(Part II) A Bridging the Gap Series: Origins of Dieting Culture and the Anti-Diet Movement

Updated: Jul 14, 2021

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 [1]. 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an expansion of the jurisdiction of the medical institution, healthism manifested as a reduction of this jurisdiction, superseded by non-experts co-opting medical perspectives.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…”.[2] 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.”[3] 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. [4] 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.”[4] 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.””[4] 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.[5] 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.”[5] 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. [5] Even social and leisure-time activities—like sitting, using electronic devices, spending time in isolation--are increasingly evaluated based on their health effects. [2]

From an economic perspective, health can be perceived as part of human ‘capital’, or economic value. [7] 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.”” [5] 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…”. [5] 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]

Phair, J. (1922). Health Propaganda. The Public Health Journal, 13(4), 145-148. Retrieved December 31, 2020, from http://www.jstor.org/stable/41972832

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. [1] 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.[6] 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.[8] 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.”[5] 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. [5] 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. [5]

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. [2] He explained that self-care sought to, “…reduce dependency on physicians and other professionals and enhance medical self-competence...”. [2] Accurately, behavioral characteristics of healthism include information-seeking, exercising patient rights, seeking multiple practitioner opinions, engaging in regular exercise, and generally following dietary guidelines. [6] 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.” [2] 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. [6] 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.[9] Though no micro