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Most people today see obesity as a public health crisis. Nationally representative Canadian
data suggest that approximately two thirds of the population are “overweight,” and one third
“obese.” “Experts” tell us that fat kills, that the current generation of children will not outlive their
parents’ generation, and that health care for “the fat of the land” will be extremely costly (Gard
2010). Some note how fat has become “Public Health Enemy Number One” (Thatcher 2004). This
discourse has been analyzed sociologically as one of moral panic: a situation where a marginalised
behaviour or group comes to be perceived as a threat to the morals, values or interests of society as a
whole and stands as the reification of a generalised social anxiety (Cohen 1980 [1972]). But it can also
be analyzed socio-historically within a construction of reality framework, which stresses the
formation of “facts” through discourse (Hacking 1999; Berger and Luckmann 1989 [1966]; Latour
1987; Latour and Woolgar 1986 [1979]).
In this paper, I use methods inspired by the Stanford School of neo-institutionalism (Drori et
al. 2003; Frank and Meyer 2007; Meyer et al. 1997; Meyer and Jepperson 2000; Ramírez, Suárez, and
Meyer 2007a) to investigate the transformation of body fat in the Canadian medical literature.
Among other things, neo-institutionalism is concerned with processes of legitimation and in the
evolution of meaning at the macro or aggregate level. Herein I evaluate how fat has been medicalized
(Conrad 1992, 2005; Sobal 1995; Zola 1983) by Canadian researchers through the study of their
research output: medical publications.
This paper is organized as follows. First, I describe the theoretical framework that inspired
this paper and Canadian perspectives on the medicalization of fat. Second, I describe the
methodology of this paper. Results are divided into two parts. Part I provides a brief overview of
Canadian weight trends and compares them to publication trends over the 1971 to 2008 time period.
Part II analyses 6,889 Canada-specific obesity-related articles published between 1985 and 2010 in
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
light of previous research on the medicalization of fat in Western societies: medical language, medical
diagnosis, medical solutions, social determinants of health and families. I conclude by reviewing the
main findings from this paper and highlight several questions this research raises: the role of
epidemiology’s rise in the making of the obesity epidemic, the importance of BMI in the
medicalization of body fat and, ultimately, who owns the meaning of body fat?
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
creation of the peptide thyrotropin-releasing factor or hormone (TRF(H), a molecule with several
clinical applications), Brumberg’s (2000 [1988]) study of anorexia nervosa and Epstein’s (1998) study
of HIV/AIDS.
The social construction of disease is often framed within the broader context of what
sociologists have called “medicalization.” Medicalization is “the expansion of medical jurisdiction,
authority, and practices into new realms” (Clarke et al. 2003, 161) or, according to another definition,
“a process by which nonmedical problems become defined and treated as medical problems, usually
in terms of illnesses or disorders” (Conrad 1992, 209). To some, medicalization has enabled the
dominance of medicine over all aspects of life and is a form of social control (Illich 1976; Zola 1972);
to others, it also facilitated the foray of sociology into medicine (Strong 1979; Hansen and Easthope
2007). Here, medicalization is understood as the process whereby a previously non-medical issue –
here, body fat – comes to be understood in medical terms, and upon which the medical gaze and its
plethora of diagnostic tools and solutions come to be used in its evaluation and “treatment.”
Medicalization is also partly political, transforming power relations between the previously-healthy
“sick” and medicine as an establishment (Moynihan 2002, 886). To study the medicalization of body
fat through an analysis of publications on the subject, then, is to study the discursive making of
obesity into a disease and is likely to shed light on the processes whereby fatness was constructed as
the public health crisis number one today.
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
One early sociological account of the medicalization of fat in the United States was written
by Sobal (1995), who carefully dissects “obesity” using medicalization theory and a social problems
perspective. He distinguishes between three main models of fatness: a moral/deviance model that
condemned fatness as bad; an illness model that medicalized fat and positions medicine as the
ultimate solution to fatness; and a demedicalized/political model of fatness, which rejects the medical
claims of illness and focuses on the rights of fat people. In doing so Sobal identifies several key
aspects of the medicalization of fat such as the growth of the risk discourse, the rise of organizational
activity to fight obesity, the development of bariatric surgery and weight-loss medication, etc. (more
below).
