Medicalizing Obesity: American Perceptions of Body and Health

Whitney Teagle is a second year history and biochemistry double major. When not in class, you can see her on the track or going on a run through the cornfields.

As we well know by now, there is a growing obesity epidemic in the United States. Doctors, politicians, celebrities, and schoolteachers talk about it, and both the idea of obesity and its epidemic nature is fixed in our collective vocabulary. Extra weight is associated with other health problems, including heart disease, high blood pressure, type two diabetes, and cancer. This has created strain on our healthcare system, economy, and even national defense, as well as a multi-billion dollar weight-loss industry.

The obesity epidemic is seen as a recent phenomenon. However, Americans have been “overweight”—and afraid of being overweight–for a long time. Advertisements dating back to the early twentieth century present various faddish diets, exercise, and appliances to help change one’s weight or shape. Yet weight was not always seen as a societal problem, and for much of history, the focus was not on health at all; instead, the focus was on masculinity, looks, and even morality. So when did weight become a health problem? When did obesity become an epidemic?

There have been several distinct stages of thinking about weight and health since the Second Industrial Revolution. At the turn of the twentieth century, concern about fitness was associated with masculinity, not weight or health. Until World War II, there was little moral stigmatization of excess weight, but during the war and throughout the Cold War, undertones conflating excess weight with character weakness emerged. By this time, obesity was still seen as an individual health problem rather than an indication of greater societal problems. This idea was reinforced during the 1970s and 1980s, when the concept of individualism pervaded American political culture. When obesity rates began to rise exponentially and political focus shifted away from individual responsibility, the situation began to be seen as a societal problem. This is when obesity began to be constructed and medicalized as an epidemic.

Although obesity rates did not start noticeably rising until the late 1970s, the foundation was laid for it well before then. As the United States has increased its agricultural productivity, there has been a gradual shift from agricultural to manufacturing and service economies. The first major shift occurred during the Second Industrial Revolution, and was accompanied by large waves of migration to cities. By the early 1900s, more people lived in cities than on farms, and worked more in factories and offices than in agriculture. This, along with new technology like improved transportation, telephones, electric lights, and elevators, had an effect on people’s lifestyles [1]. The rapid change caused the first national fitness scare. Americans were worried that their changing lifestyles would reduce American character and vigor. To keep from getting soft, and because there was an increase of leisure time, American men began to do sports. Baseball and boxing were the most popular, and basketball and football were gaining wider followings. Sports were seen as a tool for building character, and a solution to the effeminate and soft urban lifestyle [2]. At this point, however, the dialogue was about masculinity and manhood rather than about weight gain and obesity.

At this time and through the Great Depression, body ideals were heavier, especially for women. Depression-era advertisements showed beauty as being relatively curvy—“Men wouldn’t look at me when I was skinny,” one advertisement declared. Fat had a positive connotation: jolly, good-natured, like a baby. [3]. Medically, though obesity was recognized as having negative effects, it was considered healthy to carry “an extra 20 to 50 pounds of excess ‘flesh’” [4]. Obesity was not an esthetic ideal, but there was much less stigma around it.

After World War II, many of the same trends of the Second Industrial Revolution were repeated. There was another wave of urbanization (and suburbanization), and agricultural productivity continued to increase due to advancements in transportation and farming technology. Larger scale production, pesticide use, and mass-produced food led to lower food costs and an increase in processed foods [5]. From an economic perspective, exercise became more expensive as the opportunity cost was greater. With cars and office jobs, people now had to go out of their way to exercise instead of it being part of their job [6]. In sum, Americans had economic incentives to both reduce their exercise and increase their calorie intake.

At the same time, during World War II, American attitudes toward excess weight shifted. Due to emphasis on the war effort and a renewal in patriotic machismo, fat became seen as an individual weakness that would have reverberating effects for the country. Throughout the early Cold War, the idea that individuals needed to be morally, socially, and physically sound in order to ward off dangerous social forces. Individuals made up families, and families made up the nation [7]. This meant that an individual weakness—for example, obesity—had implications for the nation as a whole. In addition, new medical research grounded in Freudian psychodynamic theory framed obesity as an addiction, which further reinforced its stigma [8]. Moving forward, excess weight was stigmatized as being a character weakness with greater societal consequences.

During the “long 1970s”—from the beginning of Nixon’s presidency to Reagan’s reelection in 1984—individualism became a main component of American discourse. The attitude of independence and responsibility emerged out of a political climate that emphasized self-help and placed responsibility for one’s economic position in the hands of the individual [9]. This ideology permeated throughout other facets of American society, including views on health and body weight.  Obesity, now recognized as a health concern, was considered the fault of the individual. Because of this understanding, research and treatment of obesity was conducted on an individual-level, and the cause of obesity was understood to be some failure or laziness of those it affected [10]. This individualistic rhetoric kept the government or public health officials from intervening, even as obesity rates sharply rose, because obesity was initially seen as a personal problem, not a national epidemic.

Changes in the food market, the “built environment,” changes in schools and child care settings, and in the role of parents, contributed to the rise of childhood obesity (and subsequent later-life obesity). Increased availability of (cheap) energy-dense, high-calorie foods and drinks through schools has contributed to this. Changes in family structure, like the rise of dual-career or single parent families, have also caused an increase in demand for cheap, fast, and pre-prepared foods. In addition, people travel more in cars than they did during the early 1970s, due to changes in city design and infrastructure. Finally, children spend more time watching television and using computers and videogames, from increasingly young ages [11]. Similar factors of eating, transportation changes, and sedentary work and leisure activities contributed to the rise of obesity in adults.

