David

The “Tyranny of Normality”

I had grand plans for my first blog post, but then I read this article and, frankly, grand plans gave way to annoyance.

The article begins by suggesting that “when it comes to health, Australians are fat, unhappy and leading the world in self-deception,” citing a study that, according to Melbourne GP Dr Bert Boffa, shows that “sixty per cent of Australians are overweight or obese but only about 30 per cent realise they are.” The study also suggests that men are less likely to realise that they’re overweight than women; and older Australians are also less likely to realise that they’re overweight. I think that the gender gap in ‘self-deception’ is particularly interesting (and probably deserves its own post), but that’s not what I’m going to focus on here.

There are a lot of details missing from this article and I think that it’s important to acknowledge this before continuing. How were participants sourced? On what basis was someone deemed ‘overweight’ or ‘obese’? How was the ‘self-deception’ (or, conversely, self-knowledge?) of participants guaged? How many of the 13,000 participants in this international study (including people from 12 countries) were Australian and can this number really be used as the basis of claims about a country whose population is projected to be over 22,000,000 by the Australian Bureau of Statistics?

These questions aside, there are some definite problems with the way this data has been presented in this article.

Despite the fact that Dr Boffa acknowledges that “we’re one of the most long-lived nations on the planet,” and that the number of deaths typically associated with obesity-related complications and health issues are decreasing, as far as he’s concerned fat is still the problem here. Why? Because of the risks of a “tyranny of normality,” of course!

See, we’re meant to believe that in a country where the ‘obesity epidemic’ is not only the topic of a new scare-mongering media exposé every other day of the week, has been the reason for any number of changes in how we live our lives and view our bodies (willingly or otherwise), and has also been a topic of discussion in our Parliament as recently as February of 2011, being fat is not only seen as normal, but has become dangerously mainstream! The fatties have all but taken over, thrusting their bulging bellies upon the poor, disempowered minority of truly normal-sized people! Sure, a majority of people in Australia are meant to be overweight, but “people are sort of fooled by what’s normal.” In other words, just because there’s more of them that doesn’t make it okay for them to be that way!

Look, I’m not saying that there isn’t anything important to take away from this type of study. The fact that “Australians are suffering more chronic and disabling health problems” is definitely something that should be looked into – although the assumption that there is necessarily a ‘correlation is causation’ style of relationship between fat and diabetes is kind of silly, given that you don’t have to be fat to be diabetic. I do, however, see it as being highly problematic to couch these results in a conclusion that not only fails to acknowledge that thin people can – and do – also suffer from all of these very same problems, but that also tries to argue that fat has become normalised in a culture that, in reality, is actually quite vigilant and at times even downright vicious in its policing of our bodies.

This last point seems particularly important when you consider the second part of the study’s findings that are discussed in the article – “that depression is increasingly prevalent in Australia, with one fifth of respondents saying they had it.” Dr Boffa obviously assumes that people are depressed and anxious because they’re fat. Putting aside once again that there’s nothing to say that only fat people are depressed and anxious, isn’t it just as – if not more – plausible to suggest that overweight people are depressed and anxious because they’re constantly being told that they’re not normal? That, to me, seems to be where the “tyranny of normality” really comes into play!

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  • Moudou

    “The rate of heart attack is going down, the rate of stroke is going down, yet we’ve never been fatter.”

    For shame.

  • Michael

    The point he’s making is that killer conditions have given way to chronic disabilities. These diseases get worse as you get older and just because you can survive them doesn’t make them any less miserable. Living at 70 with diabetes is no joke.

    Obesity and diabetes have a strong statistical correlation – between 80% and 90%  of adult Type II diabetes sufferers are obese. Just why this is isn’t completely understood, but enough is understood to make a compelling case that there is a very strong relationship between the two. To dismiss this is ‘correlation is not causation, silly’ is to show a total lack of understanding of medical risk.

  • Mulberry

    Of course it’s correlated – insulin resistance causes weight gain in many. Correlation doesn’t tell you which is cause and which is effect.
    But cancer causes weight loss in a lot of people, and who is suggesting you gain weight in order to forestall it?I would also like to see a study of how many normal weight people know they’re of normal weight and how many thin people know they’re thin. Funny, I thought the “tyranny of normality was an apt description of the tyranny of those in the so-called normal weight range over those in the overweight/obese range.

  • http://twitter.com/bjkraal Ben Kraal

    Here’s the BUPA report that the ABC piece David linked to mentions:
    http://www.bupa.com/media/284419/bupa_health_pulse_2011_interactive.pdf

    The exact quote from the report is “Worldwide, almost half of people survey (49%) are overweight (BMI > 25 or more). Yet only a third of people (36%) think they are overweight.”

