The focus on overweight and obesity is a major preoccupation for health promotion organisations and individuals alike. On the one hand, weight-loss education initiatives and programmes abound, and on the other hand rates of obesity and correlated disorders skyrocket. And paradoxically, the fatter we get, the thinner we would like to be. While the population gets fatter and fatter, media portrayals, particularly of women, get more and more slender, resulting in a significant unsettling and angst amongst those who fail to achieve the articulated ideal.
Many, and indeed this author, lament the focus on weight as a misplaced preoccupation. The equation of slenderness equating to health has been questioned by many studies. While mortality may be higher in slender individuals who do not exercise than in the obese who do,1 this fact and many others like it, are lost on most health promotion organisations, which focus on obesity, rather than on those factors which contribute simultaneously to obesity and to ill-health. This may simply be an easy way out. As Glenn Gaesser writes, “A high body mass index for example, rather than being a genuine contributing factor to premature death, could be a symptom of a sedentary lifestyle and low fitness level, both of which could be the true risk factors for early mortality.”2 This illustrates an important statistical challenge which few researchers have taken on board: many independent factors co-vary with body mass index, and teasing out those factors – lifestyle, exercise and diet – is no small task. Overweight is often a symptom rather than a cause, despite remaining the hub of health promoters’ focus. This results in the ostracising of healthy heavy individuals and in unhealthy practices by even very thin people all in the name of health.
History provides an explanation for this fascination with weight. Despite the fact that the thin body has not always been the coveted norm, strong cultural beliefs about the significance of appearance nonetheless provide a foundation for the contemporary preoccupation with calorie-counting, body sculpting, exercise and diets. These practices are based on three important premises. Firstly, in the range of senses, vision ranks highest. What we see is somehow more reliable than what we hear, taste or feel. Secondly, from this follows the notion that appearance mirrors the ‘true’ inner self, and reflects a supreme order. And finally, attention to health and diet is a virtuous activity which may be witnessed in physical appearance. This article briefly reviews how these beliefs have over many centuries merged into an aesthetic of health, setting the standards which lead our contemporary society to an over-reliance on weight as an indicator of health.
We attribute a great deal of truth to vision. While the classical adage states that you cannot judge a book by its cover, we nonetheless invariably make judgements about how people ‘are’ from the way they look. These judgements can range from assessments of character to evaluation of health and fitness, and even suitability for employment. This type of assessment is pivotal to the focus on obesity and resulting practices, and issues from fundamental beliefs about the truths that image alone can reveal.
Mingling image with fundamental truths, the Greek New Testament uses the word “beautiful” to describe Christian life, and invariably translates it as “good.” Good works in Matthew 5:16 are literally “beautiful” works.3 In the Books of Wisdom,the virgin purity of Mary was said to be reflected in the “spotless mirror,” or speculum sine macula,4 the image capturing her inner nature. Her virtue “shows” and her flawlessness witnesses goodness.
Metaphorically as well, the English language uses references to vision and sight to emphasise credibility, goodness and virtue. Everyday speech includes such phrases as “I’ll believe it when I see it,” “a picture is worth a thousand words,” or “do shed some light on the matter.” As Anthony Synnott points out, ‘eye witness’ accounts are always held in higher esteem than ‘hearsay’ evidence.5 As these metaphors illustrate, sight denotes knowledge, truth, reason and wisdom. Light and vision also imply insight: being ‘bright’ is good, while having a ‘shady side’ is a liability. “God is Light,” preached John in the Gospel.
Furthermore, in both religious and popular culture, pretty things are symbolic of moral goodness. Heroes and heroines in literature and fairy tales are either beautiful looking, or will become so (Cinderella, Rapunzel, the Frog Prince) when evil spells are removed, while villains have physical flaws (ugly stepsisters, warty witches).
