The Many Frames of Obesity: Rethinking Public Health’s Approach Toward a Complex Social Issue – Denison Goodrich-Schlenker

In recent decades, the rise in obesity rates in the United States and globally has increasingly become one of the most pressing issues on the public health agenda. According to the National Health and Nutrition Examination Survey (NHANES), obesity among adult Americans (defined as having a BMI greater or equal to 30) has risen from 13.4% in 1960-1962 to 34.3% in 2007-2008 (1). Perhaps more concerning is the increasing prevalence of childhood and adolescent obesity which the Centers for Disease Control (CDC) currently place at around 17% (2).

Obesity has been viewed as a costly issue in both human and economic terms. Obesity and overweight have been linked to heart disease, stroke, type 2 diabetes, and cancer. In addition, the CDC estimates that in 2008 alone, 147 billion dollars were spent on obesity-related medical care (3).

Although obesity is widespread in the United States, it does not affect all populations equally. Data have shown that race, gender, socioeconomic status, and education level affect obesity rates, although the specific nature of the influence is difficult to determine. The effects of various sociocultural factors on obesity rates suggest the complex nature of obesity as well as the ways in which rising obesity rates have served to both highlight and exacerbate existing health disparities in the United States.

Together, the high health, economic, and social costs of obesity have pushed diet and physical activity to the top of the public health agenda. Over the past two decades in particular, public health professionals as well as local, state, and federal governments have proposed guidelines, developed action plans, and launched media campaigns to intervene in what has come to be seen as one of the fastest growing “epidemics” in American society. The question of who is responsible for the rise in obesity rates has been central to the design and implementation of these interventions. Traditional approaches have focused on the role of personal choice and lifestyle as the primary contributors to the obesity epidemic. Interventions based on this approach have frequently relied on tradition public health models such as the Health Belief model, the Theory of Reasoned Action, and the Transtheoretical model as frameworks with which to understand and intervene in individual decision-making. The primary focus of these interventions has been to provide both the informational and motivational tools necessary for people to make healthy lifestyle choices. These programs have taken the form of school-based health education, informational media campaigns, and nutritional and behavioral counseling for overweight individuals.

In recent years, however, researchers have increasingly begun to question the effectiveness of individual-level behavioral interventions. Literature reviews of information and behavioral campaigns promoting diet and physical activity reveal both high attrition rates and a lack of evidence regarding the long term efficacy of such programs (4, p.1021).

In addition, there is a growing consensus among public health professionals that a focus on information and behavioral change therapies fail to account for social and environmental causes of obesity. Researchers have thus begun to argue for a more systemic understanding of obesity. However, as media and public health discourse has begun to shift toward a more systemic and complex view of the obesity “epidemic” there has been a resurgence of notions of the importance of individual responsibility and personal choice (5, p.68). Lawrence suggests we are at a critical moment in the struggle against obesity and that the outcome is unknown: “It is difficult to know if the struggle for greater government action on obesity--especially action that moves beyond ‘information’ campaigns--will be contained by the food industry and its powerful allies or become a prolonged and far-reaching battle” (5, p.72).

This paper seeks to address what are believed to be the primary pitfalls of the dominant, informational and behavioral change approach to obesity; namely, 1)the problematic nature of focusing on weight and its impact on health more generally; 2) the role of individual level campaigns in the promotion of weight stigma; 3) the ways in which the emphasis on individual behavior change obscures the true complexity of obesity in American society. Additionally, this paper will offer suggestions for how to improve upon current public health practices, specifically addressing each of the three criticisms outlined above.

Anti-Obesity Initiatives, BMI, and America’s Weight Obsession

The vast majority of articles dealing with the rise in obesity rates begin by outlining what has become widely known among health professionals and among public discourse as the “obesity epidemic.” CDC statistics demonstrate a dramatic increase in the percentage of obese Americans between 1960 and 2007 (1). In addition, studies show that while obesity rates are higher among certain populations, weight gain has affected every segment of American society (1).

