Part Two: Moralization of Health and Lifestyle
Dr. Gabrielle Fundaro, CISSN, CHC
A Desire, A Right, and An Obligation: Definitions and Origins of Healthism
Healthism is a relatively new term, first described by American activist and sociologist Irving Zola in the late 1970’s . Zola first conceptualized the phenomenon of medicalization, which refers to both the expansion of the power of medical professionals generalizing their expertise (such as medical doctors authoring diet books) as well as the extension of the roles of health and illness in social phenomena (such as defining deviant behavior in terms of illness). He posited that it led to reductionist medical perspectives focused on immediate, localized interventions to eliminate symptoms for diseases with etiologies that were multifactorial. It also led to cultural shifts that stigmatized the less healthy and shifted the responsibility of health management from sociopolitical institutions to the level of the individual. Healthism emerged as a related but autonomous societal phenomenon that stratified individuals based on health differences and implied personal responsibility to pursue health norms. Unlike medicalization, which embodied an expansion of the jurisdiction of the medical institution, healthism manifested as a reduction of this jurisdiction, superseded by non-experts co-opting medical perspectives. Individuals began to play a much more active role in the healthcare process, seeking information to contest physicians’ stances and sometimes rejecting medical consensus in favor of their own interventions. In an exploratory and heuristic essay published the International Journal of Health Services in 1980, Robert Crawford expanded on Zola’s ideas, focusing on the socioeconomic impact of healthism. He defined healthism as, “…the preoccupation with personal health as a primary—often the primary—focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of lifestyles…”. Later definitions added that healthism, “…causes a non-political conception of health promotion by situating the problem of health and disease, and its solutions, at the level of the individual.” In other words, healthism places the responsibility for health attainment at the level of the individual, creating a form of ‘moralism’ and blame on those don’t attain it. A healthist believes that individuals are responsible for resisting or overcoming sociocultural, environmental, physiological, and psychological barriers in the pursuit of self-improvement and complete well-being. Individual choice is viewed as both the cause of, and solution to, any form of illness; therefore, poor health is viewed as a result of individual failings and character flaws.
One may notice the similarities between these perspectives and Progressive Era narratives pronouncing self-discipline, self-control and determination as means to control physical urges and body weight.  This is no coincidence. Once Americans were made aware of the connection between food intake and body weight in the early 1900’s, beliefs about weight gain and body fat shifted rapidly. Biological explanations for weight gain and body fat were replaced with assumptions that, “…anyone could potentially become thin, as long as they had the will. The problem, many feared, was that overweight people did not possess much willpower at all.” Failings of self-control, willpower, and discipline led to fatness. In the post-World War I era, bodies, “…had to be thin to “fit into our civilization.”” Thinness became an outward representation of one’s patriotism, civility, and ability to self-govern during the war years of food conservation. Those who could achieve weight loss could go on to achieve more in their professional and personal lives, as well. Neoliberalism emerged after the Great Depression as a reimagining of the economic liberalism (recognized as politically conservative today) that many Progressive Era reformers blamed for social inequities and political corruption. Neoliberal individualist beliefs placed responsibility for success or failure solely upon the individual. Success—largely established according to social norms—was accessible to anyone, and failure was due to self-indulgence and a lack of self-discipline. Over the next 30 years, neoliberal and social Darwinist ideologies became explicit cultural values in the US, where achievement, entrepreneurship, and physical fitness are lauded as the results of successful self-control and self-discipline.
Though progressive and neoliberal political ideologies seem incompatible, their collective influences have shaped a sociocultural, political, and commercial landscape that provides many Americans with access to the upper echelons of health attainment—and the expectation that everyone should pursue it. In Weighing In: Obesity, Food Justice, and the Limits of Capitalism (2011) Dr. Julie Guthman describes the current US climate of health dialogue as, “…a neoliberal perspective that subjects care and well-being to economic calculation, exalts those who demonstrate their deservingness through self-care, and justifies neglect for those who don’t.” As life expectancies have increased and causes of death have shifted from communicable disease to those associated with ‘lifestyle choices,’ our society has become increasingly concerned with disease prevention and health promotion. [2,6] In contrast to progressive reformers’ efforts to produce social change at the institutional level, neoliberalism’s influence has shifted the task of disease prevention to the individual who is expected to make the ‘right’ choices.  Even social and leisure-time activities—like sitting, using electronic devices, spending time in isolation--are increasingly evaluated based on their health effects. 
