of offering a different way to think about ‘weight troubles’ and the obesity epidemic. We remain circumspect about any absolutist claims to truth and the ‘best’ way to act (the world is messy, contingent and complex), but the metaphor of the ‘peace keeper’ is apt here rather than ‘antagonists in a war on fat’ (e.g. Bacon, 2008). Of course, we concede that this might mean little to key players at present amidst, among other things, the presentation of an ‘ethical face’ by multinational corporations seeking to be the heroes, rather than villains, of the obesity epidemic (Herrick, 2009). In this final chapter, we highlight what each of the previous chapters offer in terms of current thinking about fatness, their contribution to critique and what we envision to be the ongoing implications of critical weight studies. In so doing, we will make more precise the nature of ‘scepticism’ and necessarily complicate critique given the difficulty of this topic plus possible misrecognition, or a ‘failure’ by proponents and defenders of obesity discourse to acknowledge and credit critical perspectives in the debate. We also comment on how we feel critical weight studies may be reflexively developed amidst heterogeneity in contributors’ backgrounds, approaches, pragmatic concerns and analyses. To inform these discussions, we propose a number of areas that might further be considered to develop the obesity debate, or transform

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it into something different over time. This means that we offer both a traditional conclusion, by speaking to the insights that are raised across this collection, but also remain reflexive about the nature of the debate itself. There are, inevitably, for various reasons, important lines of inquiry that we have not fully developed or explored within the limitations of the text. In an effort to partially redress that, we use the final part of this chapter to signal our interest in developing new theoretical, empirical, politicised and practically relevant work on fatness and obesity in the future.

Health knowledge – Who can be heard and to what end? Given the various disciplines and professions debating obesity, an obvious question is ‘whose voices can be heard in the current cacophony?’ Moreover, who might usefully be able to encourage or stimulate debate in different and perhaps more imaginative ways? By this we are not alluding to the innate intelligence, or otherwise, of contributors. We do not propose an elitist orientation where contributors assume the right to speak down to specific individuals as part of what Garfinkel (1956) calls a ‘degradation ceremony’. Rather, we are referring to heterogeneous forms of knowledge (e.g. specialised understandings that are formally learnt and usually credited as well as those that are more experiential and embodied) alongside sociologically mindful sensibilities that are similarly socially distributed (e.g. according to physicality and gender, as among female fat activists, and disciplinary imperatives such as those in the social sciences and new nursing theory). As obesity scientists, governments, health agencies and multinational corporations continually moot new ‘solutions’, the range of disciplines and professions imaginatively critiquing such discourse is expanding. Thus, as Evans and Colls note in Chapter 5, a renewed focus on ‘the environment’ in relation to bodyweight has spurred geographers to question the politics of fatness and how certain policies come to define particular bodies and places as ‘fat and problematic’ in ways that may do more harm than good. The development of what Longhurst (2005) calls ‘geographical research agendas on fatness’ provides a useful complement to emerging critical contributions in, for example, law and social policy, as well as new nursing theory and dietetics, given the very real problem of size discrimination in key domains like health care, education and employment (Aphramor, 2006; Solovay, 2000). As such writings make clear, it is not only the typically pilloried fat activist community that is sensitised to the socially constructed and embodied


problems of fatness and how obesity discourse reproduces, legitimates and amplifies these. Conversely, in seeking to further critique and foster change we might ask: ‘who is not heard?’ or ‘who is unwilling or unable publicly to exercise critical judgement?’ We are not only referring here to the ‘subaltern’ experiencing ‘the weight of the world’ or ‘unexpressed and inexpressible malaises’ (Bourdieu et al., 1999; cited in Lovell, 2007: 73). Particular reference is being made to various professionals who may exercise power in a way that could make a notable difference for other people in domains such as the clinic and university. As educators, including educators of future clinicians (e.g. medics and nurses), we would seek in these learning contexts to counter possible inertia and unquestioning obedience to dominant paradigms. To quote Smith (2008: 138), when discussing social justice, this is necessary since ‘oppressive structures of social exclusion and exploitation benefit from the everyday obedient behaviours’ of people, such as health professionals, ‘even though they are neither the most influential of decision-makers nor the controlling owners of the means of production’. Yet, we remain cognisant that relevant professions and disciplines, including, but not limited to those in this book, may also become more or less excluded from or resistant to critical discussions not only on obesity but other health matters. Possible reasons for this include the reward and communication systems of science (what has been called ‘the Mathew effect’ where science of acknowledged standing is disproportionately credited while reducing the visibility of less well-known contributions) (Merton, 1968). They also include faith in commonly prescribed ‘solutions’ (e.g. eat less, exercise more), satisfaction with the status quo, fear of change, complicity with commerce and a feeling that there is no need to take critique seriously, with some potential contributors even remaining unaware that vigorous debate exists. And, all of this is not merely cognitive but embodied. This is inseparable from what have been described as ‘tacit body knowledges’ by Murray (2008), that is, embodied knowledges operating at a ‘bodily level’ that are ‘subliminal’ and ‘preconscious’ but potentially detrimental to patient care. These tacit body knowledges pervade Western culture, including the academy. Even some social scientists, despite their critical sensibilities and disciplinary imperatives, also appear unaware of vigorous inter-disciplinary debate when discussing fat as a feminist or sociological issue. Some seem to accept that the ‘energy balance model’ of bodyweight, and associated moralised ideas about diet and physical activity, are matters of unequivocal scientific fact (Crossley, 2004; Probyn, 2008).

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Exclusion or marginalisation of dissenting voices, which are facets of oppression in Young’s (1990) discussion on social justice and the politics of difference, may occur from within or outside of professions and particular epistemic communities. On the one hand, professions may silence or ignore dissenting voices from within their own membership even when these are well researched and evidence-based as borne out by the experiences of the authors in Chapter 8 (Aphramor and Gingras). Elsewhere, groups outside a given community of practice may deliberately engineer exclusion. Although there may well be deeply vested economic interests at play here (Oliver, 2006), we would stress that this need not be seen as some sort of ‘conspiracy on the part of science or expression of political mischief or health educators’ malicious intent’ (Evans et al., 2008: 13; also, see Monaghan et al., 2010, and the discussion below on complicating critique). Rather, alongside the many factors noted by Evans et al. (2008: 13–14) (e.g. changes in medicalised approaches to health in recent decades, biopower as a way of regulating bodies, the demands of capitalism and consumerism), an unwillingness systematically to critique obesity discourse might also be seen as a reflection of widely shared dispositions and (latent) interests that are generated in ‘the habitus’ and are thus part of the taken-for-granted, or what ‘goes without saying’ (Lovell, 2007: 74). In a related vein, Walkerdine (2009: 204) underscores the need to consider what ‘cannot be and is not spoken’ as part of an embodied engagement with regulative practices that have affective consequences. However it is achieved, and however we theorise such effects/affects, such silences and exclusions reify socially constructed distinctions and hierarchical divisions. This may of course be precisely the intended outcome, serving to magnify the implied boundaries, and status, between ‘lay’ knowledge, different forms of professional knowledge and, ultimately, the forms of capital that accrue to each. This not only relates to government public health promotion but also corporate health improvement efforts (Herrick, 2009). For instance, in the realm of bioethics, Zylinska (2009) notes how financial interests – such as those associated with Big Pharma – powerfully shape debate, especially in the United States. As an aside, we recognise critical weight scholars are not necessarily exempt from these all-too-human processes, including the competitive search for distinction (if not actual wealth). Nonetheless, at a very obvious and basic level, and with particular reference to health professions and policy, it is clear that the (re)production of such divisions contradicts public health rhetoric urging patient and public involvement in influencing health care (DH, 1999) and, certainly in Britain, falls short of


NHS standards requiring awareness of critical debate as expressed in the Knowledge and Skills Framework (DH, 2004). Faced with the monolithic mantra that ‘fat is “obesity” and is unhealthy’, and its cornerstones of apparent popular medical and scientific consensus, it may seem implausible to suggest critical voices should be given space. But we would reiterate that scepticism towards a weight-centred health framework, as articulated throughout this book, is not anti-science: far from being a rejection of scientific thinking, it is, for example, the dietitians’ professional obligation to examine and interrogate evidence claims. Whilst this may be a difficult and even risky task for health professionals in the context of health care systems that are driven by quotas, performance indicators and strongly constrained by performativity, as Aphramor and Gingras (Chapter 8) make clear this remains an ethical duty and one that should not be silenced (also, Aphramor and Gingras, 2007). So too, a growing science on the subjective implications of social structure on health inequalities lends urgency to the need to revisit current models of obesity and the treatment of metabolic risk. We would echo calls for more social epidemiological inquiry to be undertaken and used to inform public health policy (Putnam and Galea, 2008) – hardly the cry of anti-science, and one that tallies with calls from advocates of clinical epidemiology who are attuned to socio-economic concerns (e.g. Davey Smith and Ebrahim, 2002). Even so, constraints remain and critical weight studies are often sidelined. Reflecting on contributions to Biopolitics and the ‘Obesity Epidemic’, Walkerdine (2009) observes that critical scholarship is often ignored by the obesity mainstream. Similarly, an influential yet seemingly disheartened critical weight scholar admitted frankly to one of us that she felt obesity scientists considered her nothing more than a slightly irritating gnat to be squashed (though, we would add, small biting insects are difficult to ignore: try sleeping, for instance, with a mosquito in one’s bedroom). As explained in our introductory chapter, this silencing or lack of acknowledgement (disrespect, even) is recurrent. Perhaps we should not be too surprised about this within the contours of neo-liberal societies wherein healthism, individual lifestyle and personal responsibility for risk and body (weight) management are key dimensions and concerns that frame and constrain the current obesity debate. As Saguy and Almeling (2008) explain, the media is implicated in this and the dissemination, or amplification, of what has been termed ‘fat panic’ through the processing of scientific reports for a larger audience, while Herrick (2009) draws attention to food and drink industries

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as they market health and secure brand value as part of an ‘ethically responsible’ attack on obesity. Yet, a message emerging from these pages is that scientific research, government policy and various other entrepreneurial practices alone cannot adequately account for, understand nor address weight-related concerns. This, we recognise, is a difficult argument to make when championing critical weight studies amidst authoritative and bellicose calls to combat obesity (Chapter 1). This difficulty is further compounded in a dedifferentiated context where ‘rationalities of health care and governance’ are ubiquitous and audiences are ‘hailed’ by routinely mediated messages to construct responsible identities through (aestheticised) bodywork and consumption. Note, for instance, the proliferation of health magazines disseminating ‘scientific facts’ for the public; including ‘self-help’ materials for men (Crawshaw, 2007; Monaghan and Hardey, Chapter 3 in this volume), or the continued ‘medicalization of cyberspace’ (Miah and Rich, 2008) that provides online advice and tools to self-regulate. In recognising the conditions under which health and weight-related knowledges are produced and consumed, then, many difficult and challenging questions emerge as part of an ongoing discussion. For example, what should our commitments as researchers, critical theorists and health professionals be in expanding this debate? What form can these commitments actually take in the public realm and habitus amidst institutional sizism, embodied fatphobia and structured entrepreneurial interests that authoritatively reproduce the idea that fat is ultimately a personally correctable problem? How should we conceptualise resistances to obesity discourse? How can critical voices better be heard and how can engagement across disciplines, communities and professions be fostered under conditions of healthism, neo-liberalism and other constraints? Without naively using the ideas of conspiracy, pharmaceutical imperialism, careerism and monetary gain (e.g. the idea that the war on obesity can be reductively explained in terms of the self-interested pursuit of occupational success and the expansion of markets), these constraints undoubtedly include economic concerns for a range of parties (Moynihan, 2006a, 2006b; Oliver, 2006). And, this applies to many interested parties, but sometimes in diametrically opposed ways. Thus, as noted above, the distinction between social activism and health work may be untenable for advocates of critical public health but combining these also has its risks and may even get people ‘fired’ (Green and Labonté, 2008: xiv). What Rich and Evans (Chapter 6) call a ‘surveillant obesity assemblage’ powerfully constrains and shapes what people are able to say, think and do in relation to ‘weight’ even when, as with


dietetics, there is an ethical obligation to interrogate evidence claims and deliver effective health care.