Educational as well as religious treatises focus on beauty as a mirror of virtue. In the sixteenth century, Italian courtier Baldassar Castiglione explained that:
very seldom an ill soule [doth] dwell in a beautifull bodie. And therefore is the outwarde beautie a true signe of the inwarde goodnesse, and in bodies this comeliness is imprinted more and lesse (as it were) for a marke of the soule, whereby she is outwardly knowne.6
Renaissance portraiture also incorporated these relationships and conveyed a complex system of social and moral signifiers through the visual representation of individuals, notably along gendered lines. Portraits of women were often used to arrange marriages, and as such, were required to convey as much information as possible about the individual portrayed. Female beauty signified morality and virtue as well as membership of a particular social class. Closely linked in Renaissance thought and art, beauty and virtue were further highlighted by mottoes and emblems on the reverse of female portraits, punctuating the meaning portrayed by the primary image. The back of Leonardo da Vinci’s portrait, Ginevra de’Benci, is inscribed: “Beauty Adorns Virtue.”7
Nineteenth-century educationalist Charles Sainte-Foi echoed these views when writing:
True beauty comes from within. When woman, through sincere piety, fervent prayer, and sweet contemplation knows how to maintain herself at that height where souls are transfigured . . . her body . . . discovers the precious treasure of grace and virtue which it encloses. Each feature of the face is like the unfolding of some holy thought.8
But this attention to appearance is distinctly gendered; the expectation to achieve an ideal of beauty is a feminine burden, and of course, we can observe the unequal preoccupation of woman with weight control today.
A range of prescriptions, instructions and recommendations are directed at young women. One mother writes to her daughter: “You are not to neglect the accomplishments and ornaments proper to make you agreeable, for women are designed to please.”9 Writing in Demorest’s Monthly Magazinefor women, Annie Starr proffers the following helpful advice in a message to “homely girls” in 1880:
Knowing your plainness, you sometimes forgot to make your outside selves as attractive as you might . . . in fact, you rather viewed with contempt mere physical beauty. You are wrong; so I mean to tell you that I think any harmless method that you can adopt to make your visible selves attract is perfectly proper—nay, even your duty.10
Echoing these prescriptions, another advice-writer explains that “almost any woman, however plain in personal appearance she may be, can render herself pleasing to others, at all times and all seasons, if she will extend herself to do so,”11 implying that it is just a matter of making an effort, and indeed, a woman’s job.
By the middle of the nineteenth century, women’s magazines and books endorsed the “Business of Being Beautiful,” as one writer called it. This placed appearance plainly in the context of a commercial model. At a time where worth in society was measured by economic production, a woman’s capital was indeed her beauty, and her job was its maintenance. In an 1852 issue of Godey’s Lady’s Book, the same writer pens, almost apologetically:
We know [beauty] is rather a new doctrine; that the world, as a general thing, will cry it down under the name of vanity; but we separate the consciousness of giving pleasure by grace or delicacy from the vulgar pride in physical advantages, to which, and their display, the name more properly belongs. It is not a selfish motive, that of giving pleasure to others, and every one knows that “a thing of beauty is a joy forever.”12
She further explains that “beauty of some kind is so much the attribute of the sex, that a woman can hardly be said to feel herself a woman who has not, at one time of her life, at all events, felt herself to be fair.”13 Woman becomes defined by her ability to scrutinise, identify and modify her appearance and adhere to the rules of womanhood.
This notion that appearance reveals truths about virtue and about adherence to a “duty to beauty” is pivotal to the assumption that physical appearance can enlighten us about health or lifestyle and is important in the contemporary over-reliance on how body shape can reveal information about health practices.
