Table Of ContentXXL:
OBESITY AND THE LIMITS OF SHAME
Obese individuals are twice as likely to experience heart failure as non-
obese people. More than 85 per cent of Type 2 diabetes sufferers are
overweight. In the United States, obese and overweight individuals
make up more than two-thirds of the adult population. Public health
organizations and governments have traditionally tried to combat obes-
ity through shame-inducing policies, which assure people that they can
easily lose weight by eating right and exercising. This generic approach
has failed, as it does little to address the personal, genetic, and cultural
challenges faced by obese individuals.
XXL directly confronts the global public health sector by proposing
an innovative, alternative policy – the ‘healthy living voucher’ – for
decreasing high calorie consumption and its related health problems.
Neil Seeman and Patrick Luciani argue that many public health cam-
paigns have made the problem of obesity worse by minimizing how
difficult it is for individuals to lose weight. XXL challenges govern-
ments to abandon top-down planning solutions in favour of bottom-up
innovations to confront the obesity crisis.
(University of Toronto Centre for Public Management Monograph
Series on Public Policy and Public Administration)
neil seeman is director of the Health Strategy Innovation Cell and a
senior resident in health system innovation at Massey College, Univer-
sity of Toronto.
patrick luciani is a senior resident at Massey College, University of
Toronto.
The University of Toronto Centre for Public Management
Monograph Series
Editor: Andrew Stark, University of Toronto
Funder: The Donner Canadian Foundation
The University of Toronto Centre for Public Management Monograph
Series is an ongoing series of books on important topical matters in
public administration and public policy that will engage not only the
academic community but also policy- and opinion-makers in Canada
and elsewhere.
Books are included in the series based on their originality, capacity to
provoke public debate, and academic rigour.
For a list of books published in the series, see page 163.
NEIL SEEMAN AND PATRICK LUCIANI
XXL
Obesity and the Limits of Shame
University of Toronto Centre for Public Management Monograph Series
© University of Toronto Press Incorporated 2011
Toronto Buffalo London
www.utppublishing.com
Printed in Canada
ISBN 978-0-7727-8628-9 (cloth)
ISBN 978-0-7727-8627-2 (paper)
Printed on acid-free, 100% post-consumer recycled paper with
vegetable-based inks.
Library and Archives Canada Cataloguing in Publication
Seeman, Neil
XXL : obesity and the limits of shame / Neil Seeman and Patrick Luciani.
(University of Toronto Centre for Public Management monograph series)
Includes bibliographical references and index.
ISBN 978-0-7727-8628-9 (bound). – ISBN 978-0-7727-8627-2 (pbk.)
1. Obesity – Government policy. 2. Obesity – Economic aspects.
3. Obesity – Psychological aspects. I. Luciani, Patrick II. Title.
III. Series: University of Toronto Centre for Public Management
monograph series
RA645.O23S43 2011 362.196(cid:2)398 C2011-900674-X
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise, without the
prior written permission of the publisher.
Produced for the University of Toronto Centre for Public Management by
the University of Toronto Press.
Contents
Foreword vii
Acknowledgments ix
Introduction: The Genesis of Shame 3
1 The Paradoxical Costs of Fat 5
2 (Nearly) Everything Causes Obesity, and (Almost) Everyone Is
Different 28
3 One-Size-Fits-Nobody 57
4 Healthy Living Vouchers 106
Notes 149
Index 161
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Foreword
Obesity, as Neil Seeman and Patrick Luciani argue in XXL, is not only
a public health ‘crisis.’ It is a crisis for ‘public health’ – for the doctrines
and protocols of that field.
The very term ‘public health’ implies approaches to our well-being
that, far from being tailored to the needs of each of us as individuals,
are meant to aid large numbers: the public as a whole. Its very essence
impels it in the direction of one-size-fits-all measures. Hence, in dealing
with obesity, public health officials have exhorted us to exercise, rec-
ommended changes to food labelling, advocated the banning of trans
fats in restaurant food, issued dietary guidelines, and set forth exercise
recommendations, all of which – as the authors note with keen insight
– rely at one level on shaming the people they are trying to help.
Each of these efforts is meant to be useful to the public as a whole.
None, fundamentally, has worked. A few have even been dangerously
counterproductive, contributing to a climate in which impossible body
images become aspirational.
Public health approaches have been flummoxed, the authors argue,
because obesity is a deeply individual problem, one that manifests
itself uniquely in each case. Genes, stress, hormones, portion sizes, the
environment, commuting and fast food, depression and comfort food,
sedentary lifestyles and snack food: all play a causal role, but in each
person the mix is different.
And so then should be the appropriate treatment. Of the innumer-
able exercise and diet regimes available, and the options for surgery
and lifestyle changes, and the contributions that can be made by psy-
chotherapy and pharmaceuticals, each individual requires his or her
own tailored combination to deal with his or her own unique condition.
viii Foreword
In the face of this reality, what is ‘public health’ to do? The authors
offer an innovative answer. Borrowing an instrument used by other
public policy domains – education, welfare, housing – when the need
is to enable individuals to find their own solutions to complex policy
problems, they recommend a ‘healthy living’ voucher. Each individual,
in consultation with his or her primary care provider, would use it to
create a bespoke regimen, mixing, matching, and experimenting to find
‘whatever works.’
This is public health for the twenty-first century. XXL is compelling,
original, lucid, engagingly written, anecdote-filled, data-driven, and –
above all – deeply sympathetic, to both public health officials and pri-
vate individuals wrestling with weight issues. I am pleased to have the
opportunity – and grateful, as always, to the Donner Canadian Foun-
dation for providing the means – to publish XXL in the University of
Toronto Centre for Public Management Monograph Series.
Andrew Stark
Editor
University of Toronto Centre for Public Management Monograph Series
Acknowledgments
We are grateful to our peer reviewers and their valuable comments.
Special thanks are due to the research assistance of Mr Wendell Adjetey,
to whom we are greatly indebted. Finally, we thank our editor, Andrew
Stark of the University of Toronto, especially for his wisdom on the
reality vs theory of public policy.
All errors or omissions are our own. We are students of obesity – and
human complexity.
Neil Seeman and Patrick Luciani