Obesity decamped: Centring social justice, not weight-loss We are urged to build up a new and more objective understanding of justice by bringing heretofore neglected perspectives into our dialogues. (Smith, 2008: 137) As discussed in preceding chapters, seemingly taken-for-granted prescriptions about ‘weight’ or fatness are highly contestable and, as such, it is incumbent to reflect upon why they hold sway. As noted early in this book (Campos, Chapter 2), the scientific evidence that if people eat less and exercise more they will necessarily lose significant amounts of weight and keep it off, or health will automatically be improved as a result, is unclear or even non-existent. Indeed, such action may adversely affect biomedical health, through the promotion of risky weight-loss practices and also unintentionally damage people’s well-being by reinforcing a sense of failure and body dissatisfaction (Aphramor, 2005; Bacon, 2008; O’Dea, 2004). As Aphramor (2005) explains, such action may even leave health professionals vulnerable to patient litigation in the absence of informed consent. Nonetheless, by tapping into commonsense ideologies around fatness and gendered concerns about ‘normative embodiment’ (size, shape, weight and general appearance), proponents of obesity discourse retain compelling credibility even when supporting evidence is contradictory, uncertain, completely absent or lacking in detail (Pieterman, 2007). So, while high quality evidence consistently shows the failure of weight-loss to provide medical benefit (Mann et al., 2007), weight-loss remains the goal of many interventions and policies. This book has hopefully made clear that many influences, upstream and downstream, reproduce the value of weight-loss. Rather than reiterating the usual mantra about weight-loss, we share a different vision. Crucially, instead of asserting the need for a reinvigorated war on obesity, our focus resides in developing frameworks of understanding that offer a nuanced focus on social justice and opportunities for ‘health’ in every respect regardless of people’s weight or size (Aphramor and Gingras, Chapter 8). Itself a complex and contested area (e.g. Lovell, 2007), when we flag social justice we are referring to the institutional conditions that facilitate more equitable social relations

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and the realisation of human potentiality amidst debates about the redistribution of resources and the politics of recognition. Promoting social justice involves ‘learning about what it might mean to be human in a just world’ – an engagement that requires a ‘constant openness to re-examine what we are doing and where we are going’ (Bywaters, 2004). Here ‘deliberation’ is welcomed through ‘democratic processes’ where well-informed citizens are willing ‘to work with others to overcome what Young (1990) calls cultural imperialism’ (Smith, 2008: 135) that denigrates and demonises people. The role of publicly funded universities in promoting a just and equal society should also be reiterated as a central concern here, though, critically, this is increasingly difficult given countervailing neo-liberal market forces which exacerbate ‘carelessness’ (lack of concern for others) in the academe, in ways that are particularly detrimental to women and older people (Lynch, 2010). In all of this we do not discount that for some people there may well be proper and medically beneficial reasons and motivations for weightloss (e.g. perhaps relieving pressure on arthritic joints), assuming, that is, weight-loss could be achieved with minimal risk and sustained over time. However, contrary to the negative characteristics commonly associated with fat people – ideas which are hardly negated by the disease metaphors of obesity and are legitimated in medicine and government health reports (UK Parliament, 2004) – social justice asserts the equal worth of people amidst difference in a heterogeneous public. This is a core value of social justice and one that is shored up by commitment to chances for equality of life and opportunities in multiple institutional contexts (e.g. work, education and health care). Although of broad relevance, feminists have been and continue to be especially attuned to such concerns not least given the feminisation of poverty and other gendered injustices such as ‘glass ceilings’ (Smith, 2008: 131), ‘care ceilings’ (Lynch, 2010) and the reproduction of gender inequality within the ‘new paradigm’ of health (Moore, 2008). A commitment to social justice means being mindful of social inequality, exclusion, disadvantage, disrespect and suffering. It means honouring a commitment to seek out measures that reduce the abuse of power and privilege. These are pressing and urgent concerns, as made clear by critical commentary on capitalism and the current economic crisis which has dire implications for health (Scambler, 2009a). Of course, in the context of obesity discourse and associated modes of entrepreneurship, agents need not consciously realise or ever concede they may be guilty of ‘abuse’ and the perpetuation of conditions that limit ‘human flourishing’ (Lovell, 2007: 69). Quoting Foucault (1977)


on the operation of power in modernity (e.g. through bureaucratic administration and medicine), Young (1990: 41) explains that ‘structural oppression’ is very much related to ‘the everyday practices of a wellintentioned liberal society’. Similarly, one need only consider the label ‘Corporate Social Responsibility’ to recognise how sometimes vilified industries in the obesity debacle are able to present themselves as ethical agents given their ‘superior financial capacity’, relative to the state, to invest in research and development and ‘knowledge creation, dissemination and implementation’ (Herrick, 2009: 59). Nonetheless, when ‘abuse’ or structural oppression does occur, it includes the possibility of perpetuating a victim-blaming ideology vis-à-vis individuals’ health outcomes ‘with punitive consequences for existing health inequalities and social justice more broadly’ (ibid.). It also includes the (unrealised) perpetuation of sizist stereotypes and narratives of shame and blame that discredit and may hurt people deemed fat (Aphramor, 2006). Such processes, which Harvey (1999) would refer to as ‘civilized oppression’ (see Chapter 1 in this volume), not only potentially damage embodied identities but may also seriously limit life-chances particularly as they coalesce with broader discourses such as parenting (on the significance of ‘life-chances’ rather than ‘lifestyles’ in relation to men’s health, see Robertson and Williams, 2010). For example, in October 2009, social workers in Dundee, Scotland, removed a newborn baby from its obese mother. Having undergone a caesarean section ‘28 hours later, social workers arrived at the maternity ward to take the baby into care, after serving child protection papers’ (Anon., 2009). All seven of the family’s children were later placed into care. We are reminded, here, of Evans and Colls’ point in Chapter 5 about ‘grotesque discourse’, legitimated because of its seeming scientific status, that has ‘the power to determine, directly or indirectly, a decision of justice that ultimately concerns a person’s freedom or detention, or, if it comes to it . . . life and death’ (Foucault, 2003: 6; our emphasis). In all of this, process matters: social justice means that how we go about achieving our ends is important, asserting the central need to value people in all their diversities (Bywaters, 2004). An obvious concern here is respecting people who might otherwise be denigrated as obese, and whose bodies – as objectified flesh and a reflex of the self – are unjustly ‘scaled’ as selfish, abject, disgusting and ugly ‘in contrast to the purity and respectability of neutral, rational subjects’ (Young, 1990: 125). In connecting with recent debates in bioethics, this emphasis on ‘respect for persons’ – while important and to be welcomed – is, admittedly, not without problems given the philosophical principles it relies

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on, that is, an emphasis on the ‘self enclosed, autonomy of the rational human self’ (Zylinska, 2009: 20) abstracted from socio-political processes. Yet, if respect is to be afforded to persons, albeit with the caveat that one must also recognise and engage broader concerns, then an additional point is worth making. Namely, valuing people includes valuing people with diverse beliefs and interests in the obesity debate, people who, one might add, may very well be sensitive to a ‘personal tragedy’ model of obesity when promoting weight-loss. Hence, in holding out an olive branch, we would like to view those with conflicting views not as enemies or combatants but as participants in a collaborative community of learning where the goal is to productively engage with others, rather than ‘defeat’ them in a metaphorical battle. In so doing, our shared ideal as critical weight scholars is to offer well-reasoned, researched and informed critique that could inform views and institutional practices. This, of course, also entails reflexivity and sophistication with regards to our own analytical frameworks and commentary. We discuss this further in the next section when complicating critique amidst possible misrecognition, itself a complex aspect of social injustice and cultural domination (Lovell, 2007). When critiquing obesity discourse amidst concerns about social justice, it should be noted that diversity is a key theme for various critical writers. For instance, appeals to ‘natural’ bodily diversity are common among fat activists (e.g. Cooper, 1998; Mitchell, 2005). Critical weight studies, in our view, should listen to, work with and engage such diverse thinking albeit without simply ‘swallowing everything whole’ and ignoring how material bodies are also socially constructed and crosscut by other power axes such as gender (e.g. notions of motherhood), class and ethnicity. Regardless of the robustness or otherwise of different fat activists’ varied contributions, we know it is all too easy for activists to be prejudicially dismissed. As with the ‘wise’ orientation described in Chapter 3 (Monaghan and Hardey), we have learnt from strands of fat activism and, so, we featured a chapter by Cooper who provides an overview of fat activism (Chapter 7). As she explains, fat activism promotes social justice, celebration and forms of resistance to the stigma of obesity. Fat lib, we feel, contains ‘precious kernels of emancipatory potential’ (Smith, 2008: 135) which are relevant to the obesity debate and how people, especially women, might live and identify as fat. Cooper’s chapter provides an informative contribution that charts the chronology of fat activisms’ history, reaching back to cases as early as 1967. She maintains that despite the pervasiveness of obesity discourse and the relative paucity of direct fat activist theory, there is a tradition


of resistance that cannot be silenced. The issue of ‘resistance’ is revisited in our next section. When including fat activist thinking we should make clear that we would not deny real and putative contributors to secular trends in obesity and poor health, which are rooted in the inequities of the socioeconomic order and are also issues for social justice (e.g. sleep debt or global food poverty and inequality which have material affects on body composition) (Aphramor, 2005; Keith et al., 2006). For example, Aphramor (2005) reviews scientific evidence on how socio-economic status and associated material conditions affecting stress levels may impact human bodies, including the development of metabolic syndrome and abdominal fat deposition. Nonetheless, and in sharing Cooper’s concerns about the unjust degradation of fatness as an index of individual failure, we see problems in the ways obesity discourse seeks to standardise heterogeneous bodies and reductively pathologise bodily diversity in the name of health and ‘lifestyle change’. Hence, in decamping obesity and going beyond the politics of identity our contribution is not simply, or fundamentally, about ‘fat people’ who are oppressed because of the social meanings of, and practices surrounding, fatness in Western culture. Indeed, when complicating critique, we would maintain that this debate and the development of critical weight studies cannot be reduced to socially constructed dichotomies such as fat/thin, minority/majority, normal/abnormal and us/them (also, Monaghan, 2008). There are some basic reasons for this amidst social inequality and a ‘surveillance medicine’ (Armstrong, 1995) that blurs boundaries between health and illness. For example, note the BMI which categorises all bodies exceeding 25 kg/m2 (most adults in many developed nations) as (potentially) ill or diseased, and how, for millions of people, their health is adversely affected by global socio-economic inequalities regardless of body composition. In their different ways, each of the chapters in this book highlight the problems associated with reductive thinking about weight(-loss) and health, as ‘measured’ through objectifying obesity discourse and the application of widely used technologies such as the BMI. In light of such contributions, we would maintain that authoritative claims that most people are too heavy – and there is a need for more physical activity and lower calorie diets – are too crude and distorting of the world. They are also, despite ostensible good intentions, antithetical to the increasingly global concerns of social justice and the problem of inequitable life-chances. For instance, how are people to be afforded dignity, respect and appropriate health care when the obesity label consolidates a sense

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of undesirable differentness? How are class inequalities in health to be redressed when structured differences in opportunity, life chances and resources are authoritatively eclipsed by a focus on weight or fatness? How are we to make a difference when relations of stigma are, across many figurations, increasingly enmeshed with the logic of culpability, deviance and blame (Scambler, 2006)? Inevitably, theories, treatments and policies emerging from this divisive background require close individual scrutiny on many dimensions. The challenge this presents is exacerbated by the institutionalised tendency to try and achieve ‘broad stroke’ rationalised solutions to medical(ised) problems that are ultimately seen to reside in the individual body even when attention focuses on so-called ‘obesogenic environments’ that are deemed ‘abnormal’ and practically affect ‘everyone everywhere’ (Gard and Wright, 2005: 17). Medicalisation, a double-edged sword well documented and critiqued by sociologists (e.g. Conrad and Schneider, 1992), is a theme to which we will return in the next section. Other contributions to this book further a concern with social justice rather than promote weight-loss as a medicalised ‘panacea’. As Evans and Colls argue in Chapter 5 when critiquing anti-obesity policy in British schools, obesity is frequently referred to as an epidemic and a disease. Yet, the basis for this biomedical classification is contested as it is neither an illness in its own right – rather a measure of body size which has been correlated with some illnesses and so is considered a ‘risk factor’ – and is not contagious, usually a pre-requisite for being considered an ‘epidemic disease’. Understandably then, as discussed by Campos (Chapter 2) when critically examining epidemiological evidence and biomedical arguments, this discourse is forwarded on the basis of several (usually unstated) shared assumptions that escape due scrutiny. Compounding this, interventions tend to overstate powers of prediction and causality, whilst underplaying the complexity of health in an inequitable world. Whilst critical weight studies, fat activism and the Health At Every Size (HAES) movement differ in their theoretical and political orientations, they share the assertion that the relationship between fatness and health is more complex than that which is written into anti-obesity policy and, in seeking to further social justice, maintain fat discrimination should be explicitly challenged. Collectively then, the chapters remind us that despite current obesity epidemic rhetoric and the power of a medicalised framing, the relationship between weight or fatness, health practices and health in its various embodied dimensions (e.g. emotional, visceral, pragmatic) is


a complicated one and there remains an ongoing lack of clarity over a subject of emotive, theoretical and policy disagreement. In responding to this, preceding chapters centre concerns other than weight-loss. Notably, there is the shared attempt to engage institutional(ised) discourses and practices that could negatively impact, but also enable, lived bodies. The chapters in this volume also complicate critique, highlighting the need for more nuanced approaches, alongside the need for contributors to be mindful of how their work might be misrecognised and perhaps ‘attacked’ in a politicised and controversial field.