The corollary to the argument that beauty witnesses virtue is that vice disfigures. A fifth-century writer, inspired by the works of Loxus, Aristotle and Polémon, drew a link between unattractive physical features and undesirable personality traits: “A chest laced with flesh indicates ignorance and apathy” and “…people whose breasts droop, and whose chest is covered with soft flesh are assigned to drunkenness and sexual excess”; while “…rounded, and swollen flanks indicate vain gossip – such are just like frogs” and “…when the ankles, the end of the feet and the heels are fat and fleshy, they indicate an idiot or a fool…and 14
This argument is based on the notion that correspondence between beauty and good, ugliness and vice, reflects God’s order. Scientific rules join religious tenets to provide another cornerstone for beliefs about the symbolism of appearance. A range of scientific arguments uphold the beauty/goodness link, providing further authority in the confirmation of the relationship between appearance and virtue or vice. A mother writing to her children about natural science explained that rules of congruence could signify the presence of God: “We have reviewed all the classes of beings from insects to man, and we have recognized the hand of God everywhere. We have seen everywhere order and harmony which force our admiration. It would be impossible for us in the face of all these marvels of nature, not to praise he who created all.”15
More explicitly, anthropometrists tried to capture God’s rules by categorising groups of people on the basis of body measurement. Adolphe Quetelet, a Belgian anthropometrist described his work as dedicated to “a supreme being who coordinates all laws, established with such order in all that we see.”16 Quetelet’s opus strove to uncover those laws by describing men and women in terms of their measurements and proportions: height of the chin, diameter of the neck, circumference of the chest, distance between the nipples. Anthropometry constituted the core of many treatises of human behaviour. In 1895, Caesar Lombroso and William Ferrero published The Female Offender. They devoted this work to comparing the body types of prostitutes, female lunatics and ‘normal’ females. Though ostensibly concerned about the misuse of anthropometry, they believed in the utility of such approaches to understanding human nature. “We must not . . . be understood to advocate the total abandonment of measurements,” they protested:
On the contrary, we would retain them as the frame, so to speak, of the picture; or, rather, as the symbol, the flag of a school in whose armoury numbers furnish the most effective weapon; and we would recommend such retention the more, that whenever a difference does result on measurement, the importance of the anomaly is doubled.17
Others sought to identify both the presence and the nature of such rules and relationships. Physiognomy, for example, was devoted to confirming the link between external physical traits and personality. Johann Lavater, a well-known eighteenth-century Swiss theologian and physiognomist, defined physiognomy as the science of “the relationship of the outside with the inside; of the visible with the invisible which it embraces, of animated and perceptible matter with non-perceptible principles which emboss the character of life; of their effects with the hidden forces that produce them.”18
In 1817, Dr John Cross attempted to establish the scientific base for physiognomy. Appearance, he said, was more effective in revealing a person’s character than words or actions.
It lies with physiognomy to detect the impostor; for however well he may manage to jabber about morality, honour, or even religion, yet he cannot hinder the muscles…from obeying the central impulse; nor can he prevent an organ, whose function is perverted, from falling, according to the self-accommodating power implanted in the human frame, into colour, size and shape, most suitable to the performance of this perverted function.19
Phrenologists also attempted to couple character with the appearance of the body. They looked specifically at the shape of the skull to determine character and mental capacity. In North America, brothers and phrenologists, Orson and Lorenzo Fowler ‘read’ skulls and published a slew of books and magazines about phrenology for popular consumption, as well as embarking on lucrative lecture tours. Initially studying for the clergy, they found phrenology more marketable. They wrote, in 1857:
In accordance with [the] general law that shape is as character, well-proportioned persons have harmony of features, and well-balanced minds; whereas those, some of whose features stick right out, and others fall far in, have uneven, ill-balanced characters, so that homely, disjointed exteriors indicate corresponding interiors, while evenly-balanced and exquisitely formed men and women have well-balanced and susceptible mentalities.”20
Those ill-balanced and perverted individuals that anthropometry, physiognomy and phrenology sought to expose revealed a moral failing through the shapes of their bodies. Making eating a moral failing is the important link that underpins the contemporary conviction that we can simply tell by looking (or weighing!) if someone is healthy.
Towards the end of the nineteenth century, a change in the tone of the discussion in both moral and beauty texts about what the body represents takes place. There is a shift towards an emphasis on hygienic physical health and dietary compliance as virtuous imperatives. This implants a new approach to self-care that persists in contemporary society. Now, virtue is witnessed in an aesthetic of health.
Sylvester Graham, a conservative Christian preacher, as well as many other ‘moral hygienists’ who followed him, developed a fascination with what he perceived to be a relationship between dietary hygiene and sexual practices that established a close link between health and morality. Graham focused particularly on the relationship between the stimulating effects of digestion and masturbation. In his work Chastity, he related the story of an upstanding and distinguished family, whose children became remorseless masturbators. Graham credited this behaviour to their dietary regimen. Their mother was an “active agent in the destruction of her children,” he wrote. She served them “highly seasoned flesh-meat, rich pastry, and every other kind of rich and savoury food, and condiments in abundance, together with strong coffee and tea, and perhaps occasionally a glass of wine.”21 He advocated exercise –both to prevent “solitary vice” and to remedy its ill-effects. “Let the patient, like a rational and intelligent human being, promote the tone and action of his organs, and the general vigor of his system, by active exercise,” he preached. “Let him go to the gymnasium and with moderate beginning, and gradual increase of effort, let him swing upon and climb the poles, and ropes, and ladders . . . and walk and run and jump.”22 To this day, “Graham flour” and “Graham crackers,” bear the name of the man who focused popular attention on individual duty in the pursuit of personal health. Graham’s draconian beliefs about the consequences of rich foods implied a moral obligation to dietary discipline and recommended that visual surveillance could reveal deviance.
