Appetite 55 (2010) 219–225 Contents lists available at ScienceDirect Appetite journal homepage: www.elsevier.com/locate/appet Research report Fat bodies and thin bodies. Cultural, biomedical and market discourses on obesity§ Mabel Gracia-Arnaiz a,b a b Rovira i Virgili University, Department of Social Anthropology, Tarragona, Spain Departament d’Antropologia, Filosofia i Treball Social, Facultat de Lletres, Universitat Rovira i Virgili, Avda. Catalunya, 35, 43002 Tarragona, Spain A R T I C L E I N F O A B S T R A C T Article history: Received 1 July 2009 Received in revised form 1 June 2010 Accepted 2 June 2010 This article addresses the question of why dieting, health, and the care of the body have come to play such a central role in our daily lives, and explores the relationship of these practices to the emergence of obesity as a social and health problem. Messages urging people to regulate their food intake and get more exercise in order to avoid obesity conflict with warnings that anorexia and bulimia are among the possible consequences of overly strict diets and excessive physical activity. The relationship between diet, beauty and health has been appropriated and re-elaborated as a marketing strategy with wideranging cultural consequences. ‘‘Being on a diet’’ is no longer only a matter of biology, nutrition, medicine or science; it is also about culture, politics and society. ß 2010 Elsevier Ltd. All rights reserved. Keywords: Food consumption Body Medicalization Commodification Obesity Dieting This article is part of a larger study that aims to analyze how and why specific eating behaviors have become social problems and how dietary norms are constructed in industrialized societies, particularly in Spain.1 My objective is to show that the growing problematization of excess weight and food consumption is related to processes of medicalization, individualization and commodification, which in turn are anchored in a wider historical process of ‘‘civilizing the appetite’’ (Mennell, 1985). In the past five decades this civilizing process has intensified, resulting in four distinct but closely linked phenomena: first, the establishment of ideal body weight and dietary norms; second, the construction of thinness as an attribute of health, self-discipline and social distinction; third, the recognition of obesity as an illness; and fourth, the transformation of health and the body into business opportunities. § I am grateful to Susan M. DiGiacomo, Ph.D., my colleague in the Department of Anthropology of the Universitat Rovira i Virgili, for assistance in translating and editing the final version of the manuscript. E-mail address: mabel.gracia@urv.cat. 1 In 2006, with the support of the Spanish Ministry of Education and Science [MEC] and the Catalan autonomous government, the Generalitat de Catalunya, I began an ethnographic study in Catalonia (Spain) on the social dimensions of obesity, a project that was part of a broader program of research and development in Spain on The emergence of obesogenic societies or obesity as a social problem (CSO2009-07683) and Images and experiences of obesity in young people (AVJOVES 2008 00017). This study involves three different levels of analysis: (a) a review of the literature in medical anthropology and epidemiology on food and the body; (b) a comparative analysis of nutritional recommendations and public policies to reduce obesity in Spain, France and Mexico; and (c) an ethnographic study conducted in four Catalan clinics specializing in obesity. This article is a critical analysis of the social construction of eating problems based mainly on the literature review, part of which can be found in Gracia (2007, 2009a, 2009b). 0195-6663/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2010.06.002 The analysis of interactions between these four phenomena makes it possible to show how the medicalization of food and body weight paved the way for the marketing of health and demonstrate why a global issue such as obesity requires a holistic rather than an individualistic approach. From normal to normative: dietary regulation of the body Normativization of food consumption The modern diet is linked to historical processes of social regulation and control of human behavior through a normativization of food consumption. The influence of biomedicine on other medical systems has helped to prioritize the biological functions of foods not only over time but over space as well (Gracia, 2007). The medicalization of food can be traced to Hippocratic treatises on health and the care of the body that enjoined the reader to ‘‘let food be your medicine.’’ The development of dietary norms was an attempt initially by physicians and later by physiologists and nutritionists to subordinate the pragmatic or symbolic motives for food choices and consumption to biological considerations (Poulain, 2002), which in turn were shaped by socioeconomic and political constraints. During the 17th and 18th centuries, the body came increasingly to be seen as a machine, and even greater attention was paid to the healthful qualities of foods. The wellknown British physician George Cheyne (1773; cited in Turner, 1982) adopted the mechanical metaphor of the body – an instrument formed by circuits and flows – to explain how food constituted the fuel that supplied the human hydraulic machine. He argued that the obesity and mental illnesses from which his 220 M. Gracia-Arnaiz / Appetite 55 (2010) 219–225 upper-class patients suffered were attributable to their excessively rich diet and urged them to modify their eating habits. During the 19th century, as food production increased and food distribution became more equitable in western societies, attempts to impose limits on excessive consumption became more widespread. This was a further development in the centuries-long process of what Mennell, following Elias, has called ‘‘civilizing the appetite’’ (1985). This entailed a gradual shift away from modifying patterns of behavior principally in response to external constraints (ecological, economic and symbolic), and toward modifying behavior in response to internal constraints exercised by individuals directly over themselves through dieting, hygiene and exercise. Thus, for example, in areas of Protestant influence, and in Christian areas in general, dietary recommendations began to form part of an ethical position: the care of the body as an individual, economic and social responsibility. Turner (1999) has observed an affinity between the medical management of diet and the expansion of capitalism: discipline and restriction prevented gluttony among the elite, and sufficient nutrition kept the workers working. In the United States these principles were preached in the homes of the working classes by representatives of New Nutrition, a group of nutritionists, social reformers and specialists in home economics who attempted, without much success, to organize the workers’ food expenditure by changing their cooking habits (Levenstein, 1996). Nutrition became an integral part of culture, economy and health when the state emerged as a social regulator and food production and consumption became a state responsibility (Trentman & Just, 2006). In the 20th century nutrition was recognized as a branch of scientific knowledge, and as a consequence of international conflicts and market crises, adequate diet became a major concern for most European governments, for civil society, and for social and charitable organizations. Hunger and poverty were considered social and public health problems and the provision of food became a basic human right endowed with a moral dimension. Traditional dietary habits and forms of agricultural production were seen as potential threats not only to health and the economy but also to the common good, and therefore had to be modified. The idea of an optimum diet based on physiological research into calorie intake and expenditure and protein, fat, mineral and vitamin requirements was introduced, and became the basis on which the methods used in dietary studies were standardized. This, in turn, had wide-ranging repercussions. According to Barona (2008: 88), ‘‘the role of nutritional experts not only influences knowledge, but also inspires agricultural and health policies, education and propaganda programs aimed at disciplining and changing popular habits.’’ These programs have generated the nutritional pie charts and food-group pyramids that have been key instruments for attempting to regulate what and how much people should eat and for homogenizing food consumption the world over. If until the 1950s and 1960s, the working classes of European societies thought of good food as being, above all, satisfyingly abundant, most people now think that they eat too much because they are constantly being urged to eat less. Contemporary nutritional recommendations call for a prudent energy intake and favor variety over quantity. The optimum diet has gradually but steadily reduced the consumption of red meat, eggs and butter in favor of fruits, vegetables, whole grains, fat-free or low-fat milk and milk products, and olive oil. Although the current nutritional pie chart includes all food groups, it is now predominantly vegetarian. Nutritional standards reflect not only the evolution of scientific knowledge, but also its relationship to industrial food production (Nestlé, 2002). Health experts point out that the economic, technological and social transformations experienced by numerous countries in recent years have been accompanied by an increase in chronic diseases such as diabetes, hypertension and obesity. This association constitutes clear evidence of the relationship between modernization, the ready availability of food, and public health problems. Current dietary recommendations are legitimized as a response to increasingly sedentary lifestyles and the replacement of traditional diets by diets that are higher in fat and added sugars. Curiously, 50 years after they were first criticized for being deficient, unbalanced and monotonous, traditional diets are now viewed as healthier. Leaving to one side the question of what science understands by the term ‘‘traditional’’, it is no coincidence that broad acceptance of biomedical claims regarding traditional diets has coincided with dietary globalization and with economic interests in protecting local agricultural products and exporting these products to international markets. An example of this confluence of interests is the so-called Mediterranean diet, which was proposed in 2009 as