Epilogue

"History is not merely a project of fact-retrieval...but also a set of complex processes of selection, interpretation, and even creative intervention – processes set in motion by, among other things, one’s personal encounter with the archive...and the pressure of the contemporary moment on one’s reading of what is to be found there."

When people ask me about the past and the present with respect to obesity, the word that always comes to me is "quagmire": a quagmire for those who are fat; for practitioners who want to help patients who come to them asking how to lose weight; for scholars in the humanities and social sciences who often see in the literature on obesity the blaming of individuals for their weight without putting them in a social context; for scientists who often see their nuanced research and conclusions distorted in media headlines; and for those in the media who have to wend their way through literature that is often contradictory. Questions about obesity seem to lead to more questions. The problems of measurements, statistics, and concepts that were recognized as problematic in the past are still with us. Almost any view of obesity – its risks, its causes, and its treatments – can be challenged and is being challenged. Even the concept of normality is unclear. Disputes reflect a lack of consensus on how obesity was and is seen. Is it a disease, an illness, a condition, or is it only a fat body? Is it something that a person can’t control, or is it the result of a person’s behaviour, or is it just how the person is? Does it even depend on the individual, or is it caused by the modern obesogenic environment? Indeed, underlying much of the obesity literature is a sense of unease with the society in which we live, a belief in an earlier time when Canadians were fit and slender, a time that gets rosier the farther removed we are from it.

The conviction that eating too much was the major cause of obesity seemed obvious in the past and the treatment simple – don’t eat so much. Eating, however, is complicated. How do people see eating, and how important are family dynamics in eating? Blaming mothers was dominant in the nutritional literature on infants, children, and teens, and it still is. Yet, seldom were mothers’ voices heard. Why is that? Some interviewees blamed their mothers for not instilling a nutritional way of eating when they were children; some acknowledged resenting and subverting mothers’ attempts to control what they ate. As explained in chapter one, however, most mothers have long been doing their best to provide proper nutrition for their children, often at risk to their own health. Other interviewees recognized the challenges of mothers (and fathers) and the complexity of their own families and their eating habits. As a society, we don’t like to blame children for being obese, and we should not blame them (or not entirely), but we believe someone else has to be blamed. Heredity can lessen blame, but even that can focus on the mother. A recent study suggested that a mother’s early puberty is linked to an early puberty in her children and obesity in childhood or adulthood, as if the mother could control when she reached puberty. A more recent study in Canada focused on women who were significantly obese and then underwent weight-loss surgery. Their infants born before the surgery had genes connected to obesity-related diseases, but infants born after the surgery had genes that behaved differently, making their risk for obesity less than that of siblings born before the mother’s surgery.

The history of obesity illuminates the past complexity and contentiousness surrounding what to eat, how much, the statistics of weight, and the understanding of each of them. Little has changed. We are still trying to figure out what to eat and what not to eat. As noted in chapter one, most Canadians do not eat the recommended servings of fruits and vegetables each day. Yet, most Canadians think they eat well. Part of that confidence comes from the use of stand-alone vitamins and minerals. But experts have long noted that the best way to get the nutrients we need is through food. Recently, a study (again) found that stand-alone vitamins and minerals have "no measurable health benefits" if you are already healthy. But it isn’t easy to know what food to eat. For example, the International Agency for Research on Cancer (IARC), an agency of the World Health Organization (WHO), classified "consumption of processed meat as ‘carcinogenic to humans’ and consumption of red meat as ‘probably carcinogenic to humans.’" But what does this mean? In the press release, there was a risk estimate attributed to the IARC Working Group, yet the agency didn’t estimate the risk of each of the agents they listed as carcinogenic. Even if the press release had not mentioned a risk estimate, it is not clear that the press or most people would understand the work of IARC. The statement "gives you an idea about the strength of evidence that [a specific agent] causes cancer but it doesn’t give you any clue about how much you need to be exposed [to the agent] to get cancer." Even if you did understand what IARC was claiming, how would you change your eating habits?

Advice given to Canadians changed from generation to generation, whether the advice was about eating, nutrition, dieting, or exercise. Small wonder Canadians never seemed to be able to keep up with the advice being offered. What advice should we follow? A recent book challenges what we have been taught about milk, generally seen as a superior food for calcium. Another book argues that saturated fat is not bad and that a low-fat diet is not as healthy as many made it out to be. At least one reviewer is critical of both arguments, and there are certainly individuals who are not able to lose weight on a low-fat diet. Dr Yoni Freedhoff, medical director of the Bariatric Medical Institute, Ottawa, points out that low-fat diets only seem to make an individual hungry, whereas fat does satiate hunger. But what is new? During the period 1920 to 1980, trends in dieting often went from low-fat to highfat dieting. It seems high-fat eating is in vogue today. But it isn’t the only aspect. At the moment, sugar is deemed to be the cause of the obesity and diabetes epidemic – maybe. The author of The Case Against Sugar also sees sugar "linked" to hypertension, some cancers, and even dementia.

