Monday, December 11, 2006

The Public Health Failure in Defining Obesity in American Culture - Siphannay Nhean

Currently, public health practitioners struggle to address an escalating health problem, one that has come to dominate and continues to thrive in American society: obesity. The issue has captured the attention of the nation and sparked involvement from the science and health community alike. Despite an increased public awareness, intense media coverage and various attempts by public health officials, no true solutions have surfaced and there appears to be an inability to curb the growing problem. In the last half a century, Americans have been steadily increasing their waistline much to the dismay of the medical and public health communities. The trend is a rightward and upward shift in the distribution curve for body weight (Bray 4001). A possible explanation for the ineffectiveness of recent efforts may lie in the ambiguity and inconsistency in the definition of obesity as a public health issue. The medical and scientific communities commonly place the phenomenon alongside other genetic syndromes, citing a dysfunction in metabolic systems. Many other health professionals are quick to point to poor nutritional choices, and indolent behavior as the center of the condition. Others argue obesity as a disease is an invention of the medical community and pharmaceutical industry to capitalize on a nonfatal and incurable spectrum of symptoms. While doctors and researchers wrangle over the origins, causes, and existence of obesity, public health officials are forced to rely on traditions and techniques that have become standard for the field. Taking approaches that were perhaps effective in addressing other health issues, health professionals are attempting to generalize and apply theoretic constructs to a rampant public health emergency that has proven resistant to these efforts.

Public Health's failings in its approach to defining obesity are evident in three main areas. The first is public health's primary focus on the purely physical aspects of obesity, namely weight and body mass, discounting the various facets and measures of an individual's health. Second, public health practitioners are quick to return to the ineffective domain of informed behavioral interventions as the solution to unhealthy actions and lifestyles based upon the failed approaches to characterizing obesity. Third is the failure of the public health field to properly incorporate and decipher the broader societal factors that play a role in defining obesity, looking to place blame on negative influences and implement easily legislated generic patches. The shortcomings to accurately and adequately define obesity have led to unsuccessful efforts in combating its proliferation despite the tremendous attention and anticipation for valuable interventions.

The primary failing of the public health field in defining the issue of obesity is the fundamental focus on the purely physical attributes of the individual. Currently, obesity is defined as having a Body Mass Index of 30 or greater (USPSTF 95). Concentrating entirely upon body mass creates a very narrow view of the problem and gives little regard to other factors that can contribute the person's current physical state ranging from physical fitness, emotional concerns, mental status and even economic welfare. Author Paul Campos vehemently states,

We do eat too much junk that isn’t good for us, because it’s quick and cheap and easier than the alternative of spending the time and money to prepare food that is both good for us and satisfies our cravings. A rational public health policy would focus on those issues, not on weight, anymore than diets and diet drugs would be the solution, even if they actually made people thin (thin people with bad health habits are no healthier than fat people with the same habits) (Campos 248)

The emphasis on weight and girth is not an accurate measurement of health, and to define obesity as merely weight and fat to muscle ratios limits the generation of possible solutions to the problem.

Through this single-scope perspective on the definition of obesity, it would appear that weight loss is the true viable solution to obesity. Through the single-scope perspective on the definition of obesity, it would appear that weight loss is the true viable solution to obesity. Americans spend over $33 billion annually on weight loss and diet product services. However, even with these expenditures, Americans’ waistlines are still increasing (Kruger 402). Public health’s ardent emphasis on the Body Mass Index as an integral part of defining obesity has not significantly encouraged the American public to lose weight. By creating a single, weight-bound threshold of unhealthiness, an individual who finds himself 5 pounds over the established obesity cutoff, can lose that weight and conclude that he is living a healthier life. Emphasizing the importance of an individual’s weight alone, defining the problem of obesity as one simply of size, does not adequately address the concerns facing the growing American public.

The limitations of public health’s definition of obesity, one that focuses on body mass and physical characteristics, is evidenced in the creation of ineffective interventions. The concentration on the physical condition of the individual leads officials to develop unsuccessful solutions based upon inadequate behavioral models. Public health’s models for changing individual behavior, such as the Health Belief Model and the Theory of Reasoned Action limit the intellectual and practical foundations from which practitioners, researchers and health care professionals can build upon. The Health Belief Model states individual actions toward a healthier lifestyle rely on the notions of personal susceptibility, a projected severity of impairment, and that the actions taken would prevent or reduce these consequences without requiring significant psychological compromises (Rosenstock 300). Similarly, the Theory of Reasoned Action attempts to model the relationship between personal intentions with respect to subjective beliefs and attitudes, and the implementation of target behaviors (Choi 21). Both models assume that behavior is dictated by rational thinking that can lead to rational decisions, in this case, choices favoring healthier lifestyles and ultimately better health. The Health Belief Model purports that a person who has an understanding of the consequences of a certain disease and have the intent to change the behavior that affects their health outcome would do so with the belief that the outcome is beneficial.