a candidate for UNESCO’s Intangible Cultural Heritage status with support from the governments of Spain, Greece, Italy and Morocco. At this writing, UNESCO’s decision is expected in September 2010. At present, however, there is no scientific agreement as to whether any one of the traditional diets is healthier than the others. Normativization of body weight The formulation of dietary recommendations has run parallel to the progressive medicalization and commercialization of body weight. Current eating behaviors and practices of the body have undergone important changes over the past 100 years, in particular regarding attitudes toward high-energy foods and robust bodies. At the beginning of the 20th century most people still saw corpulence as a sign of health, and foods with high fat content were more desirable in many Western European societies (Flandrin & Montanari, 1996: 883). ‘‘Being fat’’ is more seductive when thinness means hunger, illness and poverty. In societies in which the majority of the population is undernourished and food is a primary concern for all, this sublimation of corpulence is common. In the majority of preindustrial societies, regardless of their economic system, more or less vigorous physical activity was the norm for both men and women. In spite of the effort expended in food production, however, hunger was a relatively common experience as periods of scarcity or even famine were not unusual. In such circumstances, gluttony – condemned by Christianity as one of the seven deadly sins – was an accepted and even valued social practice. Looking forward to a feast, a Trobriand islander once commented, ‘‘We will be happy and we will eat until we vomit’’ (De Garine & Pollock, 1995: 46). In this context, it is not surprising that robustness or even a certain degree of obesity was often regarded favorably. ‘‘Being fat’’ was a condition to which many aspired, but not everyone could achieve. By contrast, in industrial societies the phenomenon of lipophobia – a systematic aversion to dietary fat and the fear of becoming fat – became established over the course of the 20th century (Fischler, 1995), when biomedicine began to regard corpulence as pathological. During the first decades of the century, physicians recommended not only moderate consumption of food among the upper classes but also standards of weight and height that were decisive in the normativization of the human figure (Brumberg, 1988: 236). At the same time that excess body weight started to be thought of as a health risk, mechanisms were established to control it. The indicators used to measure it, such as the BMI (Body Mass Index), served to define healthy or pathological weight levels in relation to the individual’s height, and the imposition of dietary regimes became the most common way of trying to control body weight. Ironically, nutritional science and medical understandings of human metabolism in thermody- M. Gracia-Arnaiz / Appetite 55 (2010) 219–225 namic terms reinforced Christian morality’s condemnation of gluttony. Nevertheless, this does not fully explain the ideal of slenderness that has prevailed over the past hundred years, during which time the majority of the population has had both the means and the opportunity to be fat. A cultural consensus emerged around the lean body through the convergence of medical, class and industrial interests when particular markets (insurance, fashion, food, pharmaceutical) began to promote thin bodies as the ideal body shape. As fatness came to be equated with illness and was stigmatized not only as a preventable disease but also as a synonym for gluttony and laziness, thinness ceased to be a sign of ill health and poverty, and became a site for the production of new meanings. Moral attributes of self-control or self-indulgence and their behavioral correlates were inferred from physical appearance. A slim body was associated with good health, self-discipline, and social distinction. Recommendations concerning weight control had a greater impact on women than on men in the countries at the forefront of the so-called ‘‘age of progress’’ (Brumberg, 1988). The explanation for this lies in forms of social mobility, models of gender socialization, and the uses of food and the body. Although care of the masculine body shared a number of features in common with the attention given to women’s bodies, cultural, economic and political factors focused progressively on the control and image of the female body. The ideal feminine body became taller, lighter, and toned by dieting and physical activity. First the upper classes, and subsequently the middle classes, chose to distinguish themselves from the working classes by adopting this body ideal (Bourdieu, 1988: 188). Because thinness first acquired aesthetic value among upper-class women through their attachment to high fashion, which had already made ‘‘eating little’’ a class virtue, the thin body – disciplined and contained – came to be perceived as an instrument for upward social mobility. Goods are used not only to satisfy needs or desires, but also to classify persons and to establish forms of social differentiation, as much through the differential distribution of material resources as through the symbolic resources they mobilize. When industrial