“In the early 1950s, obesity was thought to be a major threat to people’s health; fifteen years later, public health authorities shrugged.” (p. 136) This observation encapsulates the central problem of Nicolas Rasmussen’s Fat in the Fifties: how do we account for the rise and fall … and then rise again of “obesity” as a national crisis of epidemic proportions? As Rasmussen clearly demonstrates in this compact yet rich study, the answer is complicated. It’s not that American waistlines had stopped expanding between the 1950s and the 1970s. Rather, the instability of obesity as a disease had much to do with changing ideas about its role in coronary heart disease, a major killer in postwar America, and much else besides.

Notwithstanding some instructive analyses of how fatness and its causes were perceived in popular culture, Fat in the Fifties reads mainly as a history of epidemiology, specifically, the “new epidemiology” that emerged in the 1920s and 1930s. During these years, public health authorities shifted their focus from tracking the causes of mortality available on death certificates to studying how and why the living experienced health and illness. How this related to rising public health concerns about obesity is the subject of the introductory first chapter. Here we encounter the rise of comprehensive surveys of chronic illnesses, including the Hagerstown study (1921–1924) and the National Health Survey (1935–1936), that revealed the seriousness of heart disease and in time identified obesity as one of its chief causes. Similar surveys would be conducted in the decades to come.

As Chapter 2 shows, perspectives on obesity were undergoing change during these years. The fashionable endocrinology of the 1920s and 1930s blamed overweight on thyroid deficiency that affected how metabolism was regulated. Various forms of hormone therapy, some potentially harmful, were prescribed as ways to combat it. Whereas shifting the focus of blame to one’s glands exonerated individuals from moral responsibility for their condition, endocrinology’s declining appeal coincided with new findings suggesting that obesity was less a question of hormones than uncontrollable eating. A variety of factors converged to recast the fat person as a kind of addict, a depressive, or someone with an “oral fixation” resulting from arrested psychosexual development. However it was framed, “fatness signified a grave psychiatric impairment; it was a form of sickness that was simultaneously a character defect” (p. 46). What would come to be known as “health promotion” evolved out of public health authorities’ attempts to persuade such stigmatized individuals to make healthier choices or to take “antidepressant” amphetamines like Benzedrine to curb their appetites.

Chapters 3 and 4 examine how connections between excess weight and rising death rates due to heart disease were forged during the late 1940s as the federal government wrestled with the challenge of how to address the problem. The newly emboldened American Heart Association got the National Heart Act passed in 1948 while growing numbers of public health authorities – acting on the assumption that fat people were like addicts or depressives – promoted small-scale mutual-support weight-loss groups modeled on Alcoholics Anonymous. Throughout this period the American Medical Association (AMA) resisted attempts to provide government-sponsored health care. Amid continuing AMA insistence that national health insurance would constitute a form of “socialism” that threatened doctors’ livelihoods as private businessmen, in 1953 the federal government’s Commission on the Health Needs of the Nation laid the foundation for the “coercive healthism” that continues to dominate American culture. Emphasizing “the individual’s assumption of responsibility for his own health” (p. 76), the Commission signaled a shift in American perspectives on public health. From this point on, Rasmussen notes, “education, an established technique to modify public behavior […] would gradually expand into efforts to shape private behavior” (p. 77). It appears that the seeds of our current medical neoliberalism were sown just after the Second World War.

Chapters 5 and 6 show how new studies and changing perspectives in the 1960s rendered excess body fat less of an urgent health threat than cholesterol, blood pressure and, to some extent, smoking. The physiologist and promoter of the “Mediterranean diet,” Ancel Keys, was especially instrumental in focusing attention on the quality (as opposed to the quantity) of what one ate, in the process discouraging the idea that being overweight necessarily portended illness and death. We cannot know for sure how much of Keys’ thinking on the causes of heart disease were swayed by roughly thirty years of funding from the Sugar Research Foundation. Increasingly rendered “epidemiologically uninteresting” (p. 125), obesity itself was redefined in terms of “adiposity” (high body fat content) rather than weight. With Body Mass Index now the key way of measuring obesity, it also became less interesting in light of the critical attitudes that many young people had adopted towards experts in the context of the rights-based social movements of the 1960s. Hence the distrust of medical authority that sustained such social movements as the National Association to Aid Fat Americans, the Fat Underground, and the Fat Liberation Front that began to emerge by 1970.

A valuable contribution to our understanding of medical perceptions of large bodies in the twentieth century, Fat in the Fifties is a nicely written and well-documented study of how obesity has been treated by public health experts. It also covers a lot of ground, and provides useful glimpses into how epidemiological ideas were appropriated in the wider culture. A minor quibble concerns the somewhat sharp divide that Rasmussen notes between glandular and psychological causes of overweight. Endocrinology surely played an important role in how the causes and treatment of obesity were understood in the early twentieth century, and it “sheltered the fat from moral judgment by attributing their condition to an involuntary abnormal metabolism” (p. 46). Yet one wonders how this blameless focus on glands coexisted alongside persistent popular and medical tendencies, traceable at least to the 1890s, to view fatness as evidence of laziness and immoderation in diet (as the author notes on p. 30). Moreover, the heyday of endocrinology coincided with widespread interest in sport and physical fitness for males as well as females, popular practices that encouraged and celebrated individual willpower and performance. Perhaps they were not a central concern of public health specialists, but it’s a little odd that the sport and fitness movements receive no real attention. These are minor points. On the whole, this is an impressive and informative study, essential reading for anyone seeking a grounding in medical views of fatness in the twentieth-century America.