Central to the obesity issue, however, is the important question of how we have come to define, both medically and culturally, the meaning of obese and overweight. Clinicians and public health professionals rely primarily on the Body Mass Index (BMI) as a screening tool to identify people who may be overweight or obese. This measurement is supported by the CDC which defines overweight as having a BMI between 25 and 29.9 and obese as having a BMI greater than 30 (6). BMI represents the ratio between a person’s weight and height and is a simple way for health professionals to identify people who may have weight issues. BMI does not however directly measure body fat. As a consequence, highly muscular individuals, such as professional athletes may have a BMI that would classify them as overweight (7). The CDC openly acknowledges this limitation however BMI continues to form the basis for research surrounding the rates of overweight and obesity in the US (7). Many individual-level public health interventions focus explicitly on informing people of their BMI to motivate them to lose weight. In an attempt to combat rising childhood obesity rates, the Flagstaff Unified School District in northern Arizona measured students’ BMIs and sent home letters to parents classifying children as either healthy weight, overweight, or obese (8). Similar interventions have been implemented in school districts across the country, serving both to influence perceptions of the obesity issue and to shape attempts to intervene.

In addition to forming the basis for many informational and behavior change programs, BMI has frequently served as a primary method for both understanding the impact of obesity and determining the effectiveness of a wide range of anti-obesity initiatives. Many of the articles cited in this paper that deal with the influence of social and environmental factors on obesity use BMI as the primary indication of health for a given neighborhood or population (9-11).

In spite of the widespread acceptance of BMI as an indication of health, many researchers and public health professionals have begun to critically examine both the use of BMI and the more general weight-focus of traditional approaches to obesity. In her critique of childhood anti-obesity initiatives, Sandy Szwarc argues that “even if we could exactly control for all the factors believed to go into childhood obesity, there would still be a wide range of weights among children. Some would still be naturally fat, others naturally thin. Body types are primarily simply a normal variation among us all” (12, p.104). This notion of naturally-occurring body diversity is further supported by arguments about the role of genes on body size and composition. Yung Seng Lee argues that while the environment is an important determinant of body weight, genes play a significant role in determining an individual’s susceptibility to environmental factors (13, p.45).

It is thus important to question the validity of BMI as a tool for informing efforts in health promotion and to contextualize the weight-focus of anti-obesity initiatives and American society more broadly. Natalie Boero argues that the “obesity epidemic” represents a “cultural black box” in that “pre-existing, yet largely unexamined cultural understandings of fatness form the plinth of representations of scientific debate or agreement about weight” (14, p.51). Cultural notions about what it means to be fat have thus served to structure the science of obesity by informing the ways in which areas of scientific disagreement are presented in the media. Boero argues in addition that media treatment of the obesity “epidemic” has helped to create a “fear of fat” by perpetuating the notion that it is easy to gain weight (14, p.47). In her analysis of mainstream news sources, Boero found that the media tended to glorify individual behaviors commonly associated with eating disorders as the only way to combat weight gain (14, p.47).

The focus on weight and BMI in both the media and public health campaigns contributes to an unhealthy obsession with thinness in American society with potentially disastrous results. According to the South Carolina Department of Mental Health an estimated 7 million women and 1 million men suffer from eating disorders in the United States (15). The National Association of Health Education Centers KidsHealth Kids Poll reports that 55% of 9 to 13 year-olds have experienced stress or anxiety about their weight and 59% have attempted weight loss (16). Women and girls are disproportionately affected by society’s obsession with weight. As a result, they are far more likely than men to experience weight related anxiety and/or suffer from eating disorders. In her cautionary article about childhood anti-obesity initiatives, Jennifer A. O’Dea argues: “Health education messages about overweight and weight control are likely to make young people feel worse about their bodies and themselves in general. Preventive activities must be examined for their unintended negative outcomes...” (17. p.260).

“Personal Choice” and the Promotion of Obesity Stigma

Traditional approaches to obesity have tended to focus on individual lifestyle choices and decision-making as the primary instruments for improving public health. These approaches place the locus of control firmly within the individual, asserting that people have both the power and the responsibility to implement positive lifestyle changes regarding diet and physical activity. Traditional interventions thus utilize individual-level frameworks, such as the Health Belief and Transtheoretical Models, to understand and intervene in the individual decision-making process. The Health Belief Model, which represents a cost benefit analysis of the consequences of a particular health behavior, has alone inspired a plethora of informational campaigns that seek to provide individuals with the knowledge necessary to make the “right” decisions regarding diet and exercise.