From an economic perspective, health can be perceived as part of human ‘capital’, or economic value.  This capital would be increased by engaging in healthy behaviors, and health ‘stock’ (measured in healthy time) would provide greater earnings and therefore consumption potential. Philosopher Nikolas Rose perceives the pursuit of health as a form of ‘biological citizenship,’ stating that health, “”…has become a desire, a right, and an obligation—a key element in contemporary ethical regimes.””  Beauty, fitness, health, and media industries play influential roles in both shaping and sharing body image ideals, associating specific aesthetics with success and well-being. [3,4] These industries may also cultivate body dissatisfaction and concerns about weight, appearance, or health to promote consumerism. The commercialization of wellness may even provide a platform for industries to create problems for which they can sell solutions (e.g., leaky gut). Consumers—alarmed at their prior lack of awareness—are eager to purchase them. Guthman posits that healthism—far from being a universal construct—appeals primarily to, “…those who are already self-efficacious, believe they both deserve and can obtain health….and otherwise have the resources and inclination to take on the project of health…”.  Thus, capitalism and consumerism both promote and benefit from healthism by establishing specific standards of health and placing a responsibility on individuals to invest in its pursuit. [5,6]
How Healthism Happens: Manifestations in the Lifestyle Industry
Healthy Lifestyles, Self-Care, and Good Gut Health
In the 1980’s the meaning of the term ‘lifestyle’ expanded to what we recognize currently: an individual’s behaviors and choices which lead to patterns of food consumption, physical activity, drug use, and healthcare utilization.  Roughly a decade later, the emphasis of public health campaigns about ‘healthy lifestyles’ and risk factors drove changes in patient-practitioner dynamics and discussions. [1,5] Definitions of health have evolved, as well, and are regarded by some as “…probably utopian and certainly not obtained from the medical profession…,” because they (perhaps unrealistically) encompass physical, social, and psychological well-being. These expansive definitions of health and well-being provide fertile soil for equally expansive definitions of illness and expectations about achieving ‘optimal’ health. Healthists’ wariness of chemicals, biotechnology (such as GMO foods), and ‘unnatural’ substances provide industries with opportunities to sell services or products to assuage these concerns under the guise of promoting ‘healthy lifestyles.’ Enhanced access to both medical information and screening tools such as direct-to-consumer tests have blurred the boundaries between the medical space and popular culture. Today, medical practitioners may simultaneously prescribe medications and sell dietary supplements, and the American College of Lifestyle Medicine is just over 15 years old. Dr. Peter Skrabanek, a forensic and physician who authored The Death of Humane Medicine and the Rise of Coercive Healthism (1994) has criticized ‘lifestylism,’ as a set of, “…dietary obsessions, prescribed exercise regimes, avoidance of risk behaviors, and regular self-surveillance.” These practices, “…impose discipline at the expense of freedom,” inducing vigilance, negating the necessity of pleasure in well-being, and classifying subgroups of the population based on reductionist biomarkers of health.  Similarly, ‘nutritionism’ was coined by Australian food scholar Gyorgy Scrinis in 2008 to describe a reductionist perspective of food as a collection of nutrients, undermining a more comprehensive understanding of the traditional, cultural, and sensual aspects of food. 
Crawford’s publication referred specifically to two major (and remarkably familiar) health movements in the 1970’s as manifestations of healthism: self-care and holistic healing.  He explained that self-care sought to, “…reduce dependency on physicians and other professionals and enhance medical self-competence...”.  Accurately, behavioral characteristics of healthism include information-seeking, exercising patient rights, seeking multiple practitioner opinions, engaging in regular exercise, and generally following dietary guidelines.  Despite the lack of evidence for the efficacy of holistic healing practices such as homeopathy and detoxes, Crawford lauded holistic healing for its role in taking seriously, “…the need of the sufferer to understand his or her suffering in terms of the events and experiences of everyday life.”  Crawford perceived these to be beneficial and necessary in shifting the medical perspectives from singular etiologies to a more contextual concept of health and disease that challenged mind-body dualism. However, he saw a healthist formulation within these movements, situating the problem—and therefore the solution--at the level of the individual’s mind and body.
Despite a lack of practically applicable data linking the gut microbiome to specific health outcomes or lifestyle practices, ‘gut health’ has emerged as the latest target of ‘health optimization’ and the epitome of healthist attitudes and practices. ‘Germism,’ or the fear of, “…small unseen, insidious threats capable of penetrating the body’s boundaries,” is a common characteristic of healthism beliefs which likely gives rise to concerns about certain microbes and the integrity of the gut barrier.  Additional attitudes include a fear of ‘unnatural’ substances, utilization of alternative ‘natural’ products such as detoxes, and a distrust of conventional medicine. Likely all three of these contribute to the booming business of overstated direct-to-consumer stool analyses, unfounded gut ‘detox’ products, and invalid functional medicine assays such as IgG food sensitivity tests. Though no microbial profile has been characterized as ‘healthy’ or ‘unhealthy,’ the idea of ‘good’ and ‘bad’ gut health exists, and the threat of an ‘unhealthy’ gut is cause enough for concern and the pursuit of improvement. Few industries provide such ample ammunition to create problems for which solutions can be sold; both the dangers and solutions are innumerable, invisible, and often imperceptible.
