Public health communication & the blurry line from anti-obesity to pro-ana

Public health communication is not easy. Various industries, special interest groups and lobbyists are only too willing to skew messages about health. As such, public health researchers and advocates tend to be sensitive to the different ways a health message can be appropriated.

However, public health advocates, particularly in the area of nutrition, are inconsistent in their concern that people will misuse health-related messages. If a piece of research suggests that something traditionally thought to be “sinful” – alcohol, chocolate, or fat – is not as bad as first thought, then anxious caveats will urge restraint. Yet, if a piece of research over-sells the benefits of something traditionally thought to be “saintly” – exercise or dieting – then there is silence.

Two examples illustrate the first response.

Example 1 – Health benefits of alcohol

Every so often a mainstream media source will pick up on some research that suggests that alcohol – usually red wine – can have some health benefits. Without fail a public health spokesperson or researcher will be very quick to either discredit the research or explain to the public that the research does not provide a license for unrestrained consumption.

For instance, public health nutritionist, Marion Nestle, laments in her book Food Politics that clear guidance is complicated by ‘the inconvenient finding that moderate drinking provides health benefits – alcohol protects against coronary heart disease.’ Whether this research still holds is beside the point, Nestle’s lament that alcohol could have health-benefits reflects a distrust of the public’s ability to negotiate complex or uncertain nutrition messages.

Researchers like Nestle in the US and Mike Daube in Australia are at pains to ensure the public does not misuse or misinterpret claims about the health-benefits of alcohol.

Example 2 – Relationship between weight and health is not as clear as first thought

In 2013, the Journal of the American Medical Association published an epidemiological study from Katherine Flegal and colleagues that found people who are obese grade 1 (BMI of 30-<35) had no increased risk of dying prematurely and overweight (BMI of 25-30) people may actually have greater life expectancy.

Stacy Carter and Helen Walls documented the fall-out of this res2014-12-01 16.22.32-1earch among public health researchers.

Walter Willett of Harvard School of Public Health was indignant. He described the research on NPR as ‘really a pile of rubbish’ and that ‘no one should waste their time reading it’. A UK National Obesity Forum representative told the BBC, ‘It’s a horrific message to put out at this particular time. We shouldn’t take it for granted that we can cancel the gym, that we can eat ourselves to death with black forest gateaux’.

Like the responses to research suggesting the health-benefits of alcohol, these responses to Flegal et al’s research highlight a deep anxiety that the public will misuse public health messages in a manner that undermines their health.

Anti-obesity or Pro-ana? So long as we’re skinny…right?

Despite knee-jerk concern that alcohol or weight-related research will be misused by publics, there is very little (if any) concern that anti-obesity campaigns will lead people to eat too little, exercise too much or that such messages will reinforce and legitimise disordered eating practices such as anorexia or bulimia.

Almost every time I lecture on critical obesity discourses someone will question why there is such a overwhelming focus on obesity and little focus on anorexia or bulimia. Someone will also point out that a lot of the anti-obesity messages can be construed to reinforce idealised expectations about body image.

Compare the use of computer-generated imagery in these two public service announcements (PSAs).

  1. Measure Up – anti obesity

https://www.youtube.com/watch?v=9dL4lN6GKi4&w=560&h=315

2. The Mirror – anorexia

The parameters for the non-pathologised and non-medicalised body is very narrow, especially for young women. In addition to people questioning the differing responses to obesity and anorexia or bulimia, I have had two students tell me that they used weight-focused public health messages to mask damaging practices such as under-eating and over-exercising.

Last year, Dr Richard Newton from the Butterfly Foundation noted that an increase of children and young people with disordered eating and dieting behaviours coincides with ‘a society that is putting an increasing emphasis on avoiding obesity, controlling weight and shape through dieting’.

Psychiatrist Dr Peter O’Keefe also said that anti-obesity messages contribute to the ideal that ‘if you’re thin you’re good, if you’re not, you’re bad’.

These are serious concerns with real consequences for the lives of young people. Yet the zeal for preventing obesity and perceived urgency of the problem, gives public health advocates little time or reason to pause and consider the ways anti-obesity messages can be interpreted.