capitalism began producing a diversified range of goods and services at lower relative costs in the middle of the 20th century, women of the middle and lower middle classes, and increasingly men as well, began to use these goods and the symbolic capital associated with them. Food avoidance or restriction, physical exercise, appetite-suppressing drugs, low-calorie food products, and surgery became instruments of self-control that facilitated upward social mobility. . .at least in theory, because ‘‘being thin’’ is a condition to which many aspire, but not everyone can achieve. From normative to pathological: obesity as an illness The chronic, epidemic and multi-factorial character of obesity The construction of a normative dietary pattern – the ‘‘balanced diet’’ – and a normative standard for healthy body weight has helped to define what is or is not normal eating behavior, and to turn obesity into an illness (Gracia, 2009a). Since the Body Mass Index (BMI) was established as the most frequently used scientific indicator for defining healthy weight (albeit not without controversy; see Basdevant & Guy-Gran, 2004; Hacking, 2005; Sobal, 2001), people have been urged to stay within the limits of their ideal BMI. According to the biomedical literature, obesity has dramatically increased both morbidity and mortality in several countries and driven up health care costs, making it one of the biggest public health and economic problems in the world (WHO, 2004). The Commission of the European Communities Green Paper (2005: 4) asserts that ‘‘combating the problem of excess weight 221 will help reduce long term costs for the health services. . . and will allow citizens to have a productive life even into old age’’ (Green Paper 2005: 4). Epidemiologists even think of it as a social pathology because it has a disproportionate effect on populations with fewer socioeconomic resources and, depending on location and age group, affects women more than men (Aranceta, 2008). Defined as an abnormal increase in weight due to an excessive accumulation of fat, obesity has been accepted as a global illness of epidemic proportions in which multiple factors are involved. In general, eating behavior problems, especially those related to body weight, are often believed to originate in the quantity of food ingested, as if the bodily effect of eating were a simple matter of calculating the calories consumed: eating too little results in weight loss, while eating too much results in weight gain. The reality is not so simple, given that weight does not depend exclusively on the quantity of food ingested. It is now recognized that hereditary factors determine to a considerable extent how individuals react to an environment of food abundance or scarcity (Power & Schulkin, 2009). Hormonal and neural mechanisms and genetic, metabolic and constitutional factors all intervene (Alemany, 2003). These factors, however, are insufficient in themselves as explanations of the rapid increase in the rate of obesity across the world (Sobal, 2001). According to the World Health Organization, more than 700 million persons will be obese by the year 2015. For decades, medicine has urged people to lose weight, and today health experts regard epidemiological data showing a rapid increase in overweight and obesity as symptoms of a society in which food consumption is out of control (Gard & Wright 2005: 2). It is regarded as self-evident that fat kills, that obesity in itself is a disease, and that all obese persons are or will become ill (Campos, 2004: 4). Caught between uncertainty and caution, researchers, experts and politicians use statistical data to transmit a pessimistic outlook (Menéndez, 2009: 24). For example, they often combine the overweight and the obese into a single group representing a much larger percentage of the population, although these two groups are subject to different health risks (Poulain, 2009). While some studies suggest that a small degree of excess weight is healthy (Flegal et al., 2005), no consensus has emerged regarding the effect on mortality of being either above or below normal weight. In Spain, Canada and Germany, for example, more than half of the population is overweight. In terms of the prevailing logic, this segment of the population should be considered either ill or pre-ill. According to the WHO, if nothing is done to reduce the prevalence of obesity, it will become the first non-infectious pandemic disease. In the absence of a pharmacological solution to the problem, the strategy is to address its putative causes. Health experts locate these causes in recent social and economic changes, stressing the relationship between health and culture and identifying the principal cause as the ‘‘obesogenic environment:’’ that is, an abundance of high-energy foods coupled with a sedentary lifestyle (Henderson & Brownell, 2004; Tounain & Amor, 2008). Both are understood to be a direct consequence of social change in general and deterioration in the quality of the diet in particular. Obesity, then, may be considered a logical consequence of constraints specific to modernization, and this has led many to seek its origins in specifically modern phenomena such as fast food, passive forms of leisure, central heating, mechanized transport, food