One outcome of public health’s focus on personal choice has been the creation of the notion of individual responsibility for health behaviors and outcomes. As a direct consequence of this frame, obese and overweight individuals are often blamed for their condition. According to Rebecca M. Puhl and Chelsea A. Heuer, it is precisely this misperception that weight is the result of individual behavior that has led to the stigmatization of the obese and overweight (4). Marshall Becker argues: “the individual-responsibility approach has helped to establish ‘health’ as the New Morality by which character and personal worth are judged. ‘Being ill’ is redefined as ‘being guilty.’ The obese are stigmatized as ‘letting themselves go....” (18, p.4).

Puhl and Brownell cite attribution theory as a useful framework with which to understand the development of stereotypes surrounding obese and overweight individuals. According to this model, people ascribe certain negative attributes to overweight individuals as a means of explaining the underlying causes of their condition (19, p.215) . The obese are thus often characterized as being lazy, “morally irresponsible,” unreliable, and/or lacking in will power (19-21).

Researchers concerned with the development of obesity stigma highlight its potentially disastrous consequences for public health. Weight stigma has been linked to a higher incidence of stress, depression, loneliness, and disordered eating among overweight children and adults as well as decreased participation in physical activity (4, 19, 22). In addition, stigma has served to both justify and perpetuate discrimination toward obese and overweight individuals in education, employment, and health care. Studies examining the existence of a medical stigma of obesity reveal that a significant portion of physicians ascribe negative attributes to obese patients and hold them personally responsible for their condition (23, p.555). Perhaps more concerning is the impact of obesity on physician diagnoses. Citing Packer’s article “Barriers to health care utilization: The effect of the medical stigma of ‘obesity’ on women,” Drury and Louis argue: “Obesity serves as a “master status,” overshadowing other attributes. Physicians often focus on weight solely as the cause of health problems and may refuse to perform diagnostic tests, or prescribe birth control and other medications, citing body size as a precluding factor” (23, p.555). Not surprisingly, research has shown that overweight and obese women are more likely to avoid medical care due to weight anxiety (23, p.555).

The creation and exacerbation of health disparities is thus another outcome of obesity stigma. In his article, “Stigma and the ethics of public health” Bayer poses the crucial question: “Who will bear the burden of stigma and are such burdens unfair?” (21, p.470). Cultural valuing of thinness and weight stigmatization have had disproportionate impact on women’s body satisfaction, as evidenced by higher rates of weight anxiety, dieting, and eating disorders among women and girls (15-16). In addition, the higher prevalence of obesity within certain minority ethnic communities and among individuals with low socioeconomic status means that obesity stigma will only serve to exacerbate existing health disparities and promote negative stereotypes. Saguy and Riley argue:

In that the poor or minority groups are more likely to be ill, this allows one to blame them for their misfortune. Moreover, in that an unhealthy lifestyle is taken as evidence of personal and civic (because of public health costs) responsibility, this perspective suggests that the poor are to blame for their disadvantaged social position (24, p.887).

The negative consequences of obesity stigma call into question the validity and effectiveness of public health approaches that stress the importance of individual responsibility for health outcomes. Researchers concerned with the development of weight stigma lament the continued failure of public health to critically examine the health and social consequences of “personal choice” discourses surrounding the obesity issue.

The Role of Individual-Level Approaches in Obscuring Social and Environmental Causes of Obesity

In a recent effort to combat childhood obesity in Georgia, the Strong4Life campaign features a series of public advertisements in which parental inaction is portrayed as the primary culprit in the rise of obesity rates. The tagline at the end of the ads reads “75% of Georgia parents with overweight kids don’t recognize the problem. Stop sugarcoating it, Georgia.” (25). Interventions like these help to promote the notion that individual choice is to blame for rising obesity rates. Federal initiatives, such as the Small Steps Initiative, which informs individuals about the small changes they can make to their diet and activity patterns, represent what has thus far been the dominant approach taken toward the obesity epidemic (26). These individually-based informational and behavior change interventions perpetuate weight stigma by attributing responsibility for health outcomes to individuals. They also obscure many of the underlying social and environmental causes of obesity, thereby hindering efforts at policy-level reform.

