Dr Michael Fitzpatrick
Big girls and health zealots
According to the handy colour chart for plotting weight and height provided by the Health Education Authority that I keep on my desk in the surgery, I fall into the 'overweight' category. This is a band of equivocal orange between the golden zone labelled 'OK' to the left and the stripes of deepening red to the right, as 'fat' gives way to 'very fat'. In another version of this chart in a recent bulletin circulated to all GPs on 'the prevention and treatment of obesity', the 'OK' category is subtly redefined as 'desirable'.
Perhaps it is my difficulty in coming to terms with this exclusion from the camp of the desirable that gives me little enthusiasm for health promotion in the sphere of obesity. Or it could be because I am in a state of denial with regard to the measures of diet and exercise required to rejoin the company of the elect.
Yet fat is such a happening issue that it is difficult even for an over-weight/undesirable GP to avoid it. My call to a higher level of obesity awareness came last month with an invitation to participate in a late night talk show on BBC Radio 5 Live. With me around the table were a dietician working for Kellogg's ('The fat controller'), a personal fitness trainer with celebrity clients, the editor of a health magazine, the broadcaster and journalist (and champion dieter) Nina Myskow, and Penny Cee, founder of Planet Big Girl nightclub. On the line from San Francisco was Marilyn Wann, editor of the magazine Fat! So?.
The form for these programmes is that the BBC provides a few bottles of wine (and a few desiccated sandwiches) to encourage a convivial atmosphere and the discussion flows into the early hours interrupted only by half-hourly news bulletins. But the only people drinking the wine were myself and Penny Cee...
Now I have always thought the epithet 'health fascist' rather silly. This term is commonly used by free market right wingers to denounce their more authoritarian conservative (and New Labour) colleagues for restricting individual freedoms in the name of health. But as the anti-obesity campaigners merged in a studio united front of moral outrage and dogmatism, the intolerant and coercive dynamic underlying the contemporary obsession with health was exposed.>
To avoid lazy historical analogies, I would prefer to call them 'health zealots'. They found two targets for their sanctimoniousness: the self-proclaimed fat activists, for refusing to accept their designated place on the HEA colour chart, and myself, for refusing to join their crusade, and worse, for questioning the scientific basis of much health promotion in this area.
I was shocked at the sheer rudeness of the health zealots towards the fat women on the show and their scarcely concealed disgust at their obesity. It was remarkable that people who at first appeared quite personable suddenly turned rather nasty when faced with fat women who did not project the approved image of guilt and shame. The zealots felt free to conduct a public interrogation of the fat women about their personal habits, to advise them about the risks to their health and to tell them how they should shape up. The fact that both Penny Cee and Marilyn Wann were articulate and entertaining only intensified the animosity of their opponents.
In a way my offence was even worse. As a doctor, I was expected to provide medical legitimacy for the healthy living agenda. Instead, I questioned the validity of much of the evidence linking obesity and ill-health, particularly for people in the lower grades of obesity (that is, most people) who are the main targets of dietary propaganda - a point well-made in a recent editorial in the New England Journal of Medicine (1 January 1998). The same editorial notes that the argument that losing weight contributes to better health, though plausible, remains unproven, though the adverse consequences of the Western obsession with dieting (most notably the rise of anorexia/bulimia) are familiar.
The zealots were shocked as well as outraged. Though they are well aware of the scientific controversy that surrounds many aspects of obesity, a pervasive sentiment of 'not in front of the children' dictates that 'health professionals' should toe the line in public and stay 'on message'. Nina Myskow proclaimed more than once that I should be struck off the medical register for straying from orthodoxy and scandalising the public. When I said that I did not think it was part of my job as a GP to harangue my patients on the virtues of a healthy diet, the zealots immediately concluded that this could only be explained by my ignorance of what this included and demanded, in a strident chorus, that I submit to a brief examination.
What is it about fat that brings out the gauleiter in people? I think the Australian sociologists Alan Peterson and Deborah Lupton are on to something when they point out that 'the "healthy body" has become an increasingly important signifier of moral worth' through which 'the individual can express publicly such virtues as self-control, self-discipline, self-denial and will power' (The New Public Health: Health and Self in the Age of Risk, p25).
Of all the concerns of modern health promotion, obesity is the most public manifestation of private non-conformity with the approved virtues of our age. You can be a secret smoker or drinker or eater of cream cakes; but, even allowing for careful selection of clothes, your wasteline is public knowledge. Whereas only you and your doctor have access to your blood pressure or serum cholesterol level, anybody at the bus stop could place you fairly accurately on my colour chart.
Linking weight to health makes it possible to generalise a sense of risk to the whole population. If more than half the population - including even me - is defined as being overweight, this surely justifies mass campaigns to change people's behaviour in the name of health. A major investigation of links between lifestyle and heart disease last year concluded that 'nearly everyone would benefit from being a little thinner' (British Medical Journal, 2 May 1997). In this way the influence of health professionals is extended from the sick to the well, and it becomes clear that the obsession with obesity provides a mechanism for imposing discipline over the whole of society. I think I'll forget the exercise bike and get down to Planet Big Girl night club.
Reproduced from LM issue 109, April 1998