An Iatrogenic Imperative: Weight-Goal Pursuit and Morbidity from Adolescence to Adulthood

Abstract

American medicine and public health have spent half a century organizing their approach to the body around a single conviction: that fat is dangerous and that smaller bodies are healthier ones. This weight-centered health paradigm enlists nearly everyone in the ongoing work of monitoring and shrinking themselves, and it has secured for dieting — the most ubiquitous of its prescriptions — the status of an explicit health behavior. A critical literature has contested the science underwriting this paradigm and documented the stigma it generates, but the claim at its center, that the effort to become smaller makes people healthier, has never been examined over the long term in a nationally representative sample. This dissertation takes up that question by relocating the object of analysis from the size of bodies to the demand that they change. Drawing on healthism, the life course perspective, and ecosocial theory, it treats sustained weight-change pursuit as a health exposure in its own right and follows that pursuit across five waves of the National Longitudinal Study of Adolescent to Adult Health. Three studies address three progressive questions: which social conditions sort adolescents into distinct weight-goal trajectories; how those trajectories translate into weight-control practice, including its most dangerous forms; and whether trajectory and behavior predict cardiometabolic and mental health morbidity by mid-adulthood, net of body size. Recruitment into weight-goal pursuit proves close to universal and steeply gendered in this cohort, and the way adolescents perceive their bodies matters considerably more than how the clinical apparatus classifies them. Pursuit shapes behavior most forcefully where behavior is most harmful, and dieting independently predicts escalation into clinically extreme practice rather than any broad increase in weight-control activity. By adulthood, those who sustained the pursuit carry more diagnosed conditions across both the physical- and mental-health domains, and body size explains only a small share of thisassociation. Taken together, the findings suggest the weight-centered health paradigm is an iatrogenic process: an apparatus built to avert disease which actually helps generate a share of it, distributes that harm along the same lines of gender, race, and class that structure health inequality more broadly, and then reads the result as evidence of its own necessity. The case this dissertation makes is for turning attention away from the size of bodies and toward the pursuit imposed on them, the conditions that determine who is conscripted into that pursuit, and the structural supports on which health actually rests.