Here is the script of the talk I gave in Las Vegas at this year’s CCCC. Please feel free to share and to contact me with any questions or comments.
Indexing Massive Bodies: Tracing the Circulation of Public Health Information
Anna Hensley, CCCC Las Vegas, March 2013
You don’t have to go far in the world before you get hit with another story about obesity. Over the past thirty years, the average weight in the US has increased by about 20 pounds and we’re in the thick of ongoing, panicked discourse about what this trend means. As a feminist researcher interested in discourses surrounding the body, what concerns me about this discourse is how narrow it is. By that, I don’t mean that there isn’t any disagreement or resistance to the way the obesity crisis has been framed. When I talk about how narrow the discourse is, what I mean is that these divergent voices are hard to hear and seem constantly drowned out by an overwhelming discourse that not only stigmatizes fat but that relies on a rhetoric of crisis that works to authorize troubling practices of surveillance and discipline.
In their book Democracies to Come: Rhetorical Action, Neoliberalism, and Communities of Resistance, Rachel Reidner and Kevin Mahoney argue that affect—and particularly feelings of despair—have a powerful disciplinary effect in the context of neoliberalism. When we are made to feel like there are no alternatives to the circumstances we find ourselves in, we’re less likely to resist. They argue that opening up space and envisioning alternatives thus becomes progressive and vital rhetorical action.
Scholars in the field like John Trimbur, Jenny Edbauer, and Rebecca Dingo have emphasized the importance of not treating rhetoric as static but looking at how terms, texts, and rhetorics circulate. They argue that we need to pay attention to how values shift as they move through different contexts, and also to the kinds of histories that texts and terms bring with them as they travel. The discourse surrounding obesity is complex in its ties to longstanding bias against fat, medical discourses, influences from diet and beauty industries, stigma against disability and discourses of healthism. Because of these multiple and intertwined strands operating, I want to argue that one of the ways rhetoric can productively engage with these discourses is to begin tracing some of the specific terms, scales, and studies that underlie the myriad public health claims made about obesity as a way to highlight the values underlying these discourses but also as a way to open up space for different ways of articulating the situation.
So today, to provide an example of what this might look like, I want to focus on recent debates about the practice of sending out BMI (or Body Mass Index) report cards and challenge the current terms of the debate by looking at the history of the BMI and the way it has circulated as a key frame for the way we currently understand obesity.
BMI Letters in Massachussetts
Earlier this year, a North Andover Selectwoman, Tracy Watson, received a letter from her son’s school telling her that 10 year old with a BMI indicating he was obese. According to Watson, her son is constantly active—he plays football, wrestles, and practices martial arts. When interviewed, Watson’s husband pointed to NFL player Tom Brady as an athlete who is considered obese, arguing that the BMI scale is an arbitrary measure that does not take fitness into account. (Original story here.)
The letter Watson received is part of an iniative instituted by the Massacussetts Department of Public Health in 2009 that requires schools to measure the height and weight of all students in 1st, 4th, 7th, and 10th grades and use that data to determine their BMI score. The schools are then required to send confidential letters to parents informing them of their children’s BMI and, in the event a child is underweight, overweight, or obese, advising them to consult their pediatrician.
The Massachussetts BMI initiative is just one of several examples of schools creating what have been called “BMI report cards.” Schools in Arkansas and Oklahoma also track students’ BMIs and BMI report cards have become a nation-wide policy in Malaysia. Schools and other state agencies that require the BMI reports argue that the practice is a much-needed intervention into rising rates of childhood obesity. People who support BMI screenings in schools argue that parents need to be made aware of children’s increased risk for cardiovascular disease as adults. Other schools argue that the data from the screenings allow them to plan for educational programs that will help support the health of students. But the reports remain controversial in every place where they’ve been instituted.
