Abstract
Public debate about who or what is to blame for the rising rates of obesity and overweight shifts between two extreme opinions. The first posits overweight as the result of a lack of individual will, the second as the outcome of bodily drives, potentially triggered by the environment. Even though apparently clashing, these positions are in fact two faces of the same liberal coin. When combined, drives figure as a complication on the road to health, while a strong will should be able to counter obesity. Either way, the body’s propensity to eat is to be put under control. Drawing on fieldwork in several obesity clinics and prevention sites in the Netherlands, this paper first traces how this ‘logic of control’ presents itself in clinical practices targeted at overweight people, and then goes on to explore how these practices move beyond that logic. Using the concepts of ‘will’ and ‘drives’ as analytical tools, I sketch several modes of ordering reality in which bodies, subjects, food and the environment are configured in different ways. In this way it appears that in clinical practices the terms found in public discourse take on different meanings and may even lose all relevance. The analysis reveals a richness of practiced ideals. The paper argues, finally, that making visible these alternative modes of ordering opens up a space for normative engagements with obesity care that move beyond the logic of control and its critiques.
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Notes
In this debate, obesity, being overweight and weight gain are often used interchangeably as part of the same problem (e.g. [50]).
Anne Mulder made this statement in the context of a discussion on whether dietary advice—in the Netherlands the standard medical intervention for being overweight—should be covered by health insurance. In the Netherlands, health insurance is semi-privatized: although offered by private companies, ‘basic insurance’ is compulsory for all citizens and the contents of this package is decided by the government. In 2012, the government led by the VVD decided to take dietary advice out of this ‘basic’ package but this decision was overturned later. Currently, 3 h of dietary advice per year are covered.
This study was part of a larger multi-sited ethnographic research on knowledge practices and different obesity interventions, ranging from dietary advice, fitness programmes, mindfulness courses and lifestyle coaching in the Netherlands. Field notes and interviews transcripts were translated from the Dutch. The study was undertaken following local ethics committee approval. To ensure anonymity, consent was verbally obtained and the excerpts from transcripts are not identifiable individual interviews or observations. The names I use for my informants in this paper are thus invented.
These people, (called ‘clients’ or ‘patients’, depending on the setting) some of whom I also interviewed, usually came to the professionals on their own, or were referred by a doctor (usually a GP). Although some facilities, offering more extensive treatments such as bariatric surgery, were accessible only to people classified by a doctor as obese, the techniques and interventions of practices described in this paper made no other distinction relevant to the present analysis between overweight and obese people. Consequently, I mainly use the term ‘overweight’.
Rather than the expression of individual beliefs, I take what professionals and patients/clients express to be accounts that ‘link “things”, concepts and practices together’ [42].
A distinction is thus made here between the necessary, ‘good’ bodily drive of hunger, and a deceptive, ‘bad’ drive that is a response of the body to a lack resulting from overly restrictive eating. Cf. [52] on ansiedad.
I do not separate the realm of words and materials here. Making the distinction between saying and doing rather communicates a difference between taking language as signifying a reality and as part of interactional work that goes on in practice, for example, in constructing weight as a moral issue in doctor’s consultations [48] or in the achievement of satiety in a family meal [21].
See for a discussion on empowerment as a technique/process and/or a goal, [46].
For an analysis of how (theorizing on) subjectivity changes when attending to eating practices, see [28].
Paying attention to such clinical specificities reveals, among other things, that part of the concerns and models of healthy eating that fat studies scholars, in particular those involved in the Health At Every Size Movement [2, 3], advocate for may be said to be incorporated into this intervening practice, even though they are not prominent in public discourse in the Netherlands. For instance, the call of fat activists to focus on ‘healthy day-to-day practices, regardless of whether someone’s weight changes’ [3].
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Acknowledgments
I am very grateful to my informants for many lessons learnt. I would like to thank Annemarie Mol for her encouraging intellectual support throughout the writing of this paper. Thanks too to the rest of the "Eating Bodies" team for their feedback and inspiration: Emily Yates-Doerr, Cristobal Bonelli, Rebeca Ibáñe Martín, Filippo Bertoni, Tjitske Holtrop, Michalis Kontopodis, Sebastian Abrahamsson and Anna Mann. I also thank Stine Grinna and Bodil Just Christensen for reading and discussing earlier versions. Finally, I would like to thank the two anonymous reviewers who provided me with helpful comments on an earlier version of this paper and the ERC for the Advanced Grant (AdG09 Nr. 249397) that supported this research.
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Vogel, E. Clinical Specificities in Obesity Care: The Transformations and Dissolution of ‘Will’ and ‘Drives’. Health Care Anal 24, 321–337 (2016). https://doi.org/10.1007/s10728-014-0278-3
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DOI: https://doi.org/10.1007/s10728-014-0278-3