In spite of widely-held beliefs concerning the centrality of individual lifestyle choices to the obesity epidemic, researchers have begun to examine the impact of social and environment factors on health behavior and outcomes. Numerous studies cite the role of built environment in determining diet and activity patterns. Neighborhood walkability, land use mix, and population density have all been inversely associated with BMI (9, p.1953). The potentially positive effects of these characteristics of urban environments are often mitigated by other neighborhood attributes associated with high rates of poverty; these include a higher incidence of crime, increased density of fast food restaurants, and limited access to supermarkets offering healthy food options (27, p.15).

Social factors such as race, gender, and socioeconomic status have also been linked to differences in obesity rates between populations. Research indicates that minority and low socioeconomic status are associated with higher levels of obesity however the complex interplay between various factors can serve to confound these relationships. According to the CDC, the highest rates of obesity can be found among Non-Hispanic blacks (44.1%), followed by Mexican Americans (39.3%), Hispanics (37.9%), and non-Hispanic whites (32.6%) (28). However, non-Hispanic black and Mexican American men with low socioeconomic status experience lower rates of obesity than those with higher income levels. Conversely, rates of obesity among women tend to decrease with higher socioeconomic status and education level (28).

In addition to social and environmental factors, the food and beverage industry has, in recent decades, come under attack for is role in rising obesity rates. Food costs, misleading nutritional labels, and the marketing of highly processed foods to children have all been identified as key contributors in the creation of an unhealthy and obesity-causing food environment (29, p.1027).

Acknowledging the role of social, environmental, and economic factors in the rise in obesity rates has important implications for the design and focus of public health interventions. In recent decades, however, systemic understandings of public health issues have “yielded to a far more individualistic model in which each person [is] considered responsible for his or her own health status” (5, p.58). This emphasis on individual responsibility not only obscures the complex influence of societal level factors on rising obesity rates, it has also helped to relieve governments and corporations of the responsibility for promoting substantive change.

Toward an Alternative Approach

As public health professionals move forward with anti-obesity initiatives, it is critical that they reexamine both the social and scientific assumptions that have served as the foundation for the individual-level, informational and behavior change approach to combatting rising obesity rates. This paper will argue for the need for a fundamental shift from a negative, weight-focused, and highly individualized framing of the obesity issue toward a more positive frame that promotes both body acceptance and a deeper understanding of the complexity of weight gain in American society.

The proposed approach would consist of three parts. First, public health professionals should shift the focus of campaigns away from weight loss and toward a healthy living paradigm. An important component of this would be a reexamination of the reliance on BMI as an indicator of health in current public health initiatives. This shift would be accompanied by a national media campaign to promote body diversity acceptance within both the health profession and the general public. Second, public health professionals should prioritize combatting obesity stigma as a negative outcome of current anti-obesity efforts. This would involve a media and outreach campaign to inform the general public of the complex causes of obesity in addition to training for educators and health professionals on how to identify and combat personal biases and stereotypes. Third, public health professionals should work to reframe obesity as a “systemic” issue to promote government involvement in broad-based interventions to combat the complex social and environmental causes of weight gain.

Moving Away from a Focus on Weight

Obesity research has relied heavily on the use of BMI and weight as indicators of health. Consequently, interventions often place the greatest emphasis on the importance of participants’ weight outcomes as measures of success. Not only have weight and BMI been questioned as valid risk factors, the valuing of thinness in American society shifts the tone of anti-obesity campaigns toward the negative and leads to an unhealthy obsession with weight loss. The language of “anti-obesity” illustrates this negativity and is more likely to make people feel worse about themselves then to motivate them enact important changes to their diet and activity patterns (17, p.260).