Studying the medicalization of fat over time, Saguy and Riley (2005) showed how the medical
literature as recorded in the PubMed database preceded the media in positioning obesity as a topic of
interest. Starting in the early 1990s, the media coverage of obesity ballooned, along with scientific
articles. Both lay and scientific articles blamed individuals for their obesity (rather than the
environment or genetics), pushed for individual-level solutions (rather than policy changes) and
advocated surgery.
Several studies have shown the importance of social context in shaping attitudes – lay and
medical – toward body fat (Saguy, Gruys, and Gong 2010; Stearns 2002 [1997]), comparing the
French and American attitudes toward dieting and weight. Stearns, in his pioneering work, argues
that while the French have an esthetic/health approach to weight, Americans have a
moralistic/health approach to weight. Both cultures have internalized that fatness is bad for your
health; for the French, fatness is also seen as ugly; for Americans, fatness is an indication of moral
failure and badness. Saguy, Gruys and Gong (2010) argue based on another comparative study of
France and the United States that financial and cultural dominance are distinct forces that shape
national beliefs about obesity and thus the representation of obesity in the media. We can thus
expect the Canadian experience to differ from the American and French experiences: Canada can’t
pretend to be either financially or culturally dominant; and the protestant, individualistic ethic of the
United States isn’t as omnipresent in Canada (Fetner and Sanders 2012).
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
between 1978 and 1988 (World Health Organization Expert Committee 2000 [1998], 22). Canada
started collecting systematic data on nutrition, weight and height in 2001, as part of its Canadian
Community Health Survey. As illustrated by Gard in this volume, Canada was comparatively late in
the global drive to collect population-level height and weight data. Importantly, Gard notes that “the
impulse to systematically collect population-scale data on the size, shape and capacities of human
bodies flares haphazardly through time and space,” pointing to the deeply historical, sociological and
political aspects of the recent Canadian obsession with fatness.
Arguably, the Canadian discourse has considered the social and economic factors that
underpin rising obesity rates to a greater extent than the American discourse. Jutel (2001, 292), for
instance, pointed that a 1988 document by Health and Welfare Canada (1988) pushed for concern
with weight in general rather than overweight and obesity specifically, emphasizing the wide range of
acceptable weights and the importance of a positive body image. The Canadian evaluation of
materials later evaluated by the (American) National Institutes of Health (1998) also had less fatalistic
conclusions about the negative impact of weight and emphasized health rather than weight loss.
In recent years, the pressure to make obesity into a priority area for Canadian policy in
research has grown; and as we will see, publication rates have followed. Katzmarzyk (2002) reified
the “Canadian obesity epidemic” in the title of his oft-cited epidemiological paper, noting the
importance of making obesity a “public health priority” (p. 673). In 2004, the Quebec Groupe de travail
provincial sur la problématique du poids published a report inviting immediate action. The causes behind
obesity are described as a “causal web of factors” that include international, national/regional,
community and individual factors (Groupe de travail provincial sur la problématique du poids 2004).
Similarly, Thatcher (2004, 30) notes that while controlling weight can be seen as a “personal issue, it
is, more fundamentally, a matter of politics and economics.” A report by Starky (2005, 13) for the
Library of Parliament, while uncritically positioning obesity as an epidemic and a large economic
burden, concludes with an invitation to consider and address “[s]ocial, economic, physical and
environmental factors” to “support Canadians in making healthy choices.” Statistics Canada (2006)
reported on obesity rates as part of its Health Reports, the same year as the founding of the
Canadian Obesity Network, a leading anti-obesity advocacy group in Canada. Two years later, Health
Canada (2008) discussed obesity trends as part of its Healthy Canadians 2008 Federal Report and
obesity was clearly on the Canadian health agenda.
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
In line with the findings above, Jennings (2009) studied the websites of four Canadian
provincial governments and found a general absence of policies targeting fat people individually. She
also found that Quebec mentioned the sociocultural and economic factors behind fatness more often
than Ontario, British Columbia and Alberta. Furthermore, Holmes’ (2009) analysis of Canadian
media portrayals of the obesity epidemic suggests trends that break from those found by other
scholars in the United States (Oliver 2006; Saguy & Almeling 2008), the UK and Australia (Gard and
Wright 2005). She found that the obesity epidemic largely remains unquestioned, but that the
discourse on Western decadence and decline wasn’t present in news articles. Similarly, Canadians
emphasized individual agency and strength rather than weakness and individual failure to exercise
weight control. Canadian scholars have been developing alternatives to the mainstream biomedical
model of obesity for decades. The work of Polivy and colleagues on the harms of dieting (c.f.
