Skip to main content
Log in

Clinical Specificities in Obesity Care: The Transformations and Dissolution of ‘Will’ and ‘Drives’

  • Original Article
  • Published:
Health Care Analysis Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. In this debate, obesity, being overweight and weight gain are often used interchangeably as part of the same problem (e.g. [50]).

  2. The controversial concept of ‘lifestyle’ in relation to obesity can be considered as a linguistic move that, in itself, posits weight as the result of individual behavior [16] and can pave the way for laissez-faire, neoliberal public health policy [4].

  3. 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.

  4. 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.

  5. 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’.

  6. 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].

  7. 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.

  8. 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].

  9. See for a discussion on empowerment as a technique/process and/or a goal, [46].

  10. For an analysis of how (theorizing on) subjectivity changes when attending to eating practices, see [28].

  11. 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].

References

  1. Akrich, M., & Pasveer, B. (2000). Multiplying obstetrics, techniques of surveillance and forms of coordination. Theoretical Medicine and Bioethics, 21(1), 63–83.

    Article  CAS  PubMed  Google Scholar 

  2. Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 9. doi:10.1186/1475-2891-10-9.

  3. Burgard, D. (2009). What is “Health At Every Size”? In E. Rothblum & S. Solovay (Eds.), The fat studies reader (pp. 41–53). New York: New York University Press.

    Google Scholar 

  4. Cannon, G. (2005). Out of the box. Public Health Nutrition, 8(4), 344–347.

    Article  PubMed  Google Scholar 

  5. Chang, V. W., & Christakis, N. A. (2002). Medical modelling of obesity: A transition from action to experience in a 20th century American medical textbook. Sociology of Health & Illness, 24(2), 151–177.

    Article  Google Scholar 

  6. Dougherty, C. J. (1993). Bad faith and victimblaming: The limits of health promotion. Health Care Analysis, 1(2), 111–119.

    Article  CAS  PubMed  Google Scholar 

  7. Evans, B. (2006). ‘Gluttony or sloth’: Critical geographies of bodies and morality in (anti)obesity policy. Area, 38, 259–267.

    Article  Google Scholar 

  8. Evans, J., & Colls, R. (2009). Measuring fatness, governing bodies: The spatialities of the body mass index (BMI) in anti-obesity politics. Antipode, 41(5), 1051–1083.

    Article  Google Scholar 

  9. Evans, J., Davies, B., & Wright, J. (2004). Body knowledge and control: studies in the sociology of physical education and health. London: Routledge.

    Google Scholar 

  10. Feiring, E. (2008). Lifestyle, responsibility and justice. Law, Ethics and Medicine, 34(1), 33–36.

    Article  CAS  Google Scholar 

  11. Gard, M., & Wright, J. (2005). The obesity epidemic: Science, morality and ideology. London: Routledge.

    Google Scholar 

  12. Gingras, J., & Aphramor, L. (2010). Empowerment, compliance and the ethical subject in dietetic work. In R. Harris, N. Wathen, & S. Wyatt (Eds.), Configuring health consumers: Health work and the imperative of personal responsibility (pp. 82–93). Hampshire: Palgrave Macmillam.

    Chapter  Google Scholar 

  13. Government Office of Science. (2007). Foresight: Tackling obesities, future choices. London: Department of Innovations, Universities and Skills.

    Google Scholar 

  14. Guthman, J. (2013). Too much food and too little sidewalk? Problematizing the obesogenic environment thesis. Environment and Planning, 45(1), 142–158.

    Article  Google Scholar 

  15. Henwood, F., Harris, R., & Spoel, P. (2011). Informing health? Negotiating the logics of choice and care in everyday practices of ‘healthy living’. Social Science and Medicine, 72, 2026–2032.

    Article  PubMed  Google Scholar 

  16. Howell, J., & Ingham, A. (2001). From social problem to personal issue: The language of lifestyle. Cultural Studies, 15(2), 326–351.

    Article  Google Scholar 

  17. Hoyweghen, I. Van., Horstman, K., & Schepers, R. (2007). Genetic “Risk carriers” and lifestyle “risk takers”. Which risks deserve our legal protection in insurance? Health Care Analysis, 15(3), 179–193.

    Article  PubMed  Google Scholar 

  18. Inthorn, S., & Boyce, T. (2010). It’s disgusting how much salt you eat! Television discourses of obesity, health and morality. International Journal of Cultural Studies, 13(1), 83–100.

    Article  Google Scholar 

  19. Knutsen, I. R., & Foss, C. (2010). Caught between conduct and free choice—A field study of an empowering programme in lifestyle change for obese patients. Scandinavian Journal of Caring Sciences, 25, 126–133.

    Article  Google Scholar 

  20. Latour, B. (1993). We have never been modern. Harvard: Harvard University Press.

    Google Scholar 

  21. Laurier, E., & Wiggins, S. (2011). Finishing the family meal. The interactional organisation of satiety. Appetite, 56, 53–64.

    Article  PubMed  Google Scholar 

  22. Law, J. (1993). Organizing modernity: Social ordering and social theory. Oxford: Blackwell.

    Google Scholar 

  23. Law, J. (2009). Actor network theory and material semiotics. In B. S. Turner (Ed.), The new Blackwell companion to social theory (pp. 141–158). New York: Blackwell.

    Chapter  Google Scholar 

  24. LeBesco, K. (2011). Neoliberalism, public health, and the moral perils of fatness. Critical Public Health, 21(2), 153–164.

