Metabolic surgery:
"You don't know what your transformation is going to look like"
A medical anthropological research on the perceptions of wellbeing and health among patientswho underwent metabolic surgery on Aruba
Name: Marloes van Drie
MSc Medical Anthropology and Sociology Supervisor: Dr. Else Vogel
Second Reader: Dr. Anja Hiddinga November 11, 2016
LIST OF ABBREVIATIONS
AAA = American Association of Anthropologists AZV = Algemene Ziektenkosten Verzekering BMI = Body Mass Index
HAES = Health At Every Size
HOH = Dr. Horacio Oduber Hospitaal GDP = Gross Domestic Product
IBISA = Instituto Biba Saludabel y Activo MEP = Movimiento Electoral di Pueblo NCD = Non Communical Diseases UK = United Kingdom
WHO = World Health Organisation
ACKNOWLEDGEMENTS
Before you lies my thesis as an occlusion of my Master of Medical Anthropology. This thesis is not just an occlusion of my master; it is also the end of an adventure. It brought me joy, frustration at times, and above all knowledge about the discipline and about myself.
The decision to undertake this adventure was not easily made. After I got my Masters Degree in Psychology, I was certified to work as a Medical Psychologist. However, the study program left me with lots of questions rather than with the so called “tool kit” to enter the work field. In the Master of Medical Anthropology I found the “tools” to further polish my thinking. I am proud that I am capable of presenting this thesis to you. However I owe much thanks to the people who have aided me during this process, and I would not want to start this thesis without using this opportunity to thank them.
First and foremost I would like to thank my informants, the wonderful and inspiring people on whose narratives this thesis is built. Without your openness, honesty and vulnerability, I could not have written the document that I finished today. Secondly, many thanks go out to the people I have met on Aruba who helped me realize the research project. These “gatekeepers”, as we call you in anthropological terms, made my stay on Aruba a beautiful and pleasant adventure. Alex Ponson, Yvonne Swierenga and Wendie Botjes, thank you for your interest in this project and thanks for all of the opportunities that you have created for me.
I owe much thanks to my supervisor, Else Vogel. Else has helped me to structure my mind and polish my thinking in all the phases that I went through while writing this thesis. The writing process was not always easy and I experienced her supervision as inspiring and motivating. I would like to acknowledge the Department of Medical Anthropology. I learned a lot during the courses I took.
Last but not least, Bram and Diane. Thank you for your unconditional support during the writing process.
TABLE OF CONTENT
1. Introduction 6
Thesis outline 9
2. Methodology, ethics and reflexivity 10
Data collection 10
Data analysis 11
Ethics 12
Reflexivity 13
3. Theoretical framework 15
A history of the globesity epidemic 15
One size does not fit all 17
Conceptualizing the body 18
Metabolic surgery: an uncertain cure 19
4. What is obesity? The meaning of obesity on Aruba 21
Obesity as a dangerous physical condition 21
Obesity as an economical burden 22
Obesity as a result of societal prosperity; the obesogenic environment 26
Obesity as a cultural identity 28
Interim conclusion 28
5. Pursuing good health: a patient’s exploration of metabolic surgery 30
Options to fight obesity 30
Being a good patient and being a good mother, it’s not possible at the same time: role conflicts in health seeking obese individuals 31 ‘They don’t see the real me”: conflicting identities 34 Metabolic surgery: revealing the true self or a quick fix? 35
Interim conclusion 37
6. Rebuilding life after metabolic surgery 38
Changing everyday eating practices 38
Social eating practices 39
Lack of nutrients 41
“Loose” skin and disease 43
Transformations and reflections after metabolic surgery: restoring identity 44
Interim conclusion 45
7. Conclusion and discussion 46 The potential of analysing paradoxes in patients’ lives 47
Bibliography 49 Annex A 55 Annex B 56
CHAPTER 1 INTRODUCTION
Bon Bini to Aruba, “one happy island”. This slogan pops into my vision everywhere I go in Aruba. It stands on the first poster I see at the airport, it is printed on billboards along the road and in my apartment it is the first sentence in the manual of the housekeeping to welcome me at my “home away from home”. I arrived at the island for my field study about obesity and metabolic surgery. In the past thirty years the prevalence of obesity has risen drastically in Aruban society with an estimated prevalence of 28% in 1993 to 41% in 2006 (Kock, Thijsen and Visser, 2008). This drastic rise of weight gain is not just occurring in Aruba, it occurs on a global scale over populations (Finucane et al, 2011). The World Health Organisation (WHO) released a report in 2000 that warned against a global “obesity epidemic”. The choice of the word “epidemic” triggers associations with images of close threat to citizens and pending catastrophes (Knutsen, 2015). The biomedical scientific literature I read prior to the fieldwork period continuously emphasizes the great dangers that overweight people are exposed to. The risky state of having “excess” weight severely increases risks on diseases like heart attacks, strokes, pains in joints, arthritis and sleeping problems
.
