310.1177/1363459312447254Grnning et al.

Health
12

Article

Health

From fatness to badness: The 17(3) 266283

The Author(s) 2012
Reprints and permission:
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DOI: 10.1177/1363459312447254
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Ingeborg Grnning
Norwegian University of Science and Technology, Norway

Graham Scambler
University College London, UK

Aksel Tjora
Norwegian University of Science and Technology, Norway

Abstract
Obesity (or being overweight) is now considered a by-product of membership of
developed societies. Moreover, it is considered a growing global health problem. This
article reports on a small qualitative study of adults who fell into one or other of these
categories in Norway in 2010, and who have been faced with decisions about lifestyle
versus surgical remedies. This decision making is contextualized and the principal criteria
examined. Embodiment, bodywork, self- and social identity, stigma, deviance and issues
around the idea of personal responsibility and public health emerge as key themes.
The concluding paragraphs commend incorporation of a macro- or social structural
perspective to the conceptualization and investigation of obesity.

Keywords
identity, obesity, public health, social structure, stigma

Introduction
It is widely accepted that obesity has reached epidemic proportions over recent decades,
with approximately 1.5 billion adults (age 20+) worldwide being overweight and at least
500 million obese (as defined by the World Health Organization (WHO), 2011), numbers
from 2008). Being overweight was once considered a problem only in high-income
countries, but is now raising health concerns in low- and middle-income countries as well.

Corresponding author:
Ingeborg Grnning, Department of Sociology and Political Science, NTNU Dragvoll, 7491 Trondheim, Norway
Email: ingeborg.gronning@svt.ntnu.no

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Grnning et al. 267

A large number of people go through drastic weight-loss programmes and surgeries in

order to lose weight. Our aim in this article is to locate the various decisions and actions
taken by individuals to live with or treat what is defined as their obesity within a
sociological frame. Drawing on interviews with patients admitted for treatment in one of
Norways university hospitals, our interest is in how patients view their status as obese
and how they choose between alternative obesity therapies. Treatments offered by the
hospital in this study include an intermittent residential programme, a commercial
weight-loss camp, a hospital outpatient programme and bariatric surgery (Martins et al.,
2010). From a sociological point of view, how obese patients deal with health and therapy
choices raises a complex set of questions about bodywork, self-identity, stigma, risk and
responsibility. We ask why some people choose to go through risky surgeries in order to
lose weight. We begin with a brief excursus on the sociology of the body before going
into the details of obesity treatment.

Body morality in high modernity

The relation between health and appearance may be thought of as an aesthetic of health,
in which particular looks reflect well-being, which in turn is evidence of devotion to self-
improvement practices (Jutel, 2005). Appearance reflects a morality of eating, staying
fit, taking care of oneself and so on; it speaks to an individuals true nature.
In so far as weight is regarded as an indicator of health (Jutel, 2005), health becomes
visually accessible: it is manifest in the parameters of the body. Slim and overweight bodies
signal very different living patterns. While the overweight body evidences self-indulgence
and a lack of self-discipline, the slim body demonstrates a high level of self-control. The
link between body-weight and consumption of food is taken as a given (Lupton, 1996). The
body may be experienced as a source of pride if socially and normatively acceptable, but
as a source of anxiety and humiliation if not. Being overweight is not necessarily a practical
problem, as many overweight people are active and actually healthier than sedentary,
skinny people (Blair and Brodney, 1999). However, as western democracies have become
more concerned with risk and responsibility, and even considered risk societies (Beck,
1992), the concern is not only todays problems but tomorrows. Thus healthy, active,
overweight people need, indeed ought, to be concerned with a growing list of risks,
potential side-effects of potential future obesity (Gard and Wright, 2001). The mass
media promotes a healthy, fit body, and people are increasingly concerned with their bodies
as expressions of individual identity (Shilling, 1993). The body is a personal resource that
reflects a persons self-identity and has for many modern people become a project in its
own right as appearance, size, shape and even its contents, can be reconstructed.
Having the right body shape is not only about being healthy as the obese are often
also characterized as lazy. This characterization is stigmatizing (Goffman, 1990). Obese
people are frequently portrayed as ugly, stupid, lazy, mean, self-indulgent, sloppy and
emotionally weaker than normal people (Gilman, 2008). Control and virtue are to be
found in slenderness, which gives underweight people a higher status than the overweight.
People are deemed responsible for their own health. A moral responsibility is foisted on
the individual to choose a good diet and make correct choices when it comes to lifestyle
and physical activity. Foods and behaviours are considered good or bad, which accords