Sadly, if a piece of research suggests that it’s ok to eat a piece of cake, warnings and caveats are screamed from the rooftops. But if the research says exercise more, eat less, and lose weight, then there is only nodding agreement. After all, why give an inch when we are at war with our bodies – mine and yours.

Make good choices, kid: biopolitics of children’s bodies and school lunch reform in Jamie Oliver’s Food Revolution (2015)

 

Perhaps my favourite description of Jamie Oliver is “mockney gobshite”. This analysis, however, seems a little more sophisticated and looks at the biopower of moralizing discoursed around food, schools and young bodies in the US.

Foucault News

Gibson, K.E., Dempsey, S.E.
Make good choices, kid: biopolitics of children’s bodies and school lunch reform in Jamie Oliver’s Food Revolution
(2015) Children’s Geographies, 13 (1), pp. 44-58.

DOI: 10.1080/14733285.2013.827875

Abstract
In recent debates surrounding childhood nutrition and US school lunch reforms, the child’s body serves as a contested battleground in a destructive politics of blame over obesity and diabetes. Scalar discourses of the body play a significant role in constructing food-related problems and their solutions. We illustrate our claims through a critical analysis of Jamie Oliver’s Food Revolution; a celebrated national television program centered on chef Oliver’s attempts to address childhood nutrition through school lunch reform. Informed by Foucault’s biopolitics, our analysis highlights how moralizing scalar discourses of the body frames nutrition as an individual problem of personal choice. Food politics, when played out at the scale of young bodies, masks class divisions, marginalities, and governmental policies that…

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Bioethics, obesity and the harm principle

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Fat people should pay more to fly, because they weigh more and hence use more fuel.
Fat people can’t make good food choices so they should be coerced and stigmatized into making the right choice.
These and other spurious ideas are permitted to float around opinion pages of leading newspapers and journals because a) we think we have a fat people problem; b) shocking, blunt and simplistic solutions to complex problems are key ingredients to “click-bait”; and c) if we can reduce complex problems to economic calculations then we can pretend moralistic interventions into peoples lives are “neutral” because, hey it’s the raw numbers talking.
Anyway, in the below paper published this week I argue against Peter Singer and Dan Callahan’s attempts to justify direct interventions into the lives of fat people based on a simplistic use of the harm principle and a deep ignorance of empirical and public health research on obesity. Or as H.L. Mencken quipped, “For every human problem, there is a solution that is simple, neat, and wrong.”
If you can’t get beyond the paywall send me an email or message.

The Harm of Bioethics: A Critique of Singer and Callahan on Obesity

Abstract

Debate concerning the social impact of obesity has been ongoing since at least the 1980s. Bioethicists, however, have been relatively silent. If obesity is addressed it tends to be in the context of resource allocation or clinical procedures such as bariatric surgery. However, prominent bioethicists Peter Singer and Dan Callahan have recently entered the obesity debate to argue that obesity is not simply a clinical or personal issue but an ethical issue with social and political consequences.

This article critically examines two problematic aspects of Singer and Callahan’s respective approaches. First, there is an uncritical assumption that individuals are autonomous agents responsible for health-related effects associated with food choices. In their view, individuals are obese because they choose certain foods or refrain from physical activity. However, this view alone does not justify intervention. Both Singer and Callahan recognize that individuals are free to make foolish choices so long as they do not harm others. It is at this point that the second problematic aspect arises. To interfere legitimately in the liberty of individuals, they invoke the harm principle. I contend, however, that in making this move both Singer and Callahan rely on superficial readings of public health research to amplify the harm caused by obese individuals and ignore pertinent epidemiological research on the social determinants of obesity. I argue that the mobilization of the harm principle and corresponding focus on individual behaviours without careful consideration of the empirical research is itself a form of harm that needs to be taken seriously.