The message is clear: being overweight is almost as risky as being terminally ill. If this is to be true, how can Aruba with 78% of overweight inhabitants be the “happiest island of the Caribbean”?Nowadays many Arubans tell that they live on a “heavy island” instead of a “happy island”. By saying so, they link their body weight to their personal experience of happiness/well-‐being. One of the persons who thinks of herself as heavy is Mila. I met her in the surgical ward, because she wants to undergo weight loss surgery. She is certain that she will become happier when her weight decreases. “My health is going to change because of my weight,” says Mila. She continues: “Once you lost the weight, health will follow. And once your health is better, the other things will follow. I will feel better”. Mila wants to swap her heaviness into happiness.
Mila tells me that she is impaired by her weight. She is out of breath sooner than she used to be. Her knees hurt, she’s not able to walk long distances. As she does not have a driving license, she is currently dependent on her family and friends to transport her around the island.
Over the past years she tried to lose weight, for example by dieting. However, it was difficult to maintain her diet when she was at family dinners, parties and social activities. The local dishes she had over there did not correspond with what her American diet prescribed to eat. In the end, instead of achieving her deeply desired weight loss, she had only gained weight.
Mila’s case is illustrative for many people who struggle with obesity. Her case shows that the understanding of obesity is more complex than the single explanation of a disease-‐like phenomenon. Her body size also affects her social eating practices and her everyday life practices.
Paradoxically, even fighting her weight affects her everyday life experiences and social eating practices.
Mila hopes that metabolic surgery helps her to achieve her desired weight loss. Metabolic surgery is performed in Aruba’s only hospital since the year of 2002. Back in that year, only ten patients underwent the surgical procedure. They lost up to 85% of their “excess” weight. Nowadays, on a population of 102.000 citizens, more than two hundred patients per year undergo metabolic surgery. Many more patients are subscribed to the waiting list to have the surgery in the future. Mila has also subscribed. Today, she is in the waiting room because she has an appointment with the doctor to have her weight checked. The last time she saw him, the doctor told her that her body weight is 135 kilograms. The doctor calculated that she is able to lose up to 60 kilograms through a gastric bypass: a surgical intervention that downsizes her stomach from approximately 500 millilitres to 50 millilitres, “the size of a kiwi”. The following step in this surgery is the attachment of the stomach pouch to the small intestines. However, the top 1,5 metres of the small intestines are skipped in the re-‐attachment to the stomach. These first metres are essential for glucose uptake. By skipping the first part of the small intestines and thus reducing nutrient uptake, a successful surgery should result in a substantial loss of weight.
Metabolic surgery refers to any kind of surgical interventions that affects metabolic change. The gastric bypass is the most common surgery practiced in Aruba. Sometimes patients undergo a gastric sleeve mastectomy. In this surgery a large part of the stomach is removed with the major difference that the intestines stay untouched. Currently, the ideas about the effectiveness of metabolic surgery changed from initial restriction of food intake to changes in metabolism.