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obesity discourse a pivotal role in creating a public health scare (Rich and Evans, 2005:
352). Since childhood we learn to categorize foods as yes and no foods. Dichotomizing
foods as good or bad is often implicit in both popular and medical discourses, assigning
the foods moral meaning (Lupton, 1996). In order to raise awareness among the lay
population mass media campaigns and social marketing techniques are used to spread
information about risks and benefits associated with certain foods.
While the body has become increasingly important for peoples sense of self-identity
in high modernity (Shilling, 1993), bodies are possibly more transparent through
privatized, personalized and somatized body projects in a postmodern consumer-oriented
culture (Chrysanthou, 2002). Drawing on Bury (1997), Giddens (1991) and Shilling
(1993), Chrysanthou (2002) argues that the body has become a crucial source of identity
and meaning: self-identities are only loosely connected to religion and community and
less readily associated with gender, class or age in high modernity. He argues that the
physical body is transfigured into an active utopian project in the alliance of health
information, medical technology, health consumerism and self-screening (2002: 469).
The analytic gaze is turned inwards. In the case of obesity however, this inward gaze is
not motivated by individual body projects alone, but is also a response to the felt need to
appear responsibly healthy, fit and self-disciplined. In a Foucauldian sense people
discipline themselves in order to meet a panoptical societys demands of having a healthy,
normal body. Just as Benthams Panopticon makes all prisoners feel constantly surveilled
(Foucault, 1979), obese people are self-disciplined by the feeling of being constantly
observed as noticeably fat by the society at large. An important question in this article is
therefore: what does it do to people when a (supposed) lack of self-control is manifest in
layers on ones body? Questions of shame and blame become highly relevant.

Shame and blame

Stigma usually refers to any attribute, trait or condition that distinguishes its bearer as
different from what time and place dictate to be normal (Scambler, 1998). Prejudice
and stigma are associated with being obese, which is why many of the study participants
wanted to lose weight. As they lost weight they experienced elevated acceptance in pub-
lic. Stigma and deviance are often used as synonyms. Recently, however, an analytic
distinction between them has been posited for sociological purposes, and it is one of
relevance here.
For Scambler (2009), stigma represents an infringement against norms of shame,
while deviance represents a breach of norms of blame. Stigma signals an ontological
deficit (involving being imperfect) and a failure therefore to conform; while deviance
signals a moral deficit (involving acting inappropriately) and a matter therefore of
culpability. Moreover, each of stigma and deviance can take three forms. Enacted stigma
and deviance refer to discrimination against individuals solely because of their ontological
or moral inferiority or unacceptability respectively: enacted stigma is active shaming,
enacted deviance active blaming. Felt stigma and deviance refer to internalized feelings
of shame and blame, but also, and principally, to an anticipation and fear of meeting with
enacted stigma and deviance. Finally, project stigma and deviance refer to the wilful
endeavour to deny or resist enacted stigma and deviance without falling prey to felt

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stigma and deviance. Project stigma and deviance have to date been somewhat neglected
in the sociology of stigma and stigmatizing conditions.
Drawing on the definition of stigma as the co-occurrence of labelling, stereotyping,
separation, status loss, and discrimination, as well as a power exercise, a number of
questions can be raised (Link and Phelan, 2001). For instance, what follows if those
who might stigmatise possess power enough to underwrite and maintain a separation
of us from them, and if those who might confer stigma have the power to control
access to core institutions like schooling, job markets, housing and healthcare in order
to put really consequential teeth into the distinctions they draw (Scambler, 2009:
450). In the case of obesity we suggest that what follows can occasionally be positive
as well as negative. Ironically, the separation of us from them, via a diagnosis of
morbid obesity (BMI1 above 40), might be marked by (fully covered) access to
therapy.
Campos (2004) proposes that much of the obesity discourse rests on the claim that
there is a correlation between being overweight and having bad health. Although ill
health often comes with excessive weight, the relationship between health and weight is
complicated. Monaghan (2005) questions the biomedical weight-for-height categories,
as health, size and weight are not as intertwined as often presented. Using BMI as an
indicator of health and fitness is also problematic as a high BMI is not always associated
with bad health. Despite this, BMI is typically considered the gold standard of the
obesity industry (Ruppel Shell, 2003). In fact the BMI says little about somebodys
health since it indicates weight rather than fat (and may define muscular and athletic
people as morbidly obese because the measurement does not distinguish muscles from
fat). However, our participants characterize their health by referring to their BMI, and
because of this we stick with BMI as a standard definition in this article.

Treating obesity: the surgical option

Surgical treatment for obesity has emerged to supplement or even displace more
longstanding and researched lifestyle interventions. Attempts to change the size and
shape of bodies by surgery carry a risk. In a survey of obese patients motivations for
choosing between lifestyle intervention or weight-loss surgery (Strmmen et al., 2009)
found that many patients who opted for surgery most feared social intimacy with other
patients and therefore felt uncomfortable with lifestyle (group) therapy. Many who chose
lifestyle intervention were anxious about anaesthesia and therefore wanted to reduce
weight in a more traditional manner.
Weight-loss surgery has been performed in Norway since the 1970s (Vge et al., 2002)
and is based on two main principles that can be used separately or combined: (1) a restric-
tion of the stomachs volume; and (2) a bypass intervention (Badman and Flier, 2005).
People with a BMI above 40 or BMI less than 40 but with comorbidities are classified as
morbidly obese. People who are morbidly obese may get surgery free of charge, but the
length of the waiting lists encourages many people to pay for surgery in private clinics.
Patients with a BMI over 40 are usually recommended gastric bypass while patients with
a BMI lower than 40 may choose between gastric banding and sleeve resection.

