Sociology of Obesity: How to Justify Fighting against the Development of the Obesity Epidemic

Abstract

Obesity, a complex social issue with profound health implications, intersects with various facets of society, from cultural norms to economic structures. This paper explores the sociology of obesity through multiple lenses, examining its social construction, the evaluation of societal perceptions, and the stigmatisation of obese individuals. It scrutinises the medicalisation of obesity and its consequences, urging caution in policy interventions and the interpretation of scientific evidence. Furthermore, it advocates for a nuanced approach to obesity prevention, emphasising the importance of public health policies grounded in evidence-based practices and a shared responsibility across diverse sectors. By delving into the intricate interplay between science, society. and culture, this research underscores the legitimate conditions of public health actions in fighting against the development of the obesity epidemic.

1. Introduction

Obesity is a social problem because it affects populations in a socially differentiated way. Prevalence rates do not have the same intensity in different strata of society. As such, it is a factor in both social and health inequality [1,2,3,4]. Obesity is a social problem, because the people who suffer from it bear the brunt of social stigma and condemnation. Not only do they endure the possible physical consequences of this condition, but also its social consequences; they are negatively judged and often discriminated against. Obesity is a social problem, because human nutrition is culturally determined through the definition of what is edible, as well as the way it is prepared, eaten, and implemented in specific social contexts [5]. Obesity is a social problem because many social agents can influence its development: food and catering industries and pharmaceutical industries, but also nutritionist “diet sellers”, fashion and body image professionals and public policy designers, as well as individuals and their families who are victims but are gladly turned into perpetrators and guilty parties. Finally, obesity is a social problem because the many scientific communities that study it and claim to explain it are riddled with controversy. Moreover, they are subject to the influence of lobbies with conflicting interests (the pharmaceutical and food industries, insurance, transport, health professions, etc.). For all these reasons, obesity is a subject for the social sciences [6,7,8,9], and social negative consequences come in addition to the risks that obesity poses to health [10].

According to the World Health Organization, in 2022, 2.5 billion adults aged 18 and over were overweight (BMI > 25) and of this total, more than 890 million were obese (BMI > 30). On the economic level, obesity represents first of all 2 to 7% of health expenditure, again according to the World Health Organization. But it also constitutes a considerable market (dietary food, physical activity, the paramedical and medical industry, etc.). Data that make the problem visible to the authorities and the general public [10].

From sociology, several reading grids can be deployed [7]:

The first is at the service of medical research, to identify the social factors involved in the development of obesity. This approach focuses on the socio-demographic characteristics of the individuals concerned, their lifestyles, their eating habits, and their social backgrounds.

The second approach focuses on the shifts in conceptions relating to obesity. Although it is now seen as a problem, it has not always been so. There have been and still are cultures in which this condition is seen as desirable. In the West, slimness has long had negative connotations and has been associated with disease, melancholy, sterility, and fleshy bodies with good health, liveliness, and, in a woman, fertility. So, what happened that caused it to become both a medical and a social issue? On what scientific grounds is this shift based?

Finally, the third approach is concerned with policies aimed at preventing the development of obesity. What leverage for action is used, at the level of individuals (promotion of “better” eating habits and healthier lifestyles) and at a socio-economic level (encouraging the food and restaurant industries to make nutritional changes, mobilising players using body image to reduce the pressure associated with the body aesthetics model, or fighting against stigmatisation)? What possible counterproductive effects are likely to be seen as a result of the medicalisation of everyday food and the dramatisation of obesity?

This article is not an interdisciplinary review of the literature but a position paper that aims to justify and argue, from the perspective of social sciences, the importance of preventing obesity. The argument is sociological, focusing on the social consequences of scientific positions, particularly within the field of the sociology of science.