From a biomedical gaze, metabolic surgery is regarded successful when physical parameters like permanent weight loss and reduction of comorbidities are achieved (for example the reduction of diabetes related complaints) (Chang et al., 2014; Crookes, 2006 & Buchwald et al., 2004). Research that takes into account life after metabolic surgery, however, reveals a more complex account of when and why surgery may or may not be considered a “success”. Groven, for instance, describes Norwegian patients that experienced metabolic surgery as life changing, difficult, even the primary source that worsened their quality of life (Groven, 2010). Wouters stresses that Dutch patients may feel limited in their daily functioning because of skin abundance, increased diarrhoea and malodorous flatulence and fatigue (Wouters, 2010). Ryan and Murray have written personal accounts of the effects after undergoing surgery on their lives that caused unwanted transformations in their social lives, such as changes in their partner relationships or increased feelings of vulnerability (Ryan, 2005; Murray, 2013).
While the biomedical “success” of surgery is understood in terms of decrease of weight and reduction of comorbidities, metabolic surgery may in medical anthropological terms be
regarded as an uncertain cure1 (Throsby, 2012). Patients do not know what their “transformation” will look like before they agree to undergo surgery. Karen Throsby researched life after metabolic surgery in the United Kingdom. She writes: “Even though many reach a “healthy” weight, for some, this is at the cost of ill-‐health. This tension problematizes the presumed positive relationship between health and slimness”, that many patients hope to reach after agreeing with surgery. Especially among this group of metabolic patients ambiguity exists about what is good health and what is not.
Additionally, but not less important: the tension between social and biomedical beliefs about weight and health varies tremendously over time and place. These beliefs are built upon historical, cultural and economical elements that are specific to a local context. In my research, this local context is the Aruban culture in which body size is considered a reflection of health on the one side and illness on the other side. Furthermore, body size may for example be understood differently in terms of prosperity/poverty and attractiveness/sloth.
I use the everyday life experiences of metabolic patients to gain insight in how metabolic surgery is understood in the specific local context of Aruba. Their narratives tell us what it is like to live with 1) obesity and 2) metabolic surgery and how they try to access health on this “heavy island”. I refer to this type of patient information as, what Jeanette Pols calls, patient knowledge. This is a kind of “expertise” that differs from medical knowledge, but is in no way less valuable (Pols, 2013). Their everyday experiences render how metabolic patients try to embed practical and medical knowledge into their daily lives in order to live with their changed metabolism.
In this thesis I explore the understanding of body size, obesity and health from the perspective of Aruban patients who either undergo or underwent metabolic surgery. My goal is not to provide a critical overview of obesity and metabolic surgery. My aim is to map the tensions around obesity and metabolic surgery that are specific to Aruba. I frame my informants as healthcare experts alongside the clinicians. Having the improvement of health as their mutual goal, clinicians and metabolic patients all bring their own kind of “expertise” in obesity specific health care. I argue that the tensions in their understandings of body size, obesity and health before and after metabolic surgery may provide us with valuable insights that may contribute to the improvement of obesity specific health care programs on Aruba.
1 Anthropologist Cassandra White has introduced the concept “uncertain cure” in her ethnography about living with
Leprosy in Brazil. I adopt this concept drawing upon Karen Throsby’s interpretations (2012). She used the concept to describe metabolic surgery in her paper “Obesity surgery and the management of excess: exploring the body multiple”
Thesis outline
This thesis will take the reader through patient experiences as they undergo metabolic surgery. Chapter 2 is about the employed methodology, its ethics, data analysis and limitations. It will also address a personal reflection on the fieldwork and data collection process.
Before I discuss and interpret the empirical data, this research will be placed in context by outlining the main bodies of social scientific literature on obesity and metabolic surgery that have informed this study throughout. This outline is to be found in chapter 3.