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Severe obesity can have negative health effects such as type 2 diabetes, hypertension,
excessive lipids in the blood (hyperlipidaemia) and abnormal breathing due to a physical
block of airflow (obstructive sleep apnoea) (Badman and Flier, 2005). After surgery
many patients recover from these effects and the majority experience better psychosocial
function and mental health. However, weight-loss surgery may also lead to serious
complications in relation to the surgery, the quick weight loss and later nutritional or
metabolic problems. Operative mortality is very low, but a total of 1520 per cent
experience surgical complications like reflux, vomiting, dysphagia, dumping syndrome
(Maggard et al., 2005; Ogden et al., 2006) and nutritional problems (lack of proteins,
vitamins and minerals) (Dolan et al., 2004). Despite known risks, an increasing number
of Norwegians go through weight-loss surgery every year. Some who go through surgery
have participated earlier in lifestyle interventions without achieving permanent weight
loss. Notwithstanding improved health after lifestyle therapy, many still choose to go
through bariatric surgery.

Case and research methods

In the study2 reported here we used a qualitative design with a total of 22 in-depth semi-
structured interviews, carried out between December 2009 and April 2010. The questions
concerned the informants background, choice of treatment, need for information and
participation in self-help groups and forums, among other themes. With assistance from
the Obesity Clinic (Obesitaspoliklinikken) at St Olavs University Hospital, 90 former
obesity patients were contacted by letter, 14 of whom agreed to participate. In addition,
the first author did one pilot interview while visiting Rros Rehab, and a further seven
participants were recruited through snowball sampling. In all, 17 women and five men
participated in the study. Most of the interviews took place in participants homes, while
three were conducted in cafs. The interviews lasted approximately 70 minutes and were
audio-recorded, transcribed and inductively coded with HyperResearch, a computer
software tool for data analysis, and later analysed.
Our analysis followed an inductive strategy, as suggested in concepts such as grounded
theory (Glaser and Strauss, 1967) and stepwise-deductive induction (Tjora, 2010), in
which themes being identified in the data limit concepts in the further analysis. While
there are for instance obvious gender-related issues related to the body, overweight and
obesity, such aspects have not been especially addressed in the study, nor brought up by
the female nor male participants in the study (see also Glaser, 2002). That this article
does not discuss gender issues, does by no means indicate that such themes are not
relevant in a more general sense.
Obese patients admitted at our case hospital could choose between a residential
intermittent programme at Rros Rehabilitation Centre (hereafter Rros Rehab) in the
region or a weight-loss camp at Ebeltoft Kurcenter (hereafter Ebeltoft Camp) in
Denmark. Twelve of the participants in our study had gone through treatment at Rros
Rehab, while an additional two had been at Ebeltoft Camp. These two patients and a
third patient from Rros Rehab went through surgery a few years after lifestyle
intervention.

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Grnning et al. 271

The intervention at Rros Rehab consists of intermittent stays3 (Martins et al., 2010)
in which treatment is based on activity, diet and mental therapy. Included are consultations
with a psychologist, individually and in groups, workouts and healthy cooking. The aim
is to establish new routines and eventually change the participants lifestyle. As the
participants return home, follow-up is scarce and most participants go back to living like
they did before the intervention. After a few months the participants return to the centre
for check-ups, additional workouts and continued lifestyle interventions. The two
participants who stayed at Ebeltoft Camp experienced a 21-week-long lifestyle
modification programme at a private, commercially driven health resort. The programme
is based on a conventional low-calorie diet, structured physical activity and cognitive
therapy. The two youngest participants were between 20 and 30 years old while the
oldest was over 60 years old. The characteristics and experiences of the study participants
are summarized in Table 1.

Participants accounts: analysis

The participants tell stories about the choice of surgery, excuses for being overweight,
failed diets, stigmatizing encounters and health problems. We will turn to these in the
following sections.

Table 1. Characteristics and experiences of study participants

Age Name Rros Rehab Ebeltoft Camp Gastric bypass Gastric banding
2030 Unni X
Siri X
3040 Caroline X
Ella X X
4050 Anna X
David X X
Henning X
Julie X
Kathrine X
Marie X
Oda X
Pernille X
Thea X X
Wendy X
5060 Aase X
Britt X
Fredrik X
Gina X
Nina X X
Yngve X
60+ Ruth X X
Viktor X

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Choosing surgery
Surgery is a drastic step and most participants considered it a last resort: if surgery did
not help them, nothing would. Most of those who chose lifestyle therapy were surgery-
sceptics. Some were afraid of not recovering consciousness after anaesthesia, while
others were more worried about possible post-surgery complications, consequent
lifestyle-change or adjusting to a new body. Despite this, few participants excluded
surgery outright, but rather judged it a final way out.
Participants articulated different reasons and goals for discriminating between
interventions. Going through bariatric surgery has many known complications and was
considered a big step for most participants. The complications scared Oda, but she also
worried about how her new body might look. In the event she offered the following
observation: When I was obese my fat was spread evenly and I was firm. Im not firm
anymore. Im no aesthetic pleasure. Coming to terms with my body took a lot (Oda).
Henning feared anaesthesia, but had tried a variety of diets and therefore chose to
have surgery without trying alternative lifestyle interventions: A lot of people told me
that I might not wake up after anaesthesia. I figured I had to take the chance. Ill wake up
or I wont. At least Ive tried it (Henning).
Some patients experienced post-surgery complications. Henning was experiencing
severe dumping when eating regular food. Dumping usually occurs after a high calorie
intake, but in Hennings case it occurred after eating anything but a few unhealthy foods
like bacon and chocolate. He was dependent on large quantities of vitamins and nutritional
supplements and was lacking energy. Despite this, he recommended people having
surgery if they needed it. Wendy suggested that people go through surgery if they had
failed several attempts of dieting. She believed that many obese people think that a
skinny body comes with a happier life:

Its not just the fact that you want to do what society expects, gaining a body thats skinny, pretty
and healthy. Its a strong wish inside of every person that goes into this process and theres a lot
of suffering behind it. Very few people talk about the dream behind the act. A lot of obese people
have experienced loss of family or social life. Maybe its about finding themselves and getting
better self-esteem. Its a dream about a body change that leads to a better life. (Wendy)

Nina decided to get surgery when she reached her 50s. After years of diets, stays at
Rros Rehab and self-help groups, she realized surgery was the only solution. She was
fully aware of its limitations and knew that many people regain weight at some period
after surgery: I know that Im getting a major opportunity. Im not given a magic stick,
but a tool and I think a lot of people dont realize that. Its up to me to manage the tool
the right way (Nina).
Ella and David both stayed at Ebeltoft Camp before having surgery. They lost a lot of
weight while staying there, but rapidly regained the lost weight after returning home.
When David finally decided to have surgery, he was anxious to get started:

I considered paying for surgery myself, just to get it faster If I could afford it I might have
done it, but I didnt want to get in such a big debt when I was already on the waiting list. I could
wait another year. (David)

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Grnning et al. 273

Some of the participants never considered surgery as an option. Wendy had been
struggling with an eating disorder since early childhood and had gone through a lot of
therapy. When she finally felt ready to go through a lifestyle intervention she knew she
would succeed. Losing weight was extremely important to her so her motivation never
dipped and she kept fighting:

Being overweight is tiring and your life becomes so characterized by it. I understand why I have
sacrificed this much in order to reach my goal and I understand why other people choose other
ways to reach their goal. Even if they use all their money and pay for it themselves or choose
other methods, I understand them. Getting under the knife is pretty much putting your life at
stake. (Wendy)

Those who had gone through surgery offered various legitimations for their choice.
Some felt surgery was their only way out since their eating habits were related to
physical or mental health problems, making it especially difficult to maintain a normal
weight. Most said they had learned the hard way that dieting had made them gain more
weight than they lost. Some chose to get surgery in order to avoid the stigma and prejudice
related to obesity. And some said their reason for choosing surgery was rooted in mundane
everyday experiences and challenges: being overweight was hard work. All participants
detailed the histories of their weight-gain. Some of the stories were very personal and
reached deep into the participants biographies.

Excusing conditions for being overweight

During the interviews many participants ventured an account that explained their
obesity. Pregnancies, illnesses, mental health problems and difficult childhoods were
among the reasons presented. Some also reported that they were genetically disadvantaged.
Very few presented their obesity as a product of personal flaws like laziness. According
to Goffman (1969), most people present themselves or act differently in public, or front
stage, compared with in private, or back stage. Only David and Henning confessed that
their overweight was a result of overeating. David gained weight due to frequent coffee
breaks and snacking while working as a cook in the army. For Henning a fast food
addiction made him gain weight rapidly:

I started gaining weight when the hamburger reached Norway in the early 1970s. Hamburgers
and French fries. I bought French fries two or three times a day. It was something new and it
was tasty. I went from being a normal weight boy of 3040 kilos to weighing 80 kilos in four
or five months. (Henning)

Henning and David were the only participants who volunteered statements on their
overeating. The other participants proffered different reasons for gaining weight and did
not focus on excessive eating. Many mentioned genes, as obesity seemed to run in the
family. Unni had gone through a lifestyle intervention at Rros Rehab after being
encouraged by her dad, who had attended the same programme:

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274 Health 17(3)

My dad has been here [at Rros Rehab], my uncle is here, my cousin has been here and my aunt
as well. I hope they can find some genetic error that makes it easier for people to lose weight,
at least for the people that are genetically challenged. If the genes play a crucial part there really
isnt that much I can do. If my overweight is meant to be, that is. (Unni)

None of the participants asserted that obesity could be culturally determined, although
only one had been diagnosed with a disease that is known to make dieting difficult.
Despite this, most participants believed that their genes had had an important influence
on their weight since they had been unable to lose weight no matter how much they tried.
Thea came into this category. She has been overweight since childhood. She had always
been active, but despite this her parents had chosen to put her on her first diet when she
was nine years old: I dont know if its my genes, I just know that my sister and I ate the
same food and we were treated that same way. Despite this I could never inherit my
sisters clothes (Thea).
Several of the participants experienced problems losing weight after pregnancies,
while others blamed a weight gain on poor health. Gina was confident that her weight
problem would be resolved when her knees got better: I began gaining weight for real
when I was in my 30s. When I was 45 and got knee problems I had to sit a lot and I
gained weight really fast (Gina).
People are routinely and stereotypically judged by their physical appearance. Having
a healthy body is not only about preventing disease, but plays an important role in making
people feel good about themselves and how they present to others (Shilling, 1993). While
the overweight body signals laziness and lack of self-discipline, the fit body represents a
healthy lifestyle and control. Obese people are often confronted by stereotypical
characterizations like being lazy and sloppy (Gilman, 2008). These characterizations
reflect a personal mark or stigma (Goffman, 1990).
Most study participants reported to have little control over their weight as any puta-
tively excessive eating or lack of exercise was the result of physical or mental problems
over which they had little control. The litmus test for many was a series of failed
attempts to lose weight. Diets, shakes and lifestyle interventions seemed not to have
resulted in weight reduction; some even reported that dieting made them gain more
weight than they lost.