advertising, the weakening of the family, and the increased pace of life (Lang & Rayner, 2007). Biomedical thinking about the origin and evolution of obesity has identified the same set of social causes in various countries (Fischler & Masson, 2008). As a result, these countries have adopted similar measures, drawing up protocols for therapeutic intervention and preventive strategies to deal with what is 222 M. Gracia-Arnaiz / Appetite 55 (2010) 219–225 regarded as a generalized problem of bad diet and lack of exercise. People are urged to avoid gaining weight by making rational food choices, since obesity, once established, is difficult to treat. Obese persons tend to continue gaining weight and to lack interest in dieting or exercising to lose weight (Basdevant & Guy-Gran, 2004). Paradoxically, they are regarded both as blameless victims of larger social forces, and as guilty of a failure of self-control. Although some clinical nutritionists try to treat the patient as a whole person and adapt their recommendations to the individual’s biopsychosocial characteristics (De Labarre, 2004), recriminations related to eating behavior are frequent and adopt a moralizing tone, criticizing patients’ judgment and representing them as incompetent or irresponsible: ‘‘Often. . .when we feel unhappy we compensate by eating and drinking even though we’re not hungry and it’s bad for our health and against our better judgment’’ (NAOS Strategy, 2005: 11). Many doctors who prescribe weight-loss diets are of the opinion that the overweight are responsible for their own problem through wilful ignorance of proper nutrition. In the case of fat children, this responsibility is easily shifted onto the parents, as recently happened in Great Britain when the mother of Connor McCreaddie, a 9-year-old boy who weighed 89 kilos, was accused of negligence and came close to losing custody of her son. In a similar case in Spain, a boy from Asturias was separated from his family in June 2006 for the same reason. Since then, as a ward of the state, he has managed to lose 40 of the 100 kilos he weighed at 10 years of age. From treatment to prevention As Lawrence (2004: 57) has observed, public debate on the rising incidence of obesity as a public health issue tends to be framed in two ways: ‘‘individualizing frames limit the causes of a problem to particular individuals, often those who are afflicted with the problem. Systematic frames broaden the focus, assigning responsibility to government, business, and larger social forces.’’ Public health policies aimed at controlling obesity are also situated discursively within one frame or the other. Treating obesity on an individual basis through behavior modification, an approach used until recently in several western countries, has met with only limited success (Levi et al., 2007). This has prompted recognition of the wider context that conditions individual food choices and eating habits. As a result, there has been a shift toward preventing obesity rather than attempting to cure it (Poulain, 2009: 20). The aim is to promote lifelong maintenance of a healthy body weight through a balanced diet (eating less and eating a greater variety of foods) and regular physical activity. Paradoxically, however, obesity prevention programs currently in place continue to center on the individual, emphasizing standardized guidelines for achieving a healthy lifestyle rather than addressing the underlying structural conditions that favor the development of an obesogenic society. Health authorities alternately warn that people whose BMI is above normal may be future victims of hypertension, diabetes and heart disease (NAOS Strategy, 2005: 8), and offer advice about healthy ways to lose weight without recourse to unscientific and potentially harmful miracle diets. The first international proposal for the prevention of obesity was the Global Strategy on Diet, Physical Activity and Health (DPAS), passed by the 57th World Health Assembly (WHA) in May 2004. Since then, many countries have taken specific steps. For example, Spain has created the Strategy for Nutrition, Physical Activity and the Prevention of Obesity (NAOS Strategy, 2005), which has been replicated in other countries. France has developed the National Nutrition and Health Program (PNNS 2006–2010). Mexico’s National Health Program 2007–2012, which was initially intended only to promote an integrated policy for obesity, has gone further and launched specific campaigns and action plans such as Mexico is Taking Measures, Measure Your Waist, Exercise for Your Health’s Sake, Healthy Living, and Let’s Get Control. For its part, the European Union has created a common framework to support and complement existing national initiatives Among other programs, this framework includes the Platform for Action on Diet, Physical Activity and Health (Commission of the European Communities Green Paper, 2005); the High Level Group on Nutrition; and the Strategy for Europe on Nutrition, Overweight and Obesity Related Health Issues (Commission of the European Communities White Paper, 2007). What is surprising is not only the speed with which some countries have responded to the call from the WHO, but also the similarities between the steps proposed, given the disparity in obesity rates