The first empirical chapter is chapter 4. In this chapter I provide a detailed overview of Aruban understandings of obesity and overweight, which are specific to time, location and sociocultural elements.
In Chapter 5, I merge the narratives of patients to construct the line of a fictional ‘typical’ patient. The chapter thus traces how patients start to problematize their body weight, aim to reduce it, and ultimately opt for metabolic surgery.
In Chapter 6, the narrative of this ‘typical’ patient continues after she underwent surgery. She reflects on life as she knew it when she identified herself as obese and how her life has changed through surgery. This chapter aims to give insight in patient experiences after metabolic surgery.
The outcomes of the empirical research will be summarized in the conclusion in chapter 7. This chapter also includes a discussion in which implications for practical outcomes are presented.
CHAPTER 2 METHODOLOGY, ETHICS, REFLEXIVITY
2.1 Data collection
This thesis is based on eleven weeks of qualitative ethnographic research conducted on Aruba between January and April 2016. A major advantage of organising fieldwork abroad is the enabling of analysis of everyday routines from an outsider point of view. “The ethnographer, as a stranger, can observe the minutiae of organizational life and, through analysis, offer an account of ‘what is happening’” (Green & Throrogood, 2014: 157).
The data collection started in the primary hospital of Aruba, the Horacio E. Oduber Hospitaal. This prominent building is located on the outskirts of Oranjestad, the capital of the island. The primary location of the hospital has a capacity to house 400 patients. Metabolic patients go to a separate ward for their check-‐ups, approximately 200 meters from the main entrance. This surgical ward contains two small waiting rooms and four offices for the hospital’s surgeons. An important share of my empirical data was gathered in this ward through participant observation. In the very beginning of my fieldwork I was in the ward for approximately four to five days per week. I mostly joined check-‐ups with patients to familiarize with the language (Papiamento) and the consultations to access metabolic surgery.
I additionally attended information sessions where patients could go to get information about the gastric bypass procedure. The surgeon who performed metabolic surgery hosted these sessions. Here I was able to chat with many patients about their views on and concerns with metabolic surgery. I spent my lunch break in the hospital with the doctors and the administrative staff. Thus I was able to observe and collect information by active participation in hospital life. The active participations allowed me to explore both the patient’s and the clinician’s perspectives. Furthermore, I always made sure to transcribe and write out field notes in public spaces. Arubans generally like to chat, so by working in café’s and the library in the hospital I had lots of informal conversations thus getting a sense of general perceptions of eating, health and weight.
Furthermore, I formally interviewed 16 patients who either underwent or will undergo metabolic surgery. They informed me about their lived experiences of being obese and opting for surgery. These interviews were recorded and transcribed in a verbatim and lasted approximately 90 minutes. The interviews mostly took place at the homes of the informants and incidentally in a clinical setting (i.e. ward’s waiting room or surgeon’s office). Another 17 health care professionals (ranging from hospital staff, psychologists and dieticians) informed me about the availability of obesity health care. Furthermore, I conducted an interview with the chief of the national health insurance company. Lastly I held an interview with the minister of health. These two interviewees informed me about the island’s obesity politics. Every interview was recorded and took place at
the office of the professional. All informants were recruited through gatekeepers in the field (e.g. the governor of the hospital, a prominent socialite). The questions I asked my informants were the same among patients and health care professionals. They covered topics of having/treating obesity and everyday eating experiences, to gain insight in the everyday impact of obesity. I chose to follow the topics of interest that the informants brought up, to “develop their own account on the issues important to them” (Green & Thorogood, 2011).
In addition to interviews and observations, I collected all the available literature on obesity on Aruba that I could find. Earlier Aruban research on obesity includes, for instance, a qualitative study on eating habits (1994) and a general monitor of Aruban Health (2012). Furthermore, I collected the documents on public health policies that were publicly available. The first public plan dates from 2009 and was written under supervision of the minister of health at that time, dr. Richard Visser. His policy is maintained until the day of today by the financial support to the governance of Instituto BIba Saludabel y Activo (IBISA, institute for a healthy and active life), which is the governmental institute for health promotion.