McFarlane, Polivy, and McCabe 1999; Polivy and Herman 1987), that of Ciliska (1990) on non-
dieting approaches to care for obese women and the Health At Every Size work of Gingras (2005)
are only a few such examples.
Methodology
This paper uses a methodology inspired by the macro-sociological approach of John Meyer,
Francisco Ramirez and colleagues at Stanford University. Meyer and Ramirez study processes of
legitimation: how certain ideas, inspired by a modernist ideology, come to spread around the world
and come to be taken for granted. Among other things, they studied the historical growth of higher
education (Frank and Meyer 2007; Schofer and Meyer 2005), the growing importance of science
worldwide (Drori et al. 2003) and the rise of the human rights movement (Ramírez, Suárez, and
Meyer 2007b; Meyer, Bromley, and Ramirez 2010). This longitudinal, comparative approach has
recently been applied to obesity research by Paradis (2011), whose analysis of obesity-related
publications from 1950 to 2010 established a timeline where fat as merely fat became “obesity” in
the early 1970s, an epidemic in the mid-1990s, and morphed into general anxiety about the future
since 2000 with the turn to childhood obesity. Skolbekken (1995) conducted a similar study of risk
using aggregate trends among scientific publications, but limits on data availability and information
analysis techniques at the time limited his ability to control for the expansion of medical knowledge.
In this paper I investigate different aspects of the medicalization of fat in Canada through a
study of aggregate trends among the titles of medical publications focusing on body fat. Comparing
the literature on body fat (the medicalized, i.e. publications on obesity) with secular trends on obesity
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
(the medical) yields a vivid portrait of the process; so does a closer reading of the medicalized (i.e.
obesity rates in the population) over time.
Data Sources
Weight trends
Different types of data about weight and height in the Canadian population are available:
self-reported and measured. Because self-reported weight and height tend to be systematically
distorted (Shields et al. 2011; Shields, Connor Gorber, and Tremblay 2008), the data used in this
paper come strictly from nationally-representative studies where researchers measured them directly.
Data were taken from several sources and provide 6 different time points over the 1971-2008 time
period (see Table 1). As noted by Gard in this volume, Canadian data are far from perfect and
haven’t been systematic; they are however sufficiently precise here given our comparative emphasis.
Publication trends
Data were collected from the PubMed database on April 16, 2012 using queries of the following
form: ((keyword) AND (Canada)) AND ("1950"[Date - Publication] : "3000"[Date - Publication]).
The 15 different “keywords” were: acoria, bariatrics, bariatric surgery, corpulence, gastroplasty,
hyperorexia, obese, obesity, obesogenic, polycsarcia, weight gain and weight loss. PubMed /
MEDLINE is the largest medical database in the world, and is maintained by the United States based
National Library of Medicine (NCBI 2013). Although it doesn’t cover all the medical literature
published every year, it is the most comprehensive medical database available. 1950 was initially
chosen as a start date given the rise in scientific enterprise after World War II. Meta-data obtained
from these queries were then merged by PubMed ID to keep one record per publication, for a total
of 8,283 articles over the 1950-2012 time period. Data were the left and right censored to cover
either the 1971-2008 time period (for comparison with weight trends; n=5,511) or the 1985-2010
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
time period (for longitudinal analyses of titles; n=6,889). Left censoring was done for data before
1985 given the major shift seen that year in the numbers of publications: from 1950 to 1984,
publications range from 1-12 per year (mean = 3; S.D. = 2.8); after 1985 they explode to reach 782 in
2010, with a mean of 273 publications per year (S.D. = 196.1). Right censoring was done to
guarantee a full year’s worth of data, as data input into PubMed lags actual publication.
Analysis
In order to analyze publication trends, different aspects of the medicalization of fat were
identified and hypotheses generated inductively from the literature (see below). A coding scheme of
190 keywords (see Appendix I) was thus developed. Coding of the titles of the 6,889 publications
identified was done using Python Version 3.2.3 for Mac OS X; the coding scheme covered 78.6% of
all article titles. Both weight and publication data were normalized using 1989 rates to enable
comparison of growth. All data was analyzed using R version R 2.15.0 for Mac OS X Leopard.
