Politics of Obesity: The Fat Wars

Chapter summary

Obesity has two definitions: scientific (BMI 30 or more) and socio-political.
The core fight: personal responsibility (obesity as personal failure) versus an obesogenic food environment.
Obesity is a big and powerful business, even bigger than tobacco.
A paradox: overweight people, especially women and girls, are disadvantaged.
Australian overweight and obesity rose from 56% in 1995 to 61% in 2007-08. Policy has focused on downstream measures such as social marketing and education.

Responses often create the appearance of doing something.
Politicians avoid insulting voters, and many voters are overweight.
Obesity has been called “the climate change of public health” and a test of political capability. Fixing upstream causes challenges the food, drink and advertising industries and needs action across many policy areas.

The study (2013): Katherine Flegal reviewed 97 studies covering over 3 million people and 270,000 deaths. Overweight (BMI 25 to 30) carried a 6% lower risk of death than normal weight. Moderate obesity (30 to 35) carried no higher risk. Obesity over 35 raised risk by 29%. Other studies show people with heart disease or diabetes sometimes live longer if heavier, the “obesity paradox”.
Supporters of the finding: Carter and colleagues in the JAMA Forum say the science should be separated from the politics. The result was precise, limited and cautiously interpreted.
Critics: They fear the message “obesity may not kill you” undermines public health, just as questioning the link between smoking and health would.
The author: He does not believe the finding is “true”. Confounding in trials makes summaries tricky, lumping disparate trials hides information, and correlation is not cause. Mortality is only one outcome. Illness and quality of life matter too.

Obesity carries long-standing prejudice and recent public health framing: epidemic threat, huge costs, children dying before their parents, poor character.
Fat shaming does not help people lose weight. University College London researchers followed almost 3,000 UK adults for four years and found those experiencing discrimination were more likely to gain weight.

Late in the 20th century obesity became institutionalised: strategies, government departments, handbooks, professorial chairs and research centres.
Questioning the link between obesity and health has become like questioning the smoking link, a sensitive topic with careers invested.

Flegal, K. et al. (2013) Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 309(1):71-82.
Carter, S. et al. (2013) Separating the science and politics of “obesity”. JAMA Forum.
Baker, P. (2012) Why we’re losing the battle of the bulge: the politics of obesity prevention. The Conversation.
Kersh, R. (2009) The politics of obesity: a current assessment and look ahead. Milbank Q 87(1):295-316.
Vayle, A. (2013) Are you ashamed to lose weight? Sydney Morning Herald.