Finally, I have used auto-‐ethnography in this research. Auto-‐ethnography is described as a method and way of reporting where the researcher reflects upon and uses her experiences to understand the field (Wall, 2008). I deemed this important, as before this research I worked as a psychologist in a Dutch obesity clinic. I thus entered the field with my own norms and beliefs about eating behaviour and health. During the fieldwork period I constantly reflected on the information I gathered while I processed the information. For example, one of the questions that I did not know the answer to was why obesity rates in Aruba are higher compared to other Caribbean islands. I have let my search for ethnographic data be guided by these questions during my access to the field. As a consequence, my research project transformed from an initial research about the impact of metabolic surgery into a research that investigates the perception of obesity on Aruba.
2.2 Data analysis
Although the study proposal was based on theoretical frameworks (i.e. deductive analysis), the eventual presentation of results in this thesis was primarily derived from a close reading of the data (i.e. inductive analysis) without trying to fit it within existing theoretical frameworks. Thematic content analysis was applied on all the formal and informal interviews. The transcriptions were manually coded and organised by the ethnographer, according to four major themes that were inductively accomplished. The themes were: 1) norms and values on obesity, 2) everyday eating practices before and after metabolic surgery, 3) healthy living in practice and 4)
self-‐care and coping. Results of the analysis with respect to the data are presented in chapter 4, 5 and 6 and complemented with observations, literature analysis and personal reflections.
2.3 Ethics
The research proposal on which this research is based was officially approved by the University of Amsterdam and by the ethical committee of education of the HOH (Dr. Horacio Oduber Hospitaal). I have very kindly received reimbursement of research expenses from the hospital for the exploitation of this research. However, this compensation has in no way influenced the methodology, research objective or research outcome of this thesis.
In accordance with the research ethics of the American Association of Anthropologists (AAA) and of the hospital, the main principles throughout my fieldwork and throughout writing this thesis were informed consent, confidentiality and informant privacy. All interviews were conducted after I verbally explained the agreement of informed consent and possibility to withdraw at any moment without any consequences for the to be received healthcare. For the short conversations I had in cafes and the library, I always asked permission to report their input afterwards and I was never refused to report their answers.
Most importantly, I ensured my informants that they would not be identified by their names. This was particularly imperative as Aruba is a small island where everybody knows everybody. Their answers contained personal information to the extent that using their life stories as an illustrative box would lead to violation of their privacy. Drawing upon this given fact, I chose to write chapters 5 and 6 from the point of view of a fictional patient, who is based on the narratives of all my patient informants.
Whenever I noticed that my participants were not comfortable in discussing in Dutch or English, I called in someone who could translate. This sometimes led to interesting conversations in which I was able to include the translator as an informant. For example, in one of my interviews the partner of a metabolic patient helped me to translate my questions. While her husband was enthusiastic about his surgery, she gradually expressed her discomfort about the preparatory procedures her husband attended. Although her husband felt prepared to undergo surgery, she as a wife felt worried about what was going to happen to him and to her family in general. In cases like this, I additionally asked for verbal consent to register the accounts of those who translated.
2.4 Reflexivity
At the very onset of my fieldwork I was concerned whether a person with a BMI (Body Mass Index) of 20,5 kg/ m² is able to write about obesity. I wondered whether I would be able to
empathize with people who classify themselves as obese. Furthermore, I feared that my posture provokes feelings of stigmatization and ‘othering’ among persons who identify themselves as fat. However, following Deborah Lupton (2013), everyone is caught up in or reacting to obesity discourse, whether they identify themselves as obese or not. “We are all potentially fat people, unless we take steps to constantly monitor and discipline our bodies”
I have worked before as a psychologist in an obesity clinic. On the one hand I feel advantaged as I have seen and treated many obese individuals, I can easily empathise with the patients and relate to what might be relevant for them. On the other hand, my previous interactions as a psychologist were geared towards diagnosing and treating patients, not to learn from them. My existing knowledge was at the onset dominated with medical/psychological understandings and normative judgments about obesity. Therefore I ascertained during my fieldwork that I would be constantly reflexive of my own understandings to actively put them aside. This helped me to fully follow and understand the story that informants told me about obesity and metabolic surgery.