for different countries, and for different regions in the same country. The Global Strategy (DPAS, 2004) specifies that national diet and nutrition plans should be flexible and adaptable, based on local cultural practices and associated culinary traditions, and sensitive to changing patterns of food consumption. In practice, however, this has not been the case. In Spain, for example, the integrated programs devised by the governments of the 17 autonomous communities are almost identical, despite important differences in the prevalence of obesity. In Asturias, for example, only 4.56% of the population between 2 and 17 years old is obese, but this figure triples to 15.88% in the Canary Islands. Paradoxically, the regions that have undertaken these initiatives are not necessarily those with the highest levels of obesity. The measures adopted in Spain are not very different from those devised in France or even Mexico. Emphasis is placed on nutritional education for parents and teachers, the creation of observatories for monitoring diet quality and the prevalence of obesity, improvements in nutritional labeling of food products, media campaigns in favor of healthy diet and lifestyle choices, and improving the skills of primary health care staff. There have been some attempts to create alliances between various levels of government (local, regional, and national), civil society and the private sector on the one hand, and the food industry and food service providers on the other. These commitments, however, are still in their initial phases and have yet to be implemented on a broad scale, at least in these three countries. Despite recognition of the obesogenic aspects of modern western societies, the principal strategy continues to be motivating the individual rather than developing a broad social consensus on diet and eating practices. It is certainly easier to promote nutritional education than to modify the structural factors that condition lifestyles. The Commission of the European Communities Green Paper (2005: 8) and White Paper (2007: 3) are based on the assumption that educating consumers is the first step toward enabling them to make well-informed dietary choices. This nearly exclusive emphasis on the need for nutritional education stems from the idea that the source of the problem lies in an absence of information, and that the scientifically informed consumer will make rational decisions. Studies carried out in France (Poulain, 2002) and Spain (Contreras & Gracia, 2006), however, indicate that most of the population understands the basics of good nutrition, even if this is not sufficient to guarantee the success of the experts’ recommendations. I share Arrestegui’s (2007) doubts concerning the efficacy of strategies based on creating better-informed consumers using highly interventionist methods that are difficult to apply. ‘‘Being on a diet’’: the complementarity of biomedical and market discourses The role of dieting in the prevention and treatment of obesity Paradoxically, despite the best efforts of the health authorities to inculcate healthy eating habits, the prevalence of obesity M. Gracia-Arnaiz / Appetite 55 (2010) 219–225 continues to rise although current canons of beauty favor slenderness, and a wide variety of weight-loss and low-fat foods are available to consumers. An increasing number of psychiatrists and nutritionists have condemned the cult of slenderness generated and sustained by mass culture, and have issued warnings about the harmful effects of uncontrolled dieting and its relationship to obesity and eating disorders. Some have even proposed regulating representations of the female body in the media and establishing minimum standards for the weight and appearance of runway models in international fashion shows. According to new regulations in Spain, for example, only models whose BMI is between 18 and 25 may be hired, and the use of makeup that creates an ‘‘unhealthy’’ appearance is prohibited. The Spanish Ministry of Health and Consumer Affairs has even signed an agreement with clothing manufacturers and designers to standardize sizes and promote a ‘‘healthy image’’ of female beauty, in the apparent belief that eliminating extremes of thinness and fatness will address the source of the problem. At the same time, people are exposed daily to conflicting messages urging them to restrict their food intake and to get more exercise in order to avoid obesity, and warning them against overly strict diets and excessive physical activity that may lead to anorexia and bulimia. Some researchers (Campos, 2004; Finkelstein & Zuckerman, 2008) have noted that a combination of repeated medical recommendations, consumerism, and social pressure to conform to an ideal body image has accustomed people to dieting from an early age. As a result, they enter a vicious cycle of losing and regaining weight. Although ‘‘being on a diet’’ has become a permanent rather than temporary condition and is now generalized behavior for most of the population in western postindustrial societies, it has been demonstrated that many cases of obesity originate, paradoxically, in this kind of dieting (Garner & Wooley, 1991). Doctors recommend diets for both preventive and therapeutic reasons. As a preventive measure, the scientifically