Although coding the 6889 titles between 1985-2010 does not give us access to the language and
meanings used in the full-text articles, the importance of titles in summarizing the content of the
article and as a strategy to attract the attention of readers suggests that coding titles yields an
impressionistic portrait of the evolution of the literature. Titles are purposive choices made my
researchers to convey meaning and situate their research within the current scientific debates of the
day.
Results
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
growth spur, also lagged behind increasing weights. Panel C shows the magnitude of the gap between
normalized publication trends and weight trends: the weight trends look almost flat when compared
to publications. Growth among publications was 382 times greater than growth of weight trends
(149.5% vs. 57,200%). Similarly, publications in 2008 are 4.1 times more frequent than they were in
1989 while, obesity rates were only 1.7 times greater over the time period.
400
200
0
Year
Female
Percentage
Male
20
10
0
Year
Female
300
Male
Publications
100
0
Year
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
medicalization of fat in Canadian medical publications. Sobal’s (1995) article on the medicalization of
fat is used as a starting point. As will be clear from Figure 1 (Panel A), publications were
comparatively scarce before 1985. Data analysis thus focuses on articles published in or after 1985.
Medical Language
Medicalization often leads to the creation and adoption of a medical-sounding vocabulary to
describe the object being medicalized and give the pursuit of its study a scientific veneer. Sobal
(1995, 71) notes the popularization of the term “obesity” in the 1970s and the associated decline of
“corpulence” in the medical literature. He also points to the creation in 1973 of the neologism of
“bariatric” and to the development of the medical specialty of bariatrics.
In 2000 the World Health Organization released a report titled “Obesity: preventing and
managing the global epidemic. Report of a WHO consultation” (World Health Organization Expert
Committee 2000 [1998]). This report constructed obesity as a global epidemic, a global public health
crisis.. Its massive growth has been described by Saguy and Riley (2005) as well as Paradis (2011) as ,
starting in the early 2000s.
Finally, since the early 1990s, scholars have noted the prominence of risk discourse and
defined our contemporary societies as “risk societies” (Beck 1992; Mythen and Walklate 2006),
particularly in the public health domain (Lupton 1993; Lupton, McCarthy, and Chapman 1995;
Skolbekken 1995; McDermott 2007). The rise of epidemiology over the course of the 20th century
has transformed our understanding health and illness, and was instrumental in the development of
the obesity epidemic discourse (Oliver 2006; see also the papers by Gard, by Ward, and by
McNaughton and Smith in this volume).
Based on these studies we can make the following hypotheses with respect to the Canadian
medical literature:
Hypothesis 1: Obesity and overweight should take an increasingly large part of the
literature. Codes: obesity, overweight.
Hypothesis 2: The growth of medicalized fat-related terms should be greater than that
of lay terms over time. Codes: high medicalization: adipocyte, adipose, lipid,
bariatrics, polyphagia; medium: obese, obesity, obesogenic, overweight; low:
corpulence, fat, weight.
Hypothesis 3: A stark growth in the use of the term “epidemic” should be seen starting
in the early 2000s. Code: epidemic.
Hypothesis 4: The use of “risk” among titles should rise starting in the late 1980s and
escalate rapidly over time. Code: risk.
Figure 2 shows publication trends for “obesity” and “overweight” as a percentage of the
sample. Obese/obesity (4,328 articles or 62.8% of sample) and overweight (3,075 articles or 44.6%
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
of the sample) follow similar trends: a slight decline in the late 1980s before a continued slow
growth, rather than unmediated growth. Obesity is more frequent in the literature throughout the
time period. Thus hypothesis #1 has been confirmed.
60
40
20
Obesity/obese
Overweight
0
Year
High
Medium
80
Low
% of Sample
60
40
20
0
Year
Risk
Epidemic
10
No. of Publications
8
6
4
2
0
Year
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
in 1990; BMI articles have seen a staggered growth as a proportion of the sample since 2000. The
growth lagged about five years from what Hypothesis 5 expected. As for childhood and BMI, we see
the first publications in the late 1990s and oscillating interest since then, for a total of 35 publications
(0.5% of the sample). There has been no dramatic increase in childhood BMI mentions among titles
and we have to reject Hypothesis 6.
BMI
Childhood & BMI
4
% of Sample
3
2
1
0
Year
Medical Solutions
Sobal (1995) argues that one aspect of the medicalization of obesity has been the
development of medicine-specific “solutions” or “treatments” such as medically supervised dieting,
surgery, medication and psychiatry. Histories of dieting have shown continued interest with
medically-supervised diets (Schwartz 1986; Taubes 2007).
