Culture and Inequality in the Obesity Debate
Posted by dlende on April 4, 2008
So far in the posts I’ve done on obesity, I have been focused on the biology behind obesity. Part of that is due to my class and what this particular section of the course covered—showing them a biological approach to a health problem. But as I have been going over research on obesity, I’ve collected a number of links and articles on culture, social class, and obesity. So I am going to share those here.
Let me say one thing. In biomedicine and particularly in epidemiology, there is an overarching orientation towards the individual. It is how treatment is planned, how data is collected and analysis proceeds. This approach misses out on the central insight of culture theory—that aspects of our environment get bundled together due to accumulating human action and our cultural systems of meaning making. Epidemiology, by separating out factors, has little recourse to understand the dynamics of these larger patterns. At least in epidemiology, one alternative might be Nancy Krieger’s ecosocial framework (pdf), complemented by James Trostle’s Epidemiology and Culture and Carol Worthman and Brandon Kohrt’s Biocultural Approaches to Public Health Paradoxes.
In any case, some cultural anthropology and obesity. First, check out Gina Kolata’s article Chubby Gets a Second Look, including quotes from Emory anthropologists Peter Brown and George Armelagos, teachers of mine when I was in graduate school. “Being thin really isn’t about health, anyway, but about social class and control. When food was scarce and expensive, they say, only the rich could afford to be fat… Those notions of fashion gradually gave way to a more streamlined physique… The body mass indexes of Miss America winners, according to a 2000 study, have been steadily decreasing since 1922, so much so that for most winners in the last three decades their indexes would cause them to be considered underweight.”
The LA Times has a whole series on obesity, including this last article, Culture Matters in the Obesity Debate (which includes links to previous pieces). Kelly Brownell and Paul Campos provide their takes on the symbolism of fat, access to food, social class, and poverty. In their approach, these shape the obesity epidemic as much as biology.
You might also look at the book Fat: The Anthropology of an Obsession, edited by Don Kulick and Ann Meneley. And Paul Rozin, a psychologist with an anthropological perspective, has a downloadable paper on Food Is Fundamental, Fun, Frightening and Far-Reaching.
It is clear that lower socioeconomic status is linked to higher BMI in most developed countries, including the US. However, most takes on this phenomenon either treat this as an individual phenomenon—something about those poor people—or avoid the problem to take a biological viewpoint. Inferior either in willpower or in genes… “Common sense” and science collude in completely missing the point.
So let me make the same point again: social classes bundle together elements (that’s what cultures do) that work in promoting systemic change/difference. The consistently higher BMI scores in lower SES status populations is a good indication of that.
So, some evidence? Kinra et al. offer some of the best research, using a longitudinal design with multiple measures over time of 1335 children starting in 1989. Their conclusions: “Social deprivation independently predicted BMI at age 7, the major influence being weight gain after 6 weeks of life. These data suggest that obesity risk is acquired gradually over the perinatal and postnatal periods, instead of during a prenatal or early postnatal critical window. The association of obesity risk with social circumstances and the timing of its origin offer pointers to some underlying determinants of obesity.”
This cross-sectional study by Ball and Mishra demonstrates the impact of both childhood and adult SES on BMI. The authors write, “Multiple linear regression models showed that both childhood and adulthood socioeconomic status were associated with women’s BMI and weight change… Results suggest lasting effects of childhood socioeconomic status on young women’s weight status, independent of adult socioeconomic status, although the effect may be attenuated among those who are upwardly socially mobile.”
Ball and Mishra continue, “the BMI and magnitude of weight gain among women who were downwardly mobile, as well as those among upwardly mobile women, were generally intermediate between those who remained at low status (highest BMI/weight gain) and those who remained at high status (lowest BMI/weight gain). This pattern is consistent with an ‘accumulation’ hypothesis, by which a longer duration of exposure to low socioeconomic status (i.e. during both childhood and early adulthood) is associated with greater risk for weight gain and high body mass.”
Accounting for the Systemic Effects
So, what can account for some of these effects? I see a cascade effect, starting with the links between heaviness, stigma and social mobility. Here is one of the more surprising results I found in the literature: “Comparing net worth with BMI scores, a 2004 study found obese American subjects approximately half as wealthy as thin ones. When income differentials were factored out, the inequity persisted—thin subjects were inheriting more wealth than fat ones.” Beyond inheritance, job discrimination works against heavy individuals, as a 2005 article and a 2005 chapter show.
