loss matter greatly—and in myriad ways—for both long-term physical and mental health.
The Path to This Book
We started laying the groundwork for our study on bariatric patients in 2012 and began formal ethnographic research in the clinic in 2014, but we have been engaged in studying weight and weight-loss issues for much longer. In fact, our individual research trajectories are very illustrative of the major shifts that have happened around health, weight, bodies, and nutrition research in our lifetimes alone. Alex began her ethnographic fieldwork in the islands of the central Pacific thirty years ago, when anthropologists were still overwhelmingly engaged with many smaller-scale and subsistence societies that placed a high value on weighty bodies. Alex’s long-term research in Samoa, in particular, has tracked shifting preferences and beliefs, showing an accelerating seismic shift from that traditional plump ideal to a vague preference for being thinner (which made an appearance two decades ago) to today’s strongly negative ideas about fat. Sarah’s research in the United Arab Emirates among female university students in 2009–2011 revealed that young women there expressed considerable worry about weight and invested time and energy in often-draconian efforts at dieting, in stark contrast to the pro-fat attitudes that predominated in their grandparents’ youth. Similarly, Amber’s decade of work in Paraguay has uncovered profound ambivalence around changing body norms. Many urban Paraguayans reject anti-fat discrimination while also holding harsh anti-fat views, which manifest themselves socially through men’s and women’s teasing and judgment of bodies identified as fat.
In 2010, we conducted a set of standardized surveys across a range of different low- and middle-income countries in East Africa, the island Pacific, and South America. We found that consistently strong anti-fat sentiments had become normalized across all the cultures we surveyed.18 This was a shocking finding at the time because many of the cultures we studied were still thought of as fat loving. Yet people consistently identified fat as unhealthy and unwanted and categorized fat individuals as lazy, uneducated, and unmotivated.
Of course, this was not a monolithic attitude; our samples were biased toward urbanites, who were regularly exposed to transnational media messages that equate fatness with badness and public health messages that stress obesity as a risky health condition. Additionally, there were people across all settings who stated that they found large bodies (including their own) not only acceptable but even good. Existing ethnographic research in diverse cultural settings also shows that people may simultaneously hold positive and negative ideas about fatness versus obesity and may focus on the negative frameworks when asked in an official capacity to provide ideas. In other words, long-standing cultural ideas that value larger size still retain power in many settings worldwide.19
Nevertheless, those survey results showed that more people overall see fat bodies as unacceptable and bad and will say so. In the survey data, we established that no cultural context we studied—no matter how fat positive it had been historically—was immune to the anti-fat attitudes and rhetoric that gathered momentum throughout the last half of the twentieth century. Moreover, the range of socially acceptable bodies seems to be narrowing in all of these cultures. On the other hand, the strength of expressed anti-fat convictions and the effort, money, and time people are willing to expend to meet new body norms differ from place to place. The US remains one place in the world where the drive to be thin is consistent and internalized and where people with identified fat bodies struggle across many spheres of life, including the workplace, educational settings, and social and familial circles.
Despite several decades of collective work related to weight and body in places as diverse as Paraguay and Bolivia (Amber); Mexico, Samoa, South Korea, Japan, and the US Southeast (Alex); and the United Arab Emirates and the US Southwest (Sarah), we often found ourselves listening to people who did not identify as either clinically obese or socially fat. We are certainly not alone in this. In the past few years, a critical corpus of ethnographic work engaging with obesity, fatness, and body issues has developed within anthropology and sociology, exploring the various ways that people engage with globalizing messages that vilify obesity and fat in daily life. With a few exceptions, such work has not explicitly focused on people at the high end of the weight spectrum, those most pathologized by the medical world. Where this work has had such a focus, the research tends to have tiny sample sizes; self-studies (“autoethnographies”) are common. This work also tends to be oriented around fat acceptance and/or fat positivity. “Health at Every Size,” an agenda that advocates accepting all body sizes as part of a holistic view of health, is also a common framework and point of departure for this research.
Our conclusion is that outside of Fat Studies, anthropologists have not been comprehensively attending to the stories and ideas of those who most struggle to fit dominant body norms because of high body weight, especially in contexts that are highly fat stigmatizing and spurn fat acceptance ideals. For example, the bariatric participants with whom we spoke, who were very large people in a virulently anti-fat setting, were not interested in a revolution that overturns the current stigmatization of fat. Rather, they devoted their emotional efforts, time, and money to changing their physical bodies to better fit current body ideals. Most of the clinic patients we got to know articulated deeply held beliefs that being fat is unacceptable. Even patients who did question anti-fat norms and registered lower levels of fat stigma nonetheless fundamentally believed there was something wrong with their size and therefore with themselves prior to bariatric surgery.
We think another reason that anthropologists have not focused much ethnographic attention on understanding how very large Americans relate to the extreme body norms circulating in the US today is because of the difficulty of the fieldwork. The study of norms, at least as anthropologists approach it, requires that researchers talk to enough people to understand shared concerns and themes. For what we wanted to do, including thematic analysis, one or two cases was insufficient. We needed a robust sample size that was big enough to accommodate loss of participants over time while still meeting the minimum requirements for participant observation and qualitative data analysis.20 Moreover, recruitment in anthropology in complex urban settings (we based our study in a city in the western US) commonly needs some point of entry. This is even more true when researchers want to study a vulnerable population and are themselves outsiders.
In our case, we could not rely on a politically oriented or community group of “stigma sharers” because the few that do exist are oriented around fat acceptance and “Health at Every Size” goals. We wanted to talk to people who internalized fat stigma and felt it was making their lives miserable, rather than the more studied proponents of the fat acceptance movement. We also wanted to talk to people who knew what it was like to live with fat and live without fat, medically and socially. At a time when medical, public health, and media commentary tends to make it sound like the entire planet is careening toward an “obesity epidemic” (the terminology most often used), studying a group of people who have experienced the reverse trend (extremely fat to not fat) in a fat-stigmatizing context like the US can give us insights into both the experience of unwanted physical weight and its emotional, moral, and social implications.
These considerations meant that the bariatric clinic was an excellent point of entry. However, it took a substantial amount of both administrative approvals and one-on-one relationship building to convince clinicians, who in this case understood the sensitivities and vulnerabilities of their patients, to trust us enough to fully engage in long-term participant observation and patient recruitment within the clinic. Alex spent two years prior to the study launch building trust with hospital administrators. Sarah and Alex talked to most of the bariatric providers and clarified the details of the study before the study began. Sarah provided similar explanations to preoperative and postoperative patients in meetings of the bariatric support group and the behavioral change classes on a routine basis. All three of us went through a variety of quite complex and time-intensive research clearances at the clinic and our own research institution.
One of our goals was to track the patients’ changing understandings of their bodies as they lost weight postsurgery. This