According to Sobal (1995), the glory days of bariatric surgery were in the 1970s. Recent
interest in bariatric surgery in the social science literature (Salant and Santry 2006; Throsby 2012;
Saguy and Almeling 2008) suggests resurgence since the 2000s. Germov and Williams (1996) have
suggested that the current public health messages about the problem of overweight combined with
cultural imperatives for women to be slim has lead to what they call an “epidemic of dieting
women.” Recent scholarship has highlighted how men and children now also suffer from slimness
imperatives (Bell and McNaughton 2007; Dworkin and Wachs 2009; Evans et al. 2002; Schwartz
1986; Isono, Watkins, and Lian 2009).
Oliver (2006, 617-8) traces the history of the “diseasing” of obesity to “changes in the supply
and demand of medicine” as an institution and the rising importance of the “health-industrial
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
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complex,” both of which conspired to exert pressure on regulatory bodies to officially medicalize
obesity, enable the flow of money from taxpayers and consumers to insurance and pharmaceutical
companies and give food corporations a free pass. Accordingly, he sees the pharmaceutical industry
as one of the main drivers behind the medicalization of fat.
Rasmussen (2012) argues that psychiatry was a major factor in the medicalization of fatness
in the 1940s and 50s, turning fatness into not only a physical illness but also the sign of psychiatric
illness (see also Rasmussen 2008). Reviews of the literature (Rosengren and Lissner 2008; McElroy et
al. 2004) and population-level data (McIntyre et al. 2006) however suggest that stigmatization – not
actual body size – may be a key contributor to mental health problems among obese patients, and
some have noted that mood medication may have contributed to increasing weights in the
population (Devlin, Yanovski, and Wilson 2000; Caplan 2012). Psychiatry is still very much involved
in the treatment of obesity and hopes to be further involved in its treatment, as the obesity-themed
January 2012 issue of the Canadian Journal of Psychiatry attests. Similarly, a sizable (American) literature
now deals with the health consequences of stigma (Major and O'Brien 2005; Puhl and Brownell
2006; Puhl and Latner 2007; Bayer 2008a; Puhl and Heuer 2009, 2010; Bell et al. 2010b; Scambler
2009).
Based on these studies we can make the following hypotheses:
Hypothesis 7: Dieting should hold a prominent place among articles throughout the
time period. Codes: diet, dietary, dieting, food, nutrition.
Hypothesis 8: Surgery-related terms should increase in the 1970s, and again in the
2000s. Codes: surgery, bariatric surgery, gastroplasty, surgical.
Hypothesis 9: Medication-related terms should increase over time. Codes: Anorexiant,
appetite suppressant, drug, medication, pharmaceutical, pharmacy,
pharmacology, pill.
Hypothesis 10: Mental health-related terms should increase throughout the time
period. Codes: Anorexi, addiction, behavior, bingeing, bulimi, compulsive, eating
disorder, emotion, mental, mental health, personality, psychiatry, psychology,
psychotherapy, stigma, stress.
Figure 6 shows rates of publications on diet, surgery, medication, and mental health over
time. Diet dominates (1,118 articles, 16.2% of the sample). Second most prevalent is mental health
(432 articles, 6.3% of the sample), which saw a small decline from the early 1990s to the early 2000s
(see Rasmussen 2008, 2012 on the involvement of psychiatry in obesity treatment). Surgery covered
about 3.7% of the sample and medication 1.7%. A slight increase in publications on medication can
be seen since the late 1990s. Hypothesis 7 is confirmed; Hypothesis 8 and 9 are not, as surgery and
medication remained low-interest solutions throughout the time period (with an outlier year in 1987
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
for surgery, when the total number of articles in the sample (denominator) was quite small).
Hypothesis 10 cannot be confirmed, as the trend is mostly flat throughout the time period.
Diet
Surgery
Medication
% of Sample
20
Mental Health
5 10
0
Year
Social Factors
40
Medical Solutions
% of Sample
30
20
10
0
Year
15
Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
however mostly individual (e.g. dieting, surgery, medication) and will likely outweigh broader
solutions such as policy or community-based interventions. We make the following hypothesis:
Hypothesis 11: Mentions of social factors should be rare, confirming the individualistic
bias of medicine. Codes for social factors: community, environment, geography,
neighborhood, obesogenic, policy, poverty, race, school, social, societal, socio-
economic; codes for individual-level factors: above codes about diets,
medication, mental health and surgery.