Keywords: obesity; Peter Singer; Dan Callahan; harm principle; public health

Mayes, C. (2015), The Harm of Bioethics: A Critique of Singer and Callahan on Obesity. Bioethics, 29: 217–221. doi: 10.1111/bioe.12089

Neoliberal Public Health and the Rhetoric of War

If we look beneath…the State and State apparatuses, beneath the laws and so on, will we hear and discover a sort of primitive and permanent war? (Foucault 2000, : 46-47)

At dawn, on 11 November 2008, Julien Coupat was seized by French police and ‘preventively arrested’. French Interior Minister Michèle Alliot-Marie regarded Coupat and his associates as ‘pre-terrorists’ part of an ‘anarcho-autonomist cell’ (Anonymous 2008; Nardi 2009). Prior to the raid and arrests of November 2008 Coupat and his eight friends were not ‘pre-terrorists’ but nine individuals seeking to establish an alternate form of life to the consumer-driven existence found in the affluent suburbs of Paris from which they came. Moving to the village of Tarnac the nine grew their own food and “reorganized the local grocery store as a cooperative, and taken up a number of civic activities from the running of a film club to the delivery of food to the elderly” {Toscano, 2009 #191}. According to the villagers they were charming ‘self-sufficient students’ (Anonymous 2008). However, when a nearby section of railway was sabotaged through a small explosion the farmhouse transformed into a cell, the individuals into ‘pre-terrorists’ and the friends became known as the Tarnac 9 an anti-capitalist anarchist group with global reach.

Community garden in the Bronx. Anarchist flag amidst the nations.

Community garden in the Bronx. Anarchist flag amidst the nations. Photo: C. Mayes

The seizure of Coupat as a ‘pre-terrorist’ serves as an example of the political rationality influencing governmental strategies seeking to forecast and control not only threatening events, but pre-empt the very possibility of the events occurrence. The governmental drive to pre-empt, mobilizes the biopolitical seizure of life by taking control of individual bodies and regulating the life of the population. The imperative to target subjects that threaten the security of society produces a need to identify subjects prior to the actualisation of the subject as a threat. For Coupat, his irregular form of life attracted the gaze of the Central Directorate of Interior Intelligence (DCRI), provoking preventive intervention in order to secure the population from a possible terrorist threat. Thus the urgency to prevent a terrorist event provided the conditions in which the production and seizure of ‘pre-terrorist’ subjects is possible.

The identification of pre-terrorists in order to lead a preemptive battle in the war on terror is mirrored by features in the public health’s war on obesity that seeks to identify and target pre-obese bodies in a war on obesity.  Although some may object to the suggestion of parallels between the ‘war on terror’ and the ‘war on obesity’, particularly the comparison between counter-terrorism and public health, however, it is important to note that these comparisons are not my novel creation or the cynical and hyperbolic imaginings of social theorists (Biltekoff 2007). Politicians, public health advocates, health policy makers and the media have drawn metaphorical and literal parallels between the threat to global and national security posed by terrorism and that posed by obesity.  Perhaps the most widely publicised comparison was made by the former Surgeon General Richard Carmona, who described obesity in the US as ‘the terror within’ and that ‘[u]nless we do something about it, the magnitude of the dilemma will dwarf 9-11 or any other terrorist attempt’ (Carmona 2003). Public health advocates and the media in Australia have also drawn links between the threat of obesity and the threat of terrorism (Bartlett 2008; Gard 2007). These comparisons could be explained as merely misguided attempts to draw on the rhetorical force of the post-9/11 terrorism discourse in order to heighten the urgency for action on obesity. However, I contend that the appeal to war is not merely rhetorical, but indicative of the ambiguous relationship between neoliberal politics, public health and war in the West.

created by Brandon Knowlden, an art director from Struck Creative. http://brandonknowlden.com/#/obesity-is-suicide/

“Obesity is Suicide” by Brandon Knowlden from Struck Creative. http://brandonknowlden.com

The militarisation of public health discourse and policy serves as an example of Foucault’s inversion of Clausewitz’s principle that “Politics is the continuation of war by other means” (Foucault 2004, p.48). The appeal to war enables the neoliberal state to justify intervention in the life of the population and individuals as matter of security. Rather than considering the ‘war on obesity’ as merely mirroring the rhetoric of the ‘war on terror’, I contend that they share a political rationality that aims to secure the life of the population by pre-empting future threats through acting on subjects prior to their manifestation as an actual threat.

The suggestion that the ‘war on obesity’ and public health campaigns are manifestations of neoliberal political rationality could be seen to jar with critiques that such initiatives are examples of the Nanny or Welfare State. However, while the neoliberal state may withdraw from nationalized financial system, it does not abandon its monopoly on war and violence (Foucault 2004, p.48; Harvey 2009, p.82).

