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Food, Fat, and the Absorption of Illness in India
By Harris Solomon
Duke University PressCopyright © 2016 Duke University Press
All rights reserved.
THE THIN-FAT INDIAN
The Thin-Fat Paradox
In 1999, two endocrinologists, Dr. C. S. Yajnik, from Pune, India, and Dr. John Yudkin, from London, published a side-by-side photo of themselves in the Lancet. Their report is entitled "The Y-Y Paradox." The paradox, named "Y-Y" after their last names, emerges from the bodies of the scientists themselves. They sit together, coexistent but comparative, quite peaceful, given how their bodies would ultimately anchor a controversy (figure 1.1).
The photo shows how the two scientists have the same BMI of 22.3, but Dr. Yudkin has 9.1 percent body fat, while Dr. Yajnik's level is 21.2 percent. The text below the photo explains the paradox:
The authors share a near identical body-mass index (BMI), but as dual X-ray absorptiometry imagery shows, the similarity ends there. The first author [Yajnik] (figure, right) has substantially more body fat than the second author [Yudkin] (figure, left). Lifestyle may be relevant: the second author runs marathons whereas the first author's main exercise is running to beat the closing doors of the elevator in the hospital every morning. The contribution of genes to such adiposity is yet to be determined, although the possible relevance of intrauterine undernutrition is supported by the first author's low birth weight. The image is a useful reminder of the limitations of BMI as a measure of adiposity across populations. (Yajnik and Yudkin 2004: 163)
In the Y-Y paradox, evidence emerges through a procedure, dual X-ray absorptiometry, that sends energy beams into the body to assess their relative absorptions by bones and fat. Fat inside the body, under the skin and around the organs, sends back a message: comparisons have their limits. Fat absorbs some kinds of evaluation (X-rays that will produce radiographs). But it resists other evaluative forms, producing "a near identical body-mass index" despite manifest differences in body fat between the men. Yajnik and Yudkin suggest that perhaps layers of living are the more accurate way to understand fat: in genes, in utero, in the elevator, in the marathon. In the Y-Y paradox, it is not fat itself that is anomalous. Rather, what matters are the absorptive interfaces between fat and the world. This chapter examines how those interfaces matter differently in making metabolisms uniquely Indian and the site of disease risk.
I learned about this Lancet article from my interviews with physicians, who suggested I look into the Y-Y paradox, which they referred to as "the paradox of the thin-fat Indian." This phenomenon gained its name in scientific literature (including that of epigenetics) that questions how histories of malnutrition in early life or in earlier generations influence the onset of metabolic disease in later life or later generations. These puzzles materialize the puzzling body of the thin-fat Indian. This thin-fat Indian body can be thin and fat at the same time: thin morphologically but metabolically obese according to its impaired insulin sensitivity and elevated levels of lipids. In this figure of metabolic science, time and fat absorb each other.
Any person can exhibit the characteristics of the thin-fat body. The paradigm is intended to provoke several possible conclusions from the idea that thin bodies may be metabolically similar to fat bodies. One conclusion relates to the limitations of using size to determine metabolic pathology. A second is even more provocative: If thin and malnourished bodies can show the precursors of obesity, then brute associations of obesity to broad categories of social class and geographic area merit rethinking and refinement in relation to comparative temporalities.
The thin-fat Indian as a cultural figure and scientific theory engaged several theories and debates about metabolic science in terms of the physiology of weight gain in contexts of differential nutrition. The first, called the "thrifty gene" hypothesis, was developed by James Neel in a 1962 publication in the American Journal of Human Genetics. Neel suggested that the body had an inherent tendency to store energy as fat during times of sufficient food supply, which would ensure survival during times of famine. Because contemporary (mostly urban) life has brought about a constant supply of food, the body remains in a perpetual state of fat storage, driven by a "quick insulin trigger" generated after meals. The second influential theory is called the "thrifty phenotype" hypothesis (also called the "fetal origins" hypothesis) developed by David Barker (2007), who proposed that a fetal environment shaped by maternal malnutrition would more strongly predict metabolic disease in later life. As anthropologist Michael Montoya (2011) has detailed, scholarship in population genetics, epigenetics, and evolutionary biology often appeals to such "thrifty" hypotheses even while other scholars deem the ideas unwarranted. The narrative arc of evidence here is that a lifestyle of modernity's excess activates an inner bodily force (formed either generations ago or in the fetal environment) and causes the body's energies to go awry. The words of a Mumbai physician I spoke with capture the layers of resource and failure built into these theories with a literal bang of a world working upon bodies: "Genetics loads the gun, but the environment pulls the trigger," he explained. This, even as he acknowledged that phenotypes do not map cleanly onto single genes (Sunder Rajan 2006: 191–92).