While Watson’s son laughed the letter off, thinking it funny that anyone would consider him “obese,” Watson fears the effect the letters have on children’s self-esteem and their body image. Watson’s fears aren’t at all unfounded. A recent study from the Keep It Real campaign found that 80% of 10-year-olds have been on a diet at some point in their lives. The study also found that 53% of 13-year old girls have issues with the way that their bodies look. By the time girls reach the age of 17, that number increases to 78%.
This helps illustrate the tension at play in these BMI report cards: schools are collecting this data in response to the crisis-laden rhetoric surrounding obesity. While opponents of the letters often argue that they are an invasion of privacy, supporters argue that tracking student weight has become a necessary in the face of rising rates of childhood obesity. But this practice, which makes individual children’s weight a matter of institutional concern, which places children in categories like obese, underweight and normal, and that raises the weight of some children as a problem, are contributing to national (and even international) trends of children becoming deeply body conscious at earlier and earlier ages, with potentially disastrous effects—in terms of esteem, in terms of risk for disordered eating, and in terms of the health risks associated with constant dieting.
Watson’s story has been covered by a number of news affiliates in the Boston area, as well as a few national news outlets. What’s striking to me as I read through this coverage is that there have been comments on different articles online where readers say something to the effect of: “I’m uncomfortable with these letters and would probably be upset if I received one about my child, but what else can we do? People are dying and we need to intervene.” Here is the power of despair at work. When we have a discourse that frames bodies in terms epidemics and crises, we’re more inclined to submit to invasive practices that involve forms of surveillance and disciplining we’d otherwise object to. But if we begin to trouble the frame that these claims are based on by tracing its history and tracing its context, I think we can begin to articulate some new possibilities and open up some more productive terms for talking about bodies and health.
BMI: Context and Circulation
BMI is calculated by dividing a person’s weight by the square of their height (in metric). This produces a number that places a person within one of five categories: underweight, normal, overweight, obese, and morbidly obese. A BMI of 24 is seen as normal, for instance, while a BMI of 28 would be classified as overweight and a BMI of 32 would be considered obese. The scale was originally developed in the 19th century by Adolphe Quetelet, a scientist who played a major role in developing the use of statistical averages to measure human experience. Quetelet’s scale wasn’t of much interest until Metropolitan Life Insurance Company began to use the model in the 1940s as a way to measure death rates of their policy holders. Ultimately, MetLife deemed the scale unreliable because their use of the scale depended on self-reported (and often inaccurate) weight and height data. Since then, the scale has become widely used, becoming the standard for determining rates of obesity for organizations like the National Institute of Health, the Center for Disease Control, and the World Health Organization.
There are other means of measuring body fat or determining obesity (for instance, skin fold measurements and underwater weighing), many of which are seen as producing more reliable health information. However, the BMI has become a popular scale for a couple of reasons: 1) it can be calculated using easily accessible data like data that has been self-reported or assessed through various agencies or clinics; 2) it’s inexpensive to collect large samples of data.
But for all its efficiency, the BMI has continually been criticized for its inability to measure or account for information believed important in various measures of health:
- Doesn’t account for differences in bone mass and density
- Doesn’t account for somatic differences: more or less muscular, numbers tend to be higher for people with longer torsos
- Doesn’t account for differences among various populations: women tend to have more fat than men, African Americans tend to have higher BMIs, Asian Americans tend to have lower BMIs, especially unreliable for children
- Doesn’t actually represent health problems: BMI, for instance, does not tell us if a person actually has high blood pressure or high cholesterol
- Doesn’t account for the way particular placement of fat on the body may affect health. Does a person carry their weight around their thighs or in their torso?
- Doesn’t distinguish between subcutaneous (under the skin) fat and visceral (surrounding the organs) fat.