Graham was not alone, however. Dr Vaucaire, a twentieth-century French hygienist and beauty specialist, does not deny these links, and confirms the aesthetic link between hygiene and morality. “Hygiene,” he writes, “is the morality of the body. To neglect to take the habits of hygiene . . . is a question of . . . honour, of honesty in the etymological sense of the word. For, the ancients who so aptly gave the example of a concern with natural elegance . . . the word honesty had a complex significance establishing a certain contiguity between the good and the beautiful.”23
Others described the links between hygiene (notably dietary) and deviant sexuality. John Kellogg’s fascinating description of diet and sexual deviance in The Home Handbook of Domestic Hygiene and Rational Medicine (1896) warrants reproducing in some length:
Overeating, eating between meals, hasty eating, eating indigestible articles of food, late suppers, react upon the sexual organs with the utmost of certainty. Any disturbance of the digestive function deteriorates the quality of the blood. Poor blood, filled with crude, poorly digested food, is irritating to the nervous system, and especially to those extremely delicate nerves which govern the reproductive function. Irritation provokes congestion; congestion excites sexual desires; excited passions increase the local disturbance; and thus each reacts upon the other, ever increasing the injury and the liability to future damage.24
Kellogg offers a clear link between morality, health, and nourishment. He, as well as others, intimated how dietary indulgence (associated, of course, with sexual deviance) ‘shows,’ and is an indicator simultaneously of flagging morality and of ill-moderated diet. He does not rely on body fat alone: “Pimples upon the face,” he wrote, “especially when appearing upon the forehead as well as upon other parts of the face, are strong evidences of irritation of the sexual organs, produced by self-abuse.”25
The messages of morality are explicit and implicit in much of the beauty discourse of the early twentieth century. In the American publication, Beauty, Edna Goit Brintnall wrote “Committing Obesity – Which is the Eighth Deadly Sin”26 where she equates being over-weight with serious (deadly!) moral failings. And similarly, an advertisement in Beautiful Womanhoodreiterated the notion of moral failing associated with appearance by explaining: “If you are a woman and are not beautiful, it is your own fault”27, with instructions for the products which every responsible woman should use.
This strong belief in a relationship between morality and health, and health and appearance results in the creation of an image of health, or an aesthetic which embodies being well. It is this aesthetic of health which provides fuel to the contemporary reliance on body size, shape and appearance as predictive of well-being.
Today, health maintenance, rather than religious virtue, remains a moral obligation, and thus when we scrutinise the body, we now seek visual evidence of health. Paradoxically, the ‘healthy’ look to which many aspire – a lean, tanned, muscular, and for women, pre-pubescent appearances – is often oppressive, unrealistic and fundamentally unhealthy.
Carole Spitzack describes health today as a standard for attractiveness which heightens concerns about outward appearance in an imprisoning manner particularly for women, and increasingly for men. “An aesthetics of health” she specifies “not only requires slenderness . . . but appropriate skin coloring, muscle conditioning, facial structure, and an absence of facial lines or ‘defective’ features.”28 Expressions such as “looking healthy,” “a picture of health,” “a healthy glow,” and conversely “she doesn’t look well,” suggest that health is a visual condition. But, as we have already seen, this aesthetic of health is not new, rather about the body.
