David Haslam, Fiona Haslam
Liverpool, Liverpool University Press, 2009, ISBN: 9781846310935; 326pp.; Price: £65.00
Date accessed: 24 February, 2017
The co-authors of this volume are David Haslam, the Chair and Clinical Director of the National Obesity Forum and Fiona Haslam, a former physician, art historian, and the author of a distinguished study of From Hogarth to Rowlandson: Medicine and Art in Eighteenth-Century Britain.(1) This summarizes both the strength and the weakness of this comprehensive study of the representation – and the reality – of fat in high and popular culture in the West. The study assumes a set of given physiological (and by implication psychological) models for obesity that are seen as transhistorical: if you are fat you have the following pathologies listed from apnea to … Cultural sources are then used to document the transhistorical nature of this list of symptoms, but the study also assumes that the very concept of representing fat has specific ideological implications ranging from notions of ‘gluttony’ to those of ‘sloth’. These associations are seen as being very time-bound and rooted in specific cultural and/or religious views of the body.
Yet in the 21st century even the new global medicine of obesity stresses that there may well be a plurality of often-conflicting causes (read: meanings) of obesity. Central among them, however, are social and genetic-physiological explanations:
1) A shift in ‘quality of life’ and life expectancy. We live longer now, have less physically stressful occupations, and have easier access to more food. ‘The epidemic of obesity can be understood as a logical consequence of the fact that it has become progressively easier to consume more calories while expending fewer.’(2)
2) The idea that we depend psychologically on food as a means of manipulating our immediate environment. This is an assumption that obesity is simply on a continuum with anorexia nervosa, which has been so defined by psychologists. Obesity is thus a mental illness, but this category itself shifts from a psychological to a somatic one.
3) Abundant access to poor food and the absence of structures to engage physical activity: the obesity of poverty argument.
4) The loss of control over our consumption of food because of our addictive behavior. Addiction is usually understood following the medical model of some type of pathological genetic predisposition in an individual or a group rather than a ‘weakness of will’.
5) A ‘normal’ genetic predisposition understood in terms of evolutionary biological drive to accumulate body fat in order to preclude starvation in times of famine. This is the ‘ob-gen’ (or ‘thrifty-gene’) argument discovered in work on the genetics of obesity in mice that extrapolated its findings to human beings.
6) A disruption of normal growth because of the changes in the endocrine system though pathological changes including aging (also understood as pathological).
7) The result of infection since over the past 20 years six different pathogens have been reported to cause obesity in animal models as well as humans.
What is clear is that any single explanation maybe possible for any given individual, but it is the social implications of ‘obesity’ that have now turned it into today’s ‘epidemic’ of obesity. The cultural implications of these claims are vitiated by specific, contemporary attitudes towards the body and its meanings within the system in which it is found. As a culturally bound concept ‘epidemic’ today has the power that ‘gluttony’ had in the Middle Ages. Both gain their power from the system of meaning that shapes attitudes towards socially acceptable and non-acceptable categories. We must remember that this anxiety about epidemics is a recent if resurgent phenomenon (it mirrors the rhetoric of the 19th century). As late as 1969 the then Surgeon General of the United States, William T. Stewart, suggested to Congress that it was now ‘time to close the book on infectious disease as a major health threat’. Three decades later, in 1996, Gro Harlem Brundtland, the then Director-General of the World Health Organization, gave a very different prophecy: ‘We stand on the brink of a global crisis in infectious diseases. No country is safe from them’. We moved from a sense of accomplishment to one of foreboding. The new epidemic is that of ‘fat’ – though in 2009 ‘swine flu’ has come to challenge for the moment its centrality in the public sphere. The Haslams believe that their physiology of fat reflects transhistorical (evolutionary or physiological) truths, not cultural meanings grafted onto the social implications of body size.
Constructing diseases such as obesity does not always mean inventing them. Often real pathological experiences are rethought as part of a new pattern that can be then discerned, diagnosed, and treated. Obesity as a category has been the subject of such a public reconceptualization over the past decades. It has become the target of public health campaigns and spurred a global rethinking of where the sources of danger for the public may lie. Fat people exist in the world, but the boundaries of what defines ‘fat’ and the meanings attached to it are constantly shifting. Such a rethinking mixes together and stirs many qualities in order to provide a compelling story that defines ‘obesity’ as the ‘new public health epidemic’. This is not to discount the costs, both personal and national, that overweight can accrue, but to understand why, in the 21st century, we have suddenly seen the ‘moral panic’, which was associated in the 1980s with HIV/AIDS as a potentially global disease, being transferred to obesity. Indeed, the moral panic about obesity seems to have filled a gap left by the restructuring of the moral panic about AIDS, today mistakenly seen as curable, just as AIDS filled the gap left in the West by the ‘conquering’ of syphilis.