    So it’s not, as Dr Bert Boffa puts it that “half of the Australians who are overweight don’t realise they are”. It’s that half of the Australians who have a BMI > 25 reject that definition of overweight. This is actually far more interesting than Dr Boffa’s analysis. It opens the discussion about what are sensible measures of the health of the general population. 

  • http://www.nicholasperkins.com/blog/ Nicholas Perkins

    The issue once again seems to come back to the BMI. I have massive problems with the BMI. I just can’t see how such a simplistic formula can be a determination of someone’s health, or even their risk of having a health issue. “Correlation does not equal causation” has become a bit of a catch-cry recently, but it’s true.

    The other issue is the notion of being “overweight”. Over what weight? Well, it’s some arbitrary weight that has been set by someone with no idea of an individual’s body make up, how their body works, their eating and health history etc. Even with weight watches you get a healthy weight range. Are you “overweight” if you aim for the upper number in the range or should you try for the lower number?

    You are dead set right when you mention that we need to discuss what are sensible measures of health.

  • David

    Correlation isn’t causation, though. I’m not saying that there’s no link whatsoever between the two things. I am, however, saying that being overweight or obese doesn’t necessarily mean that you are going to have diabetes.

    It could be that between 80-90% of adult Type II diabetes sufferers are obese. That doesn’t mean that between 80-90% of overweight or obese people have adult Type II diabetes; nor does it necessarily mean that it was being overweight or obese that caused all (or even most) of those cases. There’s also the possibility that people became overweight or obese after they became diabetic.

    These aren’t just matters of semantics, they’re important factors to take into consideration – and it’s just good methodological practice to acknowledge them.

  • David

    I agree, that does sound a lot more interesting. I’ll have to have a look at the link when I get home and can give it the appropriate attention – thanks!

  • Michael

    By your logic, you could say ‘it’s hard to know which comes first – the smoking or the lung cancer’. Correlation does not tell you which is cause and which is effect, yes, but the statistical relationship is not used in isolation. Enough is known for doctors to be able to state, with some certainty, that gaining tremendous amounts of weight will put you at risk of diabetes.

    The mantra ‘correlation is not causation’ is a piece of scientific wisdom that is being abused. It does not mean ‘correlation is merely a statistical artefact that has no value’.

  • http://fatfu.wordpress.com Meowser

    Oops, meant to hit the reply button, not the Like button.

    Body fat is not cigarettes.  All smokers have one single behavior in common — they put cigarettes in their mouths and light them.  There is not a single behavior adhered to both exclusively and universally by fat people.  Furthermore, you have most of your fat cells by the time you are a year old, and you can be labeled as “obese” even before your first birthday, and stay that way forever while doing everything your doctor tells you to do.  One-year-olds don’t smoke.  (Although if we keep up with the fat hate, kids not much older than that are going to start taking it up.)

  • Moudou

    “By your logic, you could say ‘it’s hard to know which comes first – the smoking or the lung cancer’”

    Er no, lung cancer definitely doesn’t cause smoking. And its not “logic” its fact, we do not know whether, insulin resistance=fat or vice versa, nor whether a tendency toward type 2 makes you more likely to gain weight or gaining weight makes you diabetic. The overwhelming majority of fat people do not have diabetes. 

    Some slim people have IR, some fat people don’t. Why do people start playing stupid when they’re losing arguments about fatness?

  • Michael

    The overwhelming majority of fat people may not have diabetes, but the overwhelming majority of diabetes patients are fat.

    Losing an argument about fatness? Sorry, epidemiology suggests otherwise.

    Fat rights is a worthy cause. People shouldn’t face discrimination and cruelty because they’re fat. Fat is difficult to lose, so there is no point in telling people to get slim.

    That doesn’t change the fact that excess adipose tissue has significant health consequences. Not everyone who is fat will get diabetes, or colorectal cancer, or sleep apnea, or post-menopausal breast cancer, or joint problems. But boy, will fatness raise your risk of getting them. Pretending that being fat is health neutral or benign does fat rights no favors.

  • Michael

    Not every fat woman is going to get post-menopausal breast cancer. Many women who are not fat will get post-menopausal breast cancer. Guess what? Doesn’t change the fact that being fat puts you in the high risk category for post-menopausal breast cancer.

    Being obese at a young age sucks, and it sucks that there may not be much that the kid – or adult – can do about it. It equally sucks that the health consequences are independent of whether that kid could intentionally lose weight or not.

  • David

    For some reasons my comments aren’t appearing, so I’m going to repost this comment from yesterday as a guest:

    Correlation *isn’t* causation, though. I’m not saying that
    there’s no link whatsoever between the two things. I am, however, saying
    that being overweight or obese doesn’t necessarily mean that you are
    going to have diabetes.