Figure 7 enables a comparison of trends in mentions of social factors with the medical
solutions explored with Figure 6. A total of 312 articles (4.5% of the sample) mentioned factors
beyond the individual in their titles (e.g. economic, community, politics, race, school, social, societal,
etc.); meanwhile a total of 1,732 articles (25.1%) were written about the medical solutions discussed
above: diet, medication, surgery and psychiatry. The share of medical solutions declined until 2000,
before picking up again; that of social factors has increased slightly since the early 2000. We can
confirm Hypothesis 11.
Families and the Future
Anxiety about the future and the inability of medicine to solve all social problems persist.
McDermott (2007) notes that while the concept of at-risk children has long roots in the medical and
public health traditions, the focus on children as at risk of sedentarity and obesity lagged behind
concerns with adult obesity, a fact confirmed by Paradis (2011). Despite early interest in childhood
obesity, with a first Canadian publication in 1935 and Hilde Bruch’s crusade in the 1940s, broader
interest in childhood obesity only emerged in the 1980s (Schwartz 1986). Paradis (2011) found a
growth rate of 1,651% in the number of articles about childhood obesity published and recorded in
the PubMed database between 1989 and 2009. She argued that the recent emphasis on childhood
obesity reflects anxieties about the financial viability of medical systems and an acknowledgement of
the failure of medicine to “solve” the “problem” of obesity.
Blaming mothers for the weight of their children has a long history (Schwartz 1986;
Mitchinson in this volume), but the proselytizing work of psychiatrist Hilde Bruch, who saw fault in
mother’s feeding practices and emotional imbalance, was critical to the involvement of psychiatry in
obesity care (Rasmussen 2012). Several authors have noted the medicalization of childhood obesity
and the tendency to blame mothers for the trend (Moffat 2010; Boero 2009; Bell, McNaughton, and
Salmon 2009). In Boero’s (2009) analysis, the news media are shown to be complicit in disseminating
and reproducing the idea that careless, negligent or overly permissive mothers are partly responsible
for the obesity epidemic. “Mother blame” lies more or less explicitly behind both the scientific and
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
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common sense solutions to the obesity epidemic. “The weight of one’s children,” she writes, “has
increasingly become a litmus test of good mothering” (p. 113). Bell et al. (2009) go further and argue
that childhood overnutrition and obesity have been both medicalized and criminalized over the past
decade. They also point out that while mothers are often accused of overnutrition, fathers are
“conspicuously absent” from the literature (p. 162).
Based on these studies we can make the following hypotheses:
Hypothesis 12: Children should be increasingly present in the literature over time,
particularly after 2000. Codes: Child, fetal, fetus, infant, juvenile, kid, pediatric,
teen, youth.
Hypothesis 13: Mothers should be mentioned regularly throughout the time period,
but increasingly so after 2000. Codes: gestational, maternal, maternity,
pregnancy, mother, wife.
Hypothesis 14: Fathers should be mostly absent from the literature. Codes: father,
husband, paternal, paternity.
Children
Mothers
10
% of Sample
5
0
Year
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Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
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Discussion
Part I of this paper showed the extent to which the medical (i.e. obesity rates in the
population) has been dwarfed by the medicalized (i.e. publications on obesity) over the time period.
The growth of the two is incommensurable even when we take the least conservative estimates of
population weight gain available – measured obesity rates. The research community’s response has
dramatically outgrown the actual phenomenon, which is alarming given the highly debatable effects
of obesity on health outcomes (Bacon and Aphramor 2011; Campos et al. 2006a; Flegal et al. 2013;
Padwal et al. 2011; Wildman et al. 2008). This gap is, however, much less prominent in the Canadian
literature than it was in the American literature (cf. Paradis 2011), suggesting a more moderate
response from the Canadian research community.
Part II of this paper investigated several aspects of the medicalization of fat in Canadian
publications: medical language, medical diagnosis, medical solutions, social determinants of health
and the role of families. With regards to language, we can confirm that obesity and overweight have
indeed accrued a larger share of publications over time; corpulence is clearly not part of medical
parlance today. Contrary to our hypothesis, highly-specialized terms did not increase over time;
rather, it is medium-level terms that dominated the discourse, with obesity and overweight dwarfing
all other terms. One could argue that the medical connotation of overweight and obesity, combined
with their familiarity to most North Americans, has facilitated their inclusion into lay discourse, thus
enabling the broadening cultural purchase of body fat as a medical problem.
