Why Public Health Initiatives & Legislation Need to Engage with Fat Food Justice

Food justice is a movement which confronts the various problems around food (in)access and hunger, along with oppression in different stages of food systems. Attention to structural barriers like poverty, racialization, and environmental degradation are foundations of the movement’s work. Food justice does not have a singular definition, through broadly this work approaches the food system through arguments for the right to food, better social safety nets, and sustainable farming practices. However, several scholars and activists have called for the movement and its proponents to address another barrier that exists both within wider society and within food justice work itself – that of fat phobia, anti-fat hatred, and weight discrimination. Fat food justice calls for “creating a world in which all bodies are valued and respected, and in which the production, distribution, preparation, and enjoyment of food is equitable and nourishing.” Following fat food justice and other perspectives in fat studies and fat liberation circles, square quotes are placed around “obesity” to indicate fatness becoming medicalized within limited understandings of health, and resulting crises of fear around fat bodies.

My recent research contributes to this call for questioning these biases within food justice work and resulting programmes. The programmes I focus on are called produce prescription programmes (PPPs) – initiatives focused on health status and income levels of individuals, in which the answer is to ‘prescribe’ them fresh fruits and vegetables for a certain number of weeks. Alongside this produce distribution, participants often take part in nutrition education activities and have medical data like blood sugar, cholesterol, weight, and body mass index collected throughout the programme. The majority of PPPs use bodyweight or BMI as fundamental eligibility criteria, both have which have been widely criticized as unhelpful measures for an individual’s health. Not only does it not capture an accurate picture of health, but the methods and tables used to build BMI as a diagnostic tool were never designed to indicate causation. More concerning is the use of racialised statistical norms underlying the BMI and medical constructions of “obesity,” which follow anti-fat rhetoric and frame nonwhite bodies as abnormal. Implementing the BMI as both an eligibility screen and progress tracker serves to reinforce norms of white Anglo- American body ideals.

Recipients of PPPs have their weight monitored throughout the programme.  In addition to discussing weight, many organizers of prescription programmes discuss “obesity” numbers within their communities and the need to rectify this, which has led to an emphasis on biometric tracking. The top three biometrics captured by programmes were blood pressure, A1C, and BMI/weight. Programme organizers discussed hope for specific improvements in these biometrics: decreased A1C, weight loss or reduced BMI, lower cholesterol, and reduced risks of a cardiac event. Organizers – and even programme participants – discussed these tests as a way to prove the assertion that “food is medicine” and the programmes make positive changes in participants’ lives. The major focus of these programmes is to ameliorate what are called “diet-related chronic diseases” – such as “obesity”, diabetes, high cholesterol, and cardiovascular disease.

At first glance, this seems like a great idea – “An apple a day keeps the doctor away” as the old English-language proverb goes. Dietary advice from medical professionals has existed for centuries, with national governments worldwide taking up this mantle in the 20^th Century. In fact, the Food and Agriculture Organization of the United Nations has identified over 100 countries with existing or developing national dietary guidelines. These guidelines attempt to change individual behaviour around eating and health-focused activities, such as eating a certain amount of produce or doing certain types of exercising for a certain amount of time. However, many of these interventions are recreating harm through their focus on weight and body shape. This is because most interventions utilize the weight-centred health paradigm, which places uncritical emphasis on individual weight and behaviour over systemic issues like poverty, unemployment, and houselessness. Nick Fox and Elise Klein have already shown Cost of Living readers the unethical ethos behind behavioural ‘nudging’ – let alone their ineffectiveness of achieving programme goals. Produce prescriptions focus on this type of ‘nudging’ through incentivizing changes in eating behaviour and patterns.

So why do these programmes continue to exist, and why are produce prescription programmes flourishing across the United States? Within the US, concern about population health status, healthcare costs, and rates of food insecurity and hunger has led to the proliferation of interventions aimed at changing individual eating behaviour with the goal of reducing healthcare costs and government spending. Recent federal legislation has created the Gus Schumacher Nutrition Incentive Program (GusNIP) to increase fresh produce purchasing and consumption and positively change the health and nutrition status of low-income persons. While GusNIP does not explicitly define what they mean by “diet-related health condition,” nor mentions “obesity” or “overweight” throughout the document. However, the expression “diet-related health condition” within public health and nutrition sciences is an umbrella term which is repeatedly used to cover “obesity” and/or “over-weight,” along with hypertension, diabetes, and cardiovascular disease.

The combination of focusing on incentivization, diet-related chronic disease, and weight-based biometrics pivots PPPs (and now federal funding) away from addressing social, economic, and political determinants of health and toward a prescribed bodily norm. While weight is not explicitly stated within the mandate for GusNIP, the concentration on individual behaviour and the use of diet-related disease as an eligibility metric pulls federal appropriations into the trap of the weight-centred paradigm. This trap narrows the focus of federal health and agriculture programmes into the moralization discourses of the new public health, which has moved from the management of acute to chronic diseases and increasingly emphasizes the role of self-control and risk. This change holds individuals with certain health diagnoses as personally responsible for their ill-health, and situates them as in need of intervention While bodily and metabolic changes from an individual’s own baseline of health can be concerning, it is the use of a singular baseline for all which presents a problem. These baselines do not encompass the spectrum of human physiology or physique, along with disregarding different cultural constructions and understandings of what it means to be healthy. This fixing of a “healthy body” within certain metrics and measurements constrains GusNIP programming to a certain set of participants, instead of addressing the overarching issues of food and healthcare access.

With the relationship between weight/fat and health not scientifically clear, bringing the lens of food justice to examinations of federal health and agriculture policy helps us to start examining whether legislation and resulting programmes are recreating inequity. If we think about food justice as a practice, several changes come to mind. One is to transform not only PPPs but the institutions that fund them to incorporate principles of justice – not only procedural and distributive, but restorative justice. While legislation and programmes are currently caught within the trap of current beliefs around fatness and health, opportunities abound. Changes in both programme organization/implementation and policies can address structural issues within food and healthcare systems, rather than blaming individual behaviour or knowledge.

About the author: Alanna K. Higgins (@foodacademics) is a PhD Candidate in Geography at West Virginia University. Her work examines the intersection of food, health, and law/policy. Her research interests include political ecology of health and bodies, food justice and sovereignty, and equitable pedagogies.