    It could be that between 80-90% of adult Type II diabetes sufferers
    are obese. That doesn’t mean that between 80-90% of overweight or obese
    people have adult Type II diabetes; nor does it necessarily mean that it
    was being overweight or obese that caused all (or even most) of those
    cases. There’s also the possibility that people became overweight or
    obese after they became diabetic.

    These aren’t just matters of semantics, they’re important factors to
    take into consideration – and it’s just good methodological practice to
    acknowledge them.

    In addition to that, I don’t think that anyone is going to try and claim that fat is ‘health neutral.’ However, thin people can be equally if not even more unhealthy or unfit than fat people, yet it’s the reduction of fat itself that is – again and again – the focus of so many people, because of the false assumption than being thin is also being healthy.

  • Michael

    You’re right. Being overweight by itself does not guarantee that you are going to have diabetes.

    Unfortunately, it does mean you have a raised risk of having diabetes.

    Thin people can indeed be very unhealthy and you are right that thin people should not be complacent about their health. There are also fat people who are very healthy.

    Unfortunately, it still remains the case that the more excessively overweight someone is, the higher their health risks become, including for diabetes. And, unfortunately, it doesn’t work the other way round – that lots of normal weight people get diabetes and suddenly become overweight. There will always be exceptions, but the fat tends to come first.

    Fat rights are important. I can’t see, however, that it does fat activism any good to claim that fat doesn’t bring problems with it, including diabetes and other metabolic disorders. The health risks and consequences are too well documented.

  • David

    Just to reiterate, no one is saying that there is *no* link between the two things (I did say ”the assumption that there is *necessarily* a…relationship…is kind of silly” in the original post), just that one does not automatically equal the other, which is essentially where the Dr. quoted in this article is going with his flawed line of reasoning. And as Ben pointed out, his comments don’t even seem to relate all that well to the actual findings of the study.

  • http://fatfu.wordpress.com Meowser

    The overwhelming majority of fat people may not have diabetes, but the overwhelming majority of diabetes patients are fat.

    The older you get, though, the more the association with body weight diminishes.  (IOW, the younger you are at diagnosis, the stronger the genetic link.)  As Paul Ernsberger once put it, if you live long enough, you WILL get t2d.  One of your internal organs has to start crapping out on you first, and since we’re doing a much better job of preserving hearts and brains than we used to, more people are going to see the pancreas start to go first.  It’s also being diagnosed at much, much earlier stages than it used to be — at lower levels of fasting glucose, and without any of the later stage symptomatology like fainting, gangrene, etc.  (And don’t think they won’t lower the qualifying FG again if the drug companies insist on it.)

    So plenty of people with the diagnosis live perfectly normal and beyond-normal life spans now, even with an early diagnosis; it’s only people who got a very late diagnosis or don’t have any kind of treatment at all who die from it anymore.  (I know this; I have examined close to 150,000 medical records during the course of my working life, and I know what people actually die from.)

    Also, risk factor =/= death sentence.  Sleeping less than 7 hours a night is a risk factor for many illnesses (and injuries) too, but people seem to do that every chance they get, and they don’t get shunned for it.  In fact, it’s considered a badge of honor to do with as little sleep as possible.

    But think the whole point of this post is to ask how two-thirds of the population a country with tens of millions (or in the case of the U.S., hundreds of millions) of people can have bodies that are said to be deviant or abnormal.  How does that even make any sense?  Even ONE-third is an awful lot of “deviants” in a population that size.  And shaming people for their supposed deviance has done precisely squat-all to make them not “deviant”; in fact, it has arguably the opposite effect.

  • David

    “But think the whole point of this post is to ask how two-thirds of the population a country with tens of millions (or in the case of the U.S., hundreds of millions) of people can have bodies that are said to be deviant or abnormal. How does that even make any sense? Even ONE-third is an awful lot of “deviants” in a population that size. And shaming people for their supposed deviance has done precisely squat-all to make them not “deviant”; in fact, it has arguably the opposite effect.”

    ZING!

  • Michael

    There are two separate issues here. One is fat shaming and discrimination and so on. That is obviously a human rights issue and is something that shouldn’t happen.

    That doesn’t change the biological reality that diabetes is a miserable disease that is being diagnosed at a younger and younger age. It’s no consolation to a child of 12 to know that they won’t die from it any more. I’m sure most kids would have preferred not to get it in the first place.