Only after I entered the field, I realised that my Dutch origin might affect the data collection process. Aruba was formerly colonized by The Netherlands and although it is officially independent since the status aparte in 1986 (Aruba Gobierno, 2016), Aruba is until today under Dutch political supervision -‐ which for example leads to dependence of Dutch accordance on political decisions. In everyday life, the island’s history with The Netherlands is noticeable through a complex relationship between native Arubans and Dutch inhabitants (12% of the total population, Dutch expats and temporal workers not included (Aruba Health Monitor 2012: 27). Inhabitants who completed their education in The Netherlands (either Aruban or Dutch) are favoured for governmental positions and accompanied civil benefits. To access governmental support one needs to apply in Dutch, although many low-‐educated inhabitants only speak Papiamento. Aruba has two major political parties, and one of them (MEP, Movimiento Electoral di Pueblo) currently promotes complete separation from the Kingdom of the Netherlands. While I was doing fieldwork, I realised that my major concern should not lie with provoking feelings of inferiority at the informants’ side because of my body size, but rather because of my nationality. In response, to enable myself to open conversations, I tried to learn Papiamento, familiarize with local habits and food. Furthermore, it helped that some inhabitants, whom I befriended, became gatekeepers, expressing their trust in me towards their relatives and friends.
A final concern is how to describe patients with a large body size. Following Warin and Gunson I need to acknowledge the ways in which language operates through our bodies and through those of the people I work with (Warin & Gunson, 2013). Some may identify with being obese, while others may not identify with this diagnosis. In this thesis I refer to “obesity” and “being obese” when I discuss the medicalisation of body weight. This generally is accompanied by
associations of disease, disciplining the body and moral failure. When I use “large bodies” however, I describe overweight among people who do not identify themselves as obese or do not experience weight-‐related complications. By separating these two concepts, I distinguish between whether people think of obesity as a problem or not.
CHAPTER 3 THEORETICAL FRAMEWORK
In the introduction I chose to present the case of Mila, as it resembles the cases of many other Arubans. She is a striking example of 1) a person with severe body weight who feels limited by it and 2) opts for a medical intervention (metabolic surgery) to redirect her life to achieve what she considers ‘healthy’: a life that is not impaired by her weight. In this chapter I will elaborate on these two assumptions. Furthermore, I will provide an overview on relevant social scientific readings that touch upon these assumptions. I will start with outlining the history of obesity and the medicalization of large bodies from a social science perspective, to unravel the context in which obesity is framed today. The next section is concerned with social scientific perspectives on this growing medicalization of body weight. In the following section I discuss the sociocultural understandings of overweight and obesity in general. Here I show that large bodies are not necessarily negatively associated. I will show that elements like time, location and history are important for obesity perceptions. After that, I will touch upon metabolic surgery as a method to reduce body weight and I will outline the main social scientific arguments concerning this intervention. Lastly, I bring forward that every geographical location needs its own research about the meaning and impact of obesity and metabolic surgery.
3.1 A history of the globesity epidemic
In the year 2000, the WHO released a report that warned against a worldwide ‘globesity epidemic’. Their choice to use the word ‘epidemic’ triggers images of associations with contamination, disease and catastrophes that threaten citizens in their wellbeing (Knutsen, 2015). The framing of obesity as a disease-‐like phenomenon (Chang and Christakis, 2002; Gremillion, 2005; Jutel, 2006; Nicholls, 2013; Felt et al., 2014) invites for medical anthropological deliberation. Nowadays, the WHO defines obesity as “the condition of abnormal or excessive fat accumulation in adipose tissue, to the extend that health may be impaired” (WHO, 2000).