People are interested in BMI data from a health standpoint because it places us into categories (normal, overweight, obese) that may correlate with higher rates of certain chronic diseases. But the meaning of these correlations is hotly debated. Despite frequent claims that BMIs that exceed the normal range are associated with higher mortality rates, a recent study found that people who fall within the “overweight” range actually have lower mortality rates than people with a BMI of 25, which is the upper limit for the normal range. However, overwhelmingly, the specific language of these categories is used to not only categorize bodies but to do so in a way that frames them in terms of their potential for disease. The CDC emphasizes on their website that BMI “is used to screen for weight categories that may lead to health problems.” But it’s not uncommon to come across discussions of overweight and obesity as already indicating disease—of being disease in and of themselves.
What’s more, despite the BMI’s reliance on a “normal” category, BMI is less about statistical averages (which is where it began) and more about prescriptive norms. BMIs in the US are rather evenly distributed across the normal, overweight, and obese categories but the overwhelming sense is that we should all fit into a normal category—something troubling given the basic nature of human diversity and the various limits of BMI as a framework. Again, while organizations that rely on BMI data like the CDC, NIH, and WHO use the word “normal” to refer to people with BMIs between 18.5 and 25, it’s not at all uncommon to see some slippage in terms in public discussions of obesity where this “normal” category is referred to as “ideal” or as “healthy.” This slippage reminds us that with the way BMI circulates, this “normal” category isn’t “normal” in the sense of being average—it instead represents a rather narrow window of acceptable embodiment that we’re supposed to fit into.
So if we return to the question of the “fat letters” being sent home with children in MA, what does understanding the context of the BMI open up for us? I want to put forth a couple of suggestions:
- The terms and history of the BMI appeal to late capitalism—it’s efficient, it places bodies into discrete and universalized categories, and it further normalizes the body. In this spirit, sending home letters is a relatively easy, hands-off intervention that works to place responsibility for children’s body size on parents and implicitly moralize parents’ attempts (or lack their of) to act on the letters they receive. What would it look like for schools to stop treating student bodies as problems to be dealt with and instead create holistic programs that treat student bodies as integral to their learning experience and to carve out space for movement and well-being in educational settings.
- As Julie Guthman argues in her book Weighing In: Obesity, Food Justice, and the Limits of Capitalism, small shifts can take on big meaning. It could only take a weight loss or gain of a few pounds to shift between categories. This is important because these categories are the basis for a lot of panic-inducing claims that we’re bombarded with. It’s a very different thing to say that 2/3 of Americans are overweight or obese than to say that, on average, Americans have gained around 7 pounds over the past decade. When we keep this in mind, and keep in mind the frequent shifts and changes bodies—especially children’s bodies are undergoing—I think it gives us more pause and allows for a more measured response.
- The categories outlined by the BMI are arbitrary and are less about statistical averages and more about prescriptive norms. Value difference and challenge scales that don’t allow for difference. What’s more, the categories are a distraction—we get fixated on a number that is, at best, a thin reflection of health. What happens if we remove an emphasis from weight and instead focus on key health indicators? What happens if we talk with children about health in holistic ways that emphasize mental wellbeing, and that remind us all that our bodies are not static and any productive version of wellness needs to focus on caring for our bodies as we can throughout our lifetimes.
- The BMI contributes to the medicalization of weight where bodies are framed as problems to be fixed or potential problems to be avoided. Given the statistics from the Keep It Real campaign, these messages about good bodies and bad bodies are weighing heavy on children. We need to develop frames for talking about wellness that aren’t pathologizing or moralizing bodies. But we also need to develop ways of talking about health and wellness that don’t makes these moral categories—that is, that remind us that being a healthy person is not the same as being a good person, and that illness and disease are not personal failings.
I think there is more that we can cull from exploring BMI in more detail—and there is a lot of work that remains to be done about the way these terms circulate. But the point I hope I’ve made is that when we start to unpack the values and politics that give rise to frameworks, we can start to challenge them more productively. This work isn’t just a matter of contextualizing terminology and frameworks, and it isn’t just a matter of debunking bogus claims that we might come across. It’s about engaging in and encouraging critical health literacy practices that move us out of a place of despair and into a place of possibility.