2. The Social Construction of Obesity

The change in the epistemological status of obesity from “risk factor” to “disease” to “global epidemic” has contributed to its visibility. It has thus become a political, social, and media issue. In the context of food crises, obesity gradually became the “obvious” demonstration that “something is wrong” with modern food and began to represent the dreaded consequences of this crisis. Sociology helps to identify the impact of the social aspects in scientific and media debates, be it deliberate influences such as those of lobbyists, or the phenomenon of collective representations that weigh on both lay and scientific representatives. Thus, obesity is an outstanding object for studying the relations between science and society. Dramatisation has brought obesity onto the political agenda, but when it becomes excessive under the effects of media focus, we face the risk of counterproductive effects that reinforce the stigma of obese subjects and contribute to food anxiety in the general population [6,7,11,12,13].

The sociology of sciences is interested in the medicalisation of obesity, i.e., the background of its definition and the modalities of its management by the medical system. It studies the conditions of its inclusion in different medical fields, the concepts that contribute to its definition, measurement, and designation as a health issue, and finally, it analyses the possible consequences of its management and treatment. It is particularly attentive to scientific controversies, not to take part in their resolution, but to understand the social stakes involved. It is thus an invitation to take a critical look at the dramatisation of obesity.

This part of this paper mainly studies the social representations of the big and fat which underlie the valorisation of slimness and constitute the foundation on which the stigmatisation of people with obesity is based.

2.1. The Changes in Social Representations of Big Bodies and Fat

The valuation of fatness or slimness varies in geographical space and from one culture to another. An analysis conducted on the “Human Relation Area Files” shows that 81% of the 58 traditional cultures for which data on values associated with body size are available consider that the ideal of feminine beauty can be described as “plumpness” [14]. In many cultures, the ability to store fat is seen as a sign of good health and vitality, and individuals with high body fat reach social positions of power and prestige. But the full figure and its value also vary over time within Western cultures. For Europe, the medieval aristocracy valued an image of the slim, slender, frail, small-breasted woman, of which Cranach’s paintings are a demonstration, beyond of course the portrayal conventions that varied over time. From the Renaissance onwards, the model of body aesthetics changed; the “beautiful women” were more “coated”. Largeness and overweight became signs of wealth and success. They are signs of detachment from necessity and denote a social position. Around 1930 in France, the first signs of a change appeared, but it was not until the 1950s that the model of slimness started prevailing, while overweight became a sign of bad health rather than a sign of success [15,16,17].

Why do views on corpulence differ from one culture to another and fluctuate over time within the same culture? In social contexts where food is limited, a corpulent body is a positive quality. When abundance is established, the aesthetic model of slimness appears. Slimness then becomes a sign of success, prosperity, and even wealth. By contrast, being overweight is then regarded as unattractive, but also as morally incorrect; people with overweight are those who eat more than their share. In the 1970s and 1980s, the image of the fat man was used to denounce the “capitalist” that exploits his workers, and the overfed Northern countries that “starve” the Southern countries through post-colonial economic organisations. In this perspective, fatness is “morally incorrect”: it signifies selfishness and attests to a lack of self-control.

However, in all eras, even when fatness is the dominant model, the social representations of obesity are characterised by ambivalence. There is always a frontier, a threshold beyond which the positive figure of obesity turns into the fat one who no longer respects social rules. It is therefore not correct to say that developed countries have moved from a pro-obese body model to an anti-obese one. In reality, the threshold between “properly fat” and “too fat”, which socially distinguishes “slightly overweight” and obesity, has been lowered [15].

Not all cultures view obesity in the same way, and in Western cultures, large bodies were valued more highly in the past than they are today. In order to shift from a more positive view of obesity to one of condemnation, a number of individuals in developed societies, on a global scale, have had to persuade others that the situation was truly problematic. In this perspective, obesity presented as “abnormal”, as a “deviation” from the norm, is therefore a social construction whose stages should be examined.

