The Medicalization of "Obesity" (long post)

Cross culturally, conditions and situations that are outside the norm are often seen as social problems, and social control is often the solution. These days, our culture views fat individuals as not normal, not okay. There was a time when fatness was viewed positively -- as beautiful and as an indication of health. During the past century, however, fatness was moralized and seen as "bad." Then it was medicalized and seen as a sickness. Both of these labels remain in place today. However, a movement has grown attempting to demedicalize and de-demonize the large body. 

In cultures and times when food is not readily accessible, fatness becomes more desirable and fashionable. However, easy access to food resources, as occurred during the agricultural and industrial revolutions, set the stage to view fatness as unfavorable.  Since the 1950s fatness has been increasingly viewed as negative.  

One unfortunate result of this movement is the frequent stigmatization of the "obese,"  viewing them as outside the norm and therefor bad, sinful and ugly.  This allowed the moral model of fatness to arise, which suggests that fat people are responsible for their condition and should be punished as a means of social control to get them to toe the line, lose weight and look "normal." 

Medical claims that obesity is unhealthy took off after the Metropolitan LIfe Insurance Company undertook research to help improve profit. Their mostly faulty research was (incorrectly) analyzed to show that the fatter a person got, the more unhealthy they become. The statsitican who worked for Met Life, Louis Dublin, set out to convince doctors that fat is unhealthy, speaking at medical conferences, etc. At first doctors were highly resistant, but eventually succumbed to the onslaught. Perhaps they also saw another avenue of income, the medicalization of body size. 

Medicalization is a process by which nonmedical problems become defined and treated as medical problems, usually in terms of diseases or disorders.  Medicalization of obesity occurred as medical people and their allies made increasingly frequent, powerful and persuasive claims that they should exercise social control over fatness in contemporary society.

The medicalization of an issue occurs in many different forms and changing the name of a condition is part of the process of medicalization.  Hence, terms to describe fatness shifted to view fatness as a sickness, such as obese, adipose and overweight.  Medicalization becomes more thoroughly entrenched when more medical categories become involved.  Obesity has done this by broadening the terminology to include weight disorders, eating disorders and metabolic disorders. 

Obesity then had to be defined as a disease in order to successfully medicalize it.  In order to designate a condition as a disease it has to apply to a medical models.  Obesity has been made to fit into several available medical models, including genetic deviance, endocrinological disturbance, personality disorders, addiction, and substance abuse, etc.  (To be clear, "obesity" is often none of these things.)

Organizational activities are another part of the medicalization process.  Those who treat fatness have formed their own organizations, published their own journals, held professional conferences and training institutes for the purpose of drawing attention to obesity as a problem and encouraging the application of medical models in dealing with it.  The treatment of obesity was further sanctioned by governmental agencies such as the National Institutes of Health (NIH) which discussed obesity in their consensus conference in 1985 which concluded that "In recent years, obesity has become a public health problem of considerable importance in the United States." 

Medical professionals began to expand their responsibility and jurisdiction over the treatment of obesity.  In his book, Jeffrey Sobal divides the techniques into two general areas: technological interventions which include surgery such as jaw wiring, intestinal bypass surgery, gastric bypass surgery and (lipectomy) and drugs which include hypermetabolic drugs, appetite controlling drugs and laxatives and diarrhetics.  Physicians became gatekeepers for the treatment of obesity by meting out prescription drugs which further entrenched the medicalization of obesity. 

Next came the psychiatric and psychological treatments for weight and eating problems.  Psychotherapy was used to treat obesity, and therapists encouraged the public to seek psychiatric treatment for their fatness and treat it as a medical problem rather than a moral problem. 

Portraying eating as a compulsive urge contributed to the medicalization of obesity by shifting the control of eating from being conscious (and therefore good or bad) to being unconscious (and therefore sick or healthy).

There are claims by psychologists and psychiatrists that overeating occurs because people have maladaptive personalities.  That obesity is the obvious result provides the medical professionals with legitimated authority as exclusive gatekeepers for dealing with obesity.  This actually works to create a monopoly for the source of treatment for obesity.  Medicalization was furthered by psychologists who began to use behavior therapy which, in effect, puts people an extended patient role whenever they are involved with food. 

Since most people see changes in eating as the best way to deal with obesity, the medicalization of dieting was next, and the public was eventually barraged with specialized products and medically supervised weight loss regimens. 

Weight loss products and specially constituted foods support the general medical model of obesity even though they are typically self-prescribed and used without medical supervision.

Sobal states that these people enter a patient-like sick role, even though they are not under direct control of physicians and approach weight loss using the medical model.  Physician sanctioned diet books have furthered this movement.  "The major trends in dieting have been towards medicalization beginning with the medicalization of eating, moving through the development of specially formulated foods and including medical supervision or prescription of what is eaten."

Weight loss organizations, most of which are established by nonmedical groups, typically use a medical model in their treatment of obesity. 

Medicalization is directly related to profitability, and people in the medical community quickly realize that the potential profit in terms of money and increased health is large in the field of organized weight loss.  The medical community challenges weight loss organizations that deviate from accepted medical models, coops the ones that are successful and willingly gets coopted by organizations seeking medical prestige and support.