Furthermore, the Theory of Reasoned Action “suggests that behavioral change ultimately is the result of changes in beliefs, and that people will perform behavior if they think they should” (Fishbein as quoted by Salazar, 132). The limitations of these models including their failure to account for variations in thought processes (irrational thinking) and outside influences (socioeconomic status, culture, etc.,) become truly evident as practitioners attempt to apply sociological theory into public health practice. Public health’s failure to adequately define obesity as more than a physical condition forced researchers and officials to seek solutions that could not and did not address the problem. The issue, therefore, lies within the field’s narrow approach to defining obesity within the American population. Thus, it is suggested that new guidelines to classifying and characterizing obesity include more than physical dimensions, behavioral idiosyncrasies and social interaction.

In addressing the shortcomings of the current definition of obesity, public health practitioners should consider economic and cultural influences. Many citizens argue that economic constraints often affect their choices in food consumption. The limitations upon accessibility and feasibility of healthier options are important aspects in understanding and grasping the foundations of obesity. Healthier foods are certainly not promoted in local stores who carry substandard produce while charging comparable high prices for them. For consumers, the likely choice for economic sake, may include the weekly sale of two-for-one potato chips, hot dogs and macaroni and cheese. “If you walk around Boston, the first thing you may notice is that food choices are not equally distributed geographically. The poorer neighborhoods simply do not have access to highly nutritious food choices” (Siegel 4). The issue then becomes apparent that obesity is not purely physical dysfunction either in genetics or weight and more importantly not completely behavioral either. It seems that monetarily, healthier choices may not be the “best” option given financial constraints. A definition of obesity therefore, should incorporate economic factors.

In addition to the economic facet of obesity, another key component that needs to be considered is the cultural aspect. America has long since been the “melting pot” of cultures with the vast number of immigrants throughout the nation’s history. People bring with them certain cultural and familial values that intertwine with the American way but better yet, with being American. Many scientists, doctors and researchers now argue that perhaps American culture is to blame for the rise of obesity.

‘Mexican Americans come to the United States with health as good as whites and Asians—and much better than whites and Asians at equivalent socioeconomic status—and within a few years become much worse,’ says adjunct professor of maternal and child health Julia Walsh, M.D., D.T.P.H. ‘The longer they are here, the more they approximate the health of African Americans, who have the poorest health. We seem to generate health disparities that did not exist previously.’ (Broder 8)

Acculturation, in some ethnic groups, has significant impact upon health. Thus, it would behoove public health practitioners to note that perhaps obesity, easily defined physically by above normal weight for height, to also include cultural background, which plays a distinct role in how health is perceived, modeled, and evaluated.

The approach to defining the public health problem of obesity must include multifaceted influences that have significant impacts upon the health of a diverse population. Economic status and cultural background are only two examples of overlooked and undervalued influences that practitioners should and must consider when approaching public health issues. Dr. Nancy Krieger supports the multilevel approach to defining public health issues, arguing:

The field of epidemiology today suffers from the absence of not only a clearly articulated and comprehensive epidemiologic theory, but, it seems, even the awareness that it lacks such a theory. The science instead is taught and viewed as a collection of methods to be applied to particular problems involving human diseases and health. (Krieger 889)

Obesity, therefore, must be defined as more than a physical condition. The incorporation of other aspects including behavior, economic status and cultural background are important. Adopting a broader perspective, exemplified in a comprehensive definition of the obesity problem, will most certainly lead to the development of more extensive and effective interventions.

Works Cited

Bray, G. Obesity: The Disease. Journal of Medicinal Chemistry 2006; 49:4001-4007.

Broder, M. Is American Culture to Blame for Poor Health?. School of Public Health, University of California, Berkeley Alumni Public Health Magazine: 7-9, Spring/Summer 2006.

Campos P. The Obesity Myth: Why America’s Obsession with Weight is Hazardous to Your Health. Conclusion (pp. 247-251). New York: Gotham Books, 2004.

Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.

Flegal, KM, Carroll MD, Kuczmarski RJ and Johnson CL. Overweight and Obesity in the United States: Prevalence and Trends, 1964-1994. International Journal of Obesity 1998; 22:39-47.

Krieger N. Epidemiology and the web of causation: has anyone seen the spider? Social Sciences & Medicine 1994; 39: 887-903.

Oliver, EJ, Lee T. Public Opinion and the Politics of Obesity in America. Journal of Health Politics, Policy and Law; 30 (5): 923-954.

Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.

Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.

Siegel M. Soft drinks being singled out as a cause of obesity problem; analogy to tobacco seems detrimental to public health efforts. The Rest of the Story: Tobacco News Analysis and Commentary (blog), March 7, 2006. Available at:

Story M. Building Evidence for Environmental and Policy Solutions to Prevent Childhood Obesity the Healthy Eating Research Program. American Journal of Preventative Medicine 2006; 30 (1): 96-97.

United States Preventative Services Task Force. Screening for Obesity in Adults: Recommendations and Rationale. American Journal of Nursing 2004; 104 (5): 94-102.


Anonymous Stephanie said...


I really enjoyed your paper. It was well supported and very well written. I couldn't agree more with your argument. Public Health definitely needs to start looking deeper- to the social, cultural and economic factors that play a vital role in obesity. Thanks for writing such a great paper.

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Anonymous Anonymous said...

Right on. There is way too much emphasis on BMIs. The men in my family are always getting into trouble come middle age because they are skinny, but have clogged arteries from years of eating junk food and never excerising. I hope plenty of pcps read your blog and get a clue! -Heidi

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