Complicating critique, responding to misrecognition In tandem with opening up ethical enquiry, and to offer a brief summary, contributors to this book question or reject the scientific foundations of epidemic rhetoric (Campos, Chapter 2). They empirically explore how discrediting terms such as ‘obesity’ (and their everyday, vulgarised equivalents) impact bodily sensibilities and potentially spoil men’s identities (Monaghan and Hardey, Chapter 3), or interact with discourses of female beauty in varied and not always disempowering ways among women (Tischner and Malson, Chapter 4), including female fat activists (Cooper, Chapter 7). Critiquing the ‘truths’ driving anti-obesity policy, as directed at children, chapters also explore how these technologies operate as a ‘grotesque discourse’ (Foucault, 2003) that has the potential to harm (Evans and Colls, Chapter 5) while also constituting a broader ‘surveillant assemblage’ (Haggerty and Erikson, 2000) that operates in myriad contexts of learning (Rich, Evans and De Pian, Chapter 6). In the penultimate chapter, health professionals contend that obesity – as currently conceived in the clinical and academic worlds – has no medical salience (Aphramor and Gingras, Chapter 8). Their central argument is that within the tight constraints of an energy balance model, the political bearing of data on poor health is defused in simplistic, unproductive and unimaginative readings. Furthermore, the health impact of sizist treatment and policies is normatively discounted and, disturbingly, this is within a health care profession. We are reminded, here, of symbolic interactionist sociology on the professions which has brought to light aspects of professions that most ‘insiders’ would rather ‘conceal’ or ‘underemphasise’ (Cuff and Payne, 1979: 100). Authors in this book, as might be expected given their divergent backgrounds and concerns, use various theoretical frameworks and concepts to examine how obesity discourse has come about under particular socio-historical and cultural conditions, and the kinds of

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regulatory work it might do as it is recontexualised in different settings. In complicating critique and considering the prospect of obesity-related interventions, we would assert that one must consider the specificity of various forms of intervention and the reconfigurations of obesity discourse in different contexts. While analytical and empirical attention is directed at more formal contexts like schools, as when Evans and Colls question both the justifications for, and the implications of, the focus on children in UK anti-obesity policy (Chapter 5), or dietetics as a field of knowledge and practice (Aphramor and Gingras, Chapter 8), other authors consider interactional contexts ranging from the pub and street (Monaghan and Hardey, Chapter 3), to online environments (Rich , Evans and De Pian, Chapter 6). These chapters reveal, among other factors, the challenges facing sceptics when attempting to offer moral or ethical commentary on anti-obesity policy/interventions, shared discourses (including everyday vocabularies), symbolic violence, the experience of embodiment and the nature of critique. The cases are not exhaustive, of course, and we suggest further avenues in our final section of this chapter. Our contention, in light of these varied contributions, is that one cannot usefully approach each area with the same ethical expectations, nor moral critique. Indeed, given that critiquing obesity discourse is likely to encounter resistance among those with a deeply vested interest in combating obesity, and, such parties and their allies may take exception to what they misrecognise as unjustified criticism, it is incumbent for obesity sceptics to embrace the complexity of the different issues they explore. As this collection has hopefully made clear, this means examining the relationships between different sites, individuals and agencies involved in the (re)production of obesity discourse to better understand its (re)articulations and (re)configurations. For Evans and Colls (Chapter 5), this means examining, among other things, ‘the movement of obesity knowledges and practices between and through different spaces by the multiple actors deemed “responsible” for “obesity” ’. In taking up this challenge, Rich and colleagues (Chapter 6) suggest that in order to understand the assemblage of policy, intervention and discourse a more subtle and complex understanding of surveillance, and of the landscape of anti-obesity policy and practice, is needed, which captures the fluidity and interrelationships between various sites. Walkerdine (2009) captures the complexity of this landscape and the challenge it presents. After critiquing a simple politics of opposition, she comments:


we cannot know in advance what will be created from an intervention. We cannot predict totally its effectivity. This makes it both more complex and more hopeful, as those who have suggested that this provides a new space for political action have suggested (Massey, 2005). (Walkerdine, 2009: 203) For any sceptic, theorist, activist and health professional, this is perhaps both a daunting but refreshing prospect. One issue we might revisit in the context of this expanded thinking about what specific interventions might bring forth is the simplistic distinction made between ‘lay’ discourse and medical discourse, and their supposed opposition. Sociologists exploring such issues have shown that it is perhaps more useful to posit a ‘spectrum of knowledge(s) about health and scientific issues’ rather than an expert/lay schism (McClean and Shaw, 2005: 729). Certainly, we remain mindful here of any recourse towards essentialising medicine or medicalised injunctions as always and ultimately surveillant; doing so may fail to capture the complexities of health(care), policy and practice as they unfold in the embodied social world and limit the persuasiveness of critique. For critique to be persuasive, then, there is a need to remain mindful that the realities confronting us are, like the body itself, infinitely rich and ‘multi-dimensional’ (Shilling, 2005) in their specificity and complexity. Even when directing attention specifically at ‘the social’ (rather than intransitive biological realities, which remain enmeshed with society), sociological understandings or explanations of social practices can only ever be partial (Weber, 2001). As social scientists aiming systematically to explore and critique ‘the social’ in the interests of ‘public fairness’ (Young, 1990: 112) and social justice (Lynch, 2010) we therefore concede the messiness of reality (note, for example, that the model presented by Monaghan and Hardey, Chapter 3, is an ‘ideal type’ or heuristic device rather than an actual reproduction of social reality). Nonetheless, such realities and social processes deserve our careful and sustained attention in ways attuned to moral and ethical issues because they are highly consequential for people’s shared lives, comprising embodied relationships and corporeal concerns. Key domains include medico-moral and other contexts (e.g. legal, educational, arenas of popular culture) wherein knowledge-claims about the body, health, weight and fatness are interpreted in multiple and perhaps conflicting ways.

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In exploring moral and ethical issues, chapters in this book consider how the inscription of bodies through obesity discourse is a complex process, the product of policies and practices that may have unknown consequences (we write more on this below). Obesity discourse produces ‘bodies that are certainly being written, but simultaneously bodies to write on’ (Sundén, 2001: 229) in ways likely to elicit an emotional response. It would be naïve, however, to suggest that biopower and other forms of regulation associated with obesity are themselves inherently bad or readily quantifiable and uniform in their effects. Efforts to ‘control’ the behaviours of populations (albeit in this case, the weight/health of populations) will inscribe bodies in different ways along axes of power and intersections of identity. This point emerges in Chapter 4, where Tischner and Malson argue that fat bodies are written onto in ways that render them always-already gendered bodies. Their chapter shows how obesity discourse converges with other discourses (e.g. beauty) to produce variations of affect (and effect). In cultures where bodily form signifies (lack of) self-control, fatness is a reflex of presumably poor health and immoral character (see also Halse, 2009; Murray, 2008). In the case of the women in their research, fatness became the metonymy of the woman’s body and entire being, with the potential to ‘spoil’ (Goffman, 1963) their gendered identities. Debating obesity also means taking the trouble to better understand the complexities of resistance. For individuals, ‘being fat’ or labelled ‘fat’ (overweight, obese and so on) means more than is captured in the frameworks of obesity discourse and is instead variously constituted through, but not limited to, other frameworks to do with queerness, identity politics and embodiment (see LeBesco, 2004). To return to Chapter 4, Tischner and Malson reveal how their study participants offered accounts that moved beyond and resisted the reductionist and truncated terms of dominant obesity discourse so that fat bodies figured as empowered, strong, enabling and able to engage in activities (e.g. orienteering, professional dancing) that are often socially constructed as reserved for slim people. Cooper, in Chapter 7, takes these themes further, highlighting the playful, subversive, multi-layered and creative forms of resistance offered by fat activism. She renders hierarchies of knowledge problematic and reveals the value in fat identity and experience by highlighting the diversity of fat history and culture. This particularity of diversity and experience would be lost, Cooper reminds us, if the drive to eradicate obesity is successful, as she confronts the implied boundaries between legitimate ‘health knowledge’ and ‘lay experience’.


This is a difficult ethical terrain to negotiate, but in doing so, Cooper raises pertinent questions; for example, even if there were conclusive evidence which revealed categorically a negative relationship between fatness and health, should this necessary mean that one should frame decisions concerning fatness only in medical terms? Such decisions are more complicated than looking at the health benefit ratios: some individuals may consider that fat identity and experience have greater value than living a life deemed to be ‘healthier’ at a lighter weight. Newer, liberating possibilities for being fat are created by Cooper’s semi-fictitious international fat girl gang, the Chubsters. Members both shape real life events and also tap into a playful form of resistance about alternative futures by promoting an imaginary parallel world based on myth, lies, jokes and pop culture. In response to the depiction of fat people as the ‘embodiment of safe, affable jollity’, Chubster humour is aggressive, angry, unnerving and politically astute. Here the body becomes a somatic site of resistance, a site of agency and creativity that shapes the Chubsters’ actions and interactions. These women take control over their bodies, but not through the sorts of regulative practices prescribed through the individualistic tendencies towards ‘self-improvement’ evident in obesity discourse. They exert a bodily agency generated through identity and embodiment which ascribes alternative meaning, asserting rights to read and name their own bodies in the ways they see fit as they appropriate alternative, sometimes fictitious, imagery of the ‘fat’ body. For some, these imagined spaces may provide the means through which to negotiate discourses within which the body becomes inseparable from one’s prescribed character or worth by others. By extension, and to balance possible celebratory tendencies, we would reiterate that agency is exercised under potentially discrediting and disabling social conditions, which remain embodied (Murray, 2008). Tischner and Malson (Chapter 4) note that fat women risk their femininity while various fat activist groups have been relatively short lived (Cooper, Chapter 7). In all of this, we are reminded of social theorising which complicates the idea of ‘resistance’ and the meaning this concept may have in critical social analyses. Robertson and Williams (2010: 63) state this term often implies that ‘non-compliance’ with medicine is ‘the politically correct choice’ yet ‘this seems to provide only partial insight into the complexities involved in understanding’ health and, we would add, debating obesity in ‘epidemic’ times. The possible rejection of critical social scientific arguments as overly simplistic and a slur on health professionals’ occupational pride relate back to the subordination of alternative modes of being and knowing

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in a stratified world. Following Walkerdine’s (2009) reflections on the (lack of) uptake of critical scholarship, we fully recognise critical weight scholars risk being accused of naivety insofar as they allegedly claim doctors, in particular, are more interested in controlling laity than promoting health and well-being. Indeed, we are aware of key contributors to the obesity debate who, in their discussions with us, have unquestionably reproduced popularised versions of bioethical debate that has the ‘individualized doctor-patient dyad as its structuring relationship’ but which, as Zylinska (2009: 21) explains, is part of a larger ‘biopolitical regime’ comprising moralisation, moral panic and cultural prejudices as manifest among the general public and scientists. Unfortunately, complicating critique under such conditions could increase space for possible confusion, or, more likely, the possibility for misrecognition and social injustice (Lovell, 2007). This is within a larger politicised field where diverse contributors are positioned by some as ‘friends or enemies’ (Gard, 2009) and are thus considered either supportive or antagonistic. In responding to such difficulties and clarifying our critique, a useful classic sociological distinction that has informed our own work but which we would like to spell out here is that between manifest and latent functions (Merton, 1957). That is, differences between what people think they are doing and other ‘below the surface’ functions (including those associated with ideologies and biopedagogies) which may never be articulated or even realised by people themselves. In making this point we do not consider ourselves more intelligent than proponents or defenders of obesity discourse. Rather, we approach the debate with a different interpretive lens that is attuned to sociological concerns, including the pervasive and complex issue of misrecognition where dominant groups refuse to listen to those who are marginalised in obesity debates, or position them in ways we consider incredulous. Merton has provided insights on ‘the unanticipated consequences of purposive social action’ and what he went on to describe as ‘the latent and manifest functions’ of social action (Merton, 1936, 1957). While we concede aspects of his work do not escape critique, notably, issues concerning the explanation of social phenomena (function does not necessarily explain particular actions), Merton’s thinking usefully clarifies confusions between subjective dispositions or motives and objective consequences. Thus, among other things, Merton (1957) cites the Hopi rain dance and members’ beliefs when performing this ritual. Beyond the Hopi’s shared taken-for-granted or manifest meanings is the latent function of increasing social solidarity in the face of a potentially


serious problem (lack of precipitation, crop failure, starvation). Lest some readers miss our point, consider ideal typical modes of obesity epidemic entrepreneurship. When doctors, politicians, corporations, charities and others seek authoritatively to combat obesity, ‘raise awareness’ and promote slenderness in the population, the manifest goal is to do good work by aiming to benefit people’s health, well-being and even save health services and governments money. While subjective beliefs can be bracketed here for one moment, it is to be anticipated that many of these enterprising ‘agents of power’ (Smith, 2008) are genuinely concerned about health and view themselves as good, compassionate people (rather than prejudiced, for example, or overzealous controllers who are meddlesome). We would not necessarily doubt their self-conceptions or sincerity, their subjective dispositions (also, Throsby, 2009) even if they might sometimes be highly paternalistic and elitist (Monaghan et al., 2010). However, what we are especially concerned with in our role as critical weight scholars are the negative unintended consequences of these purposive social actions, and various latent functions that may go beyond specific agents’ or groups’ expressed goals or conscious realisations. In that respect, control and regulation plus other sociologically relevant themes, which are obviously bigger than the flesh or the promotion of biomedical health (e.g. ideology, healthism, the expansion of profitable markets, disease mongering, the intersections of racism and sizism, class distinction and disdain, the impact of social structural inequalities and poverty on bodies) remain significant issues to explore and debate in all their complexity. This is the very stuff of critical weight studies as a sociologically imaginative project. We would argue that such challenging analyses should not be derailed by de-politicised and unreasonable objections where we are naively thought of as engaging in, for example, conspiracy theory or ‘doctor bashing’. While the highly profitable food and drink industry, much vilified for purveying ‘junk’ food, might be seen as fair game for critical social analysis even when the industry endorses Corporate Social Responsibility strategies (Herrick, 2009), social analyses such as our own are sometimes considered ‘astonishing’ by those who misrecognise our work as a wholesale attack on medicine and medics. We have little interest in entering the debate on these terms, just as we would avoid a thesis of pharmaceutical imperialism, since, as explained within the sociology of health and illness, ‘it is too simple to see actual or potential patients as passive beings, acted upon by the marketing devices of Big Pharma who invent medical conditions and manipulate individuals into identifying with them’ (Rose, 2006: 480; cited by Marshall, 2010: 215; our

