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Hide PaneExpand allCollapse allEmily Yates-Doerr's book begins with the story of sibutramine, an anorectic drug (appetite suppressant), which although withdrawn from sale in the UK, USA, China, and India, found a ready home in the Guatemalan market. Why does a country with the world's fourth-highest rate of chronic malnutrition need diet pills? The answer is because half the women of reproductive age are overweight or obese—and they've been told so through waves of nutritional advice and advertising, creating demand for anything that can help them to approximate an ideal body shape.
The Weight of Obesity is based on Yates-Doerr's doctoral work in anthropology, for which she travelled to Guatemala's second largest city. Maps call it Quetzaltenango, but it is known to its residents as Xela from the K'iche' phrase Xejaljú no'j, which means “below the ten spiritual guides”. There's serendipity in the name. Yates-Doerr's book is an enquiry into the many guides to nutrition, bodyweight, health, and obesity to which the city's residents have become subject.
The so-called nutrition transition is Yates-Doerr's target—an idea that started to circulate in the early 1990s, coined by Barry Popkin in analogy to the demographic transition. It points to the cluster of changes in human society and food systems that have resulted in higher rates of obesity in the shift to a more Western diet.
Popkin noted that the transition led to both undernutrition and overnutrition. But the central logic of transition is one of history on rails—undernourished people become overnourished as they move through the inevitable adoption of a Western diet. It is, Yates-Doerr points out, awkward for this thesis when archaeological evidence suggests that Guatemalans have not always been malnourished, but became so through colonialism. In other words, the nutrition transition becomes less compelling if societies undergoing it start healthy, and end both undernourished and overnourished.
The great merit of Yates-Doerr's work is the damage she does to the idea of transition, and its concomitant implication of progress. Guatemala's recent past has been shaped by international demands for food. The 1954–96 civil war, in which about 200 000 people were killed or disappeared, was precipitated by the US Central Intelligence Agency after a political row between the democratically elected Guatemalan government and the US-based United Fruit Company. Today, stitched into arrangements such as the Central American Free Trade Agreement, Guatemala grows food for overseas consumers demanding healthy produce. This food is grown with pesticides, the effects of which Guatemalan mothers have seen and don't trust. For their children, they buy potato crisps at the local market instead of fresh fruits and vegetables, because they're more certain that they aren't from the export-reject pile.
Mothers are also implicated in changes in cooking practices. The traditional, nutrient-dense diet of stew, usually batch-cooked by a few women for dozens of people, has become harder to find as rhythms of work and sociality have changed. Today, family units cook for themselves, and the economies of scale and shifting demands on women's time mean that it's cheaper to buy premade food for a family of five than to cook from scratch for 20 people, even if the meals are nutritionally poorer.
Paradoxically, as society has become more individualised, its medicine has become less attentive to individual conditions. Modern nutritional education encourages everyone to find the same qualities of healthiness inherent in food. This perspective contrasts with K'iche' indigenous practices of hot or cold foods, imbalances that in turn relate to a person's circumstances rather than the foods themselves. This more individualised and thoughtful approach is only beginning to be emulated by precision medicine.
For health practitioners, Yates-Doerr's book offers wise counsel. Labelling obesity as a pathological condition is not necessarily helpful, and neither is transforming “the familiar social negotiations that surround eating into abstract and unfamiliar terms”. Diabetes, heart disease, and metabolic syndrome have social bases, and asking patients with diabetes to lose weight in an obesogenic environment can amount to little more than blaming the victim. This situation, however, doesn't leave practitioners without tools; the advice to eat better rather than to lose weight—an insight with support from behavioural economics—is worth taking seriously. But such tools are effective only when practitioners understand the social context, and the links between the medicalisation of obesity and the forces that produce it.
Ultimately, Yates-Doerr suggests, we might want to consider the opposite of obese not as thin, but as fat. Obese is the pathological and individual reading of a body, whereas fat is a social and historical one. It's an idea that deserves more elaboration than this short, accessible book can contain, but other authors have usefully undertaken the task. For those health-care providers ready to be discomfited by the role of their discipline, The Weight of Obesity is an excellent indictment of nutritionism.
For more on overweight and obesity in Guatemala see Martorell R. Intervention and Policy Options for Combating Malnutrition in Guatemala. New York: Inter-American Development Bank, 2012
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