Change Your Body or Change Your Mind
Social discourses are described as, “…a set of socially constructed ideas that people hold (un)consciously within their social life and which determine particular social practices, forms of subjectivity, and specific relations of power.”  These discourses are fundamental to the maintenance of social standards and norms, influencing the way people interpret, understand, and conduct themselves and their place in society. Authors have elucidated current ‘discourses of obesity’ in which fatness is seen as a sign of the individual’s failure and irresponsibility to control their body weight, “…despite having the necessary tools for its surveillance through various control techniques and disciplinary measures related to diet and physical activity.”  A higher bodyweight implies laziness, weak self-discipline, and irresponsibility which will invariably reduce individual and social productivity and competitiveness. Thus, people should manage their weight and body through the disciplined practices of eating carefully and exercising regularly in order to manipulate the simple equation of calories in versus calories out. The association of fatness with ‘bad’ lifestyle choices elevates smaller bodies by associating them with ‘good’ lifestyle choices and conflates health efficacy with good citizenship.  “Healthism thus allows bodies to be signs of individual character, and, hence, deservingness.”  Those who engage in a ‘healthy lifestyle’ and practice self-care are perceived as more deserving of access to healthcare compared to others that fail to adhere to social norms or engage in ‘unhealthy’ behaviors. Obesity, then, becomes a, “…litmus test of biological citizenship.” 
Healthism may be less obvious in the dialogue of fat acceptance movements and weight-neutral approaches, but some authors have provided compelling, critical explanations. [6,11] Dr. Kathleen Lebesco, author of Revolting Bodies: The Struggle to Redefine Fat Identity (2003), has criticized the Health and Every Size ™ approach for its health-centric messaging (the pursuit of health-seeking behaviors), arguing that it may be complicit in moralizing health efficacy.  Similarly, Samantha Murray, author of The ‘Fat’ Female Body (2008) has pointed out, “…that a type of disembodied autonomy underlies fat activism, where one is replacing one set of negative stereotypes with positive, celebratory ones.”  As one navigates the wellness, fitness and health industries, they are faced with parallel choices: “…in the case of the war against obesity, modify my eating and exercise to fit a certain model of health and beauty, or, in the case of fat activism, I can alter my mind to stop seeing my body as loathsome. If the public health outcry tells us to change our bodies, fat activists tell us to change our minds.”  As Welsh (2011) points out, however, “My beliefs about my own body are not separate from having a body, nor are they separate from the long history of discourse about bodies in my social world.” Though fat acceptance and body positivity movements encourage the emancipation from current social norms and beauty standards, they, too maintain an individualist perspective that the ‘self’ is in charge of pursuing the proper attitude and behaviors, arguably fitting the norms of a specific subculture.
A Society At Risk: Implications of Healthism
Crawford, Guthman, and others have evaluated healthism for its potential benefits as well as its harmful effects on individuals and society. Healthism has likely played an integral role in the shift toward client-centered strategies, accessible biomarker screening tools, and greater health literacy. Access to care, information, and resources can be empowering and supportive of health management. The harm lies primarily in the moralization of health and the emphasis on personal responsibility which may lead to ostracization, discrimination, and lack of institutional change. [2,5] Healthism devolves from empowering to oppressive once it dictates that individuals must behave in specific ways to achieve a consensus definition of health regardless of infringements upon their ability to live in accordance with personal values. Guthman describes the evolution of healthism as a transition, “…from a critical perspective of both the biomedical establishment and industrial toxins, to an embrace of self-care, to an utter devolution of health responsibility to the individual…”. 
Guthman posited that healthism has coupled health efficacy with, “…notions of rights, responsibilities, and good citizenship…,” while justifying the exclusion or neglect of those who ‘fail’ to adhere to social norms.  Healthism has also created what Crawford referred to as a ‘potential-sick role.’  The quantification of health based on risk factors provides scaffolding for health and ‘sickness’ stratification. Ranges, risk factors, and norms serve as comparators against which individuals can be evaluated as non-normative and potentially ‘risky’. Individuals are categorized as more or less potentially (or actually) sick based on their cumulative risk factors. As biological citizens, they are expected to uphold the moral obligation to reduce their potential for sickness. Greater potential for sickness is met with more intense social pressures to minimize that potential by making the ‘right’ choices (of a healthy lifestyle). Those who fail to meet these expectations are perceived as irresponsible, and perhaps even lacking moral fiber. In the US, the structure of the current healthcare system and internalization of these ideas have arguably contributed to the notion that unhealthy individuals are an economic burden, and that obesity is a moral, ethical, and social problem. 