The medical community does not practice outside of general cultural beliefs. In a society which places a high value on appearance as predictor of inner well-being, so too do medical researchers. The statistic cited by the American Dietetic Association and the American National Task Force on the Prevention and Treatment of Obesity to justify pharmacotherapy for obesity treatment is that obesity accounts for approximately 300,000 deaths annually in the United States. However, the study which is attributed to supporting this position did not estdemonstrates that these deaths resudemonstrates that these deaths result from “diet/activity patterns.”29 The researchers do not examine whether or not these diet and activity patterns subsequently lead to obesity, nor whether obesity independent of diet and activity patterns is predictive of death, yet this is the message that the national agencies borrow. Paradoxically, a number of studies have reported that thinness presents a higher risk of mortality than obesity.30 Furthermore, the widely recommended strategy of weight loss in the "over-weight" is also predictive of higher mortality. Gaesser explains that the bulk of epidemiological evidence fails to support the "lose weight – live longer paradigm."31
The fact that despite this research, we still evaluate health by weighing the body confirms how we see the appearance of the body as revelatory of its inner workings. An increase in body weight, we believe, indicates dietary indulgences or poor fitness practices. This may be due in part, to what neurosurgeon and bioethicist, Grant Gillett, refers to as “…our present medicalised and statisticised environment in which all aberrations of the body are tracked, investigated, and recorded.”32 We can weigh people and come up with a certain number, or measurement, though we cannot quantify their lifestyles, or their health.33
Unfortunately, the fear of being weighed may lead patients to postponing or canceling medical appointments. Women who perceive themselves as overweight, or who have a BMI greater than 27 often delay or cancel medical care. They fear being weighed or being scolded for their weight.34
And of course, we need not tarry on a discussion of media focus on weight. Innumerable articles suggest that ‘looking good’ equates to ‘feeling good’ (i.e: beauty = health), and that working hard will result in a muscularly defined, trim and slender body. Anyone can do it (“just do it!”) particularly with the (paid) support of the gym and weight loss industry.
But, while determining health on the basis of normative aesthetics may be common, it is deeply flawed. Art historian Barbara Stafford joined with ethicists John Puma and David Schiedermayer to review the hidden role of visual and perceptual preferences in medical judgments about the abnormal.35 There is a standard of homogeneity, they write, which governs how medical professionals respond to patients, how the law protects patient rights and what defines our medical priorities. Normality, the dreaded bugaboo to which we aspire in cultural practices is, not surprisingly, just as deeply ingrained in medicine: “The unstated perceptual norm that governs our reactions to patients is predicated on a symmetrical and minimalist conception of beauty. Less is more. Even wins over odd. Homogeneity is better than complexity.” Thin, it would seem, is better than fat.
And such beliefs spill over into health policy. The National Institutes of Health’s Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: The Evidence Report, 36 recommends the medical treatment of large bodies as pathological. It proposes an algorithm for the management of overweight and obesity with two components: patient examination, and treatment options, with if/then pathways to indicate various strategies and clinical options. The design of the algorithm reinforces standards of practice that view the body as an object to be observed and measured, a body somehow independent of the person it comprises. “Examination” is an unfortunate choice of word in the sense that it contains the linguistic notion of scrutiny or inspection. Not only does this posit visual input on a hierarchically higher plane, it also assumes an inert patient scrutinised by an authoritative specialist, and denies the lived experience of the subject. Information about physical activity and/or nutrition is not even included in the schematic representation, as if indeed secondary to the quantitative measurement. The patient does little more than contribute to a more complete picture obtained through the measurement of body dimensions.
The large body is measured and judged in advance of any assessment. The enlightened medical vision ‘knows’ what the patient cannot, and consequently, neglects the important question: just how healthy are you? With our current understanding of body function, health and illness, we can be self-reflexive and we can know more than what meets the eye. We can look beyond conventional ‘wisdom’ which is, in fact, deeply rooted in moral and theological beliefs about the meanings of the body. We can shift the categorical boundaries to recognise not only a wider interpretation of beauty, but mainly, a more inclusive definition of health.
*A shorter version of this paper was published in the Healthy Weight Journal
Annemarie Jutel is a senior lecturer in sports studies at Otago Polytechnic in Dunedin, New Zealand. Her work focuses on the cultural values associated with body size and presentation as well as the barriers to women’s participation in physical activity. Her current and forthcoming articles appear in The Journal of Sport and Social Issues, The International Journal of Sport History, Healthy Weight Journal and Perspectives in Biology and Medicine.