The phrase “obesity epidemic” was popularized in the early 1990s, and it has taken a long time to be classified as such [12]. Little was written about obesity before 1900. This is partly due to literacy rates being low, so there was a smaller audience. Additionally, there was not a national media, so ideas and literature took a long time to spread.The popular medical information was written was for upper and middle classes because they were the ones that would be able to change their lifestyles. Because those that were more likely to be overweight were upper class, excess weight had a more positive connotation so would not have been as likely to be viewed as a problem. However, the largest factor  was that there likely was not very many overweight people to begin with, so it was not a widespread problem. Most people worked in agriculture and had little leisure time. Transportation also took more energy [13]. Only after World War II did excess weight begin to have a negative connotation, and even then it was not framed as a (physical) health problem.

As obesity became associated with other negative health problems, medicine began to recognize it as a problem in its own right. Medical definitions have focused on measurable characteristics like cholesterol, glucose levels, or BMI in defining obesity. This is where the cultural definition of obesity comes from–diffused down from the medical establishment [14]. American culture responded by creating a “do it yourself” health culture centered around these measurable characteristics. Dieting has been the primary way of changing, and other things such as non-doctor directed cosmetic surgery have also arose as part of a cultural reaction to obesity. The doctor-patient relationship historically worked to solve obesity as an individual’s problem, but as it has become an epidemic, the solution has become more about changing the individual’s lifestyle and environment.

The future of research and healthcare about obesity seems to be shifting away from the individualistic rhetoric of the “long 1970s.” Concerted media and popular reform efforts have pushed this thinking toward institutional and societal causes. Rather than seeing individual doctor-patient interactions as the primary solution for obesity, a public health orientation has emerged, focusing on policy and changing public environments (like adding walkways and bike lanes to roads). This shifted frame of thinking is captured by the word used to describe it: an epidemic.

 

[1] Ryan Engelman. “The Second Industrial Revolution, 1870-1914.” US History Scene. April 10, 2015. Accessed May 20, 2016. http://ushistoryscene.com/article/second-industrial-revolution/.

[2] Michael Alosi. “The Evolution of the Social Functions of Sports & the Advent of Extreme Sports.” Point B. December 6, 2007. http://www.pointbmovie.com/Learn_files/SportsFunction_Alosi.pdf.

[3] Kerry Segrave. Obesity in America, 1850-1939: A History of Social Attitudes and Treatment. Jefferson, NC: McFarland &, 2008.

[4] Garabed Eknoyan. “A History of Obesity, or How What Was Good Became Ugly and Then Bad.” Advances in Chronic Kidney Disease 13, no. 4 (2006): 421-27. doi:10.1053/j.ackd.2006.07.002.

[5] Roger Horowitz. Putting Meat on the American Table: Taste, Technology, Transformation. Baltimore: The Johns Hopkins University Press, 2006.

[6] Bo MacInnis, and Gordon Rausser. 2005. “Does Food Processing Contribute to Childhood Obesity Disparities?”. American Journal of Agricultural Economics 87 (5). [Agricultural & Applied Economics Association, Oxford University Press]: 1154–58. http://www.jstor.org/stable/3697689.

[7] Elaine Tyler May. Homeward Bound. New York: Basic Books, 1988.

[8] Nicolas Rasmussen. “Stigma and the addiction paradigm for obesity: lessons from 1950s America.” Addiction 110, no. 2 (2015): 217-225.

[9] Bruce J. Schulman. The Seventies: The Great Shift in American Culture, Society, and Politics. New York: Free Press, 2001.

[10] K. D. Brownell, R. Kersh, D. S. Ludwig, R. C. Post, R. M. Puhl, M. B. Schwartz, and W. C. Willett. “Personal Responsibility And Obesity: A Constructive Approach To A Controversial Issue.” Health Affairs 29, no. 3 (2010): 379-87. Accessed May 20, 2016. doi:10.1377/hlthaff.2009.0739.

[11] Patricia M. Anderson., and Kristin F. Butcher. 2006. “Childhood Obesity: Trends and Potential Causes”. The Future of Children 16 (1). Princeton University: 19–45. http://www.jstor.org/stable/3556549.

[12] Natalie Boero. Killer Fat: Media, Medicine, and Morals in the American “Obesity Epidemic”. New Brunswick: Rutgers University Press, 2012.

[13] Kerry Segrave. Obesity in America, 1850-1939: A History of Social Attitudes and Treatment. Jefferson, NC: McFarland &, 2008.

[14] Harriet Brown. Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight–and What We Can Do about It. Philadelphia: Da Cappo Press, 2015.

 

Further Reading

Beller, Anne Scott. Fat and Thin a Natural History of Obesity. New York: Farrar, Straus and Giroux, 1977.

Gilman, Sander L. Fat: A Cultural History of Obesity. Cambridge, UK: Polity, 2008.

Schwartz, Hillel. Never Satisfied: A Cultural History of Diets, Fantasies, and Fat. New York: Free Press, 1986.