We don’t always understand how decisions are made about how much weight is good or bad for us. For example, in 1995, the WHO Obesity Task Force lowered the body mass index (BMI) at which individuals would be considered obese. The task force was funded by Abbott Laboratories; at the time, Abbott Laboratories manufactured an obesity drug and diet products, certainly a conflict of interest that many would see as problematic if they had known. As in the past, practitioners today generally agree a balance of food is best for health. Their advice to dieters is to limit the size of food portions and to make sure the variety of foods are balanced to provide nutrients for health. Even more, obesity experts are now accepting that a dieter doesn’t need to achieve an "average" weight to be healthy: it is acknowledged that a healthy spectrum of weight is quite broad. However, the goal for too many Canadians is still a limited spectrum of weight driven by the desire to meet a specific body image. That is the area where the fatness advocates and fat studies are significant.

Being healthy has generally meant being fit, and being fit was deemed attractive. In the rhetoric of the cause and treatment of obesity, exercise was included. But the rhetoric on fitness seldom went beyond the idea. Practitioners in the past were not enamoured by exercise, either as a cause of obesity because Canadian didn’t exercise enough, or as a treatment. Yet, there are significant studies demonstrating that people with high BMIs who are fit live longer than people who have "normal" BMIs but who aren’t fit. It doesn’t mean that high BMI people don’t have other risks. But people who have "normal" BMI can have health risks too. A recent study on exercise by the London School of Economics found moderate exercise – brisk walking – is the best; people who were moderate in their exercise rather than vigorous, had lower BMIs and were generally healthier. But British Columbia’s Dr Brett Belchetz looked at the study and concluded that while moderate exercise was best for women, it wasn’t for men under fifty. For them, vigorous exercise was best. Although exercise helps, how fitness is achieved is not something that most health experts are taught. Certainly, it was not something that seemed to be part of medical treatment. Indeed, there is much connected to obesity about which most doctors have little expertise. Past physicians couldn’t keep up to date with new developments. Christopher Labos, cardiologist and epidemiologist at the McGill University Health Centre, describes the same concern today. In his words, "New doctors are often told that five years after medical school half of what they learn will be proven wrong." Dr Gilles Plourde and Denis Prud’homme, in their 2012 article "Managing Obesity in Adults in Primary Care," reflect another concern, one they have in common with their past colleagues: practitioners today generally don’t know how to deal with their obese patients. Looking at several studies, it would seem that 45 per cent of physicians don’t feel able to help their obese patients. According to another study, only 49 per cent of overweight or obese patients are given advice for weight loss – 50 per cent of those are advised to diet, and 41 per cent to increase their exercise.

The complexity and contentiousness of all these factors simply makes it difficult for practitioners and lay people to know how best to deal with obesity or being fat. Studies of and attitudes towards obesity have emphasized the negativity of fatness. Or is it that the stigma placed on fatness has made obesity negative? We expect medicine to be a science and that science will lead us to the best practice. Science through medicine was an actor in the history of obesity, although how it was used and understood was at times problematic. If we still don’t understand science and seldom read it, we learn about it through the media. Statistics are at the core of understanding science in a modern society; yet, too often, we don’t understand statistics either. For example, many of us don’t seem to understand the language of correlation (link, associate, and risk) or cause and effect, and the differences between them. Without some understanding of scientific methodology, it is difficult to evaluate the information science provides. Also, medicine often has to function in areas of scientific uncertainty, where the scientific research may suggest courses of action but does not demonstrate their efficacy. This situation is very much the case with obesity.

Fatness can be a stressful condition for many. The lives of the interviewees after 1980 were still full of pain about how they had been treated in the past and how they are still treated today. Too many find their physicians unable to see them as individuals who are more than their weight. But physicians are not alone. Stephanie described the discrimination she experiences in the workplace as a result of being fat. Having lived in the United States, she found such discrimination stronger in Canada. Laura has a sense of people always judging her and making assumptions about her because of her weight, for instance thinking that she is less intelligent because she is fat. Nina has noticed shifts in how people respond to weight. When she was fat, hardly anyone held a door open for her or greeted her; when she lost weight, both happened. Thus, civilities of life are withheld from those who are fat. As Randy put it, however, "A sandwich doesn’t judge you."