Weight loss organizations which use a medical model typically use calorie control, extremely low calorie - high protein diets and behavior modification as their modus operandi.  Other weight loss organizations apply moral rather than medical techniques.  For instance, Overeaters Anonymous uses spiritual support as a way of avoiding overeating.

 Sobal maintains that the individual roles in medicalization include those who are crusaders and those who are experts. 

Crusaders lead the efforts to declare obesity as a major health problem within the medical domain and suggest that it can be cured with medical intervention.  One of the most influential crusaders was previously mentioned Louis Dublin, who was a major statistician for the Metropolitan Life Insurance Company. 

Experts are those authorities who make claims about obesity with their support used to document claims and refute opposing claims.  They should weed out fraud and quackery, but they are often as biased as crusaders. Those who like to think of themselves as experts include  the American Medical Association's Council on Scientific Affairs as well as individuals such as Janet Manson, Charlie Burnell and others (although I believe they mostly compound problems). 

Medicalization becomes even bigger when we view those who have vested interest in portraying fatness as a social problem in applying a medical problem to control it.  The health care industry is obviously at the center of medicalization, but it is assisted by the pharmaceutical industry, the fitness industry, the food and food service industries, the apparel industry, the fashion and beauty industry and the entire weight loss industry.

The insurance industry, however, has been fairly careful about sitting on the fence.  On the one hand, they are quite sure that overweight is a health risk factor for disease and early mortality.  On the other hand, they have been painstakingly opposed to designating obesity as a disease that would be included for reimbursements.  The medicalization of obesity, then, has been furthered by the various interest groups which all make claims to define fatness as sickness. 

On the other side of the coin, we have the demedicalization of obesity.  Advocates seek to normalize large body size as neither badness nor sickness.  These "size activists" work to politicize weight, to demedicalize it and use political strategies to achieve these changes which focus on oppression rather than badness or sickness and seek restitution rather than punishment or treatment.  

Activities that demedicalize parallel those that medicalize.  Demedicalization began with renaming fatness in a more neutral or positive term. Rather than "obesity," or "overweight," terms that portray bigness as neutral and even normal are used, including fat, large, ample, and "of size".  (This is why I put quotes around "obesity" and "overweight" when I use them.)

The category of fat acceptance was expanded to make it more powerful and is now called size acceptance and has taken the shape of a Size Acceptance Movement.  Organizations also play an important role in the demedicalization of obesity.  In 1969 the National Association to Aid Fat Americans, later changed to the National Association to Advance Fat Acceptance, was formed (NAAFA).  Other groups included the Association for the Health Enhancement of Large Persons (AHELP), the Association for Size Diversity and Healthy, the Council on Size and Weight Discrimination and others.  Parallel to medical journals for obesity, magazines such as Radiance and Big, Beautiful Women have emerged as well as an increasing number of articles and books that make positive and demedicalized portrayals of large people. 

Experts in the scientific community refute the claims made by much of the health care industry which minimize the negative health effects of fatness or focus on the harms of dieting.  Other experts focus more on the political and look at discrimination and stigmatization. 

This movement, which rejects dieting and focuses on wellness and self-esteem, has emerged in opposition to the predominant medical model intervention for weight control.  

Just as with medicalization, the government has been called in to aid the demedicalization of obesity.  In 1990, the United States Congress held hearings that revealed abuse within the diet industry and led to action on control of weight loss advertising.  While these activities and others like them have helped the demedicalization of obesity, the Size Acceptance Movement is still a minor voice in public forums about body weight.  Unfortunately, it has not had the success of other efforts to promote rights of specific groups, such as women rights or gay rights. 

While movement towards demedicalization is growing, it is a small yet different voice in the traditional chorus of the stigmatization of obesity in the growing bandwagon of medicalization of fatness.

Currently, moral, medical and political models are all being applied to people with high levels of body fat with a dynamic competition between models permitting multiple definitions of obesity as a social problem.  We can anticipate future changes in the social construction of body fat as an issue as competing claims are made to define it as a moral deficit, medical disease or political discrimination.

References and Resources

Sobal, J (1995) The Medicalization and Demedicalization of Obesity.  In: Maurer D and Sobal J (eds) Eating Agendas: Food and nutrition as social problems.  Hawthorne, NY: Aldine de Gruyter.

Paradis, Elise. “Obesity” as Process: The Medicalization of Fatness by Canadian Researchers, 1971-2010 in Ellison J, McPhail D and W Mitchison (2016). Obesity in Canada: Critical Perspectives. University of Toronto Press, pp. 56-88. (Download a copy of this chapter.)

 

About Karin Kratina, PhD, RD, LDN, SEP

Karin can help you escape food and body angst and learn to manage your eating and weight naturally. Visit www.EatingWisdom.com for free handouts, online courses and more tips on mindful, intuitive eating and healing disordered eating.

2018 Adapted from © 2011 Karin Kratina, PhD, RD, LDN and Amy Tuttle, RD, LCSW