    Article  Google Scholar 

  25. Lettinga, A., & Mol, A. (1999). Clinical specificity and the non-generalities of science. On innovation strategies for neurological physical therapy. Theoretical Medicine and Bioethics, 20(6), 517–535.

    Article  CAS  PubMed  Google Scholar 

  26. Mol, A. (2006). Proving or improving: On health care research as a form of self-reflection. Qualitative Health Research, 16(3), 405–414.

    Article  PubMed  Google Scholar 

  27. Mol, A. (2008). The logic of care: Health and the problem of patient choice. New York: Routledge.

    Google Scholar 

  28. Mol, A. (2008). I eat an apple. On theorizing subjectivities. Subjectivity, 22, 28–37.

    Article  Google Scholar 

  29. Mol, A. (2012). Mind your plate! The ontonorms of Dutch dieting. Social Studies of Science, 3, 379–396. doi:10.1177/0306312712456948.

    Google Scholar 

  30. Mol, A., & Law, J. (2004). Embodied action, enacted bodies. The Example of Hypoglycaemia, Body & Society, 10(2–3), 43–62.

    Article  Google Scholar 

  31. Mol, A., Moser, I., & Pols, J. (2010). Care in practice: On tinkering in clinics, homes and farms. Bielefeld: Transcript Verlag.

    Book  Google Scholar 

  32. Monaghan, L. F. (2007). McDonaldizing men’s bodies? Slimming, associated (Ir)rationalities and resistances. Body & Society, 13(12), 67–93.

    Article  Google Scholar 

  33. Moreira, T. (2006). Heterogeneity and coordination of blood pressure in neurosurgery. Social Studies of Science, 36, 69–97.

    Article  Google Scholar 

  34. Moser, I. (2005). On becoming disabled and articulating alternatives. Cultural Studies, 19(6), 667–700.

    Article  Google Scholar 

  35. Moser, I. (2012). Perhaps tears should not be counted but wiped away: On quality and improvement in dementia care. In A. Mol & J. Pols (Eds.), Care in practice: On tinkering in clinics, homes and farms (pp. 277–300). Bielefeld: Transcript Verlag.

    Google Scholar 

  36. Mulder, A. (2011) Opinie artikel NRC: Preventie van leefstijlziekten leidt tot hogere zorgkosten. http://www.annemulder.nl/?p=1167 (last accessed 10/11/2013), originally published in NRC Handelsblad on 29/04/2011.

  37. Muroff, J. A. (2011). Policing willpower: Obesity as a test case for state empowerment of integrated health care. Houston Journal of Health, Law & Policy, 11, 47–78.

    Google Scholar 

  38. Pearce, S., & Pickard, H. (2010). Finding the will to recover: Philosophical perspectives on agency and the sick role. Journal of Medical Ethics,. doi:10.1136/jme.2010.035865.

    PubMed  Google Scholar 

  39. Persson, K. (2013). The right perspective on responsibility for ill health. Medical Health Care and Philosophy, 16, 429–441.

    Article  Google Scholar 

  40. Pols, J. (2005). Enacting appreciations: Beyond the Patient Perspective. Health Care Analysis, 13(3), 203–221.

    Article  PubMed  Google Scholar 

  41. Pols, J. (2013). The patient 2. Many: About diseases that remain and the different forms of knowledge to live with them. Science & Technology Studies, 26(2), 80–97.

    Google Scholar 

  42. Prior, L., Pang, L. C., & Haut, S. B. (2000). Beliefs and accounts of illness. Views from two cantonese-speaking communities in England. Sociology of Health & Illness, 22, 815–839.

    Article  Google Scholar 

  43. Sharkey, K., & Gillam, L. (2010). Should patients with self-inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate. Journal of Medical Ethics, 36(11), 661–665.

    Article  PubMed  Google Scholar 

  44. Struhkamp, R. (2004). Goals in their setting: A normative analysis of goals setting in physical rehabilitation. Health Care Analysis, 12(2), 131–155.

    Article  PubMed  Google Scholar 

  45. Struhkamp, R. (2005). Wordless pain: Dealing with suffering in physical rehabilitation. Cultural Studies, 19(6), 701–718.

    Article  Google Scholar 

  46. Tengland, P. (2008). Empowerment: A conceptual discussion. Health Care Analysis, 16, 77–96.

    Article  PubMed  Google Scholar 

  47. Vogel, E., & Mol, A. (2014). Enjoy your food: On losing weight and taking pleasure. Sociology of Health & Illness, 36(2), 305–317.

    Article  Google Scholar 

  48. Webb, H. (2009). ‘I’ve put weight on cos I’ve bin inactive, cos I’ve ‘ad me knee done’: Moral work in the obesity clinic. Sociology of Health & Illness, 31(6), 854–871.

    Article  Google Scholar 

  49. Womack, C. A. (2012). Public health and obesity: When a pound of prevention really is worth an ounce of cure. Public Health Ethics, 5(3), 222–228.

    Article  Google Scholar 

  50. World Health Organisation (WHO) (2013) Obesity and overweight, Fact sheet N°311. http://www.who.int/mediacentre/factsheets/fs311/en/.

  51. Wright, J., & Harwood, V. (2009). Biopolitics and the ‘obesity epidemic’: Governing bodies. London: Routledge.

    Google Scholar 

  52. Yates-Doerr, E. (2012). The weight of the self: Care and compassion in Guatemalan dietary choices. Medical Anthropology Quarterly, 26(1), 136–158.

    Article  PubMed  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Else Vogel.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10728-014-0278-3

Keywords

Navigation