Of course the war waged against terrorism is of a different order to that waged against obesity. While the former requires an explicit appeal to the state’s monopoly on violence, the latter is a ‘peaceful’ continuation of war through a politics that is “perpetually to use a sort of silent war to reinscribe that relationship of force, and to reinscribe it in institutions, economic inequalities, language and even the bodies of individuals” (Foucault 2004, p.16). The continuation of war through politics “sanctions and reproduces the disequilibrium of forces manifested in war” and instils this disequilibrium in the political institutions and the bodies of individuals.

In launching a ‘war on obesity’, the intervention in the life of the individual and population is framed by the Hobbesian mythos that the state provides security and protection. Considering obesity as threat to be secured and in employing the terms of war, the neoliberal state can justify intervention into the lives of the people. Against the background of the neoliberal monopoly of war the future is secured through the production and governance of subjects in the present. It is here that the wars on obesity, drugs, gangs, poverty and terrors begin to resemble each other.

References

Anonymous. 2008. “Cabbage-patch revolutionaries? The French ‘grocer terrorists’.” The Independent, December 18, 2008.

Bartlett, Lawrence. 2008. “Obesity more dangerous than terrorism: experts.” The Age, February 25, 2008.

Biltekoff, Charlotte 2007. “The Terror Within: Obesity in Post 9/11 U.S. Life.” American Studies no. 48 (3).

Carmona, Richard H. 2003. Remarks to the American Medical Association’s National Advocacy Conference. edited by U.S. Department of Health and Human Services. Washington, DC: U.S. Department of Health and Human Services.

Foucault, Michel. 2000. “Society Must Be Defended.” In Ethics: Subjectivity and Truth, edited by Paul Rabinow. London: Penguin.

———. 2004. Society Must Be Defended: Lectures at the Collège de France 1975-76

. Translated by David Macey. Edited by Arnold I. Davidson. London: Penguin.

Gard, Michael. 2007. “Is the War on Obesity Also a War on Children?” Childrenz Issues: Journal of the Children’s Issues Centre no. 11 (2):20-24.

Harvey, David. 2009. A Brief History of Neoliberalism. New York: Oxford University Press.

Nardi, Sarah. 2009. The Coming Insurrection. Adbusters, 14/07/2009.

The Trial of Homo Abacus: Security through Calculation

From out of the whirlwind:

Where were you when I laid the foundation of the earth?

Tell me, if you have understanding. Who determined its measurements – surely you know!

Or who stretched the line upon it?

On what were its bases sunk, or who laid its cornerstone when the morning stars sang together and all the sons of God shouted for joy?

(Job 38: 4-7)

Fate, providence, karma and the “sins of our fathers” are some of the paradigms used to explain disasters – from the micro to the macro. Each paradigm has a certain economy of security – prayer, sacrifice, confession – that wards off (or halts the cycle) of disaster. In this predictive age of the present, however, there is a continual fine-tuning of statistical analyses, scientific measurements, and mathematical models that purport to replace superstitious incantations with scientific exactitude. Prayers are still offered, by some, but like software licensing agreements that are hastily clicked on, earlier economies of security have become a mere formalities. Haollowed practices. Remnants of a simpler past.

Moving away from fatalistic or providential understandings of disaster and toward calculating control has placed human agency at the centre of prediction and prevention. It is not a god that can save or destroy us, but homo abacus. The fallout from recent events such as the Fukushima nuclear plant crisis, Deepwater Horizon oil spill or the L’Aquila earthquake demonstrate this shift.

The scientific community, government inquiries and investigative journalists increasingly place human agency in the centre as the cause and control of disaster.[1] Was the Fukushima plant designed and maintained to withstand a tsunami? Did BP, Transocean and Halliburton cut costs in construction and maintenance in order to increase profits? Why didn’t the scientists of the Major Risks Committee predict the effect of the L’Aquila earthquake? The inability for these scientists to adequately answer this final question resulted in jail sentences “for underestimating an earthquake that killed 309 people in the town of L’Aquila in 2009”.[2]  Although natural events undeniably play a role in these scenarios, contemporary security strategies and discourse position human agency as the crucial point on which attempts to govern unknown futures stand or fall.

