This fundamentally complex cultural phenomenon is the departure point for this book. The expectation that people must engage in everyday weight loss is now deeply socially ingrained in countries like the United States. The science of weight loss suggests that the more people try to lose weight through dieting, the more likely they are to gain even more weight in the long term.4 Thus, weight-loss efforts are only loosely related to actual weight, and they are only loosely related to success at weight loss. Moreover, obesity itself does not always equate with ill health. There are plenty of skinny people with diabetes, high cholesterol, and other physical pathologies that are commonly portrayed as co-occurring with obesity.5 There are also plenty of people who, if weighed in a doctor’s office, would find themselves diagnosed with morbid obesity and quickly thereafter classified as diseased from a medical (and social) standpoint . . . but who would have no other symptoms of disease aside from a higher weight-to-height ratio. In other words, weight deemed excessive is viewed as inherently diseased, whether or not it correlates with lived experiences of illness symptoms and diseases such as diabetes, cardiovascular disease, and the like.6 In other words, social beliefs about obesity map poorly onto current scientific and medical evidence. Making the situation still more confusing, “fat” and “obese” are slippery words/concepts that are often used interchangeable by many people. What is clear, however, is that it has become a basic social fact in many countries in the world today that fat bodies are unacceptable, are unhealthy, and reflect a lack of personal commitment to other valued traits that include hard work, personal responsibility, and goal-oriented individual success.
In this book, we use detailed ethnographic data collected with bariatric surgery patients in one hospital case study to understand how and why the cultural obsession with weight loss is such a prevailing characteristic of our modern, media-connected societies. We stress that this obsession is at its core a cultural one, although it uses medicalized rhetoric and many of the flows of power and influence happen in and between clinical settings. This book unravels how and why weight and our efforts to escape it have become such a collective and heavy burden, taking up so much of our attention and causing so much daily worry. Our story is about understanding how and why weight norms are core to so many people’s basic senses of self. Our case study in based in one city in the United States, but in many ways it is a universal story about life in an increasingly globalized world in the new millennium.
It’s Not Just about Weight—It’s about Fitting In
The lifelong struggles with weight and size, as described by the bariatric patients we got to know, are not unique. However, the avenue that they eventually chose to go down to lose weight—that is, opting for bariatric surgery—does make them unusual. The surgery and its consequences also give people who undergo it unusual insights into both weight and weight loss. This is one of the reasons why we chose to focus on bariatric surgery as a rather unique lens for understanding (and, hopefully, disentangling) weight-related experiences. Where else, in the early twenty-first century, might one find a community of people who have—collectively and individually—experienced the social and physical consequences of extremely high weight, followed by the loss of a significant portion of that weight?
Among other things, this expensive surgical intervention facilitates rapid weight loss to an unparalleled degree. Bariatric surgery encompasses a number of different types of surgical interventions on the stomach and intestines, usually through the reduction of stomach capacity and gut length. All trigger weight loss because they profoundly alter how the body takes in, absorbs, and excretes food. Bariatric surgery is also sometimes referred to as metabolic surgery because it manipulates (via surgery) a normal organ system to change an individual’s biology to improve their metabolic health. The surgery has a relatively short history, corresponding to the relatively short history of global concern with obesity and metabolic health.
Surgeries to promote weight loss via malabsorption of nutrients and/or restriction of volume in the stomach and gut began to appear more than sixty years ago but did not become popular until the 1990s, and then primarily in the “advanced economies” of North America, Europe, and Asia.7 Not coincidentally, the 1990s were also a time when public and medical attention to rising rates of obesity in populations around the world became acute, along with a concordant demand for solutions. A cluster of conditions, including high blood pressure, high blood sugar, excess weight around the waist, and hyperlipidemia, began to pop up routinely in populations—a disease profile commonly known as metabolic syndrome. With the increase in metabolic syndrome, then, we see an increase in metabolic/bariatric surgery.
Bariatric surgery, as other researchers have observed, may not be a perfect solution to promote increased overall health; but it is the most effective weight-loss mechanism currently available, and it is also effective as an intervention for certain diseases. By that, we (and others) mean that the surgery is effective in reducing weight, type 2 diabetes, hyperlipidemia, and joint pain.8 It also, however, has a host of unpleasant side effects precisely because it causes malabsorption and alters anatomy.
Surgeries categorized as bariatric, weight loss, and/or metabolic come in various forms and via different types of programs. The most commonly used surgeries currently are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Of these, the gastric band is very popular in the United States, despite the fact that it triggers less weight loss than the others and has a less pronounced effect on diseases like type 2 diabetes. It is popular because it is the only one that is potentially reversible: the band can be removed. The most commonly performed bariatric surgery types within the program we studied were laparoscopic vertical sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. In a gastrectomy, a bariatric surgeon removes much of the stomach, hugely decreasing the capacity of that organ to take in and process food and forcing everything to go more or less straight into the intestines. One patient described her new stomach as a “small banana” in shape and size. In a bypass, a bariatric surgeon creates a small walnut-sized stomach pouch, seals off the rest of the stomach, and then reattaches the small intestine to that small pouch, “bypassing” much of the stomach and part of the small intestine. Weight loss occurs because the redesigned stomach-intestine combination cannot tolerate food in any quantity or foods high in sugar and fat and because the redesign promotes malabsorption of food. Although the surgeries themselves are typically straightforward, the long-term consequences of the stomach and intestinal rerouting cannot be overstated. They necessitate an entirely different, lifelong approach to one of the most basic of human activities: eating.
The massive weight loss precipitated by bariatric surgery gives people who go through the process special insight and understanding into what it means when bodies do not, then suddenly do, fit in. In other words, in choosing to focus on weight in this research, we are in fact looking at the very human struggle to “be normal,” to adhere to the norms accepted by most people. This is the heart of our story. How does a person know whether they fit in or not? Why do people care so much? What happens when an individual is unable to meet basic social norms about how they are meant to look and act?
Although this book is first and foremost an ethnographic account of what it means to undergo extreme weight loss, it is also fundamentally about understanding norms around body, weight, and appearance.9 Norms are shared but unwritten rules about how humans should act and be. Norms help people understand what is expected and what will be accepted by a wider group. What are the processes by which norms infuse themselves into people’s lives? In what ways do these norms form our sense of self and identity, and how do individuals accept and resist them? How do people define success or failure in relation to them? What are the implications when norms change, with regard to the effects on human society and biology?
Our focus in this book is on shared body norms and shared experiences of struggling to meet them. As such, our analysis focuses to a large extent on drawing out core experiences that cut across diverse participants’ experiences over time. In doing this, we focus on similar themes that emerged for people, despite the many differences within our sample with regard to each person’s weight, dieting history, marital and familial situation, socioeconomic status, age, gender, race, and ethnicity. The literature tells us that all of these factors may