The US Obesity “Epidemic”: Metaphor, Method, or Madness?

Abstract

In 2000, US Secretary of Health and Human Services Secretary Tommy Thompson mobilized the US public health infrastructure to deal with escalating trends of excess body weight. A cornerstone of this effort was a report entitled The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. The report stimulated a great deal of public discussion by utilizing the distinctive public health terminology of an epidemic to describe the growing prevalence of obesity in the US population. We suggest that the ensuing controversy was fueled in part by the report’s ambiguous usage of the evocative term “epidemic.” In some passages, the report seems to use “epidemic” in a literal sense, suggesting that rising prevalence of excess body weight should be defined technically as a disease outbreak. Other passages of the report present the same key term metaphorically, leaving readers with the impression that the epidemic language is invoked primarily for rhetorical effect. Here, we explore dynamics and implications of both interpretations. This analysis sheds light on the ongoing public argument about the appropriate societal response to steadily increasing body sizes in the US population; likewise, it capitalizes on the accumulated knowledge that the field of public health has garnered from combating diverse historic epidemics. Our interdisciplinary approach deploys critical tools from the fields of rhetoric, sociology and epidemiology. In particular, we draw from metaphor theory and public address scholarship to elucidate how the Call to Action frames public deliberation on obesity. We turn to the applied public health literature to develop a reading of the report that suggests a novel approach to the problem—application of the Epidemic Investigation protocol to streamline the public health response and reframe the public argument about obesity.

Keywords:

• David Satcher
• Epidemics
• Epidemiology
• Public Argument
• Public Health
• Rhetoric

Notes

[1] The importance of excess body weight for health has been established by associations with multiple adverse health outcomes, including mortality itself and the major causes of US death such as coronary heart disease, congestive heart failure, breast cancer, colon cancer, stroke, diabetes, and hypertension (Calle et al. 1999; US HHS 1998). Excess body weight also leads to problems that impair quality of life, such as osteoarthritis and sleep apnea, as well as considerable stigma (Teachman et al. 2003 2003; US HHS 1998). Estimated lifetime costs for cardiovascular disease and its risk factors increase by nearly 200% for severe obesity (Thompson et al. 1999).

[2] For example, in 2003 special issues of the Journal of the American Medical Association and Science were devoted to articles on obesity research. Health Politics, Policy and Law featured a special issue on obesity in 2005, while the International Journal of Epidemiology devoted a 2006 special issue to the topic.

[3] Subsequent clinical guidelines for Canadian, English, and US primary care physicians advocate addressing weight in the clinical setting, focusing on data showing that even moderate improvements in lifestyle and weight carry health benefits (Douketis et al. 1999; NHS Centre for Reviews and Dissemination 1997; Serdula, Khan and Dietz 2003; US Preventive Services Task Force 2003; Weisberg 2002). Notably, these initiatives do not reach those who do not access the healthcare system. As obesity is most common among the poor (Martikainen and Marmot 1999) who tend to have diminished healthcare access, this may be a considerable omission. Even among those who do access medical care, clinical guidelines typically focus on obesity treatment, rather than prevention. In addition, among obese patients, intervention is limited by the healthcare funding structure; health insurance plans frequently do not cover obesity treatment for most individuals, and the cost of self‐pay options is frequently prohibitive (Gregoire 2004).

[4] The basic thrust of the World Health Organization report was subsequently affirmed in a Canadian “call for action” that also characterized escalating excess body weight trends in “epidemic” terminology (Lau 1999). It should be noted that Oliver (2006, 39–43) traces origins of the move to categorize obesity in epidemic terms to US CDC scientist William Dietz. Collaborating in 1998 with US CDC colleague Ali Mokdad, Dietz developed and circulated a vivid set of PowerPoint maps that provided convincing visual evidence supporting his characterization of escalating weight prevalence as an “epidemic.” These maps were eventually published in an influential article, “The Spread of the Obesity Epidemic in the United States, 1991–1998” (Mokdad et al. 1999), which argued for classification of the US obesity problem as an epidemic.