Another hint that the Canadian take on obesity as a public health crisis was more moderate
than the American one can be found in the fact that the word “epidemic” has not permeated the
Canadian literature deeply. Risk, on the other hand, has established itself as an important part of the
medical discourse, with close to 10% of articles by the end of the time period. This suggests two
things: first, that epidemiology and its risk discourse has made serious inroads into Canadian obesity
research; and second, that obesity is conceptualized both as a risk factor for disease (such as diabetes
and cardiovascular disease), and as a disease in itself (obesity).
Turning to body mass index as the main diagnostic tool for obesity, its prevalence has indeed
increased over time among titles, although trends on childhood BMI are not as clear, given their low
occurrence. Closer analysis of publication texts would be needed to investigate the prevalence of
BMI and its impact on obesity research.
18
Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
Different medical solutions take unequal but nonetheless important places in the literature.
Dieting is the main emphasis, followed by mental health. In the aggregate, it was found that medical,
individual-level concerns or solutions (such as drugs and surgery) dominate public-health oriented
concerns or solutions (such as community initiatives and policy). The slow rise of the latter, however,
shows shifting interests within the medical community to consider the social determinants of health,
as expected given the rise of epidemiology and the recognition of the psychosocial bases of health
and illness (Hansen and Easthope 2007). Surgery and medication did not experience the expected
growth yet remain of substantial concern in the literature. This is unsurprising in a country with a
more collectivist orientation to health care delivery and cost sharing than the United States. Stigma, a
hot topic in the United States (e.g. Puhl and Heuer 2009, 2010), was noticeably and unexpectedly
under-represented in the literature (MacLean et al. 2009). Given that stigma is relatively new as a
concern among obesity researchers (c.f. Puhl and Brownell 2006; Puhl and Latner 2007; Puhl and
Heuer 2009), we could still see a literature on stigma emerge in Canada over the coming years.
Paradis, Kuper and Reznick (2012) is one such example.
Finally, as expected, mothers were mentioned in a large subset of articles throughout the time
period (3.4% of the sample), and fathers were altogether absent. The expected rise after 2000 in
studies mentioning mothers was not seen, however. This may be partly due to comparatively lower
emphasis on childhood obesity in Canada, compared to the United States.
Conclusion
The extent to which and in which amount fat is a medical problem is still highly debated, but
the medicalization of fat is now beyond question. This paper has shown that Canadian researchers
have indeed medicalized fat over the past three decades, although it appears that this medicalization
has lagged behind the medicalization of fat as seen in the United States. Canadian researchers have
been writing about fat as a medical condition – as obesity or overweight – in as many as 6,889
articles since 1985, and in recent years they have become ever more prolific. These publications have
increasingly made an appeal to a language of risk, appealed to medical solutions to the obesity
“problem,” and expanded their jurisdiction over new populations, most notably children. By
association and because they are typically but culturally the closest individual to kids, mothers and
their pregnancies have also been medicalized.
This paper also raised questions about the role of BMI in enabling the medicalization of fat
and the ensuing moral panics discussed by other scholars (Boero 2009; Campos et al. 2006a; Gard
19
Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
and Wright 2005), and about the seemingly irreconcilable tensions between medicine and its
emphasis on individual solutions and the one-on-one care relationship on the one hand, and public
health imperatives on the other. The rising share taken by population-level, risk and epidemiological
language over the past ten years (see Figure 7) suggests that things may be changing in favour of
diminished individual responsibility. In the Canadian context, where collective solutions are more
frequent than in the United States (Jutel 2001), this will not come as much of a surprise. Similarly, the
role of “big pharma,” of for-profit health care and of the food and diet industries is not as clear in
Canada as in the United States, and the analysis provided here suggests a still marginal role for drugs
and surgery among academic publications. Food and diet, however, are critical components of the
scholarship. The impact of these industries has on policy and care provision remains to be
investigated.
Several of the trends identified above lag behind the hypothesized trends by 5 years to a
decade (e.g. BMI; childhood); several others are dampened (e.g. surgery, epidemic). The fact noted
by Gard in this volume that Canadian population-level data were historically scarce and unreliable
probably has something to do with this lag; yet I would like to argue that both universal health care
and the relatively small size of the Canadian scientific research apparatus are factors that probably
contributed to this lag and that dampening of the language used by Canadian researchers. The
“rhetorical virus” (Gard 2010, 7) of obesity as an epidemic has not caught on among Canadian
researchers.