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emphasis). For us, the idea that we present naïve conspiracy theory is incredulous and we would refute this in the interests of offering sociologically imaginative work and stimulating productive dialogue across disciplines, professions and potentially corrosive divisions. While it remains that some may well see our response as just another viewpoint, and a defensive one at that, what we are keen to stress here is that there are differences of an ontological and epistemological kind, and to conflate these differences (as is common among extreme social constructionists) is to commit what critical realists call an ‘epistemic fallacy’ (Williams, 2003). Stated differently, while it remains an empirical fact that professions do not always live up to their public pretensions (e.g. Jeffery, 1979), we would repudiate the view that our work simply comprises ‘biased’ beliefs about a supposedly manipulative and profit hungry medicine or callous health care workers. Among other things, such depictions hamper efforts to build bridges while trivialising the irrationalities (realities) of the larger social world as presently constituted. This world, wherein medical work may be a ‘calling’ for individuals independent of personal pecuniary gain (similarly, see Weber, 2001), undoubtedly includes powerful material interests and a capitalist political economy wherein individual risk factors in health discourses take ideological precedence over the damaging practices of power elites (Scambler, 2009a). It also incorporates an inequitable gender order wherein medicalised (masculinised) calls for a war on (feminine and feminising) fat are simply taken for granted (Monaghan, 2008). And, as other sociologists of health and illness observe, it includes medical settings wherein moral evaluation of patients is common and where some doctors might typify some categories of patient as ‘rubbish’ because they transgress ‘appropriate’ boundaries (e.g. presenting ‘trivia’ or being abusive and threatening) (Jeffery, 1979). By the same token, and in returning to Merton (1936) who sensitises us to various processes, we concede that unforeseen consequences need not always be negative; for instance, anti-obesity campaigns urging people to participate in more physical activity could sometimes increase family cohesion (Walkerdine, 2009). Critically, however, physical fitness, well-being and family solidarity could be similarly promoted outside a weight-centred health framework, incorporating Health in Every Respect (Aphramor and Gingras, Chapter 8), and without spoiling the identities of people who are seen as fat. In responding to potential confusion or misrecognition, we want to be clear then that we are not naively reproducing the idea that proponents of obesity discourse are co-conspirators who seek intentionally to


deceive and do harm on a grand scale (also, Monaghan et al., 2010). Yet these reactions also convey a broader problem, relating to the construction of ‘critique’ and counter discourse in the construction of particular knowledge on an uneven field of power. As critical weight scholars, pedagogues and health professionals, our inclination in our own work is to reveal the moral implications of how obesity discourse may be reconfigured in different contexts, that is, we are not saying that medicine is oppressive per se, nor that it is more concerned with morality. Rather, we maintain that there are moral consequences to particular forms of interventions. And, to reiterate, this occurs in unpredictable and not always intended and positive ways even when people diligently seek to promote health and well-being. Throsby’s (2009) recent observational work of surgical weight management clinics illuminates this point nicely, revealing how during clinical encounters there may be a series of ‘misunderstandings’ between the surgeon and patient. Throsby suggests that central to these misunderstandings was the different experiences of the concept of ‘excess’. Whilst constituting a ‘quantifiable and discrete problem of surplus’ for surgeons, for patients this comes ‘laden with moral freight that attaches to the body and self in ways that are much less confinable to the bodily portion labelled medically as excessive’. In these contexts, many of the patients appreciated the non-judgemental environment of the clinic and felt they ‘were treated more respectfully there than in other medical encounters’. However, Throsby observes that for patients the concept of excess was ‘inextricable from those wider judgements about fat bodies’. In such encounters, it is not that surgeons ridicule or stigmatise patients (although this may of course occur) but the ‘broader moral framing of obesity’ provides a ‘context for the sense of shame that the patients already bring to the social encounter’. In this sense, Throsby’s work highlights how even where health professionals may be well intentioned, compassionate and non-judgemental, broader discourses which morally frame obesity come into play in ways which pre-empt the medical encounter. In light of this, one can easily appreciate why the common foci of traditional bioethics on ‘the individualized doctor-patient dyad’ (Zylinska, 2009) is problematic. Returning to and responding to those ‘astonishing’ objections mentioned above, we want to stress that while moral and ideological currents run through obesity science (Gard and Wright, 2005), we have absolutely no interest in castigating obesity claims-makers as liars. An easy ‘straw man’ criticism sometimes levelled wholesale at critical scholars, before dismissing them and carrying on with business as usual,

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is that they unfairly caricature obesity scientists as knowingly deceiving the public (possibly due to their own greed for profit or scarce research funds). We concede such a criticism might be easily directed at some writers, such as Gaesser (2002) who offers much of interest and value from the position of an exercise physiologist and advocate of HAES. Indeed, it is easy to see how Gaesser’s reasoning may be especially difficult for the anti-obesity camp given the title of his book, Big Fat Lies (2002), possibly resulting in the baby being thrown out with the bathwater. However, while the role of fraud and greed in capitalist society and health matters cannot and should not be ignored (Scambler, 2009a), in countering misrecognition of our own work we would again return to classic sociological arguments. Consider Berger (1963: 131) on ideology and the propositions of people such as corporate executives, for whom the steering medium of money is obviously central: It should be stressed again in this connexion that commonly the people putting forward these propositions are perfectly sincere. The moral effort to lie deliberately is beyond most people. It is much easier to deceive oneself. It is, therefore, important to keep the concept of ideology distinct from notions of lying, deception, propaganda or leger-domain. The liar, by definition, knows that he [sic] is lying. The ideologist does not. [ . . . ] Most theories of conspiracy grossly overestimate the intellectual foresight of the conspirators. By the same token, when aiming convincingly to challenge obesity discourse and complicate critique, we would stress that the concept of ideology does not and should not be read as a moral taint against individual proponents of obesity discourse. At the same time, the road to hell is paved with good intentions and while we do not align ourselves with imagined angels it is worth recognising Young’s (1990: 112) point that ‘an idea functions ideologically when belief in it helps reproduce relations of domination or oppression by justifying them or obscuring possible emancipatory social relations’. These are structural and discursive issues that transcend any one individual and often involve the implicit assumptions and reactions of well-meaning people. We do not intend to labour the point but we are particularly attuned to negative reactions and misrecognitions when entering debates on obesity with various groups. These, after all, are people who perhaps feel we are unfairly criticising them (or, if not them personally, then it may be assumed we are berating other people, such as ‘the poor Surgeon General’ as expressed by a scientist at a conference one of us


recently presented at). Certainly, there are legitimate complaints raised by sociologists concerning what could be seen as the unfair representation of doctors (Graham, 2006). While some health professionals or educators are fatphobic and their practices impede care, with ‘fat bigotry’ identified as a problem in the medical profession (Joanisse and Synnott, 1999), we are careful to avoid caricatures lest we are seen to be simply ‘condemning condemners’ as a means of justifying our own accounts among conflicting narratives and the competitive search for distinction. While the idea of ‘preconception’ (Gard and Wright, 2005) or ‘prejudice’ emerge in this book, we would reiterate that our work does not aim through bias or malice to scold doctors and other enterprising proponents of obesity discourse – though, as an aside and in remaining passionate, there are limits to this when encountering people who advocate ‘barbaric form[s] of social control’ (Scambler, 2009b) such as endorsing more stigma towards fat people. More often, if some advocates of obesity discourse are negatively labelled by particular audiences, even labelled ‘Narrow Fucks’ by the Chubsters (Cooper, Chapter 7), then it may be because of their own symbolically violent injunctions. Going from the ‘poor’ US Surgeon General, note Campos’ reference in Chapter 2, to Judith Stern of the American Obesity Association. Stern claimed that any expert who opposed FDA approval of a weight-loss drug, Redux, ‘should be shot’, even though there were serious scientific concerns. The approved drug, which was not particularly efficacious, was subsequently removed amidst accumulating evidence of fatal side effects (also, see Lutwak, 2003). On a pragmatic level, while there are myriad types of obesity epidemic entrepreneur with different interests (and degrees of investment) in constructing fatness as a correctable problem, simply berating the health professions makes little sense to us. This would be counterproductive since it has always been our intention to promote productive dialogue with those directly involved in medicine and the life sciences – people often charged with directly intervening in other people’s lives in order to combat obesity, as part of a state legitimated and commercially supported assemblage of practices (Monaghan et al., 2010). Clearly, the possibility of discussion is not helped in the obesity debate by caricatures of either health professionals or critical weight scholars, including, to challenge that dichotomy, critical scholars who also work as clinicians (note Lucy’s multiple positioning, for instance). As far as critical contributors go, their work may very well be (and often is) more sophisticated than is implied by those misrecognising and attacking their efforts. Thus, as our discussion above makes clear with regards

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to medicalisation, and, indeed, as some of our previous publications underscore (e.g. Aphramor, 2006; Evans et al., 2008; Monaghan, 2008; Rich and Evans, 2005), we are concerned with and critique certain processes, forms of knowledge and authoritative messages and practices that may unintentionally be corrosive in their effects. We would add that these effects, amenable to empirical analysis, could also be felt by clinicians, whether this is in their role as patients, educators or living everyday lives as citizens in a fatphobic culture (Monaghan, 2010a, 2010b). In sum, our goal is to better understand the complexities of health knowledge and care, counter misrecognition when offering alternative understandings to the debate and further the politicisation of fatness (and, we might add in regards to some of our disciplinary concerns, the politicisation of an embodied sociology that is ‘fit’ to engage the vicissitudes of health and illness). A key issue for us is the need to critique the various medicalised meanings and practices as they are reconfigured through particular discourses, cultures and institutional processes that may come to bear upon people’s identities and relational bodies. In exploring these processes we have touched on different but related concepts of medicalisation, lifestyle, individualism and health (concepts which have been theorised elsewhere, see Crawford, 1980; Ballard and Elston, 2005; Metzl and Herzig, 2007). We have discussed the tendency of obesity discourse to be framed by these concepts in their varied guises so that preceding chapters are infused with politicised, moral and ethical considerations. One upshot of this is that the chapters bring to light inequalities which may require a re-theorising of the role of particular medical(ised) practices in society and other ethical concerns discussed in our final section below.

Future agendas Contributors to this book have drawn upon a wide range of theoretical positions and issues. This is by no means definitive, and there is an extensive range of other perspectives and research that might also have been included in this text. Of considerable interest to us has been the diversity and range of individuals, communities and disciplines entering the obesity debate. As such, rather than remain confined to expanding the views represented in this debate, we argue there is a need to reconsider how disciplines and communities engage with each other under social conditions wherein some voices are (dis)credited more than others.