Moral panics can reflect ‘real’ situations in the world. The very term had its origin in Jock Young’s study of the beginnings of the British drug scene: ‘The role of the police as amplifiers of deviance, negotiators of drug control as seen in Notting Hill’.(3) It has since been used to analyze social ‘epidemics’ such as ‘child abuse’ and, of course, the American ‘war on drugs.’ Obesity clearly exists in the world; but how it is defined is culturally, not scientifically, limited and the centrality of it in the mental universe of any given individual is heavily dependant on the role of anxiety associated with it. In our ‘dieting’ culture obesity has come to have meanings well beyond health and beauty; it has become a danger to the ‘body politic’ because of the every mounting costs of those diseases associated today with obesity and so well described by the Haslams.
Scientists at the annual meeting of the American Association for the Advancement of Science in February 2002 had already warned the government that obesity was now a ‘global epidemic’ – no longer confined to western, industrialized societies. This reflected a growing consensus in the 1990s that obesity (not smoking) was going to be the major public health issue of the new millennium. By 2005 the ‘war against obesity’ had replaced the ‘war against tobacco’, even though worldwide tobacco sales continue to increase. The phrase ‘war against obesity, sloth, and addiction’ appears in the UK in The Times as early as 1981 (4), and though sloth now seems an odd concept to be associated with the medicalization of obesity, the ‘laziness’ of the obese (read: their resistance to treatment and their non-compliance and their recidivism) is part of the vocabulary of obesity today.
As I noted this is a comprehensive study of BOTH ‘medical’ and ‘cultural’ representations of obesity, which makes the problem of the volume even more engaging. The notion that representations validate medical views seems very 19th century, very much enmeshed in a Rankian positivism rarely seen today in studies of medical imagery. Yet the study is sophisticated enough to engage in a rather good summary of the ideological meanings grafted onto to the constructed categories of obesity over the ages. But in its analysis of medicine remains a sphere seemingly devoid of ideology. Thus the representation of medical knowledge is one that centers on the ‘facts’ of contemporary medicine and their antecedents. That there are recent approaches to obesity that are no longer seen as ‘scientific,’ such as the psychoanalytic ones proposed by Hilde Bruch in the 1950s, is ignored. But of course in the 1950s these approaches assumed that they were the cutting-edge scientific explanation – and they were! Such claims of science as a true representation of the world, rather than a flawed or partial one, seem to be inherent to the science of obesity itself. And yet as indicated by my list above, even the medical authorities of our day seem not quite clear as to what obesity is and what its implications are. Do we assume that we are a fat collecting species? Do we assume that we are an addictive species? Is this not an inherent contradiction: if collecting fat is natural because it is preprogrammed in us genetically due to evolutionary processes how can it be pathological? How can an addiction to food be anything but natural and therefore non-addictive?
The Haslam volume brings together a wide range of sources, wonderful reproductions, and a basic approach that will give many students pause. Certainly we know what is ‘fat,’ don’t we? They ask already. We certainly do at any given point and this volume makes that clear. But our present wrestling with body size is yet one more point on the spectrum of dealing with ‘fat,’ now seen as a danger to health and, therefore, to society. An economic imperative seems to underline much of this discussion. Like the discussion about smoking in the 1960s, it is not just a public health but also a question of economic impact that caused governments to focus on certain aspects of risk. Today’s cigarette is the high fat, high sugar snack. Both are certainly dangerous but they also are the focus of a moral panic. The history of this may be better sketched in a number of other, more recent studies, such as my own Fat: A Cultural History of Obesity.(5)
- Fiona Haslam, From Hogarth to Rowlandson: Medicine and Art in Eighteenth-Century Britain (Liverpool, 1996).Back to (1)
- Michael L. Power and Jay Schulkin, The Evolution of Obesity (Baltimore, 2009), pp. 41–2.Back to (2)
- Jock Young, ‘The role of the police as amplifiers of deviance, negotiators of drug control as seen in Notting Hill’, in Images of Deviance, ed. Stanley Cohen (Harmondsworth, 1971), pp. 27–61.Back to (3)
- Annabel Ferriman, ‘The man who will try to persuade us to give up some of life’s good things’, The Times [London], 7 August 1981, 12.Back to (4)
- Sander L. Gilman, Fat: a Cultural History of Obesity (Cambridge, 2008).Back to (5)
Thank you for allowing us to respond to this review by Sander Gilman whose work we have admired and enjoyed.
The purpose of a review, however, is to give potential readers an idea of what to expect from a book. Gilman disappoints by using the flimsiest of references to Fat, Gluttony and Sloth as a hook to write an essay of his own on swine flu, HIV, BSE, tobacco, drugs and child abuse, finished off by what might be considered as a brazen plug for his own work. In fact the majority of his review is lazily cut and pasted from pp. 20–2 of his own Fat: a Cultural History of Obesity.
But more disappointing is his misunderstanding or misinterpretation of the aim and the audience of our book which we hope will be read and enjoyed by a general readership as well as to those particularly interested in medical, social and cultural history. With this in mind, we have deliberately avoided using such complex language as that sometimes employed by the reviewer in order to make our study accessible to a wider readership. In his review Gilman states: ‘The Haslams believe that their physiology of fat reflects transhistorical (evolutionary or physiological) truths, not cultural meanings grafted onto the social implications of body size’.
a) We are not sure what this sentence means (or why we seem been granted our own physiology)
b) This is an example of the rather complex language that we have omitted in Fat, Gluttony and Sloth in order to ensure that our study is widely accessible.
