Obesity has been at the forefront of the public health agenda in the United States since the late 1990s. Commonly considered a simple condition of excess for most of the 20th century, I argue that in order for scientific inquiry into obesity to be considered legitimate, an important transformation was required: obesity needed to be reconstructed as a complex condition, in need of multidisciplinary collaboration and significant, sustained research investment. Drawing on document analysis, in-depth interviews with obesity researchers, and ethnographic observation, in this article I show how the frame of complexity has been instrumental for obesity researchers carving out a legitimate area of scientific inquiry. I trace how complexity has been mobilized over the past 60 years, first during infrastructure building activities that occurred beginning in the early 1970s, as well as field expansion activities that institutionalized the frame during the 1990s and 2000s. While the complexity frame has largely been successful in attracting sustained investment in biomedical and public health research on obesity, it has differentially benefited researchers and those impacted by obesity.
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In 1998, BMI thresholds for overweight and obesity were lowered, and differences for women and men were dissolved. Threshold for overweight category was lowered to 25.0 from previous standards of 27.8 for males and 27.0 for females (Flegal et al. 1998; Boero 2013). This collapsing has been widely critiqued, even with some attention from those within the obesity research community (Kassirer and Angell 1998; Squires 1998). BMI is a measurement tool used to classify individuals based on weight and height, calculated as weight divided by height squared (W/H2), and has been the standard metric for weight classification since 1977 (Bray 1979).
While biomedical obesity research certainly existed before the 1970s, researchers had not formed organized communities. The documents and conference proceedings analyzed for this article trace early discussions around organizing efforts to the very late 1960s, and the first coordinated meetings and plans for journals occurring in the 1970s. In 1968, the NIH was granted funds to open the John E. Fogarty International Center for Advanced Study in the Health Sciences. Named after John E. Fogarty, a congressman who advocated for the NIH funding and died in 1967, the Fogarty International Center (FIC) is the arm of the NIH that seeks to advance global public health (NIH n.d.). After it was established, the FIC hosted a series of conferences focused on emerging issues in preventative medicine. The first, held in 1971, concentrated on diabetes, the next two (1973 and 1977) focused on obesity.
My analysis of these documents from this period does not support that obesity researchers were directly concerned with alleviated the stigma that this prevalent narrative produced for individuals classified as overweight and obese. The stigma surrounding obesity has long been documented, as well as its racialized and classed undercurrents. Obesity was, and continues to be, often equated with laziness, moral failing, indulgence, and gluttony (Greenhalgh 2012; Saguy 2012; Boero 2013; Sanders 2019). Importantly, though not the focus of this paper, a significant area of obesity research is concerned with stigma (e.g., Puhl and Brownell 2001; Puhl et al. 2013, 2017; Puhl and Heuer 2009). This body of research, as well as social science research, has shown that stigma has implications for people seeking care—suggesting that overweight and obese individuals might not seek care because of the prejudice and bias they fear they will face in healthcare settings and their health concerns may not be taken seriously (Guthman 2011; Hobbes and McKay 2018; LeBesco 2010).
The National Institute of Arthritic and Metabolic Diseases was established in 1950 under the Omnibus Medical Research Act. It was renamed in 1972 to the National Institute of Arthritis, Metabolism, and Digestive Diseases, and later in 1981 to the National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases (NIADDK). Arthritis was dropped from the name in 1986 when a division of the institute became the core of a new institute, the National Institute of Arthritis and Musculoskeletal and Skin Diseases. NIADDK was renamed National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) which is its current name (NIDDK 2018).
The American Obesity Association (AOA), which identified as being made of lay persons, profession providers, and industry supporters, was established by obesity researchers and has been critiqued by social scientists for its conflicts of interest and false representation as a lay person organization (Boero 2013; Campos 2004; Oliver 2006). The AOA no longer exists as a standalone organization. In 2006, AOA and the North American Association for the Study of Obesity (NAASO) merged to create The Obesity Society (TOS). TOS’s mission is to “lead the charge in advancing the science-based understanding of the causes, consequences, prevention and treatment of obesity.” (The Obesity Society Strategic Plan, n.d.) Many prominent obesity researchers involved in these organizations have received support from pharmaceutical and food industries.
The AMA was, in a sense, the last holdout. As shown above, the 1998 NIH guidelines labeled obesity a disease. The Internal Revenue Service (IRS) recognized obesity as a disease in 2002, so that weight-loss expenses could be deductible. The IRS had accepted weight-loss expenses since 2000, but only if they were in the service of treating a specific disease. For the AMA, however, this decision sparked debate both within the medical sphere and among the general public. The disease declaration was widely covered in the media. In particular, the AMA was critiqued for making this decision against the advice of their delegates charged with disease deliberation, the Council on Science and Public Health (CSAPH). The CSAPH advised against disease status because of the reliance on body mass index (BMI) when defining obesity (CSAPH 2013).
The metabolically healthy obese population (MHO) and the ‘obesity paradox’ suggest that obesity is not always unhealthy. The MHO population does not exhibit the metabolic disorders that typically accompany obesity, such as hypertension, insulin resistance, or lipid disorders (high blood pressure, Type II diabetes, and high cholesterol) (Roberson et al. 2014). Initial studies suggested that MHO are healthy obese individuals who are at low risk to develop metabolic and cardiovascular diseases (Wildman et al. 2008; Achilike et al. 2015). Metabolically, these individuals are more similar to ‘normal’ weight individuals than to individuals closer in their shared BMI classification. The obesity paradox refers to a phenomenon observed by Gruberg and colleagues in 2002 in which they saw better outcomes among coronary heart disease patients undergoing percutaneous coronary intervention that were overweight and obese (Gruberg et al. 2002; Antonopoulos et al. 2016). Both MHO and the obesity paradox sparked some debate within the obesity research community as well as calls further research.
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I would like to thank the participants who generously shared their time and perspectives. Additionally, I thank colleagues and mentors at the University of California, San Francisco and Drexel University who have engaged in conversations about this project since its inception. In particular, my appreciation goes to Kelly Joyce, Christian Hunold, Janet Shim, Emily Vasquez, and Rosalie Winslow for their helpful comments on earlier versions of this manuscript and enthusiasm for the project. Finally, I thank the three anonymous reviewers for their insightful and constructive comments. This manuscript is comprised of original material and is not under review elsewhere.
Conflicts of interest
The author has no conflicts of interest, monetary or otherwise, relevant to this manuscript to report.
The research protocol for this study was approved by the Institutional Review Boards at Drexel University (while the author was a student there) and subsequently at the University of California, San Francisco (where the author is currently a student).
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Jeske, M. Constructing complexity: collective action framing and rise of obesity research. BioSocieties (2020). https://doi.org/10.1057/s41292-020-00182-9
- Collective action framing
- Scientific institutions