Our motivation for raising this agenda is not, as one might expect, to ensure only that critical perspectives are better heard. Rather our argument here is that unless the obesity debate is extended, unless we find better ways to talk across disciplines and think in different ways about fatness, concepts of the body and health, then communities may ultimately be ill-prepared to address current issues, much less future concerns which bring forth increasingly complex moral and ethical deliberations. In other words, weight-related issues cannot be removed from broader discussions which critics might currently or potentially become embroiled in, such as the ethics of enhancement, humanness, surgery, pharmaceuticals or the use of advanced technologies to alter the body. In this sense, the sort of moral discussions which obesity sceptics may be pressed to respond to may be even greater in future years. These may bring critical weight scholars into new territories of advanced debates such as those on the nature of humanness, changing concepts of the body, technology and health. Indeed, following Zylinska (2009), public debates about our human futures – debates that implicate everybody in liberal democracies and which cannot simply be left to credited experts – acquire particular salience. This, she elaborates, is in an age of new media where human relational subjects, as already enhanced, continue to co-evolve with technology and thus continue to expand the realm of bioethical concerns. To put this into context, and in drawing this chapter to a close, we highlight a number of what might be considered ‘cutting edge’ concerns that may in the future require prudent consideration. Perhaps most obviously, rapid developments in technology confront us with a series of questions about how we understand multi-dimensional bodies and the production of health knowledge and debates about obesity in late modernity. For example, the structures of health care and health knowledges are changing following the development of the medicalisation of cyberspace (Miah and Rich, 2008) and virtual environments. The possibilities for transforming health care through online environments are real. Although many of these possibilities are yet to be realised, they will pose new challenges and questions about medical care and how weight, and accompanying medical categories such as obesity, might be constructed and understood. Returning to the earlier point about not knowing what interventions and knowledges these may bring forth, it would be premature and reductive to assume that these technological advances will be either wholly liberating or oppressive. As such, this alludes to a broader point about the nature of critique where critical weight scholars may be required to engage with more precise questions.

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In other words, general objections which on one level call into question broader social body norms – that is, on the basis of practices being ‘sizist’ – may not be sufficient if critical weight scholars are to be recognised and heard in these complex moral and ethical debates. Indeed we might ask if the obesity debate is presently able to cope with addressing the questions that arise from the shift from ‘medicalization’ towards ‘biomedicalization’: Biomedicalization describes the increasingly complex, multisited, multidirectional processes of medicalization, both extended and reconstituted through the new social forms of highly technoscientific biomedicine. (Clarke et al., 2003: 161) As advancements in medical technology are applied to weight-related encounters, future debates about obesity may need to turn towards expanded theoretical frameworks such as posthumanism. Consider, for example, recent developments in nanotechnology that ‘promise’ innovative ways of altering eating patterns and thus the ‘treatment’ of obesity. How will critical weight scholars engage posthuman developments like these? As technoscientific advances are used to monitor and modify weight, this not only raises a number of questions about the social degradation of ‘excess’ weight, but implies a broader set of questions about how, why and when weight is to be treated in this way and for what purpose? Discussions about weight management may therefore intersect with wider concerns about the conceptual distinctions between therapy and forms of human enhancement (see Miah, 2008), a concern also passionately debated at a recent European Science Foundation conference on ‘the perfect body, normativity and consumerism’ (ESF, 2009). On the one hand, nanotechnologies may be applied to those who are considered to fall within weight-related disease categories and considered ill. This in itself is a complex discussion, as evidenced by the current debates about whether weight-loss surgery is considered to be ethical and safe. However, on the other hand, the potential use of nanotechnology as a commercial product in consumer culture could bring forth a minefield of even more complex and nuanced ethical discussion. What if, for example, new technology developed to treat obesity is commercialised as a means of weight control or preventative product for people not deemed overweight? In this sense, obesity debates may take us into broader bioethical discussions about the legitimate applications of


medicine. Future medical concerns may prompt critical weight scholars to become further involved in moral commentary on the boundaries of human intervention and the possible reproduction and amplification of social inequalities associated with, for example, gender. This is amidst other politicised concerns. For example, some feminists argue body studies should be ‘explicitly political’ but should also avoid ‘being moralistic or overly-political, thereby ignoring the aesthetic features of contemporary body practices’ (Davis, 1997: 15). Interventions, such as nanotechnology may currently seem more like provocative prospects in weight-related practices, hence their absence in any substantive form as chapters in this book. However, as noted above, the construction of obesity as a disease category, and not only an aesthetic concern (affront), has warranted its inclusion as a subject of hi-tech medicine. Indeed the application of biomedical technologies for enhancement purposes in relation to bodyweight might not seem such a remote prospect given that surgical weight-loss procedures are not only undertaken on those who are deemed to be in ill-health, but increasingly seen as a form of enhancement by those who may be, by medical standards, at a weight which presents no risks to their health. Here, one might also consider the relationship between obesity discourse and the current and future commercial character, safeguards and regulation of weight-loss products and services. This again relates to the politics, and political economy, of bodies and technologically fashioned bodily aesthetics. The cosmetic adaptation of bodily ‘excess’ already populates the media landscape, for example in surgical makeover shows that ‘moralise/amplify’ the obesity epidemic (Monaghan et al., 2010). We raise these concerns on the basis that they speak to broader problems that arise through the pursuit of health as a limitless category (see Rich and Evans, 2009) that is never fully achieved and which – like the body itself – is assumed can always be further perfected. This is an important issue given the ways in which the market is increasingly being brought into the sphere of health (Herrick, 2009), and the gendered aestheticisation of health. We refer the reader back to Tischner and Malson (Chapter 4). In their focus on experiences of the ‘large woman’ they reveal how closely obesity discourse and beauty discourses converge in the lives of women, encouraging the containment of female bodies in ways that are ripe for sophisticated feminist critique. Thus, how one comes to define ‘weight’ in medical terms and cultural terms will have a bearing on how it is received in ethical discussions about enhancement and therapy. Other commentators offer useful frameworks for engaging such issues. For instance, Miah (2008: 4) offers

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a typology comprising three categories to distinguish between enhancement and therapy in modifications. One of these is the alteration of traits of contested value, which would include interventions like cosmetic surgery. The contested status refers to the degree to which the value of the modification is relative, depending on one’s particular value system. This relative value implores critical weight scholars to reflect on the different moral regard they may have for individuals’ different reasons for ‘choosing’ medical(ised) interventions. As Miah (2008) observes, these debates are made more complicated when one considers that undertaking some forms of enhancement, which are grounded in the aesthetic, may yield developments in medicine that can help therapeutic cases. The basis for intervention might vary and there may be proper reasons for an individual who is morbidly obese to make what might be seen as a controversial decision to undergo surgical modifications. However, as Throsby (2009) observes of obesity surgery: Even at its most successful according to its own terms, leaves patients still dealing with physical effects of surgery, the moral judgements that attach so readily to those who undergo surgery, the physical and socially stigmatising consequences of weight-loss, and in many cases with bodies that are still viewed by others as problematically big, with all the moral judgements that that entails. This is not to discount that, for some people, electing for surgery has value: not only are these life changing procedures, but even the process of being accepted for weight management surgery may be a legitimating process where it is ‘experienced as recognition that they were suffering from a genuine medical problem whose direct management was beyond their control’ (Throsby, 2009). Medicalisation, as we mentioned above, is a double-edged sword and, in some instances, there may well be a ‘brighter side’ (Conrad and Schneider, 1992). Ethical debates about weight-loss surgery to alleviate serious ill-health are complex enough. However, when health care, consumer culture, medical grounds and cultural idea(l)s converge, the motivations and rationales for engaging with modifications may be even harder to discern. At this juncture we do not intend to get into a nuanced discussion on these matters. Rather, we point to this future developing landscape to reiterate the need for dialogue across groups not only from the biosciences, but also ethical, post-human, social theorists (and many other researchers and interested parties) if these debates are to be well informed. This will necessarily entail, inter alia, complex scrutiny of


claims made by various obesity epidemic entrepreneurs who have hitherto dominated the debate, including those espousing surgery and other technologies on medical grounds. In this sense, discussions surrounding human enhancement also require us to further complicate critique and debates about obesity. The literature has barely touched upon these issues. For instance, some categories of anti-obesity interventions or treatments might well be scrutinised and deemed to be oriented towards enhancing the body in some way to fit in with normalised medical ideas, rather than therapeutic ones. Consider the many women who employ various kinds of medical intervention for enhancement purposes; women, who may be ‘overweight’ by medical categories (e.g. BMI) but who do not experience illness, suffering or diminished quality of life. It is obviously the case that the associated risk of future ill-health could work here as a ‘legitimate’ justification for interventions. Chapter 5, by Evans and Colls, offers some useful insights into how obesity may be susceptible to demands of this nature insofar as it is constituted as a ‘virtual disease’ that may have no medical consequence, now, or in the future, for the individual defined as ‘obese’. In doing so, this focus on future projection and risk raises moral questions about the legitimate classification of otherwise healthy individuals as diseased. This question of legitimacy should, we would add, be underscored in obesity debates since the harm constituting symbolic violence is ‘in proportion to its legitimacy’ (Bourdieu, 2000; cited by Lovell, 2007: 71, emphasis in original). In Chapter 7, Cooper suggests it is this projection of future risk that implicates not only those who are currently overweight or obese by medical standards but those classified as ‘normal’. Hence, the principles of fat activism may appeal to a broader audience than those who identify as fat, including ‘wise’ contributors to the obesity debate (Monaghan and Hardey, Chapter 3). As far as the current debate goes, this implication of ‘normal’ weight-categorised bodies as ‘legitimate targets’ is not simply an imagined future scenario: risk-based pre-emptive action and policy is clearly evident in existing health promotion and anti-obesity initiatives. In Chapter 5, Evans and Colls reveal that ‘the focus on children and young people in obesity policy is motivated (in part) by the drive to identify those who are pre-symptomatic at the largest temporal gap possible’. Such temporalities allow assertions that children’s bodies are problematic in their capacity to shape the future. Consider, then, a parent who wishes to ensure their child is free from the putative future risks of obesity. Ideas of early intervention and foetal intervention already populate the media and medical landscape – are pre-emptive

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modifications (and even abortions of foetuses with a genetic predisposition towards obesity) a future reality (also, LeBesco, 2004)? Our point here is that there are different accounts for which one might raise concerns about anti-obesity interventions. At one level, some might call into question the (gendered) social body norms that legitimise such practices (for example, the notion of sizism as a vehicle of sexism), but these might not be persuasive reasons to prevent their application on the basis of cases where medical treatment is deemed ‘essential’. This is precisely why an expanded understanding might play a key role in informing future ethical debates about fatness, obesity and decisions concerning policy, intervention and ‘treatment’. For example, if discussion continues with the abstracted individual as evidenced in ‘traditional bioethics’ (Zylinska, 2009), the ways in which stakeholders understand different forms of suffering connected to fatness (e.g. psychological, social and physical stress) will remain limiting. Many children experience psychological or social trauma through the stigma of being bullied about their weight (see Evans et al., 2008). All too often, though, the response to this is to send a child to fat camp in order to work on themselves, to lose weight, take part in physical activity and in doing so, hopefully, rebuild their self-esteem. In other, more severe, cases this has warranted surgery where the health risks are deemed to be greater, or the removal of children from parental care and their placement into social care. Equally, for many adults labelled ‘obese’, often the assumed action is for the individual to diet, exercise or undergo some form of weight management procedure. In short, the onus of change resides with the individual and there are many entrepreneurs eager to administer this. But when and how can broader appeals be made to the societal, rather than individual, level of health (where the burden of responsibility for change falls onto the child or adult to ‘fit in’ with society)? In Chapter 2, Campos draws on recent evidence that highlights the risks of over-the-counter diet pills. His work and that of Aphramor and Gingras (Chapter 8) underlines the need to better understand the confounding variables, rather than merely assuming fat is the cause of disease and therefore promoting weight-loss as the appropriate ‘cure’. With this in mind, we want to reiterate that far from being antimedicine we do not discount the importance of medical procedures per se, including types of surgery undertaken on people carrying ‘excess’ fat (for whatever reason) and facing serious ill-health. Whilst we may have our own reservations about the ‘proper’ use of medical technologies, this is not an argument against their use per se, nor is it intended


to be a critique of ‘medicine’ per se. For example, Aphramor and Gingras (Chapter 8) remind us that current approaches to obesity have prevented due consideration of very fat people as a group with distinct medical requirements: research into appropriate anaesthetic use for very fat people is a notable gap (though there are recently revised practice guidelines in the United Kingdom (Reynolds, 2007)). What then do progressions in medicine and human enhancement mean vis-à-vis how we come to understand obesity, weight and fatness as embodied social categories? Can we make moral and ethical distinctions between not only medical interventions but the sort of policy-related interventions that now exist in settings such as schools and dietetics? Can the objects and objections of sceptics be made less speculative and more precise if we are to create a moral and ethical framework? Can we also attend to that which is unspoken and affective in the embodied life world (Walkerdine, 2009)? How would it be if the science on the macro-social determinants of health, so often sidelined in policy, was instead afforded proportionate consideration, with research directions and resource allocation changing to reflect this? This connects with our earlier point concerning aspirations for dialogue across disciplines and professions, and in a way that goes beyond, without leaving out, fleshy bodies. We have argued that it will be necessary to carefully conceptualise matters of surveillance, ethics, morality and regulation, and the functions they perform, within our own work as critical weight scholars. It is not enough to rely on criticisms of medical power and medicalisation. A more nuanced articulation of the precise objections arising from individual interventions will need to be balanced against broader social justice agendas. We forward this argument partly on the basis of the reactions we have encountered from different disciplines and professions when we have presented critique and offered alternative ways of thinking about bodies, weight and health. Unfortunately, these alternative frameworks are often automatically dismissed on various grounds; that they are not scientifically valid; not all people will find the same value or benefit in every intervention. For one of us, perhaps the worst response from an established figure working in the context of children’s health and obesity was: ‘it may be the unfortunate case that one or two individuals may die from anorexia, but obesity is an epidemic which requires urgent action’. In ongoing and future discussions, arguing against obesity discourse, on the grounds of its broader basis of being regulative and stigmatising, may have limited utility if particular distinctions are not pursued. For instance, calling for an end to the construction of obesity as a