However, instead of assessing obesity by fat accumulation, obesity is in Aruba defined according to the assessment of BMI. But where does the BMI come from and how does it indicate a physical state in which body tissue threatens health? The answer lies in epidemiological research.
In the early twentieth century, medical research found that increased risk of mortality was associated with overweight (Ulijaszek & Lofink, 2006). With the goal of statisticians and epidemiologists to assess health risk management, the need for tools to compare body weight across places and over time increased (Hacking, 2007; Fletcher, 2014). Isabel Fletcher, in her history of development of BMI, describes how over the years several tools were developed to assess body fatness. The tools included time-‐consuming measurements of the abdomen, under
water weighing, body imaging through X-‐ray, ultrasound and anthropometry, of which BMI is the most common one. Ultimately, the BMI was widely adopted as the standard measure to assess body fatness, because the upper end of body weight distribution corresponded with increased risk of mortality and chronic disease: coronary heart disease, high blood pressure, stroke and diabetes II (WHO, 2000), but also because of its user friendliness and low assessment costs (Hacking, 2007). Although it was never meant to apply to individual assessment, BMI has evolved into the preliminary tool that is used today to classify obesity. The categories currently range from underweight (<18,5 kg/m²), normal weight (18,5-‐25 kg/m²), to overweight (25-‐30 kg/m²) and obesity (>30 kg/m²).
Classifying weight creates insight in who is prone to develop weight-‐related disease and who is not. The French philosopher Michel Foucault introduced the term biopower for this process of classification. Biopower refers to practices in which epidemiology, statistics, demography and technical information about health and illness among populations may be used to achieve political goals (Rabinow & Rose, 2003). Medical information shapes what is considered “normal” and what is “abnormal” or “deviant” in a social sense. In the case of obesity, this means that through medical, popular and governmental discourses, obese individuals are encouraged to lose weight until they reach the normalized BMI range and to keep their weight lowered to avoid health risks. The classification of weight further provides information on who is at risk to develop comorbidities and who will be at risk to consume costly healthcare (which is an expensive procedure for the state) and who is not. These statements are political as they capture assumptions on how citizens should be to become efficient and burden free for the state. The term governmentality, also coined by Foucault, describes modern states’ regulation of the individual to reduce risk situations that threaten the productivity of the population as a whole. It represents a modern view of health regulation that takes place when nations moralize and direct citizens by influencing their self-‐care (Foucault et al., 1991). In the Western neoliberal society2, governmentality led to a focus on individuals’ responsibility for their own health (Guthman & DuPuis, 2006; Knutsen, 2012). Hence, the obese individual is encouraged to take responsibility for controlling his/her body weight with the ultimate goal to reduce (assumed inevitable) future health risks.
2 I refer to neoliberal society as a social environment that attempts “to tear down what its adherents considered
restraints to capital accumulation” (Guthman and Dupuis, 2006: 441). Obesity, in this definition, is regarded as a limitation for optimal development of capitalism. For example, obesity is reducing work related productiveness (Murphy, 2004) and it is problematic for flight companies in terms of fuel costs (Yee, 2004).
3.2 One size does not fit all
BMI has evolved into a simple tool to assess weight that is medically deemed “normal” and “abnormal”. However, this indicator has it shortcomings to approximate health impairment through body weight. One of the major flaws of BMI as a classification tool is its inability to distinguish between bodily tissue distributions that vary over populations. For example, research showed that BMI and fatness do not correspond well among Chinese populations (Li et al., 2002). Furthermore, the use of BMI cut-‐off standards as classification of obesity among children is problematic because of altered ratios of body tissue (Cole et al., 2000). These studies and many more show that a certain weight range does not necessarily correspond with increased health risks.