2.2. Stigmatisation of People with Obesity

Stigmatisation is defined as a discrediting and exclusion process that affects an individual considered “abnormal” or “deviant”. The label “deviant” is attributed to an individual by other supposedly “normal” individuals during social interactions [18]. The subject is then reduced to the “deviant” characteristic that becomes a stigma, and his or her other social qualities take a back seat. For people with obesity, the status of “fat” takes precedence over all other qualities of the subject. Once this label has been awarded, it justifies social discrimination and exclusion measures of varying severity. The trap closes on the stigmatised person when having lost some of their self-esteem, they find the discriminatory treatment to which they are subjected normal and legitimate. The stigmatisation process takes place in five stages:

• The label “deviant” is attributed to an individual by other individuals in the course of social interactions;
• The individual is then reduced to his or her stigma, with all other social qualities taking a back seat;
• The label makes certain social discriminations possible and justifies them;
• The stigmatised individual internalises the devaluation;
• The stigmatised individual considers his or her fate justified;
• The trap closes in on him.

It then justifies a series of social discriminations, even exclusion. The stigmatisation of people with obesity can become a vicious cycle when the person with obesity accepts and considers the discriminatory treatment and prejudices they suffer as justified. This leads to self-depreciation, which in turn results in a deterioration of one’s self-image. From the simple purchase of an aeroplane or cinema ticket to the heavy aesthetic influence that weighs on them, people with obesity are devalued, marginalised, and banished from society. In contemporary developed societies, they face stigma. On this theme, two categories of sociological works have been carried out: those that aim to list and describe the forms of stigmatisation of obesity, and those that seek to make life easier for people with obesity and reduce the importance of the discrimination they suffer.

The description of obesity stigmatisation [16,19] shows how some negative attitudes towards these people can turn into real discrimination and affect their social trajectories. Statistically significant links have been demonstrated at different levels. People with obesity have a lower rate of access to higher education. They find it more difficult to find a job. Their average income level is significantly lower. Their professional promotion is slowed down. Finally, their domestic life and access to and use of community facilities are more complicated. Obesity in Western societies can be considered a true social handicap.

Children play a leading role in the stigma phenomenon. Obese adults declare that children are a significant source of stigmatisation. Previous studies have shown that from the age of three, children clearly show stigmatising behaviours towards overweight subjects, whether adults or other children [17]. However, many studies highlight the existence of negative attitudes towards people with obesity on the part of medical or paramedical staff within health institutions. These various studies show the permeability of the medical environment to the dominant values of society (here, the slimness ideal) and the crucial influence of these values on the roles of the health system’s staff.

Members of the medical system sometimes play the role of “great stigmatisers” [20,21]. Medical ideology and its diffusion in society (medicalisation) participate in the justification of “labelling” them as deviant and contribute to the stigmatisation of people with obesity. The importance of this discrimination is such that it has sometimes led legislators to take it into account, under pressure from associations of overweight people who have organised themselves to fight against what they refer to as “the tyranny of morphological correctness”.

An objective assessment of the stigma phenomenon has shown that social positions are partly determined by corpulence. For this, the notion of social mobility, which reflects an individual’s movement within the social structure, must be used. It is said to be intra-generational if it compares the position of one individual at two points in his or her life (beginning of career and end of career, for example), or inter-generational if it compares the position of a son and that of his father, for example. It can be ascending, descending, or equivalent depending on whether the displacement rises, goes down, or stays at the same level of the social scale.

Obesity slows down ascending intra-generational mobility and increases descending intergenerational mobility. The latter is influenced by three main factors, level of education, professional activity, and marriage, which have different impacts depending on gender. For men, education and professional activity play a more important role. For women, marriage is considerably more important, although its significance tends to diminish. For example, slim women are more likely to have ascending marriages—that is, to marry men of higher social status than themselves—and large women, on the other hand, are more likely to have descending marriages—that is, to marry men of lower social status than themselves [20,21]. Under the pressure of the aesthetic model of slimness, marriage acts as a “marshalling yard”, orienting slim women towards the top of society and large women towards the bottom. Managers and recruiters are more likely to give obese staff negative evaluations than slim staff, which slows down their social progression [11]. In such a context, the commodification of health also contributes to the phenomenon of stigmatisation. This occurs through the implicit discourse that supports the offer of diet products, slimming or weight control diets, or, more broadly, the advice of fitness coaches. All of them use, more or less, obesity as a deterrent to be absolutely avoided. Thus, the figure of the obese person becomes that of personal and social failure [22].