The purported obesity epidemic is another example. Although in this instance everyone is expected to adopt the practices of homo abacus – the calculating and measuring human. There are obvious differences between the obesity epidemic and the L’Aquila earthquake or Deepwater Horizon disaster. My point is not that they represent equivalent threats to society, but that a similar rationality is in operation that seeks to govern unpredictable and incalculable events that are entwined with human agency. Just as the L’Aquila earthquake cannot be dismissed as tragic natural disaster beyond human control, the obesity epidemic cannot be dismissed as relatively benign social and biological phenomenon that is plateauing.[3] Rather both have provoked countless experts that are producing knowledge, developing techniques and deploying strategies to govern future unknown threats to population health, safety and economic security.

Further, like the scientists of L’Aquila who stood trial and were sentenced for failing to predict the earthquake, each of us are on trial while simultaneously serving as jurors in the trials of others. Although some more so than others. Counting calories in. Counting calories out. Measuring waist circumference. Assessing daily percentage intake. Weighing bodies. Pinching flesh.  Dividing body mass by the square of height. These are some of homo abacus’s (in)calculable duties that secure the self and others. These are the new incantations of control that make us believe we can prevent the whirlwind and answer any questions it may pose.


[1] Risa Maeda, “Japan Fukushima probe urges new disaster prevention steps, mindset,” Reuters, July 23, 2012; Steven Mufson, “BP, Transocean, Halliburton blamed by presidential Gulf oil spill commission,” Washington Post, January 6, 2011.

[2] Sunanda Creagh, “Researchers alarmed by jail sentence for Italian scientists,” The Conversation, October 23 2012.

[3] Michael Gard, The End of the Obesity Epidemic  (New York: Routledge, 2011)., 168

From Mental Illness to Personal Responsibility: A Technological Transformation of Bulimic Purging

The continuing crusade against overweight and obese individuals has taken yet another bizarre and grotesque turn with the unveiling of “AspireAssist”, a personal “stomach pump [that] sucks food out of the user’s belly before the body can fully digest it”.

AspireAssist

Such a development is not all that surprising. The so called obesity epidemic has transformed ethical and social norms to position those with bodies, habits or attitudes that represent obesity as fair game – the hunting metaphor is apposite.

The state of emergency that is the obesity epidemic has seen public health advocates earnestly recommend that obese children be placed in foster care, bioethicists argue that obese adults should be stigmatised and discriminated against, and hospital CEOs suggesting it is acceptable to refuse to hire overweight or obese people.

In this milieu of panic and desire for strategies that “really work”, AspireAssist has developed a personal stomach pump. The video on the ABC News website is more detailed, but the clip below is clear enough.

According to AspireAssist it “works by removing a portion of the food from the stomach before it is absorbed”. By using AspireAssist 20mins after eating, the pump removes 30% of the stomachs contents to reduce the amount of calories, nutrients, fats etc absorbed by the body and thereby making the individual slimmer. My interest in AspireAssist is not the extraordinary and ethically questionable attempt to normalize bodies to conform to artificial measurements such as the BMI. But the way this technology transforms a practice that most medical professionals characterise as a mental disorder.

This act of removing the contents of the stomach to achieve the goal  “normal” weight and body image is not dissimilar to bulimia nervosa, a condition that since the 1980s has been regarded as a mental illness. The DSM-IV describes individuals with bulimia nervosa as engaging “in inappropriate behavior to avoid weight gain (e.g., self-induced vomiting), and are overly concerned with body shape and weight. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa maintain body weight at or above a minimally normal level.”

For an individual to excuse themselves from the table to go and vomit in the toilet 20mins after sharing a meal with friends would be, according to the DSM-IV,  inappropriate. Such behavior ordinarily invokes social concern and justifies medical intervention. However, the technology of the stomach-pump transforms medically defined deviance (purging) into medically approved compliance. Performing a near identical function to purging, the use of the personal stomach-pump does not incite medical intervention as it is the medical intervention and it does not invoke social concern as it is a response to the social concern of obesity.