Failed diets
Fourteen of the participants had been through lifestyle intervention programmes at Rros
Rehab or Ebeltoft Camp. Of the 12 who had undergone surgery, three had first gone
through lifestyle interventions. According to Wendy, about a third of those who go
through lifestyle interventions succeed, that is, they experience a permanent weight loss.
Wendy was one of two participants who had successfully lost weight after staying at
Rros Rehab. After an initial loss of weight she was determined to succeed on her own.
She believed that most people prefer to lose weight on their own, but that a lot give up
after experiencing a succession of defeats.

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Grnning et al. 275

Unni, Siri and Viktor were the only participants who had not tried dieting on their
own. After witnessing a number of failed attempts on the part of others, their impression
was that dieting was generally counter-productive. The other participants had tried
everything from diets, shakes and self-help to lifestyle therapy. They all experienced
early weight loss before regaining it later: Ive fought against my weight since I was 14
years old. Ive gotten fat by dieting. When I look at pictures and think about what
happened I realize that I wasnt fat when I first started dieting (Ruth).
For some participants their eating habits seemed to have led to eating disorders.
Before surgery, Anna got up at night to eat bacon, chips or chocolate. Her eating disorder
grew more severe and she eventually defined surgery as her last and only option. Anna
tried all kinds of diets to no effect. Her family practitioner prescribed exercises and
regular personal follow-ups, but nothing seemed to work. When she eventually applied
for surgery her eating disorder was out of hand: I gained more weight for every diet. I
recommend surgery, at least if you have additional problems (Anna).
Resort to surgery following repeated failures of interventions based on lifestyle
change was a major theme in peoples accounts. Ella and David each spent four months
at Ebeltoft Camp. They lost a lot of weight and felt motivated to continue the weight-
fight when returning home; but neither succeeded:

We were there for four months and after that we were let loose now youre ready for the rest
of your life! You return to the life you had before leaving and you realize that you havent done
any changes. You get back to the same family, the same everyday life and that was your problem
in the first place. (Ella)

Although only a few patients obtained a permanent weight loss after lifestyle inter-
ventions, several claimed to have experienced better health, more developed muscles and
less fat. But this was deemed an insufficient return and bariatric surgery was often
chosen:

I have been dieting many times and the lifestyle intervention at Rros Rehab was divided into
sections. A few weeks of therapy followed by a few weeks at home, before going back to the
centre again. Thats how Ive been dieting earlier and I just cant do it. I figured surgery was my
last chance. (Marie)

Most participants mentioned innumerable failed diets as important for choosing

surgery, but many also considered stigma and prejudice towards the obese important
factors.

Prejudice towards the obese

In Norway one is supposed not to harass people on the basis of their body size. However,
felt stigma and deviance are pronounced, and enacted stigma and deviance far from
unknown: We have the ability of lying to ourselves when were fat. We tell people were
happy with our weight, but were not. Life as obese is not a good life and you meet a lot
of prejudice (Julie).

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276 Health 17(3)

According to Ruth, there is a lot of shame associated with obesity and the general
attitude is that you just have to get a grip. Wendy had the same concern and stated that
most overweight are met with prejudice as they are considered lazy and demanding.
Most participants had experienced comments about their weight in this vein:

Most people have a mirror and we can see for ourselves that were not exactly normal-sized.
Were all served comments and we tell each other that we dont care, but we do. It becomes
really easy to sit down and feel sorry for ourselves. (Fredrik)
The participants were asked to compare the cancer association with the obesity
association. While cancer is considered a status diagnosis obesity is closely related to
shame:

Theres a lot of anxiety connected to cancer, but no shame. Obesity is associated with both
shame and anxiety. Some people think its contagious. You dont want to be with obese people
cause theyre unpleasant to look at and you dont want anything to do with them. (Wendy)

In addition to comments and stares, Anna had noticed that people avoided her when
she was obese: If you go to the cinema you dont sit down next to a woman thats
overweight. I noticed that people avoided me when I was fat. It makes you feel sad, at
least I did (Anna). After surgery and massive weight loss people treat Anna differently:

I had surgery during Christmas and Easter, [the year] before we were at a party with old
classmates and I noticed that the only ones that talked to me were the ones I knew really well.
When I went to a class reunion some time ago I met some of the same people and they wouldnt
leave me alone. Some of them didnt recognize me, and they sat down next to me. It was the
same people that avoided me earlier. (Anna)

Siri had gone through lifestyle intervention and was considering surgery. She preferred to
keep her dieting a secret and informed only her closest friends about her stays at Rros Rehab:

They can all see that Im overweight, but they dont have to know that Im part of a programme.
People would probably ask me how Im doing and if I exercise, and maybe I havent exercised
that day or maybe not for months. Itll make me feel bad. (Siri)