based optimum diet described above has come to be viewed not just as a mainstay of the healthy lifestyle but as a panacea believed to confer social, economic and psychological benefits as well. From this perspective, not only does an optimum diet provide the nutritional and caloric balance necessary to maintain a healthy and appropriate weight; it also imposes order and structure on everyday life, establishing on a daily basis what, how much, how and with whom a person should eat. Individual responsibility for health is emphasized, and people are urged to develop true nutritional competence. Dietary prevention involves a double process of medicalization and moralization that entails changing inadequate dietary habits and transforming them through learning into a new set of good practices. According to doctors, healthy eating not only satisfies the palate, but also allows people to feel better physically and psychologically about themselves and with others (Ascher, 2005). Nutritional education has become the bastion of this preventive process. Children are taught at increasingly younger ages to control their food intake because it is believed that habits begin in childhood, become more established during adolescence and tend to be consolidated in later life (NAOS Strategy, 2005: 21). The aim is to get individuals to correct or adjust their eating behavior in accordance with scientific recommendations that will help them avoid becoming ill. The overzealous pursuit of prevention may, however, end by increasing the number of potential patients. Thousands of Spanish people, for example, seek medical treatment for weight problems despite the fact that they are not obese, only slightly overweight (Gracia & Comelles, 2007). Dietary recommendations for therapeutic ends are also grounded in notions of self-control and individual responsibility for health. In clinical settings, the central axis around which the 223 treatment of obesity revolves is the concept of nutritional rehabilitation. Its aim is to get patients to achieve and maintain their normal body weight and to adopt healthy eating habits (Gracia, 2009a, 2009b: 200–201). Doctors see nutritional rehabilitation as fundamental to ensuring that patients recover from the illness not just physically and psychologically, but also socially, and in this it resembles the use of dietary recommendations as prevention. They believe that the diet must be followed to the letter over months or even years if necessary, because it makes patients feel secure, provides order in their lives and helps them to combat their obsession with weight and food (Zamarrón, 2003: 171). Maintenance of a strict dietary routine is based on the belief that patients’ eating behavior lacks structure; that they alternately adhere to self-imposed food restrictions that have no rational foundation, and indulge in eating binges. Consequently, nutritionists demand that patients improve their dietary knowledge and change their misguided dietary practices, replacing them with what clinicians define as a normal diet based on structured meals and regular eating times (Fernández & Turón, 2001: 123). The goal is to inculcate healthy habits by means of the optimum diet, which is administered almost as if it were a medicine. Nutritional intervention is oriented toward inculcating a strict dietary model regarding what patients must eat, in what quantities, where, with whom and with what frequency and timing (2009b: 199). Paradoxically, treatment consists of replacing one set of dietary obsessions judged to be pathogenic with another that conforms to the biomedical nutritional model. Lipophobia in obesogenic contexts The powerful health products and body care industries have taken up the recommendations of medical professionals and public health authorities in favor of the optimum diet and normative body weight, issuing numerous and contradictory messages of their own (Gracia & Comelles, 2007). This market not only reflects and to some extent drives profound cultural changes; it also sustains numerous professions and business enterprises. Advertising offers clues for understanding the role of the food industry, aided by scientific and technological innovations, in this shift in perceptions. These marketing strategies have created and popularized the rhetoric of well-being, and are principally responsible for the commercialization of the term ‘‘health’’, an umbrella concept that subsumes a broad range of other concepts: pleasure, beauty, convenience and psychological well-being (Dı́az Rojo, Morant, & Westall, 2006: 154). Products advertised as ‘‘-light’’ or ‘‘-free’’ – as in cholesterol-free, sugar-free, alcohol-free, fat-free – are some of the many examples. Fats, sugars and calories are represented as being incompatible not only with health but with the ideal figure. Conversely, products containing fiber, lactic acid bacteria, minerals, and fatty acids represent a new generation of health products designed both to protect a sense of well-being and to prevent illness (Contreras, 2002). The personal care industry fuels many business enterprises whose prosperity depends on awakening and encouraging people’s desire to improve their appearance as a way of improving their quality of life (Hubert, 2004: 8). Neo-capitalism