AspireAssist’s stomach pump probably won’t become a common tool. The panopticon was not widely implemented either. But like the panopticon, the personal stomach-pump represents a rationality of a specific (bio)political moment in which the bodies of individuals are considered to pose such a threat to the population (and themselves) that spectacular interventions are justified that transform the logics of pathologies into the logics therapies.

Lifestyle Intervention and the Aesthetics of Obesity and Smoking

The sustained concern over obesity as a threat to population and economic security has led to a proliferation of medical and non-medical experts intervening in the daily lives and practices of individuals. These interventions commonly fall under the rubric of lifestyle. Seen as both the cause and solution, the modern lifestyle is the target of modification strategies and techniques.

Of course, interventions into lifestyle are not entirely new or exclusive to obesity. Smoking, homosexuality, extreme sports or drug-use have all been described as lifestyles with associated health risks that justify outside intervention. Yet, I contend that obesity is unique in its characterization as a political, economic, aesthetic and public health problem that emanates from individual choices and practices.

The uniqueness of obesity is partly evidenced in comparison to smoking. While smokers have attracted a significant share of vitriol and harassment, much of the blame for smoking and the associated health impacts is reserved for “Big Tobacco”. If repentant, smokers can be characterized as the victims of industry deception and chemical addiction. Although there is anger directed toward “Big Food”, obesity is primarily framed as the result of individual choice and lack of control.

Furthermore, there is an aesthetic difference that distinguishes obesity from smoking. While there are active efforts to counter the “coolness”of smoking, the iconic images of Humphrey Bogart or Audrey Hepburn with cigarettes in hand continue to influence Western aesthetics. And the more recent fictional characters, Don Draper and Joan Halloway stubbornly resist the cliché that “kissing a smoker is like kissing an ashtray”. In contrast, the aesthetics and celebrity of obesity are comical, grotesque or both. Cartoon characters like Homer Simpson or Peter Griffin who eat anything within reach, from a week old sandwich to the legs of a paralytic friend, serve to confirm the message that obesity is grotesque in form and the result of lack of control.

This aesthetic also carries with it a judgement on the ability of an individual to self-govern and also to govern others. Kim Beazley, the former leader of the opposition in Australia was once told by Prime Minister Bob Hawke that the Australian people wouldn’t elect a fat prime minister. A contemporary example in the US is Chris Christie. Since at least the 2012 Republican primaries Christie’s weight has been a continual talking-point. These discussions are set to increase as speculation grows over his intentions to run for President in 2016.

Contemporary concerns about obesity and its relation to aesthetics, self-governance and the governance of others resembles regulations over sexual conduct in Ancient Greece. In examining the problematization of sexual practice in Ancient Greece, Michel Foucault outlines the link between a husband’s sexual conduct, household management and governance of the city. According to Foucault, the Greek husband’s authority and control over his home (of which his wife was a part) reflected his ability to have authority and control over himself and the life of the city.  While the husband was free to engage in sexual practice outside of the conjugal relation, “having sexual relations only with his wife was the most elegant way of exercising his control” (HSII, 151). Further, when Aristotle condemns extra-marital sexual relations as dishonourable it is not that the activity deviates from a moral law or order, rather such action demonstrates the husband’s inability to conduct himself in relation to the ethical substance of pleasure with the appropriate degree of self-control and mastery.

The example of Nicoles the ruler of Cyprus illustrates this point. According to Isocrates, Nicocles explains his conjugal fidelity in saying, “I am the king, and because as somebody who commands others, who rules others, I have to show that I am able to rule myself.” Therefore if Nicocles wishes to rule others and the city with glory and authority then he must rule himself first. Foucault argues that for the Greeks the mode of subjection was politico-aesthetic in which “political power, glory, immortality and beauty are all linked together at a certain moment.” Thus the Greek free man is at liberty to engage in sexual activity with someone other than his wife, however if he has accepted the politico-aesthetic mode of subjection, if he wishes his existence to be characterized by self-mastery and beauty, then he will recognize the particular rules of conduct that are constitutive of that subjectivity.

In a somewhat similar fashion, the American (or Australian, or any citizen of a Western liberal democracy) is free to indulge in whatever culinary and dietary activity he or she wishes, however, in return the society will discount beauty and the capacity for self-governance and the governance of others and thereby justify interventions into their daily choices, activities and practices.

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