Not only BMI has been criticized, obesity itself is also subject of debate. The Western medicalisation of obesity as a dangerous health status resulted in associations with gluttony, sloth, lack of self-‐discipline and something which individuals chose to “let” happen (Knutsen et al., 2012; Guthman & DuPuis, 2006; Greenhalgh, 2015). Driven by a concern with internalisation of stigma and following eating disorders, feminist scholars have protested against the moral, cultural and aesthetical convictions that favour thinness among females. They unravel the functioning of discourses on obesity as war on large bodies, which is covered under a medically substantiated message (Greenhalgh, 2015; Bordo, 1993).
The Health At Every Size movement (HAES) presents a slightly different point of view. Their understanding of obesity bridges the gap between medical concerns about the link between BMI and health on the one side, and feminists’ claims about the cultural war on obesity on the other side. Members of HAES question whether space exists for various opinions in ‘the obesity debate’, which is au courant, dominated by “medically proven” arguments against fat. Relating themselves with fatness rather than with obesity, HAES-‐members reject moral condemnation that is associated with large bodies. Their main concern is to extend the obesity debate with the intention to disconnect body size from disease3 (Rich, Lee & Aphramor, 2011).
The social informed criticism on obesity and body size is important for this research as it outlines the paradoxes in discourses about body weight and health. For example, BMI is now used to assess risks on health impairments due to “excess” weight over populations. However, these risks are impossible to translate directly to the lives of individual persons who identify themselves as obese. Likewise, the experience of being sick cannot directly be translated to body weight. By outlining these discourses, I stress that the biomedical explanation of obesity that link health experiences to “excess” weight is a one-‐sided explanation of a phenomenon that may be
explained in various alternative ways. We need to take this into account when we want to learn of patients’ health experiences.
3.3 Conceptualizing the body
In the previous sections I first outlined biomedical understandings of obesity. Secondly, I provided an overview of the main bodies of social understandings of obesity. Furthermore, locally specific elements like differences in culture, economic/social status and food access all have a dominant share in shaping body weight and (aesthetic) bodily perceptions. Thus, these locally specific elements shape various perceptions of obesity over time, place and social meaning making (Garth, 2013).
That obesity in local socio-‐material contexts may take on quite distinct and surprising meanings, is particularly evident in the work of anthropologist Jessica Hardin. She discusses the Samoan understanding of obesity as an embodied form of Mana4, a divine interconnectivity between supernatural forces and the village chief. Corpulence here is the physical proof of presence of divinity (Hardin, 2013). Anne Becker describes obesity as a Fijian protection mechanism against macake, an illness explanatory model that is marked by lack of appetite (Becker, 1995). Eileen Anderson-‐Fye, in turn, shows how in Belize, ‘curves’, regardless of body size, are associated with beauty, attractiveness and fertility (Anderson-‐Fye, 2004). Alexandra Brewis, in her geographical assessment of body norms, outlines how Tanzanians wield a fat-‐ neutral consensus that hence does not result in fat stigma. However, Brewis also points to the worldwide migration of Western body ideals. She shows, for example, how as a result, Mexicans and American Samoans wield both positive and negative fat conceptions at the same time: on the one hand, they think of fatness as a sign of good caregivers, and on the other hand they adhere to Western medicalized understandings of fatness as health-‐threatening (Brewis et al., 2011). Becker also found a transition of ideal body conceptions among Fijians that shifted in only a few decades from corpulent to slim (Becker, 1995). She writes: “The fluidity of body weight ideals is neither unique to Fiji nor historically extraordinary” Indeed, Americans have undergone the same transition in body ideals in the twentieth century, as Susan Bordo points out in her book “Unbearable Weight” (Bordo, 1993). Nowadays, other geographical areas follow: the popular discourse that links large bodies to sickness becomes increasingly prevalent. Likewise, throughout this thesis it will become clear that Aruba’s local understandings of obesity and overweight are subject to change as well.