The global obesity epidemic is a recent phenomenon, and there has been a dearth of research or literature on its history. Gilman’s work is an admirable exception, and Fat, Gluttony and Sloth acknowledges its importance, especially ‘Fat boys’, which is referenced several times.
There are different strands of work relating to the history of obesity by various commentators: work such as Gilman’s written from the academic cultural historian’s viewpoint, and aimed at an academic and intellectual readership; versus that of authors such as George Bray from the Pennington in Baton Rouge and Stephan Rössner from Karolinska in Stockholm, both world leaders in the medical science of obesity and its clinical management. Fat, Gluttony and Sloth follows in the footsteps of its clinical predecessors, but is aimed at a wider, less academic, more general audience. Gilman’s own new volume advances the cause of cultural studies, but is not from the same pool as Fat, Gluttony and Sloth so should not be held up as a competitor. Fat, Gluttony and Sloth is the first time all the strands from clinical to pharmacology, art, literature and religion have been drawn together in one work, and has been done from the perspective in which its authors are skilled.
The distinction between a clinician’s view of obesity and a historian’s could not be better highlighted than by Fat: A Cultural History of Obesity, Gilman’s new offering. His historical and sociological views are excellent and entertaining. But when Gilman turns to clinical matters, the result is woeful confusion. His mixing up of narcolepsy (‘narcolepsy seems to be the appropriate diagnosis for the fat boy’s problem’ (p. 65)) and obstructive sleep apnoea, in a youth whose Epworth Score is off the scale, but has no evidence of narcolepsy is naive, but his confusion surrounding hypothyroidism and hyperthyroidism: Graves disease, myxoedema, and thyrotoxicosis; is unforgivable. His suggestion of treating ‘exophthalmosis’ (actually ‘exophthalmos’) with thyroid extract, would get him struck off the medical register in an instant. His application of ancient, historical, non-evidence-based, psychological regimes to assess Dickens’ ‘Joe’s’ mental state to a 21st-century readership is disingenuous to say the least. Whereas Gilman trawls literary critics’ views on Dickens’ work, we assess the clinical aspects of his condition based on the original text rather than speculation.
David Haslam is a practising GP who sees around 10,000 patients per year in primary care, as well as many of the biggest people in society in his twice weekly Luton and Dunstable Hospital Bariatric Surgery Clinic. He has recently been awarded an Honorary Chair at Robert Gordon University in Aberdeen in recognition of his international work in producing guidelines and providing education to combat obesity. He is chair of two national charities with the same aim, and has written several text books and over a hundred scholarly articles on the subject. Fiona Haslam’s career was spent in clinical medicine until her retirement when she obtained a degree in art history and a PhD for her work on medicine in art, and has written extensively on the subject. Hence the book has been written mainly from a clinical perspective, as the authors have a unique body of knowledge and experience in this arena.
With regard to our use of medical imagery, chapter 12 is prefaced by an acknowledgement that images are used by artists to express meaning in narrative, and that their views might be biased and do not necessarily reflect the true picture in society as a whole. They do, however, provide some useful information regarding the presence of obesity and perceptions of how it has been viewed over the years. Gilman’s comment, therefore, that we have notions that our representations ‘validate medical views’ is unwarranted.
To address specific criticisms:
1) ‘These associations [gluttony and sloth] are seen as being very time-bound and rooted in specific cultural and/or religious views of the body’. The authors are documenting historical views and comparing and contrasting them to modern attitudes.
2) ‘Yet in the 21st century even the new global medicine of obesity stresses that there may well however, are social and genetic-physiological explanations:’ The multifactorial nature of obesity – clinical, environmental and cultural – is clearly tackled in the book, from the introduction onwards
3) A shift in ‘quality of life’ and life expectancy. We live longer now, have less physically stressful occupations, and have easier access to more food. ‘The epidemic of obesity can be understood as a logical consequence of the fact that it has become progressively easier to consume more calories while expending fewer’ This statement is comprehensively covered from the introduction onwards. To die 10 years prematurely, a person must achieve ~65 years, and as the obesity epidemic is in its relative infancy, most obese individuals have not gained sufficient age to die ten years prematurely. When they do, we will see life expectancy reduce.
4) The 1950s onwards isn’t ignored, just (in the main) beyond the scope of the book. Modern diets and behavioural/psychological regimes are documented by other authors, and outside the sphere of relevance of this book, but Fat Gluttony and Sloth covers good and bad science equally.
5) Gilman’s ‘criticism’ of our ‘basic’ approach is perhaps a compliment. It is a popular, entertaining, sometimes provocative, approach to the subject of obesity, covering aspects of the history of obesity through medicine, literature and art.
Fat, Gluttony and Sloth is not intended to compete with volumes such as Gilman’s own excellent work, but to be complementary to it, intending to attract a different readership to the subject.