2.3. Avoiding Dramatisation

The perspective of the sociology of sciences on obesity is to examine the effects of putting obesity high on the political agenda on the one hand and the media coverage of obesity on the other. It considers that the dramatisation of this issue can have counterproductive effects [12,23] and calls for caution. The first point lies in the very definition of obesity. Previous researchers put forward the idea that too great a diversity of methods for measuring obesity (ratio to “ideal weight”, calculation of BMI, skin folds, ratio of waist to hip circumference measurements, positioning of weight on a reference population, etc.) was the main obstacle to carrying out meta-analyses [1]. It was therefore urgent to promote a single method for making comparisons, which was made possible by the generalisation of the BMI. However, while this choice is a step forward for communication between researchers, it has drawbacks that cannot be underestimated. The arguments supporting the medicalisation of obesity are the epidemiological evidence of statistical links between obesity and morbidity and between obesity and mortality. The latter link would take the form of a U-shaped curve for women and a J-shaped curve for men. That is to say that mortality increases with both low (leanness) and high (overweight) body mass indices. So, there would be a range of BMI values between 18 and 25 that could be described as ideal, i.e., where health risks are the lowest. Some of the most serious work is beginning to call for caution in two directions: firstly, in the universal use of the tool and secondly in its interpretation with regard to overweight. On a global scale, all men do not have the same physical type. Although obesity specialists often state that the BMI is valid for “Caucasians” only, generalisation trends often—if not always—prevail, and many studies use it with its interpretation scale for populations of other physical types. Based on previous studies, researchers have proposed redefining body size classes for Asian populations by lowering the obesity threshold to 28 rather than 30, based on the links between cardiovascular risk factors and BMI [24]. On the opposite, for Oceanian populations, these same authors (and on the guidelines of the South Pacific Commission) propose to move it to 31 or 32 [25].

The second point is the frequent aggregation that is made between overweight and obesity. Used to alert the general public and political actors, it is one of the main reasons for the aforementioned dramatisation. There is a case here for scientific controversy (i.e., contradictory arguments published under the same conditions of legitimacy). A scientific controversy can be defined as the coexistence in the scientific field of contradictory positions supported by “legitimate” scientific arguments—that is, those published in peer-reviewed journals. In an optimistic, positivist view of science, controversies can be seen as the consequence of competition between paradigms. They disappear when one paradigm prevails. Arbitrating controversies and overcoming them is one of the ways in which science advances, but in some cases, empirical data do not allow us to arbitrate the controversy definitively. The evaluation of the consequences of obesity on mortality in the United States, for example, ranges from 400,000 deaths per year to nearly 26,000 with a ratio of 1 to 15 [26,27]. However, one of the main points of the controversy concerns the impact of overweight on mortality. There is also a downward reconsideration of risk factors for BMIs between 25 and 30, and one researcher even attributes positive effects to slight overweight in her epidemiological model [28,29,30]. Behind the apparent consensus, there are scientific controversies surrounding obesity. Controversies can be divided into those concerning management and treatment strategies, and those concerning the measurement and explanation of the extent of the phenomenon. These controversies include the use of body mass categories on an international scale, the measurement of excess mortality attributable to obesity, the impact on life expectancy, and whether obese children become obese adults.

The purpose of the sociology of sciences is not to take any part in the debate on the substance, which is the role of epidemiology and the medicine of obesity, but simply to note the controversy and to prompt an assessment of the issues underlying it [7]. Both authors above are recognised scientists, and the references cited have been published in a prestigious peer-reviewed journal. It should simply be remembered that controversy is inherent to modern science, the very sign that it is “moving forward”. It is through the process of surpassing and arbitration that knowledge progresses. The epistemologist Georges Canguilhem wrote, “Science is a discourse that is normalised by its critical rectification” [31].

3. Sociology “Pro” Obesity

Sociology “pro” obesity is intended to contribute to the building of a public policy for the prevention of obesity. One of its first missions could be to participate in clarifying the legitimate conditions of public health interventions in fighting against obesity epidemic development.