In the lower socioeconomic classes, myriad social pressures discourage “healthy” eating and increased activity. As Kelly Brownell writes:
People living in poverty find it hard to be physically active. Leisure time is rare and concerns with neighborhood safety keep both children and adults indoors. Poor individuals are less likely to work for companies with fitness facilities, and there is no discretionary income to join health clubs, have personal trainers, etc. Poor schools have worse facilities and fewer organized sports, and safety issues prevent children from walking or biking to school. Food is a major issue as well. Studies have shown that poor individuals have limited access to healthy foods and considerable exposure to high-calorie, nutrient-poor foods. Declining numbers of supermarkets in inner cities is part of the reason. In 1963, there were 34 full-service supermarkets in inner-city Los Angeles; that number had dropped to 14 in 1991. By 2002, there were only 5. If one does not own a car, a trip to a supermarket might require several transfers on a bus and then the task of carrying groceries on the return trip. Poverty not only complicates access to stores with healthier foods, but drives people toward cheap foods. This encourages purchase of packaged snack foods, sugared drinks and fast foods, and discourages purchase of the more expensive fruits and vegetables. The reality stares us in the face – poverty discourages physical activity and encourages excess calorie consumption.
Besides inequality, we can also turn to issues that fall more into the sociocultural realm, for example, the synergy between body image, social pressures, and social networks. Not surprisingly, people often associate with other people who accept and reinforce behaviors, ideas, and so forth, particularly in the face of stigma and exclusion. Drug abuse, for example, is significantly influenced by friends who use drugs, and this impact is due both to picking friends who use and the social influence of those friends on individual use. With obesity, we can imagine similar impacts on eating, activity, and social views of the body.
Nicholas Christakis and James Fowler found that obesity spreads through social networks. “A person’s chances of becoming obese increased by 57% (95% confidence interval [CI], 6 to 123) if he or she had a friend who became obese in a given interval. Among pairs of adult siblings, if one sibling became obese, the chance that the other would become obese increased by 40% (95% CI, 21 to 60). If one spouse became obese, the likelihood that the other spouse would become obese increased by 37% (95% CI, 7 to 73). These effects were not seen among neighbors in the immediate geographic location. Persons of the same sex had relatively greater influence on each other than those of the opposite sex.” (For a great article discussing the relevance of network thinking to health, including a great multi-level graphic, see this pdf essay by Albert-Laszlo Barabasi which builds off the Christakis and Fowler article.)
How does such a thing happen? Here are two interesting results in relation to body image. McLaren and Kuh (2004) write on “Women’s Body Dissatisfaction, Social Class, and Social Mobility.” Using a sample of 912 54-year-old women in a prospective study, they found that for any given BMI, women from “non-manual” (i.e., higher) classes were “more dissatisfied with their weight than women from the manual classes as adults.” Level of education had a greater effect on dissatisfaction for weight than “occupationally defined social class,” pointing to the formative influence of studying together. Finally, for any BMI, women who were “downwardly mobile” ended up as more satisfied with their appearance, more evidence for the impact of social mediation on body satisfaction.
This article, “Kids’ Obesity Not Weighing on Parents’ Minds,” describes research which found that “40 percent of parents with obese children describe their child as ‘about the right weight.’ And, less than 10 percent of parents with obese children say they are ‘very concerned’ about their child’s weight.” Indeed, the National Poll on Children’s Health showed that “only 13 percent of parents with obese children ages 6 to 11 rate their child as being very overweight, compared with 31 percent of parents with obese children ages 12 to 17.” From the perspective of canalization, where weight gain by age seven has a significant impact on adult obesity, this discrepancy is bothersome. But in terms of body image, it’s not difficult to imagine that younger children are also unconcerned about their weight, until the stigma associated with emerging sexuality and ideals of beauty emerge during adolescence.
We can also focus on the acquisition of eating behaviors through the influence of households, already shaped by social class, social networks, and poverty. In his paper “Aetiology of overweight and obesity in children and adolescents,” Claudio Maffeis writes “Early experiences with food, feeding practices and family food choices affect children’s nutritional habits. In particular, the parents are responsible for food availability and accessibility in the home and they affect food preferences of their children. Diet composition, in particular fat intake, influences the development of obesity. The high energy density and palatability of fatty foods as well as their less satiating properties promotes food consumption.”
Birch and Davison (2001) take this argument further, “Results of the limited research on behavioral mediators of familial patterns of overweight indicate that parents’ own eating behaviors and their parenting practices influence the development of children’s eating behaviors, mediating familial patterns of overweight.” Interestingly, they argue in terms of patterns of eating: “In particular, parents who are overweight, who have problems controlling their own food intake, or who are concerned about their children’s risk for overweight may adopt controlling child-feeding practices in an attempt to prevent overweight in their children… Parents need to understand the costs of coercive feeding practices and be given alternatives to restricting food and pressuring children to eat.” (For more on parental modeling and control, see this Brown and Ogden article.)
Put differently, the “dieting” approach, or a binge-and-purge stance, do not help children develop a stable regulatory approach to eating (see my comment on uncertainty in the previous obesity post). This style of eating can “interact with genetic predispositions to promote the development of problematic eating styles and childhood overweight.”
I’ll end by repeating something of a mantra: a focus on behaviors, experiences, relationships, contexts and all the rest help us understand how culture and inequality can significantly shape people’s lives. This focus also permits us to understand the interacting systems within people that function through the domains of culture and inequality to also significantly shape people’s lives.