Crawford and Guthman both discuss the risks of individualist perspectives regarding the personal responsibility to pursue health. Of course, individual responsibility is not synonymous with blame; individual responsibility is an empowering charge to take autonomous action when possible. Individuals with an internal locus of control—the belief that outcomes are (controllable) results of personal choices—report better self-assessed health and less healthcare utilization compared to those who believe they have little control over their circumstances. [5,13] Likewise, self-efficacy, or situational self-confidence, is associated with long-term maintenance of behavioral change. Blame, however, is applied by external audiences who perceive one’s actions—or lack thereof—as a form of wrongdoing. Healthism, according to Crawford, “…risks fostering the illusion that individual responsibility is sufficient. It leaves unexamined the “voluntary” assumption about human behavior, through which it is taken for granted that because individuals can and do choose to act differently, it simply remains for them to make such choices. In other words, it promotes a conception which overlooks the social constraints against “choosing.””  While mindset and perspectives are associated with positive outcomes, “healthism disables because human capacity cannot be advanced in the subjective sphere alone.”  Crawford calls for ideologies, practices, and political movements that, “…enhance our social capacity to control the conditions of our existence…”, coupling personal agency with institutional change for a more viable strategy of health management. 
Now, at the intersection of progressivism, neoliberalism, and advancements in nutritional and biomedical sciences, healthism has expanded the moralization of food and bodies to entire lifestyles. Within the wellness, health, and fitness industries, healthist perspectives may lead to biases, stereotyping, and discrimination against those who do not fit social or subcultural norms of appearance, attitude or behavior. Importantly, as Guthman points out, the neoliberalist encouragement of individual choice-making is not simply a, “…choice between two moral equivalents, but between the right and the wrong ones, shedding some light on the hidden morality of choice.”  Thus, healthism, in these contexts, promotes personal choice as an alternative—or even the surrogate—to political efficacy and institutional change, potentially leaving individuals and society at risk. 
 Turrini. (2015). A genealogy of “healthism”: Healthy subjectivities between individual autonomy and disciplinary control. Eä Journal, 7(1), 11–27. www.ea-journal.com11  Crawford, R. (1980). Healthism and the medicalization of everyday life. International Journal of Health Services, 10(3), 365–388. https://doi.org/10.2190/3H2H-3XJN-3KAY-G9NY  Jiménez-Loaisa, A., Beltrán-Carrillo, V. J., González-Cutre, D., & Jennings, G. (2019). Healthism and the experiences of social, healthcare and self-stigma of women with higher-weight. Social Theory and Health, 0123456789. https://doi.org/10.1057/s41285-019-00118-9  Veit, Helen Zoe, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013  Guthman, Julie. Weighing In : Obesity, Food Justice, and the Limits of Capitalism. Berkeley :University of California Press, 2011.  Greenhalgh, T., & Wessely, S. (2004). “Health for me”: A sociocultural analysis of healthism in the middle classes. British Medical Bulletin, 69, 197–213. https://doi.org/10.1093/bmb/ldh013  Kesavayuth, D., Poyago-Theotoky, J., Tran, D. B., & Zikos, V. (2020). Locus of control, health and healthcare utilization. Economic Modelling, 86(June), 227–238. https://doi.org/10.1016/j.econmod.2019.06.014  History Timeline. (n.d.). Retrieved December 18, 2020, from https://www.lifestylemedicine.org/ACLM/About/History/ACLM/About/History_Timeline.aspx?hkey=bf9605f3-8cd3-4616-9899-97a93653b6a7  The myth of IgG food panel testing | AAAAI. (n.d.). Retrieved February 4, 2020, from https://www.aaaai.org/conditions-and-treatments/library/allergy-library/IgG-food-test  Cani, P. D. (2018). Human gut microbiome: Hopes, threats and promises. In Gut (Vol. 67, Issue 9, pp. 1716–1725). BMJ Publishing Group. https://doi.org/10.1136/gutjnl-2018-316723  Welsh, T. (2011). Healthism and the Bodies of Women: Pleasure and Discipline in The War Against Obesity. Journal of Feminist Scholarship, 1(2004), 33–48.  Carter, S. M., Entwistle, V. A., McCaffery, K., & Rychetnik, L. (2011). Shared health governance: The potential danger of oppressive “healthism.” American Journal of Bioethics, 11(7), 57–59. https://doi.org/10.1080/15265161.2011.566668  The authors note that reverse causality cannot be ruled out; in other words, an internal locus of control may be fostered by the pre-existence of good health, whereas unpredictable illness may lead to a more external locus of control.  Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48. https://doi.org/10.4278/0890-1171-12.1.38