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problem may make no sense to medics who are treating patients who are morbidly obese and seriously ill, immobile or facing life threatening conditions. For some patients, this may after all be seen as a ‘potential life transformation’ (Throsby, 2009). In such cases, the disavowal of surgery or problematic forms of intervention seems unlikely to take place on grounds of moral objection related to sizism. However, to make a case against the pursuit of obesity as a priority health concern for all, or to argue against its construction as an epidemic is an entirely different critique and one which concerns many authors in this book. These points bring us to one of the main conclusions for this text. For many contributors, it is the slippage from the particular (i.e. cases where ‘excess’ body fat may threaten an individual’s health, as with extreme cases of morbid obesity) to the general (where all are deemed susceptible to risk) that raises concerns. Certainly, this might not imply that there are no grounds at all for particular medical interventions or policies related to weight management. As similarly expressed by Robertson and Williams (2010) in a different context, those medicalised interventions critiqued by social scientists as forms of governmentality and surveillance cannot always ‘be ruled out per se as having no value, or even as being “health damaging” ’ though ‘the bigger issue’ concerns whether such practices are most effective, under which circumstances and for which people, ‘and whether there are more effective approaches that could be taken, such as the reduction of poverty’ (p. 62) or, we would add, reducing income inequality (also, Lynch, 2010; Wilkinson and Pickett, 2009). Yet, rationales for investment into individualised interventions to tackle obesity are hegemonic amidst moralised ideas about future bodily risk, which is imagined to be personally manageable or avoidable in light of expert knowledge. After all, as argued in contemporary social theory, we inhabit societies that are highly sensitive to risk (Beck, 1992) and wherein ‘major political and personal problems are both problematized in the body and expressed through it’ (Turner, 1996: 1). Correspondingly, and to ground these abstract points, the type of ethical discussion advanced by critical weight scholars may inform how we read campaigns such as the UK NHS Change4Life, targeted at children. It states that due to ‘modern life’ 9 out of 10 kids today could grow up with dangerous amounts of fat in their bodies. This can cause life-threatening diseases like cancer, type 2 diabetes and heart disease – so it’s really important that we do something about it. (Change4Life, 2010)


There is little doubt that many individuals experiencing these conditions will likely require and welcome medical intervention. It would be difficult to argue against the problems typically associated with obesity in such cases. However, authoritatively and alarmingly claiming nine out of ten children may experience life threatening conditions, caused by fatness, reductively frames the issue in a highly problematic way and begs very different kinds of questions and interventions. Critical scholars have thus raised concerns about current initiatives and policies that target those who might not experience suffering now, but who are the subject of such pre-emptive policies on the basis of projected future risk. In fact, following intervention by some contributors to this volume, it was recommended that some of the wording of the Change4Life campaign be altered to better reflect the actual degree of scientific uncertainty in extrapolated claims of risk. Finally, if we are to move beyond (un)intentionally recriminatory approaches, we need to not only develop more sociologically imaginative dialogue across disciplines and professions, but also consider a more diverse range of perspectives as to what constitutes ‘health’ – itself an enigmatic construct (see, for example, Quennerstedt, 2008). To achieve this end, we will need to think differently about what the embodiment of ‘health’ might entail rather than ultimately holding individuals accountable for their weight and for the consequences and outcomes of particular health circumstances. Doing so means finding more nuanced and politicised understandings of health and health care that are rendered meaningful across socio-economic, cultural, gendered, classed and ethnic contexts. Such understandings deserve their own specificity rather than being conflated into standardised, or ‘McDonaldized’ (Ritzer, 2004), approaches that currently hold sway in the obesity epidemic terrain. They may also need new vocabularies that capture alternative narratives. For example, consider a qualitative study of body image concerns among African American and Latina college women: participants’ orientation was towards a body ethics encompassing values of self-valuation and self-nurture, and away from dominant body aesthetic ideals described by Euro-American women, involving discipline and restraint (Rubin et al., 2003). The authors point out that understanding embodiment from the standpoint of body ethics, rather than body aesthetics, may prove a more useful and relevant approach to study in the field. It is in listening differently that such re-framings can emerge, and, this underscores the need to recognise, rather than misrecognise or dismiss, the contribution of critical weight studies and other contributions emerging from and allied to the social sciences. In challenging common

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body narratives, recycled obesity discourse and associated practices or pedagogies, it may be anticipated that such studies will have increasing relevance. This, we would stress, is in a larger society where individuals often feel responsible or accountable for the potentially ‘biographically disruptive’ (Bury, 1982) ills which, regardless of weight, all people might very well experience as they grow, age and deteriorate as mortal, flesh and blood bodies. As such, the relevance of critical weight studies is expansive and, we would maintain, should be expanded beyond reductionist, essentialising and limited debates about obesity and ‘fat people’ who supposedly neglect themselves and burden society more generally. In that respect, what we call ‘critical weight studies’ has relevance as an explicitly politicised, theoretically informed and empirically grounded project that seeks critically to incorporate everybody in sickness and in health in these ‘epidemic’ times.

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Index

Note: In this index notes are indicated by n. Aas, K. F., 140, 147 Abbasi, K., 126 abuse, child, 21 see also neglect, and fat children; children, removal from parents Acheson, Sir, D., 221 Acker, K., 165 activism critique of, 185–6 defined, 166–7 and obesity discourse, 186 politically aware, 174 post-structuralist/post-modern, 183–5 threads/themes of, 175–85 activists, 165–8 activity, health benefits of, 44–5 see also fitness, and health/weight; exercise, and women adult ill health, and childhood obesity, 128–32 Aerobic Center Longitudinal Study, 44 aerobic fitness, and health/weight, 44 Almeling, R., 4, 37, 225 always-already gendered bodies, 236 Anderson, B., 43, 132 Annandale, E., 12 Anon., 197, 229 anti-discrimination legislation, 179 anti-fat prejudice, 170 Aphramor, L., 1–28, 61, 66, 82–3, 111, 116, 167, 176, 192–213, 219–54 appearance, women’s, 97–9, 108 Ardern, C. I., 61 Armstrong, D., 11–12, 68, 129, 139–40, 143, 147–8, 151, 231 Arthurs, J., 99 Association for the Health Enrichment of Large People (AHELP), 179 Atkins, J., 64

Atkinson, M., 67 at-risk register, fat children, 21 Austin, S. B., 60, 168 Bacon, L., 3, 5, 15, 83, 176, 192, 198, 201–2, 207, 221, 227 Bakhtin, M., 63 Ball, K., 149, 158–9 Ballard, K., 244 Banting, W., 64, 66 Barlow, C. E., 44 Barthel, D., 66 Bartky, S. L., 96, 99 Basham, P., 64, 77–9 Battle Horgen, K., 167 Beausoleil, N., 23–4 beauty discourse, 247 beauty, and health, 99 Beck, U., 13, 252 Beckett, L., 24, 142 Behavioral Risk Factor Surveillance System, 44 Bell, K., 61, 91 Bendelow, G., 21, 23, 183 beneficence, 196 Bennett, W., 47 Berger, P., 82, 242 Bernstein, B., 156 Big Fat Blog, 182–3 Big Fat Lies, 242 Big Moves, 181 Big Pharma, 239 biomedicalization, 246 biomedical technologies, 247 Biopolitics and the ‘Obesity Epidemic’, 225 Bishop, J., 195, 197 Blair, S. N., 44, 52, 199 blogs, and fat activism, 182 Blood, S., 99

259

260

Index

BMI, 37, 54–5n., 61, 116, 130, 231 bodies always-already gendered, 236 children’s, 249 commodification of, 18 female/uncontrolled, 91–2, 110 as information, 140 men’s, 61–7 bodily aesthetics, 69–70, 247, 253 and the prejudiced, 75–8 and the proud, 73–5 reinventing/amplifying, 63–7 and the stigmatised, 78–80 Western culture, 85 and the wise, 80–3 bodily sensibility, 72 typology of, 72 body data, 140 body ethics, 253 body image, and health, 66 Body Image Taskforce, 179 body pedagogy, 24 body project, 98, 110 body size, gendering dynamics of, 100–3 body work, 93 Boero, N., 116, 122 Bordo, S., 23, 63, 79, 81, 91–2, 96, 99–101, 105–6, 176, 194 Bornstein, K., 184 Bourdieu, P., 20, 62, 70, 223, 249 Bovey, S., 178 Braidotti, P., 157 Braziel, J. E., 90 Brissett, D., 2 British Association of Cardiac Rehabilitation (BACR), 203 British Dietetic Association, 196, 197, 198–9 Brittingham, K., 184 Brooks, L., 178 Brown, L., 7, 20 Brown, L. S., 176 Brownell, K. D., 43, 167 Bruch, H., 170 Brunner, E., 206 Bruno, F., 14, 116, 132–3 bullying, of fat children, 124 Burgard, D., 177

burnout, and dietitians, 209 Burns, M., 5, 23–4, 90 Burroughs, W. S., 165 Burrows, L., 24, 142 Burt, V., 170 Bury, M., 254 Butler, J., 91 Bywaters, P., 228–9 Campbell, I., 64 Campos, P., 3, 5, 18, 21, 25, 36–55, 64, 77, 80, 82, 90, 121–2, 127–8, 176, 196, 203, 227, 232–3, 243, 250 Carmona, R., 2, 65 Chandola, T., 207 Change4Life, 144, 186, 252–3 CHD and diet, 199, 201 and weight/BMI, 195–6 Cheney, K. E., 120–1 Chernin, K., 92, 167 childhood and criminal psychiatry, 131 obesity, 115, 131–2 and Western cultures, 130–1 children and anti-obesity policy, 115–16, 249–50 bullying of fat, 124 geographies of obesity, 118–21 mapping of bodies, 145–52 and obesity, 115, 131–2 removal from parents, 140, 147, 229, see also abuse, child; neglect, and fat children size discrimination of, 21 surveillance of, 128, 139–45, 150, 152–9, 160 Children’s Geographies, 120 Choosing Health: Making Healthy Choices Easier, 66 Chubsters, The, 184–5, 237 Church, T. S., 199 civil rights, for fat people, 170 Clare, A., 67 Clarke, A. E., 246 Cliff, K., 24 Coalition of Fat Rights Activists, 182

Index Code of Professional Conduct, dietetic profession, 198–9 Cogan, J. C., 5 Cohen, L., 5, 81, 83, 85 Cohen, S., 2 Colls, R., 5, 9, 14–15, 17, 26, 65, 82, 115–34, 144, 222, 229, 232–4, 249 commodification of health, 85 communicated violence, 20 community, and fat activism, 178–9 community-building, and exercise, 177 Connell, R. W., 63, 70–1, 84, 91 Conrad, P., 232, 248 constructions of childhood, 119–20, 121 of female bodies, 101–2 of obesity, 124 of obesity epidemic, 121–2 social, of fatness, 19–24 of women’s appearance, 97–9 consumer responsibility, 66 Cooper, C., 3, 6–7, 10, 71, 82, 107, 164–86, 193, 221, 230, 233, 236–7, 243, 249 Cooper, R. S., 3, 6–7, 10 Corporate Social Responsibility initiatives, 13 corporeal realist epistemology, 22 Council on Size and Weight Discrimination, 179 Cowden, S., 212 Crawford, R., 11–12, 61, 65, 90, 220, 244 Crawley, S. L., 101, 103 Crawshaw, P., 62, 76, 226 Crespo, C. J., 44 criminal justice policy, 131 Critical Obesity Research, 28n. critical weight studies, 23–4, 225, 230, 254 Crossley, N., 223 Cuff, E. C., 233 cyberspace, medicalisation of, 245 data trimming, 52–3 data, use of, 147 Davey Smith, G., 15, 17, 205–6, 225 Davidoff, F., 208