During her stays at Rros Rehab, Wendy experienced that the therapists brought the
group for a walk in the city centre:

Youre visible enough when youre overweight and when you stroll around with a big group of
obese people its a shock for the environment The reactions from the society are reinforced
when that many big people are together. Overweight people are considered demanding. Youre
lazy and demanding thats the prejudices. (Wendy)

One popular belief is that overweight people are themselves to blame for their body
size. During an intensive period of dieting Fredrik needed a few days of sick leave in
order to focus on his new routines, but was met with little understanding:

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Grnning et al. 277

I went to see my doctor and he gave me the following comment: Eat less and exercise more
and stop complaining! I thought you dont understand jack shit. I asked him if he expected
me to pay for the consultation and he said yes. I told him to forget about it and I havent seen
him since. (Fredrik)

In order to avoid embarrassing incidents, stares and comments, several of the

participants withdrew from social activities. Feelings of shame left a lot of participants
isolated from social gatherings and activities. According to Thomas dictum (Thomas
and Thomas, 1928: 572), what man defines as real becomes real in its consequences.
Situations become real (i.e. being fat) when they are experienced as real (i.e. the feeling
of being fat). Goffman (1990) shows how the body plays an important role in mediating
the relationship between peoples self- and social identity. Peoples self-identity is
dependent on being accepted as a full member of the interaction order. If individuals
bodily appearances and management mark them as failed members of society, they may
internalize this and incorporate it into what become spoiled self-identities. According
to Goffman, individuals typically see themselves through a mirror that reflects societys
prejudices. In the presence of embarrassment, a gap only too readily opens up between
virtual and actual social identity.
As some participants mentioned prejudice and stigma as important factors for losing
weight, others wished for a more functional body. Others, however, worried more about
the health risk their excessive weight represented.

Obesity and health problems

Most participants at Rros Rehab lost a lot of weight during the stay, but regained the
weight on returning home. Despite this weight gain most of them claimed to have
maintained the physical shape they gained at the rehab centre as a result of an increased
daily activity level and a healthier diet, which is consistent with Monaghans (2005)
argument. In this article we do not discuss whether the participants health problems are
a result of excessive kilos or inactiveness.
Health problems related to obesity usually appear with age. High blood pressure,
problems with knees and backs, a high risk of type 2 diabetes and difficulty moving were
important factors precipitating surgery. Health seemed especially salient to the oldest
participants as the risks of developing cardiovascular disease and diabetes increase with
age. Anna had surgery a few years ago. After surgery her life changed drastically and she
no longer relies so much on medication:

I have arthritis and used to take four different pills. Now I dont have to take any pills. I used to
have high blood pressure as well and took an additional two pills for that. I had a tray filled with
pills. (Anna)

The participants spent a lot of time and money on managing footwear and clothing.
Worrying about how to get her shoes on in the morning could keep Britt awake through
the night. Several participants reported that their aspiration to lose weight was mostly
related to a desire to be more mobile, to make life easier, and to be able to do things that

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278 Health 17(3)

their weight was preventing them doing: Practical things like being able to bend down
to take my socks off without twisting and turning. Everyday dreams. Everything becomes
easier, both everyday life and work if I only lose those 20 kilos (Nina). Nina had been a
surgery-sceptic for a long time, but had recently decided to get surgery:

Ive asked myself a few control questions. I am over 50 years old. Do I really want to continue
living like this? There are lots of mountains I want to climb and things I want to do. Im a risk
to myself. I hoped that I could lose weight in a traditional way, but Ive realized that its not
going to happen. (Nina)

Researchers and health professionals often equate being overweight with bad health.
Monaghan (2005: 312) is one of the critics of this view and he fears that health profes-
sionals and policy makers can be blinded by fat. He finds the obesity case exaggerated,
as overweight peoples health is often significantly improved through diet and physical
activity without weight loss (Gaesser, 1998; Galloway, 2006). According to Monaghan,
using excessive fat as a health indicator can also be misleading since it is not always cor-
related with poor health. Monaghan argues that social inequalities, psychosocial stress
and various forms of discrimination also have important impacts on health. By referring
to a study of 22,000 male participants from middle to upper socio-economic groups,
Monaghan shows that men who were overweight and fit had cardiovascular and all-
cause mortality rates that were similar to those who were lean and fit. Their mortality
rates were significantly lower than those who were lean and unfit.
Thus participants had different reasons for choosing surgery. While some felt their
weight was dependent on their genes or health problems, others had given up on dieting
after years of failed attempts. Some were tired of meeting with stigma and prejudice, while
others hoped that weight-loss surgery would afford them better health. In the discussion
we take a closer sociological look at the participants reasons for choosing surgery.