An alternative approach would shift the focus away from weight outcomes and toward a more holistic measure of health. Proponents of such an approach argue for “decreasing the focus on the undesirable features of obesity and [moving] towards a focus on the public health benefits of healthy diets” (30, p.2). Measures of the effectiveness of public health efforts should thus incorporate more qualitative data such as changes in diet among participants, frequency and enjoyment of physical activities, and individuals’ body image perceptions. These measures provide a more accurate and holistic understanding of an individual’s health risks. In addition, the general shift in focus from weight loss to the promotion of a healthy lifestyle is more likely to contribute to prevention efforts as healthy lifestyle measures can be applied to everyone. In fact, it can be argued that the current weight-focus of interventions undermines public health goals by confining health risks commonly associated with obesity to individuals with weight concerns. People with a “normal” body weight may consequently consider themselves immune to diseases associated with obesity and fail to implement important changes to their diet and activity patterns.

For people who are struggling with weight concerns, interventions emphasizing healthy lifestyle measures over weight or BMI represent a more positive and attainable means of working toward a healthier lifestyle. One potentially motivating finding of obesity research has been that “Physical activity appears not only to attenuate the health risks of overweight and obesity, but active obese individuals experience lower morbidity and mortality than normal weight, sedentary individuals” (20, p.257). In light of the difficulty of sustained weight loss for many individuals, public health interventions should stress the significant health gains that can be achieved from modest improvements in diet and activity patterns. In general, a refocusing of public health research and initiatives is needed in order to dispel deeply held beliefs regarding the association between thinness and health. The use of “lifestyle” data over BMI will consequently serve to combat Americans’ obsession with weight loss and reduce the incidence of eating disordered behavior.

A shift in the way public health interventions measure an individuals’ risk factors for disease needs to be accompanied by a nation-wide media campaign that simultaneously promotes acceptance of body diversity and healthy living. The campaign would include public advertisements in which individuals are celebrating “what their bodies can do.” Ads should feature both men and women of various body types, engaging in healthy behaviors. They should emphasize the importance of 1) enjoyment (of both physical activity and healthy eating), 2) non-judgement and body acceptance, and 3) control. The ad campaign should utilize the fundamental principles of advertising theory (i.e. promise, support, and core values) to move away from traditional public health messaging and toward a more positive and motivating communication strategy. It is also critical that those designing the campaign consider the specific populations they want to target and choose their messengers and spokespersons accordingly. One recommendation would be to use a combination of celebrities and average citizens in the same advertisement as a way to combat Hollywood standards of beauty while allowing for self-referencing or viewer identification with the promise. In general, the campaign should strive to alleviate weight-related guilt and anxiety while encouraging individuals of all body types to celebrate their bodies and take pleasure in being healthy.

Combatting Obesity Stigma

The valuing of thinness in American society and the dominant belief in the importance of “individual responsibility” for weight gain have also served to perpetuate weight stigma within both the medical profession and public discourse. So far, there has been relatively little examination of the causes and effects of obesity stigma as well as the role of public health campaigns in promoting weight prejudice. Some public health professionals go so far as to argue that stigma represents a potentially useful tool for motivating individual behavior change, thereby ignoring research that demonstrates the harmful effects of stigma on individual health. Underscoring the negative implications of stigmatization for treatment of AIDs victims, Bayer highlights the gravity of stigma for public health in general: “The profound effects of stigmatization have created an environment in which public health is gravely at risk” (21, p.464).

An effective approach to obesity must therefore prioritize an effort to combat stigma and weight-based discrimination on multiple fronts. First, government and public health professionals need to invest in an aggressive public outreach campaign to promote awareness of the prevalence and consequences of obesity stigma. These messages would be separate from but complementary to the media campaign promoting body acceptance and would serve to inform the general public of the complex nature of obesity and the damaging effects of weight-based discrimination. Messages should strive to equate obesity stigma with other forms of discrimination to reframe it as an issue of human rights.

The second component of an intervention to combat obesity stigma should include mandatory training for educators and health professionals on how to identify and combat personal biases. Educators should be taught how to appropriately address weight stigma in the classroom--whether it be through leading discussions about body diversity or dealing with instances of weight-related bullying. Health professionals should learn how to prevent weight-biases from informing diagnoses, decisions about preventive care, and interactions with patients.

Through public outreach and training for educators and health professionals, public health advocates can hope to garner greater support for the enactment of more broad-based legal protections against weight discrimination. However, success will depend largely on the ability of health advocates to reframe obesity stigma as a human rights issue.