3.1. How Can the Fight against Obesity Be Justified?

In recent years, public health has entered the era of Evidence-Based Medicine, i.e., a policy based on scientific evidence. Now, “if there is one thing that doctors and dieticians know for sure, it is that the classic attitude in the management of obesity generally ends in failure” [32]. This only confirms what a previous researcher mentioned many years ago: “Most obese people do not continue their weight loss program. Among those who do, the majority do not lose weight and among those who do lose weight, most regain their weight” [33]. The “diet control” side of the equation is rather disappointing. The problem with restrictive diets is that they often work in the short term, but very rarely in the long term. Such effects are sufficient to maintain hope of success and to sustain a demand that is fuelled by women’s magazines and to which a plethora of products and services, as well as an entire segment of the food supply, cater. On the prevention side, the few actions that have worked are the exception. Obesity puts scientific rigour to the test. Stunkard was talking about fad diets, so he is right in the long run. No wonder then that the warnings are numerous and straightforward. For example, an editorial in the New England Journal of Medicine stated: “Until we have better data on the risks of being overweight and the pros and cons of trying to lose weight, we must remember that treating obesity can be worse than the disease” [34]. And for several decades the observation of failure has remained relevant despite “considerable” developments in knowledge [35,36]. This knowledge has not been able to curb the development of obesity [37]. It is unrealistic to believe that applying the same recipes that did not work in previous years will solve the problem. In the strategy of putting obesity on the political agenda, part of the scientific community has shown optimism about its ability to tackle its development. The time has come to assert the need to step up public research in several areas: epigenetics, microbiota, and ultra-processed food. Research is also needed into determinants that go beyond voluntary individual behaviour [13,19,38,39,40]. Not forgetting the more classical related topics such as the physiology of fat cells, physical activity, psychological, social and cultural factors influencing eating habits and the relationship with the body, and the organisation of food systems. Some years ago, some academics even suggested a moratorium until more knowledge was accumulated [41]. These suggestions went unheeded, certainly because inactivity in the face of a worsening problem was seen as defeatism. On the contrary, the WHO is encouraging governments to “accelerate action to stop obesity” [42].

Despite the difficulties in implementing plans that are based on sound scientific evidence and past experience, some public health officials believe that in the face of such a serious problem, we cannot stand by and that even in the absence of solid data, action must be taken. Such a position is based on both the principle of precaution and the intergenerational responsibility for the health risks and the economic imbalance in health systems caused by the development of obesity. Indeed, the classic approach to public health consists in taking action only when validated and safe knowledge is available to support it. However, when a risk or disease trend is inexorably spreading, the application of the precautionary principle can suffice to justify interventions. It is always legitimate to act even if we are not sure of the effects. But in this case, they should be grounded in up-to-date knowledge, and the actions should be systematically evaluated.

3.2. Monitoring and Evaluating Actions

In the 1980s, the WHO emphasised the importance of giving evaluation a central role in the management of public health programs [43]. However, in the case of obesity, evaluation remained superficial. While the development of obesity is well documented, the history of the control measures developed at the population level calls for caution. Among the many thousands of actions undertaken, very few have been assessed, and very few of those have proved effective. The willingness of the promoters of the actions is not in question, and some have even drawn up plans with objectives that can be verified. However, due to the complexity of the issue because of its multifactorial nature, the slower timeframe for its effects compared to public health actions, and the cost of in-depth evaluation, which can often be higher than that of the initiative itself, evaluations have been reduced to superficial matters. So it would be wrong to say that there is no evaluation, but current evaluations mainly focus on the number of people concerned and changes in their knowledge and sometimes their perceptions. Most of the time, they are carried out on relatively short timescales. However, interventions are only meaningful if their effects are measured and the results are used to guide new actions. Otherwise, we fall into the trap of activism and run the risk of seeing those who launched the calls for action comment on the rising prevalence statistics the following year and once again assert the imperative need for action. Without monitoring and evaluation, interventions run the risk of being counterproductive.