Discussion
Obese people are often confronted by stereotypical characterizations like being lazy and
sloppy (Gilman, 2008). These characterizations reflect a personal mark or stigma
(Goffman, 1990). Goffman (1963, 1969) considers the body a material property of the
individual, which is controlled in order to facilitate social interaction. The meanings
ascribed to the body are determined by shared vocabularies of body idiom, which is the
most important form of non-verbal communication in public. Individuals present them-
selves on what Goffman (1969) refers to as the front stage. Private matters are normally
hidden or reserved for backstage interaction. Severe obesity cannot be hidden backstage
but the reasons for becoming obese can be summarized in an account or narrative.
Goffman again: people who are obese are discredited, rather than discreditable, but
can nevertheless opt for covering that is, work to downplay or render less intrusive their
conspicuously stigmatizing attribute. Mental and physical health problems, pregnancies
and childhood traumas were some of the reasons participants included in their accounts
to explain their overweight. Most avoided presenting themselves as lazy and greedy by
explaining their weight problem through factors over which they had little or no control.

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Grnning et al. 279

David and Henning were exceptional in informing us that their overweight was the result
of overeating. By telling us about their food-weakness they put themselves in a more
vulnerable position than the other participants.
The distinction between stigma and deviance, together with their enacted, felt and
project dimensions, are particularly useful in considering obesity and its impact of
peoples biographies and decision making. Shame and blame run like threads through
participants narratives for self and others. David, for example, frequently avoided social
invitations and gatherings through felt stigma and deviance, feeling both shame and
blame. It is a common finding in the literature on chronic illness and disability that felt
stigma can be more disruptive of individuals social and working lives, and ultimately
their biographies, than enacted stigma (felt and enacted deviance are only rarely identified
as such) (Scambler, 2009). We have seen that several of the study participants had
experienced enacted stigma and deviance in the form of off-the-cuff comments and
stares; but clearly in some cases, like Davids, felt stigma and deviance were stronger and
more intrusive.
As was suggested earlier, the body, upon which can be inscribed shame and blame,
represents an individuals self-identity. For many the body has become a dynamic site of
aspiration in its own right. People trying to lose weight are constantly working on this
site. There are restrictions attached to how the perfect body should be achieved and
maintained. While working out is considered legitimate, correct and virtuous, surgery
can be seen as morally problematic (Sassatelli, 2005); the surgical option carries a risk of
enacted and felt deviance. Many consider weight loss surgery the easy way out. Dieting
has a higher status, which makes you more of a worthy patient.
The participants all made the point that surgery is a tool they had to learn how to use.
Patients undergoing surgery have to learn how and what to eat, how to cope with the
known-about-ness and marks of surgery and how to handle its less accepted side-effects
(Throsby, 2008). The challenge was to normalize the surgical intervention and rebut
accusations of having cheated. By emphasizing their role as disciplined weight-fighters
and minimizing the significance of the surgery, people announced that their obesity was
a personal responsibility. None of the participants considered surgery an easy solution.
After surgery, patients lose a lot of weight in the first year, but have to work hard to
maintain this reduction in the second and subsequent years. Wendy believed that patients
who lose weight on their own, as it were through will-power and self-discipline, are
granted more respect than those who opt for surgery as there is a general belief that easy
fixes will be punished eventually.
A dialectic between the logics behind attributions of shame and blame is apparent
here. Being significantly overweight, especially to the point of obesity, remains an
offence against what Goffman (1990) calls norms of identity or being, and is thus
stigmatizing or shaming. But this is not all. There are sanctions also against those who
are held accountable, or blamed, for being fat: popular stereotypes of laziness, greed
and lack of self-discipline argue for moral culpability. Nor is this just a matter of public
comment and prejudice. As the rationing of health care in developed societies becomes
more explicit, behavioural conditionality is increasingly being regarded as a reasonable
criterion to prioritize treatments. It would be surprising if this were not debated sooner
rather than later even in the relatively prosperous and welfare-oriented Norway.

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280 Health 17(3)

An eventual questioning or denial of the surgical option for obesity, at least in publicly
financed medicine, might be anticipated for those who cannot demonstrate sustained
attempts to self-treat through lifestyle interventions. It is a matter, after all, of personal
responsibility; for which a Foucauldian technology of the self is a major pillar of post-
welfare statist governmentality, amounting to an efficient form of social control (Dean,
2010). In Norway, governmentality can be broached in terms of the official guidelines
concerning nutrition and exercise (Helsedirektoratet, 2011). Advice is found on official
websites, in commercials, newscasts and TV programmes about health and fitness.
Although far from everyone leads an active, healthy life, there is a ubiquitous awareness
of the benefits and risks linked to different lifestyles. Staying fit and eating healthily is
commended while obesity is associated with low status as well as shame and blame. A
latent inward gaze is produced and legitimized within the official policy to fight obesity,
which in various ways is made manifest in our participants lives.
As if in anticipation, study participants hard-won, post-operative public acceptance was
undermined when they confessed to their surgery. Oda did not want to be associated with
weight-loss surgery and chose to tell only close friends and family about the intervention
(felt stigma eliding here into felt deviance). When she lost weight in the first year a lot of
people assumed she had got cancer. She said she preferred to keep a safe distance from
obesity associations and forums and did not want to be associated with weight-loss surgery.
Acceptance rates for bariatric surgery differ between societies as different countries
have different traditions and orientations to welfare and to surgery. A significantly private
or fee-for-service health care system in the USA encourages more cosmetic surgery than
occurs in Norway. In Norway taxes are high and health care universal, publicly funded
and free of charge: morbidly obese patients are as yet covered for surgery. But surgery is
expensive and since obese people are often defined as deviant, many consider weight-
loss surgery a strictly unnecessary intervention. According to Wendy many obese
consider receiving weight-loss surgery as something shameful. Julie had more than once
been called a tax parasite for getting surgery for free. When she started to lose weight she
proudly told people about the intervention. Negative reactions soon made her revise this
policy of disclosure, as many people believe the obese have themselves to blame.
As considerations of the role and policy potential of personal responsibility enter
Norwegian public discourse, it is being asked whether body size most reflects social,
psychological or biological/genetic processes. Several informants claimed to be
genetically challenged given that obesity ran in their families. While obese people
themselves, as well as some researchers hunt for a genetic basis for obesity, the wider
society, including the State and most medical doctors, seem reluctant to accept obesity as
a genetic phenomenon (Ogden and Flanagan, 2008). Pace Foucault, it is perhaps likely
that Norway begins to follow the post-1970s neo-liberal lead to replace its welfarist
policy commitment to reduce enacted stigma in relation to obesity by a post-welfarist
policy commitment to promote enacted deviance in relation to obesity. The ethics of the
deployment of stigma and deviance in public health policy is now being openly debated
(Bayer, 2008). Should fat people (like smokers for instance) be blamed and feel ashamed
for the sake of their and the public health? Would they then feel more responsible for
doing something about it? Or do stigma and deviance represent an outmoded and
barbaric form of social control (Burris, 2008: 475)?