Davis, K., 18, 247 defensive medicine, 15 Degher, D., 80 Deleuze, G., 143, 155 De Pian, L., 21, 26, 139–60, 233–4 deviants, fat men as, 62 Devine, C. M., 209–10 diabetes, type 2, 45 Diaz, V. A., 43, 48 Dickenson, J., 202 Dietbreakers, 176 diet drugs, 48 see also diet pills; Redux dietetic professionals, 192 and ethics, 195–200 need for change, 210–13 and shame, 207–12 sizism in, 194, 198, 200, 202–4 dietetics, 192–3 diet industry, 67 dieting adverse impact of, 43 and weight gain, 47 diet pills, 43, 250–1 see also diet drugs; Redux diets, women’s, 103–7 Dijck, J., 144 discourse analysis, 94, 96 beauty/health, 99 obesity, see obesity discourse discrimination of children, 21 and health, 46 discriminatory practices, 20 discursive psychology (DP), 94 Ditto, Beth, 181 diversity, 230 drugs, diet, 48 see also diet pills; Redux DuPois, M., 193 DuPuis, M., 119, 134 Durazo-Arvizu, R. A., 40 Easthope, G., 11, 13–14, 18 eating female, 105–6, 110 and power, 106–7 Ebrahim, S., 15, 225

261

262

Index

Edgley, C., 2 Edison, L. T., 182 Edward, K-L., 211–12 effectiveness of surveillance, 252 of weight-loss, 197 Ellert, U., 195 Elliot, Mama Cass, 174 Elston, M., 244 embodied sociology, 22 embodiment children, 129 gendered, 22 normative male, 61, 84 empowerment, of women’s fat, 107–9, 110 enhancement, human, 246, 248, 249 entrepreneurship, 78, 239 environment, and bodyweight, 222 environments, obesogenic, 118 ephedra, 43, 48 epidemiology, 38, 54n. and obesity discourse, 14, 15 Ericson, R. V., 143, 145, 147–8, 152, 154–5, 159–60 Ernsberger, P., 176 ethics body, 253 and nutrition professionals, 195–200 and obesity, 245, 246 European Science Foundation, 246 Evans, B., 5, 115–34 Evans, J., 2, 4–5, 8–9, 12–13, 21, 23–4, 64–5, 82, 104, 139–60, 167, 204–5, 222, 224, 226, 229, 232–4, 244, 247, 249–50 Evans, S., 204–5 Evans (shops), 180 Evans Young, M., 176 Everett, B., 167 Evers, K. E., 153 evidence-based medicine (EBM), dietetics, 204–5 evidence, weight loss and health, 227 exercise, and women, 177 Fabrey, W. J., 169–72 Farnham, M., 175

Farrell, S. W., 44 fashion, and fat activism, 179–81 fat activism, 230–1 and fashion, 179–81 and feminism, 172–3 history of, 168–75 fat activists, 71, 165–8 Fat And Fit Group Health Action, 177 fat bastard, 60, 69, 71, 84 fat bodies, 62 normalising of, 111 Fat Bottom Revue, 181 ‘Fat’ Female Body, The, 92 Fat Femme Mafia, 181 Fat Girl Flea, 180–1 Fat Girl Speaks, 181 fat hatred, 167 Fat-In, 168–9 Fat Is A Feminist Issue, 176 Fat Is Contagious: How Sitting Next to a Fat Person Can make YOU Fat, 184 Fat Lip Reader’s Theatre, 181 fat man category, 71 fat maps, 118, 151–2 fatness as lifestyle disease, 12–13 social construction of, 19–24 visual impact of, 70 Fat News, 178 fatphobia, 194–5 Fat Power, 169–71, 185 Fatshionista, 180 Fat!So?, 186 Fat Studies, see Critical Obesity Research Fat Stuff, 184 Fat Underground, 171, 172–4 Fat Women Here to Stay, 175 Fat Women’s Group, 178 fat-zine culture, 182 fear, generating, 123 femininity, 91, 92, 100–2, 110 feminism, and fat activism, 172–3 feminist perspective, fatness, 22–3 fen-phen, 48 fidelity, 197, 199 Field, A. E., 55 Fishman, S. G. B., 173–4

Index fitness, and health/weight, 44, 199, 240 Flegal, K. M., 39–42, 49–51, 54 food choices, children/monitoring, 146 food industry, 67 Foresight programme, 196 Foucauldian Discourse Analysis (FDA), 94–5 Foucault, M., 93–6, 109, 117, 122, 124–5, 130–2, 202, 228–9, 233 Framingham study, 43, 52 Frank, A., 61 Freespirit, J., 172–3 Freire, P., 172 French, Dawn, 181 French, S. A., 48 Freund, P., 21, 206 Frith, H., 91 Fullagar, S., 12 Gaesser, G., 5, 7, 41–2, 83, 242 Gagen, E., 120, 128 Galea, S., 225 Gard, M., 3–5, 19–20, 76–7, 116, 121–2, 124, 127, 132, 175, 232, 238, 241, 243 Garfinkel, H., 70, 222 Garner, D. M., 47 Gavey, N., 5, 24, 90 gender and body size, 100–3 and healthism, 93–4 inequalities, 16 and power, 91 gendered embodiment, 22 gendered messages, and weight-loss, 24 Gentry, W. D., 13 geographers and fatness research, 222 geographies, childhood/obesity, 118–21 Gergen, K. J., 94 Giddens, A., 70, 84 Gill, R., 91, 99 Gingras, J., 5, 9, 16, 27, 61, 83, 111, 167, 192–213, 225, 227, 233–4, 240, 250–1

263

GirlFrenzy, 182 Glassner, B., 66 Gleeson, K., 91 Goffman, E., 25, 61, 71, 73–4, 76, 80, 82, 108, 178, 236 Goldmember, 60 Goldstein, J., 204 Goode, E., 165 governance, social, 140 Grace, C., 196 Graham, H., 205 Graham, R. H., 243 Gray, G. E., 202 Gray, L. K., 202 Great Shape, 177 Green, J., 7, 221, 226 Green, S., 159 Greenwald, M., 7, 20 Gregg, E. W., 48 Gregg, J., 62, 65, 81, 83, 85 Grimshaw, J., 99 Grosz, E., 118, 144, 149, 157, 160 Grosz, E. A., 91–2, 96, 101 grotesque discourse, 125 Guattari, F., 143, 155 Guerrini, A., 64 Gugliotta, G., 48 guidelines, dietetic, 196 Gurin, J., 47 Gussow, J. D., 207 Guthman, J., 119, 134, 193 Haddon, G. P., 177 Haggerty, K. D., 143, 145, 147–8, 152, 154–5, 159–60, 233 Hahn, R. A., 44 Hale, B., 13 Hale, L., 13 Hall, J. R., 184 Halse, C., 12, 151, 236 Hamm, P., 43 Hanna, K., 183 Hansen, E., 11, 13–14, 18 Haraway, D., 154 Harburg, E., 13 Hardey, M., 3, 60–86, 93, 123, 158, 210, 226, 230, 233–5, 249 Harding, K., 172 Harrison, P., 129

264

Index

Harvey, J., 20, 229 Harwood, V., 2, 141–2 Haskew, P., 176 Haslam, D., 64 Hawkley, L. C., 207 Hayles, N. K., 154, 157 health and beauty, 99 benefits, of physical activity, 44–5 and body image, 66 causes of poor, 18 discourses, and media, 144 embodiment of, 253 and fat activism, 175–6, 177 as individual responsibility, 11–12, 14, 16, 18, 76, 124, 250 risk, see risk and social discrimination, 46 and weight loss, 46–54 Health At Every Size (HAES), 83, 155–6, 176, 177–8, 200–2 healthcare, emotions of, 219 health education, school based, 143 Health in Every Respect, 83, 204–7, 240 healthism, 12, 65–6, 93–4 healthy eating, and CHD, 201 Healthy Weight Journal, 179 Healthy Weight Network, 179 Hellmich, N., 40 Henderson, M., 21 Henwood, F., 16 Herman, P., 176 Herndon, M., 5 Herrick, C., 5, 13–14, 18, 119, 122, 221, 224–5, 229, 239, 247 Herzig, R. M., 244 Hochberg, M. C., 43 Hollands, R., 86 Holloway, S. L., 119, 129 Hollway, W., 95 Holm, S., 196 Hooper, L., 195, 200 Hörschelmann, K., 120 Horton, J., 116, 120, 129 Houston, C., 210 Howes, D., 68 Hughes, G., 80 Hughes, K., 66

HUGS Programme, 176 human enhancement, 246, 248, 249 Hutchby, I., 159 Hyde, A., 184 identification processes, 79 identities masculine, 93 sexed/gendered, 91 identity work, gendered, 61 Ikeda, J., 192, 197, 212 ill health, and risk factors, 132 see also risk inequalities and fatness/health, 193, 231, 252 gender, 16 health, 206 and obesity, 17, 20 social, 17, 18–19 in structural power, 179 information, bodies as, 140 insecurity, ontological, 120 International Size Acceptance Association, 178 internet and fat activism, 182 and health-related information, 16–17, 245 medicalized cyberspace, 152–3 Iribarren, C., 43 Jacqui, G., 9, 27, 192 Jain, A., 197 JAMA studies, 51–2 James, A., 120 Jeffery, R., 240 Jeffery, R. W., 37 Jenkins, T., 175 Joanisse, L., 194, 243 job satisfaction, and dietitians, 209 Jones, J., 174 Journal of the American Medical Association, 39, 50 justice principle of, 199–200 social, 227–33 Jutel, A., 3, 5, 107 Kaloski Naylor, A., 6, 9, 28, 183 Katz, C., 116, 120

Index Kawachi, I., 206 Kearns, R., 116 Keith, S., 79 Keith, S. W., 107, 231 Kennedy, B., 206 Kennedy, B. P., 206 Kernan, W., 43 Kirk, S. L., 209 Kirkland, A., 185, 199–200 Kleffel, D., 207 knowledge, health, 222–7 virtual environments, 245 Knowler, C., 204, 206 Kolata, G., 176 Korkeila, M., 47 Kraftl, P., 116, 120, 129 Krieger, N., 17, 19, 205–6, 219 Kurth, B-M., 195 Kwan, S., 66 LaBonté, R., 7, 221, 226 Lake, Ricki, 181–2 Lamarche, B., 45 Land, J., 168 Largesse, 174 Lau, D. C. W., 203 Lawrence, M., 92 Lawrence, R. G., 11 Leahy, D., 21, 24, 143 LeBesco, K., 5, 10, 90, 172, 180, 236, 250 Lee, C. D., 44 Lee, N., 129 Lee, N. J., 182 legislation, anti-discrimination, 179 Lewis, M., 147 Liebman, B., 49 life-chances, 229 lifestyle, 18 lifestyle disease, fatness as, 12–13 lifestyles, and social structures, 45–6 Lipsedge, M., 193–4 Lissner, L., 43 Littlewood, R., 193–4 Living Large, 182 lobbying, and fat activism, 179 Local Government Association, 20–1 London Fat Women’s Group, 175 Longhurst, R., 60, 73, 222

265

Lorde, A., 208 Louderback, L., 169–71, 179, 185–6 Lovell, T., 223–4, 227–8, 230, 238, 249 Lupton, D., 4, 12, 16, 65, 78, 90, 103, 106 Lutwak, L., 243 Lynch, K., 228, 235, 252 Lyon, D., 139–40, 150 Lyons, Pat, 177 Making Waves, 177 Makino, M., 48 Malins, P., 147–8, 151–2, 156 Malson, H., 90–111, 233, 236–7, 247 Mama Cass Elliot, 174 Mann, T., 197, 204, 227 mapping, children’s bodies, 145–52 maps, fat, 118, 151–2 Marchessault, G., 177 Markula, P., 99 Marmot, M., 15, 83, 85, 206–7, 221 Marsh, P., 62 Marshall, B. L., 239 masculine identity, 62, 93 masculinity, and health advice, 84 Maurer, D., 168 Mayall, B., 121, 129 Mayer, V., 206 McAfee, Lynn, 179 McAleer, Paul, 182–3 McClean, S., 235 McKeith, G., 167 McMaster, J., 63 McNaughton, D., 61, 91 McPhail, D., 64, 119 Mead, A., 196, 199, 201 media and fat activism, 182–3 and fat people, 62, 170 and health discourses, 144, 225, 247 medical discourses, 93 medicalisation and dieting, 104 of obesity, 2, 11–19 Medicalization of Cyberspace, 17 medicalized cyberspace, 152–3 medicine, militarised, 22