Yet, we are not condemned to inaction. According to a sound interpretation of the precautionary principle, it is reasonable to take preventive action, even in the absence of well-established knowledge, provided that it is monitored and real evaluations are carried out. The assessment should focus not only on cognitive aspects, i.e., what has changed in people’s knowledge, representations, and beliefs, but also on behaviour, routines, and systems of norms. This includes dietary practices, physical activity, and finally anthropometric or biological parameters. All of this, of course, over time, not just in the few months following the intervention. To improve methodological expertise, research is needed, and experts in this field must be involved. So, data coming from evaluations could be aggregated. In this way, evaluation will become a place for producing empirical data and knowledge that will enable policies to be guided by stopping, in full knowledge of the facts, what could be counterproductive and deploying actions that “work”. For a science-based public health policy to be built, objectives must be based on established knowledge or at least on sound assumptions.

This condition may seem obvious, but it is not always easy to meet, particularly when it comes to managing change. Many literature reviews, including a meta-analysis on the subject, conclude that it is difficult to establish a link between nutritional knowledge and food consumption [44,45]. Even more problematic is the fact that the cost of evaluation sometimes exceeds the cost of action.

3.3. Towards a Policy of Shared Responsibility

Thus, as a result of weaknesses in the level of evidence and scientific argumentation, too often in the medicalised discourse on obesity, scientific knowledge and moral representations are intertwined. The medical community must be aware of their role of the “great stigmatiser” that they are likely to play, as well as perceive the consequences of that role. Medicalisation’s most severe disadvantage is that it gives a form of scientific legitimacy to the stigma of obesity and locks individuals into a new dietetic–psychological deviancy.

So, should obesity prevention be de-medicalised? The answer lies in the dissociation between obesity and overweight on the one hand, and the medical and social dimension of the obesity problem on the other. In the French collective expertise on childhood obesity, Arnaud Basdevant has taken a clear position: “Promoting thinness to avoid obesity would be an unrealistic, unfounded and dangerous proposal. There is no argument to define a theoretical weight to which everyone should refer univocally; the zone of recommended weight is wide. At the risk of being caricatural, we propose to ‘de-medicalise’ the prevention campaigns, i.e., not to refer to the disease but rather to well-being. The culinary culture and the positive aspects of dietary models that do not promote obesity should be valued” [41,46,47]. To de-medicalise prevention does not mean to deprive education programs of nutritional science knowledge, but rather to articulate it with the sociocultural dimensions of food. This invites us to move from nutritional education to food education in order to address the different horizons of the act of eating—its link to health, its link to pleasure, and its social and symbolic dimensions, etc.—while respecting the processes of socialisation and the construction of identities that combine social, regional, and religious dietary specificities.

Despite intense scientific activity and significant advances, the knowledge acquired on obesity remains limited. This is evidenced by the poor results obtained in terms of treatment and prevention. This is also evidenced by the ongoing controversies within the scientific community. By challenging the disciplinary approach, by questioning the relationships between science and society, obesity is undoubtedly one of the greatest tests of humility that modern science faces today.

4. Conclusions

What can we do concretely about it? For over 50 years, the scientific community has been faced with an increase in the prevalence of obesity in almost all countries, despite an undeniable accumulation of knowledge. Faced with its inexorable evolution, it seems legitimate not to sit idly by and to pursue preventive measures against the development of obesity. But only if they are subject to a thorough evaluation. It is possible that some of the many measures taken may have counterproductive effects. But we still need to give ourselves the means to identify this problem.

This article invites interested parties to explore under-exploited avenues. The fight against the stigmatisation of obese people, which is the classic credo of the social sciences, arrives first. There are both ethical and health reasons for doing this. Ethical reasons, because stigmatisation is the starting point for discrimination at schools, at universities, and in the workplace. Health reasons, because social exclusion, loss of self-esteem, and suffering the looks of the others are often accompanied by compensatory eating practices.

In addition, this article calls for actions in two directions. The first is the reaffirmation of the need to increase the research effort. The second is the imperative of putting in place in-depth evaluation systems and aggregating the results to be able to pursue those that have positive effects and stop or modify those that have no effects or negative ones.