Toward a Systemic Framing of Obesity

Individual-level approaches to obesity not only promote stigmatization of obese and overweight individuals, they obscure the complex and multifactorial nature of weight gain in American society. In general, interventions that seek to alter health behavior by focusing on individual cognitions and attitudes have shown little promise as a means of promoting sustained behavior change among populations. This failure indicates the important role of social and environmental factors on individual health behavior.

Many researchers have argued, for example, that the higher incidence of obesity in minority and low income communities is the direct result of social and economic barriers to healthy diet and exercise. Maslow’s Hierarchy of Needs provides a useful framework with which to understand the way in which individuals prioritizes various human needs (31). The hierarchy is frequently represented as a pyramid, with the lower order needs (physiological, security) forming the bottom portion. The framework posits that lower order needs must be satisfied in order for an individual to pursue needs located higher up on the pyramid such as love and belonging, esteem, and self-actualization (31). Health would most likely be located in the top half of this schema, thereby representing a higher order need (31). Maslow’s hierarchy is particularly useful in understanding health behavior in low income populations. Many of the impediments to healthy diet and activity patterns among low income individuals can be classified according to Maslow’s model as unfulfilled lower order needs. Characteristics often associated with low income communities such as high crime rates, homelessness, and food insecurity consequently represent an important stumbling block for public health interventions that only target individual-level behavior change.

To meaningfully address rising obesity rates, it is therefore critical that public health advocates work to shift the debate toward a more systemic framing of the causes of weight gain in American society. A systemic view of obesity rates not only acknowledges the impact of environmental factors such as crime rates, neighborhood walkability, and access to supermarkets on individual health behavior, it also posits the important role of government intervention in the creation of a healthy and equitable food environment.

To promote population-level change, public health professionals should thus intervene by 1) working with communities to improve built environments and lower crime rates, particularly in areas with high obesity rates; 2) encouraging the federal government to take a more active role in combatting the social and environmental causes of weight gain; 3) pressuring the food and beverage industries to take greater responsibility for the creation of unhealthy food environments.

More specifically, public health officials should play a more active role in urban planning and community anti-crime initiatives to improve built and social environments, particularly within low income rural and urban communities. Neighborhood improvement plans should focus on aesthetics (i.e. graffiti, building repair), walkability (availability of sidewalks, proximity of commercial areas), and the development of community parks and playgrounds that are easily accessible to residential areas.

On the policy-level, public health professionals should pressure policy-makers to take a more active role in efforts to combat rising obesity rates. The federal government needs to allocate more spending to support and incentivize the development of state and local anti-obesity initiatives. In addition, the government should take a more active role in school-based health promotion by mandating daily physical activity and expanding programs to provide breakfast to all children in schools across the country. Finally, the government needs to exercise greater regulatory power over the way in which the food and beverage industry manufactures and markets food.

Most of these recommendations are not new. Some of them have in fact already been implemented to a certain extent by public health professionals as well as federal, state, and local governments. However, a more concerted and far-reaching effort is needed to substantively address the causes of rising obesity rates. The implementation of specific policy changes requires a more general shift in the way government and public health advocates think about the issue of obesity. It is only when the “body politic bears responsibility for the shape of individual American bodies” that policy-makers will be pushed to enact substantive reform (5, p.57).

Conclusion

Rather than examine a specific public health intervention, this paper has sought to provide a critical analysis of the more general way in which obesity has been thought about and addressed within both health and public discourses. Efforts to improve American diet and activity patterns have been shaped by a set of core beliefs or assumptions that have served to frame the issue as 1) a problem of weight and 2) a matter of individual choice and responsibility. This particular way of framing the “obesity epidemic” has served to promote both a societal obsession with thinness and the stigmatization of overweight and obese individuals. In addition, by focusing on changing individual attitudes and lifestyle choices, this dominant approach fails to account for the powerful impact of social and environmental context on health behavior.

The limitations of current understandings of the “obesity epidemic” and their adverse consequences for public health thus necessitate a shift toward an alternative approach. To bring about population-level change and attenuate existing health disparities, interventions should promote body diversity acceptance, combat weight stigma, and address the wide range of social and environmental factors that shape individual lifestyle choices in American society.

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