266

Index

men, bodies of, 61–3 men, fat, 60 Merton, R. K., 223, 238, 240 metabolic risk, 192, 193 Metzl, J. M., 244 Miah, A., 4, 9, 17, 122, 140, 144, 152–5, 226, 245–8 militarised medicine, 22 militarised metaphors, 104 Miller, W., 5, 201 Mills, C. W., 8, 103, 220 Mitchell, A., 230 Mokdad, A. H., 46 Monaghan, L. F., 1–28, 60–86, 90–1, 93, 99, 104–5, 107, 111, 123, 125–8, 134, 158, 194, 204, 207, 210, 219–54 Monahan, T., 150 Moon, G., 116, 118 Moore, S. E., 16 Moore, V., 228 morality, and obesity, 2, 240, 241 morbidity/mortality, and social status, 15 More People Should Be Fat, 169–70 Morgan, D., 91 Morgan, J. F., 195 mortality, and weight loss, 48 mortality risk, and weight, 39–42 Moynihan, R., 226 Muhr, T., 69 Murphy, H. C., 195 Murray, S., 23, 63–6, 70, 76, 85, 90, 92, 97, 107, 166, 178, 182, 185–6, 223, 236–7 NAAFA, 171–2 Nakanishi, N., 55 nanotechnology, 246 Nash, J., 183 Nast, H. J., 118 National Child Measuring Programme, 142, 145–52 National Child Monitoring Programme (NCMP), 126–31 National Health and Nutrition Examination Survey (NHANES), 40

National Health Interview Survey, 47–8 National Screening Committee (NSC), 127–8, 129–30 National Size Acceptance Network (SIZE), 178 Neel, J. V., 45 Neitz, M. J., 45 neglect, and fat children, 21, 152 neo-liberalism, 93 Nettleton, S., 16–17 Neumark-Sztainer, D., 24 New Haven Fat Liberation Front, 174 new health paradigm, 16 new public health paradigm, 16 New Social Studies of Childhood (NSSC), 119 Nicolson, P., 102 NOLOSE, 180–1 nonmaleficence, 196 normative male embodiment, 61, 84 Notkin, D., 182 Nowotny, H., 132–3 nutrition professionals, see dietetic professionals obesity agenda/commercial interests, 85 crusaders, 78 crisis, see obesity crisis defining, 37 discourse, see obesity discourse epidemic, see obesity epidemic term, 81, 192 time bomb, 115 truths/lies, 121–6 as virtual disease, 15, 132–3, 249 obesity crisis construction of, 2 and men’s fatness, 61 see also obesity obesity discourse, 4, 6–7, 64 and beauty discourse, 247 challenges to, 174 and fat activism, 186 as grotesque discourse, 125–6 negative effects of, 23–4, 90, 167–8 resistance to, 156–9, 236–7 see also obesity

Index obesity epidemic, 3, 123 constructions of, 19, 252 entrepreneurship, 14, 78, 239 medicalised understandings of, 11–19 see also obesity obesogenic construction, of fat, 185 obesogenic environments, 118, 232 observational medical studies, 38 O’Connell, C., 199 O’Dea, J., 24, 227 Ogden, J., 176 O’Hara, L., 62, 65, 81, 83, 85 Oliver, E., 5, 224, 226 Oliver, M., 179 Olson, M. B., 201 online resourses, and fat activism, 182–3 oppression, 20, 172, 173, 181, 193–4, 229 Orbach, S., 22, 90, 92, 102, 104, 176 osteoarthritis, 42–3 ÓTuathail, G., 123 overweight, defining, 37 Padded Lillies, 181 Paffenbarger, R. S. Jr., 44 Pamuk, E. R., 48 Papadopoulos, D., 95 parents, with fat children, 20–1 Parker, I., 95 Parr, H., 118 Passeron, J. C., 20 patriarchal society, women in, 101, 109–10 Payne, G. C. F., 233 Pearce, N., 13, 28 performance, and fat activism, 181–2 Perhamus, L., 155 Petersen, A., 4, 12, 16, 78 phenylpropanoloamine, 43–4 see also diet drugs; diet pills physical activity, health benefits of, 44–5 see also fitness, and health/weight; exercise, and women Piasecki, Amanda, 180 Pickett, K., 18, 252

267

Pieterman, R., 23, 227 Pile, S., 118 pills, diet, 43, 250–1 see also diet drugs; Redux Plsek, P. E., 211 plus-size clothes, 179–80 policy anti-obesity, 134n., 253 anti-obesity/children, 115–16, 132, 133 anti-obesity/sin, 123 criminal justice, 131 politics of bodies, 247 fat, 178 Polivy, J., 176 post-modern fat activism, 183–5 Post, Steve, 168–9 post-structuralism, 95 and fat activism, 183–5 Potter, J., 94 poverty, 252 power and eating, 106–7 and gender, 91 and monitoring, 146 of normalization, 124 power structures, and obesity discourse, 167 Preissler, J., 165 prejudice, dietetic professionals, 192–3 prejudiced, the, 75–8 Pretty Big, 180 Pretty, Porky and Pissed Off, 181 prevention programmes, industry-led, 18 Pritchard, G., 86 Probyn, E., 91, 223 Professional Beauty Qualification, 92 proud, the, 73–5 psychological effects, of measurement, 128 public health interventions, basis of, 36 public health policy, 36–7, 65 public health promotion, 14 Purtilo, R., 197, 199 Putnam, S., 225

268

Index

Quennerstedt, M., 253 Radiance, 182 Redux, 48, 242 see also diet drugs; diet pills Reidpath, D., 22, 168 Relly, J. E., 173 research, obesity, 5 and fat activism, 176 issues in, 52–3 resistance, to obesity discourse, 156–9, 236–7 resources, public health, 37 respect for persons, 229–30 responsibility consumer, 66 individual, 11–12, 14, 16, 18, 76, 124, 250 Reynolds, T., 193, 251 Rich, E., 1–28, 122, 139–60, 219–54 rights of children, 134 for fat people, 170, 171, 200 Riley, K., 3 Riley, S. C. E., 23 risk, 54n. metabolic, 192, 193 projection of future, 249, 253 of underweight, 40, 41 and weight, 37–42, 42–6 of weight-loss, 198 risk factor data, 15 risk factors, and ill health, 132 Ritzer, G., 17, 253 Roberts, N., 176 Robertson, S., 7, 62, 67–8, 83, 85, 229, 237, 252 Robison, J., 83, 176, 186, 198 Rodin, J., 43 Rogers, W. A., 16, 152, 205, 208 Rogge, M., 7, 20 role conflict/ambiguity, dietitians, 209 Rose, N., 93, 99, 103, 239 Ross, B., 127–8 Ross, H., 210 Roth, G., 176 Rothblum, E., 7, 20, 176, 183

Rubin, L., 253 Ruddick, S., 116–17, 121, 124–5, 130–3 Saguy, A., 3–4, 37, 225 Said, E., 213 Scambler, G., 3, 11–12, 15, 22, 73, 228, 232, 240, 242–3 Schauss, A., 61 Schechner, R., 181 Schneider, J., 232, 248 Schoenfielder, L., 165, 168, 174, 178 school based health education, 143 schools, surveillance in, 146 Schuftan, C., 205 Schwarz, H., 176 science and fat activism, 175–6 obesity, 5 Scott-Jones, Karen, 174 screening programme, obesity, 127 see also National Child Measuring Programme; National Child Monitoring Programme (NCMP) sedentary lifestyle, health risks of, 44 Seibert, D. C., 209 Seid, P. R., 23 self-control, women’s lack of, 109–10 Serdula, M. K., 47 Shadow On a Tightrope, 174, 175, 178 Shakespeare, T., 74, 179 shame and dietetic profession, 207–12 of patients, 241 Shaw, A., 235 Sherman, J., 21, 152 Shilling, C., 22, 62, 67, 98, 157, 159, 220, 235 Shipley, A., 48 Simmons, R., 167 sin, Christian notions of, 123 Sinker, D., 165 size and empowerment, 108–9 gendering dynamics of, 100–3 size acceptance movement, 178 size discrimination, of children, 21

Index size-oppression, 193–4 see also oppression SIZE: The National Size Acceptance Network, 178 sizism, 3, 194 and dietetic profession, 198, 200, 202–4 Skelton, T., 120 Smith, A. M., 223, 225, 227–8, 230, 239 Smith, D. E., 91, 95, 99, 102 Smith, S., 3 Sobal, J., 12, 63, 167–8 social action, 238 social constructions of fatness, 19–24 stereotypes as, 70 social discrimination, and health, 46 social governance, 140 social identities, 71 Social Model, 179 social networking websites, and fat activism, 182 social status, and morbidity/ mortality, 15 social structures and obesity discourse, 167 role of, 17, 18, 206 socio-economic status, 231 see also inequalities sociology of the body, 22 sociotechnical feedback, 150 Solovay, S., 179, 183, 186, 222 somatic society, 62 somatic surveillance, 150 spending, public health, 37 Spieglman, D., 55 Spoel, P., 16 sport, and women, 177 Sprang, G., 209–10 Spurlock, M., 167 Squires, S., 49 statistics, and weight/health, 38 Stearns, P. N., 111 Stephen, A., 210 stereotypes, male, 70, 71 Stevens, J., 49

269

stigma and fat children, 124 and fat men, 62, 84, 85 and gender, 22 of obesity, 2–3, 232 social, 193–4 stigmatised, the, 78–80 Stimson, Karen, 174 Stinson, S., 182 Strathern, M., 193 Strong, P., 1, 90, 220 Stunkard, A., 170 Sundén, J., 236 surgery, obesity, 247, 248 surgical weight management clinics, 241 surveillance of children, 128, 139–45, 150, 152–9, 160 effectiveness of, 252 instruments, 142, 145 medicine, 139–40, 151 surveillant obesity assemblage, 93 resistance/mediation in, 155–9 Swarc, S., 176 symbolic violence, 20 Synnott, A., 68, 197, 243 tacit body knowledges, 223 technologies of the self, 93 technology, and collecting data on children, 141, 152 thinness, social construction of, 23 Thomas, B., 195, 197 Throsby, K., 12, 90, 239, 241, 248, 252 Tischner, I., 90–111, 233, 236–7, 247 tolbutamide, 208 see also diet drugs; diet pills Tomrley, C., 6, 9, 28, 183 traits of contested value, 248 Trautner, M., 66 Troiano, R. P., 41 Tuomilehto, J., 45 Turner, B., 62, 69, 252 type 2 diabetes, 45 ugliness, 22 underweight, risks of, 40, 41

270

Index

University Group Diabetes Program (UGDP), 208 University of Texas, 44 Ussher, J. M., 99, 101 Valentine, G., 119, 129 value, traits of contested, 248 valuing of people, 230 Van der Ploeg, I., 140, 155 Van Gaal, L. F., 203 Vaz, P., 14, 116, 132–3 veracity, 197, 199 victim blaming, 206 violence, symbolic/communicated, 20 virtual disease, obesity as, 15, 132–3, 249 virtual environments, and health knowledge, 245 see also internet visibility, women’s large bodies, 109 Wahlberg, D., 52 Walker, S., 43 Walkerdine, V., 8, 224–5, 234–5, 240, 251 Wall, T., 54, 150 Wann, M., 71, 185 Wardlaw, M. K., 201 Warelow, P., 211 Warin, M., 5 Warne, D. K., 55 war on fat/obesity, 22, 36 Watson, J., 22, 61, 70–1, 84 weight and CHD, 195–6 and health risk, 37–42, 42–6 and mortality risk, 39–42 as public issue, 65 weight cycling, 43, 197, 201 weight gain, and dieting, 47 weight-loss ethics of, 195–200 and health, 46–54 and mortality, 48 risks of, 198 treatments/outcomes of, 43, 196–7

well-being, 4, 15, 19, 26, 65, 90, 111, 115–8, 128–30, 132–4, 176, 200, 206, 227, 238–41 Wernick, A., 62 White, R., 193 Wienpahl, J., 55 Wieser, B., 168, 174, 178 Wiggins, S., 94 Wii fit, 141, 153–4 Wilkinson, R., 18, 206–7 Willenheimer, R., 196 Williams, L., 54 Williams, R., 7, 237 Williams, S. J., 19–21, 23, 180, 220 Willig, C., 94 Wilson, Carnie, 181–2 Wilson, T., 211 Winslow, R., 45 wise, the, 80–3 Wolf, N., 28, 92, 101, 176, 178, 181 women and appearance, 97–9, 108 attitudes to obese, 63 and bodily appearance, 91 and body size, 100–3 empowerment of fat, 107–9 and food/diets, 103–7 in patriarchal society, 101 role of, 66 as targets, 16 Wooley, O. W., 176 Wooley, S. C., 47 Wright, J., 2–5, 19–20, 24 Wright, S., 76–7, 116, 121–2, 124, 126–7, 132, 142, 232, 241, 243 Yager, Z., 24 Yan, L. L., 50–1 Yoga For Round Bodies, 177 Young, M. I., 5, 20–1, 221, 224, 228–9, 235, 242 Your Weight, Your Health, 203, 204 Zembylas, M., 157 Zureik, E., 145–6, 152, 159 Zylinska, J., 19, 224, 238, 241, 245, 250

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