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Grnning et al. 281

Concluding comments
In this article we have reported the findings of a small qualitative study of contextualized
decision making on the part of obese or overweight individuals attending lifestyle and/or
surgical treatment programmes in Norway. A number of themes have emerged, including:
the pragmatics and aesthetics of bodywork; the salience and poignancy of embodiment
of self- and social identity; the role of stigma and deviance in all their dimensions in
personal choices for or against surgery; and the growing neo-liberal tendency to premise
policy making on notions of personal responsibility.
The social structural underpinnings of cultural norms and individual choice have not
been emphasized here. The participants in this study, however, have exposed shame,
blame, lies and embarrassment as shared experiences. In a sense the development of
obesity therapy programmes represents an institutionalization of social relations in which
personal tragedy and shame (i.e. stigma) are metamorphosed following a trajectory from
micro-phenomena of everyday interaction via meso-phenomena like life-style and surgical
intervention programmes to macro-phenomena of public health policy into matters of
oppression and blame (i.e. deviance): Enacted stigma and deviance can elide into
government, and felt stigma and deviance into governmentality (Scambler, 2009: 453).
In terms of future research programmes, we would encourage a focus on the ways in
which classifications, diagnoses and treatments of obesity and excessive weight are put
into a broader social structural context, bringing into play not only state policies and
activities, some of which might be deemed excessively bureaucratic or oppressive, but
class-generated forms of commodification or exploitation. This macro-orientation
would throw light on the ways in which norms of shame and blame and their enforcement
relate to deeper social structures. A second focus would be on what we have called
project stigma and deviance. A number of quotations from study participants show that
by no means all passively internalize social norms. Some who are reflexive about such
norms actively resist them, and most do so now and again. Theirs remains a neglected
form of resistance within medical sociology.

Acknowledgements
We wish to thank the participants for kindly sharing their very personal accounts and experiences
during the interviews. Thanks also to Magnus Strmmen at the Obesity Clinic at St. Olavs Hospital
for helping us recruiting participants, to Alex Broom for inspiring discussions in an early stage and
to Anita Das and other colleagues at the Norwegian EHR Research Centre for support. The review-
ers and editors of Health: provided constructive comments to previous versions of the article. The
study is funded by the Norwegian University of Science and Technology.

Notes
1 The BMI is calculated by a persons weight in kilograms divided by height in metres, squared.
A BMI of 30 or higher is stated as overweight while a BMI over 40 classifies as morbid
obesity (World Health Organization, 2006).
2 The project is approved by The Norweigan Social Science Data Services and treated by
Regionale komiter for medisinsk og helsefaglig forskningsetikk.
3 Maximum ten weeks at Rros Rehab, eight weeks at home, four weeks at Rros Rehab, four
to five months at home, and two weeks at Rros Rehab, followed by two weeks every six
months after the first year up to five years.

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282 Health 17(3)

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Author biographies
Ingeborg Grnning is a PhD research fellow in medical sociology. Her projects title is Personal
health records: A sociological exploration of the patient in the making. Grnning is affiliated with
the Department of Sociology and Political Science at the Norwegian University of Science and
Technology and the Norwegian EHR Research Centre.

Graham Scambler is Professor of Medical Sociology and Director of Centre for Sociological
Theory and Research on Health, at the Research Department of Infection and Population Health,
University College London (UCL). He has published widely on themes such as health-related
stigma, the differential prestige attaching to medical diagnoses, and patient education and
empowerment. Scambler is editor of the journal Social Theory & Health.

Aksel Tjora is Professor of Sociology at the Norwegian University of Science and Technology.
With background from computer science and management (and sociology) he has been researching
on information technologies in health services since 1995, with a number of publications. He has
initiated a new thrust within Norwegian medical sociology, with an annual conference starting in
2005, and several edited books on changes in the patient role. Tjora is editor of the Norwegian
Journal of Sociology.

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