[5] It is notable that, with this move, Satcher fortifies a common (yet erroneous) belief that all epidemics are infectious diseases. Since overweight and obesity are obviously not infectious, this element of the report is in tension with other passages that label the prevalence of excess body weight as a literal epidemic.

[6] An Epidemic Investigation is a formal protocol for coordinating public health responses to disease outbreaks classified as epidemics (Brownson 1998b, 71–72). We discuss the Epidemic Investigation protocol more thoroughly in later sections of this paper.

[7] As Camus’ story of The Plague illustrates, invocation of epidemic terminology can activate an audience’s imagination to view apparently unrelated and isolated phenomena as parts of a coherent universal. In terms of rhetorical strategy, the effort to move an audience’s focus in this fashion by way of metaphor involves what Italian rhetorical theorist Giambattista Vico (2002) calls “ingenium.” In Vico’s view, ingenium works by triggering the “universale fantastico”—a thought process that stimulates collective imagination about universals by fusing together an audience’s mental faculties of memory, invention and fantasy (Bevilacqua 1985). Because this process fires the imagination to grasp new relations between particulars, it enables audiences to change their perceptions regarding what are apparently heterogeneous phenomena that reside in isolation from each other, and instead see the things that tie the particulars together in a universal whole. This is an important part of the framework for understanding overweight and obesity presented in Call to Action, since the report steers readers to interpret excess weight prevalence as a public health problem deserving broad‐based, societal response. This perspective is clearly distinct from a view that sees isolated cases of overweight and obesity as instances of individual weakness or moral failing.

[8] In Ogden and Richards’ terminology, the tenor of the metaphor is the escalating prevalence of excess body weight (the thing to which the metaphoric word or phrase refers), while the vehicle of the metaphor is the set of all possible associations relating to the concept “epidemic.” The report steers readers to interpret the ground of the metaphor (the specific quality of the vehicle that informs the tenor) as quantity—the large number of new cases points to the fact that overweight and obesity have “reached epidemic proportions.”

[9] This line of argument parallels broader academic critiques of “therapy culture” (Furedi 2004), a collective social condition where individuals become emotionally dependent on government‐driven public health interventions for identity affirmation. Notably, while Richman, Roberts and Campos invoke the specter of heavy‐handed state coercion to underscore their critique of the obesity “moral panic,” Furedi suggests that therapeutic authority “seeks to exercise control not through a system of punishment, but through cultivating a sense of vulnerability, powerlessness and dependence” (Furedi 2004, 203).

[10] For example, one survey conducted in spring 2001 found that “Most Americans do not see either the public’s or their own weight as a serious health problem … Americans are able to recognize that obesity is a complicated issue, but most still place the source of obesity in the hands of the individual. Given these factors it is not surprising that there is little enthusiasm for imposing regulations or taxes on food products” (Oliver and Lee 2002, 25–26; See also Oliver and Lee 2005). However, more recent research conducted after release of the Call to Action indicates a shift of opinion. An April 2003 survey showed that 85% of respondents “said that it is important for the government to implement” obesity prevention programs (American Heart Association 2003), while a 2003 review of opinion surveys conducted between 2001 and 2003 found that “a slight shift occurred toward favoring government intervention in certain circumstances” (Wellever, Reichard and Velasco 2004).

[11] Analyses in the field of medical sociology have pointed out the myriad challenges entailed in developing effective public health interventions designed to address entire populations. For example, David Mechanic (1978, 204–205) isolates an inability to pinpoint necessary causes of disease conditions and difficulty in implementing control measures as two interlocking factors that complicate population‐based interventions. Such complicating factors have driven refinement of the Epidemic Investigation protocol, which provides a practical framework for focused action in the face of uncertainty.

[12] In the parlance of medical sociology, this strategy constitutes an attempt to influence the “social construction of medical knowledge,” which helps determine “professional and institutional practices of the health care system”. Brown elucidates how this concept differs subtly from the “social construction of illness,” which has received the bulk of attention in traditional constructionist writing in this area (Brown 1996, 96).

[13] This outcome may also help minimize the tendency, noted by Frank Furedi (2004), for individuals perceived as “diseased” to become targets of victim‐blaming in “therapy culture.”