Ultimately, the medicalization of fat raises the fundamental question: who owns the meaning
of body fat? Is it the medical establishment, governments, or the fat and not-so-fat people who
suffer in a culture that despises it and condemns it as a death sentence? As I have tried to show in
this paper through a longitudinal analysis of medical publications is that the transformation of
fatness into a disease has been a process. Language played a critical role in the definition and
transformation of our perception of body fat – as it plays in the construction of any other reality. In
this case as in other medicalization cases, this transformation is political, and its future dependent
upon the continued critical analysis of our discursive environment and its impacts on our lives.
20
Chapter in Ellison J, McPhail D and W Mitchison (2016) Obesity in Canada: Critical Perspectives.
University of Toronto Press, pp. 56-88.
Acknowledgements
The author wishes to thank Arvin Fahramand for Python coding assistance, Niall Byrne for
comments on the manuscript, the “Obesity” in Canada workshop attendees and volume editors for
their helpful feedback.
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Appendix I
Coding scheme
'abnormal', 'abuse', 'abusive', 'addict', 'adipocyte', 'adipos', 'adolescen', 'aetiolog', 'anorexi', 'anorexiant',
'appetite suppressant', 'arteriosclerosis', 'arthrit', 'atherosclerosis', 'attitude', 'behavior', 'behaviour',
'binge', 'BMI', 'body fat', 'body mass index', 'bulimi', 'cancer', 'carcin', 'cardiac', 'cardiorespiratory',
'cardiovascular', 'child', 'children', 'choice', 'cohort', 'committee', 'community', 'compulsive',
'conference', 'control', 'cost', 'deviance', 'deviant', 'diabetes', 'diet', 'dieting', 'disability', 'double blind',
'drug', 'eating', 'eating disorder', 'economic', 'education', 'emotion', 'endocrin', 'energetic', 'energy',
'environment', 'epidemic', 'epidemiolog', 'epigenetic', 'esteem', 'etiolog', 'excess', 'exercis', 'experiment',
'expert', 'family', 'families', 'fasting', '\\bfat\\b', 'father', 'fatty', 'feeding', 'fetal', 'fetus', 'financial',
'\\bfit\\b', 'fitness', 'food', 'genetic', 'geograph', 'gestational', 'global', 'glycemi', 'health', 'heart',
'heredit', 'histor', 'husband', 'hypertension', 'ideal weight', 'income', 'inequality', 'infant', 'infectious',
'infectobesity', 'intervention', 'issue', 'juvenile', 'kids', 'lean', 'lipid', 'longitudinal', 'manage', 'matern',
'medicaliz', 'medication', 'meeting', '\\bmen\\b', 'mental', 'mental health', 'metaboli', 'moral', 'morbid
obesity', 'morbidity', 'morbidly obese', 'mortality', 'mother', 'movement', 'neighbourhood',
'neighborhood', 'neuro', 'neurolog', 'normal', 'nutrition', 'obesogenic', 'organisation', 'organization',
'orthorexi', 'overfeed', 'paediatr', 'pandemic', 'paradox', 'parent', 'paternity', '\\bpaternal\\b',
'patholog', 'pediatr', 'personalit', 'pharmac', 'pill', 'policy', 'politic', 'polyphagi', 'portion', 'poverty',
'pregnan', 'prevent', 'problem', 'profit', 'psychiatr', 'psycholog', 'psychotherap', 'public health',
'\\brace\\b', 'randomized', 'rates', 'restrict', 'rheumatolog', 'right', 'risk', 'sedentar', 'school', 'sick',
'sickness', 'size', 'slender', 'social', 'societal', 'social class', 'social determinant', 'social mobility', 'socio-
economic', 'socioeconomic', 'stigma', 'stress', 'surgery', 'surgical', 'tabagism', 'technique', 'technolog',
'\\bteen\\b', 'teenage', 'therap', 'thin', 'tobacco', 'treatment', 'trend', 'weight', 'wife', 'women', 'world',
'youth'
Legend: Codes surrounded by “\\b” are codes that were not used as roots for other codes. For
example, searching for “\\bmen\\b” would not yield links to “menopause,” but “men” would yield
men, menopause, enjoyment, etc.
27