    People are also better off sleeping properly. Culturally, people may feel a sense of reward for running on adrenaline, but the body doesn’t know or care about ‘everybody does it’. It just feels awful. Diabetes – or breast cancer, colorectal cancer, sleep apnea, bladder leakage, weight-related arthritis – also feel awful, even if they don’t kill you and if more and more people have them.

    As to bodies being considered deviant – bodies are certainly culturally constructed. They’re also biologically constructed. There is a biological range of ‘normal’ for humans. This can shift radically depending on the nutrition available – you can see it in the way height changes rapidly depending on local conditions. Some of it is also genetic and we’re seeing genetic expressions that we’ve never seen before, because of a new food environment (new in evolutionary terms). Even taking all of that into account, there is only so far the human body can change before it becomes extremely unhealthy. Once it’s got into that range, you can say it’s not longer within normal range. Everybody seems to complain about the BMI, but even with all its faults, it still remains a consistent predictor of certain types of medical risk.

    The question about all of this, of course, is what you can do about it. Once the body is fat, there’s no point fat shaming, exhorting people to become thin when they can’t, etc etc.

    But that doesn’t change the fact that higher fat IS associated with a heightened risk for a number of disease processes, diabetes among them. For health, it really is better not to get obese in the first place.

    I’ll give it up at this point. I just wish that people who are abusing the  ‘correlation is not causation’ argument would also give it up.

  • David

    It’s not being abused here, though. And you’re not actually saying anything different to what is being said by myself and other commenters, at least that I can see. The only difference is that you’re focusing on the ‘fat is unhealthy’ aspect and the responses you’re getting are essentially saying, ‘this is not untrue, but it’s not exclusively the case…but either way, why is it that fat in particular is the focus?’

    I’m not trying to be a smart arse, but I don’t see how your points are extending the conversation at all.

  • http://fatfu.wordpress.com Meowser

    Disqus isn’t letting me edit, but the first two sentences were a little murky, so let me restate:  In elderly populations, the association with body weight diminishes.  (And the younger you are at diagnosis, the stronger the genetic link.)

  • http://fatfu.wordpress.com Meowser

    Here’s the problem with that line of reasoning: If one makes “not becoming obese” a priority, what happens when a person requires a life-saving medication that has weight gain as a side effect?  I can tell you what happens a lot of the time: people refuse the drugs, solely because they’re freaked out about the prospect of getting (or staying) fat.  Not that there aren’t alternatives to medications that work for many people, but for some of us, these drugs are a lifeline.  And there are now dozens of medications with this potential side effect.

    So if you’re 12 and you have a seizure disorder, and your already precarious social standing is hanging in the balance, and you know that taking the only medication that’s ever controlled your seizures is going to make you much fatter than you would otherwise be, what are you going to do?  If you’re like most kids, your parents are going to have to hold you down and shove the pills down your throat, because nothing, but nothing, will get you shunned worse than being fat.  (And don’t think for a second that the near-constant discrimination that comes with being fat doesn’t take a toll on health; in countries where fat people are celebrated and fat is considered beautiful, they don’t have the so-called “obesity-related illnesses” we have in Western countries.)

    And if you’re a parent who’s gotten the “your child is at risk for obesity” lecture, who knows, maybe you don’t even want them to have the drug in the first place, even if they could have a fatal seizure, or commit suicide.  If you think that never happens, think again.  Even parents freaking out about the lecture and putting their kids on diets (or, in the case of older children, the kids putting themselves on diets), arguably has more deleterious long-term health effects than just simply letting them be.  Furthermore, when everyone is freaked out about fat, guess what happens?  Yep, more eating disorders, more smoking, more serious depression.  You always, always, ALWAYS have to weigh one risk versus another.

  • Moudou

    When you compare a direction of causation that is unknown, with one that is, you’re throwing in the towel on that point. I did not mention any prognosis on fatness, so if you wish to respond to me, stick to what I actually say.

    But as you raised it, the weight and health graph is U Shaped, meaning that either ends of the spectrum are more likely to be showing some difference in function from the mean, obvious.

    The difference between the thin and fat ends is that with the former, the ‘obesity scientists’ attempt to excuse it away. Saying if you are thin you’re more likely to be dying (yup) so its not what it seems on the face of it etc.,  by this ‘obesity’ experts undermine their own thesis of taking fatness at face value and soft soaping one end of the curve. It is refusing to think that anyone who isn’t fat is always honourable and fat people sneaky, that “undermines fat rights” whatever they are.

  • http://fatheffalump.wordpress.com/ Fat Heffalump

    Your last paragraph really, really nails it for me.  The reason so many fat Australians are depressed is more often than not they’re being told that they’re somehow defective, abnormal.  And being BULLIED for it, not just informed of it.

    Great post.

  • David

    :D Thanks!

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