has made deep cultural inroads, not only encouraging the transformation of excess body weight and food consumption into a health and social problem but turning thinness and fatness into business opportunities. While the medical establishment warns against excess weight as a threat to health, the consumer economy is inundated with relatively cheap food products of doubtful nutritional quality, while the cost of more healthful foods has progressively increased. The body is no longer manipulated only through food and diet; today the pharmaceutical and biotechnology industries not only complement the diet but also supplant it, offering new possibilities 224 M. Gracia-Arnaiz / Appetite 55 (2010) 219–225 for improving health and physical appearance. Achieving a sense of well-being has come to depend in large measure on having an attractive and healthy-looking body. The lipophobic and obesogenic marketplace has grown to include body care products and services directed primarily at women, but also increasingly at men. These include pharmaceutical and cosmetic products, fitness programs and, more recently, reconstructive surgery. Under these circumstances, it is difficult to separate interests related to health from interests related to the market in biomedical discourses. One of the effects of these processes is, paradoxically, the increase in fatness. Possible explanations for obesity, however, should be located not only in the progressive medicalization and commercialization of food and body weight, but also in the farreaching lifestyle changes that have occurred. One of the causes of obesity can be found, at least in part, in the construction of contexts that discourage fatness discursively, but encourage it in practice. In a society whose economy depends increasingly on sedentary jobs and activities but also demands greater and greater flexibility from the work force, people find it harder and harder to follow recommended dietary routines, and are more likely to gain weight. Impelled by complex and at times divergent rationalities, people make dietary choices that are increasingly diversified and irregular. Maintaining an optimal diet requires adherence to a daily routine. The difficulty involved in establishing such a routine in these circumstances is one of the reasons why it is so hard to follow nutritional recommendations. People’s lives are full of unpredictable micro-events, work and family demands, and financial constraints that constitute obstacles to control of dietary routines. The amount of time spent on the preparation and consumption of meals is decreasing and people increasingly favor highly processed foods that can be prepared rapidly, often in the microwave. What is driving this trend is the need to save time and manage family members’ conflicting schedules and food preferences as efficiently as possible. If preventive strategies focus on changing unhealthy food choices and/or eating behaviors instead of the socioeconomic conditions that cause them, both the diagnosis and the treatment of the problem appear to be mistaken. Conclusions Many explanations for the rising incidence and prevalence of obesity, as well as the strategies proposed for reversing this trend, are based less on scientifically demonstrated fact than on probable or possible causal factors and relationships. This is a cause for concern on several grounds, not the least of which is the high cost of the resources currently being mobilized to prevent obesity. Although obesity is widely regarded as a pathology partly determined by social causes, few of the studies in which both medical and public health interventions are grounded have explored seriously the socio-cultural sources of certain eating behaviors. The ‘‘environment’’ is not a nebulous and complex abstraction, but a specific and specifiable form of social organization resulting from equally knowable historical processes. In contemporary societies, this means making a serious effort to understand the economic and political conditions associated with consumer capitalism. These conditions affect everything and everyone, although not necessarily in the same way. Not all fat people are ill, and not everyone eats badly. The occurrence of obesity is very uneven both within and across cultures. How people eat and manage their health varies according to socioeconomic status, gender, age and ethnic origin. Food practices depend on the interaction between micro- and macro-structural factors that vary from one society to another. Current strategies have not been designed to deal with these kinds of social questions. Many obesity prevention programs are based on a biologically reductionist and homogenizing conception of good dietary practice (an optimum diet) and healthy lifestyles (regular exercise), according to which obesity and its associated illnesses can be combated if individual behavior is suitably altered. The socio-cultural context in which obesity is produced is approached, if at all, as a series of individual ‘‘lifestyle choices’’ without regard for the ways in which these choices are channeled and constrained by larger forces. Food preferences and eating behavior are inseparable from the lifeworld of which they form part. 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