I found the photo of the Y-Y paradox compelling. As a configuration of two bodies from colony and empire, it does cultural work in asking the viewer to "see" a paradox of biology as a common thread between bodily histories. Famine and its political history consolidates in the peculiar similarities and differences between a British scientist and an Indian scientist. If that thread is followed, the picture of the paradox poses something different than binaries of nature and culture, of kindling and sparks, of guns and triggers. The thin-fat Indian destabilized "thrifty" sciences even as it drew on them as resources. What mattered was not so much the distribution of triggers to nature or culture, to genes or environment — binary distributions that anthropologists of science and medicine have shown to be contingent, local, and enmeshed (Fullwiley 2011, 2007). The thin-fat body, made flesh metabolically, offered a different pattern of cause and effect than linear narratives of economic transition and resultant indulgent eating. A metabolic body informed the YY paradox, and the Y-Y paradox discerned a metabolically unique Indian whose fat may be visible and/or lying in wait. The "and/or" already was accounted for by knowing the metabolism in terms of time. The thin-fat Indian crystallized past and present events outside and inside the body, as well as the rural-urban continuum grounding these events. "Thin-fat," not just "fat," demanded attention, because thin-fat demonstrates how the absorption of time becomes a trope for Indian bodies. These bodies, in turn, de- and restabilize everyday knowledges about somatic disorder.
The fat body in India is certainly not a novel medical concern, despite recent claims to "globesity" that pose a neat arrangement between India's economic transitions and bodily accumulation (see Arnold 2009). Globesity casts the world as a "biological public" in which a global health problem is both the defining feature of life and a teleological rationale for its own intervention (Livingston 2012: 31). The biological public of globesity is vulnerable because of its relations between inheritance and lived environment. However, the plastic fat body — the thin-fat Indian — anchors contemporary concerns in India around metabolic disease. This is a body that emerges from the sciences of epigenetics, wherein plasticity refers to an organism's ability to vary according to its surroundings. Specific to this chapter, the plasticity at stake is that which circulates in the Y-Y hypothesis and outside it, in terms of understanding how and to what extent environments are inherited and lived.
Plasticity can be understood as the ability to give or take shape. Across the life sciences and science and technology studies scholarship that engages these sciences, plasticity is a feature of life that raises questions about what sort of sociotemporal worlds emerge at the interface of the material bodies and environments. As Hannah Landecker explains, the scientific narrative of epigenetics in relation to those variations is suffused with hope, for if it is the case that metabolisms are "open" to change during critical windows of possible exposure — by the mother surrounding a fetus, by toxins breathed in, by food eaten — then perhaps it is the case that plasticity is a pathway to solutions. "This may sound like biological fatalism in just another form," Landecker (2013b) writes, "but the great hope of epigenetics is the essential plasticity of the body: if the body is open to environment, then it is open to environmental intervention. Might we then be able to treat the metabolic diseases of adulthood — diabetes, obesity — by engineering the diets of pregnant women, infants, children and adolescents?" (179). Plasticity as a way of understanding life via the gut has several key correlates. It ties in with ideas about the brain, whose neuronal plasticity of cells and signal pathways also raises questions about the openness between the body and the world (Kuzawa and Quinn 2009; Malabou 2008; Wilson 2015). This linkage between the imprints of guts and brains also connects to debates in developmental biology, particularly in developmental systems theories of biology. Like neural connections, metabolic connections do not and need not fit easily into arrangements of cause and effect or of biological determinism and social idealism. As Landecker points out in the same passage, the emergent sciences that scrutinize plastic connections can lend themselves to hope. My intent is to show how such a hope for change operates through specific tropes in the Indian context, where figures such as the thin-fat Indian manifest a pedagogy of plasticity. The thin-fat Indian is instructive, because its endorsement teaches that fat is an important substance of change over a lifetime, and that the parameters of health and illness are metabolic.
In 2008, the body mass index, or BMI, for Indians changed. (BMI, a calculation of metric height over weight squared, is a measure of body mass, with the mass of fat most often of interest.) This change underscored how a substance like fat becomes a substance of time. While global standards diagnosed a person as "overweight" at a BMI of 25, the new Indian BMI diagnosed overweight status at a BMI of 23. More Indians came to be at risk for metabolic disease, and this occurred at thresholds different from those for other populations. Using this event as a backdrop, this chapter maps out the currents of plasticity running through it. First, I explore the creation of this Indian body mass index and describe the cultural and political work required to turn 25 into 23. The development of the Indian BMI points out the vernacular particularities of plasticity in the face of claims to a global trend of metabolic disease. The creation of 23 aimed to expand diagnosis of metabolic plasticity while giving it local grounding, such that metabolic disease would be more apparent to at-risk persons and their doctors.
Second, I describe what it takes to enumerate this intensified risk and how plasticity appears through the trope of the bad copy: the body that can only be comparable in its shortcomings. Third, I explore conversations in Manuli with my neighbors about everyday metabolic disruptions. I discuss expressions of tenshun, an embodied critique of the stresses that life poses to the impressionable body. The body of tenshun is open and malleable to the stressful times of the city — crowded trains, long commutes, violence, bureaucracy, and the everyday grind of family life in tight spaces. Sometimes persons are understood to be porous to stresses and to let them pass through without a hitch. More often than not, though, stress sticks and creates lasting damage. Lastly, I return to the Y-Y paradox and the figure of the thin-fat Indian. Discussions with Dr. Yajnik and his interlocutors elucidate what the thin-fat body can do for advancing understandings of metabolic disorder.
I came to understand that scales were productive ethnographic sites to work through the question of how plasticity's actions are recognizable to people in specific moments and through specific cultural figures. If the thin-fat Indian makes plasticity matter, scales offer observational and methodological inroads into those matters. Scales do this in at least two senses. As instruments for measuring weight, scales are technologies of truth, however partial. Historically, the domestication of the scale from public venues into homes was essential for mainstreaming the measurement of body weight. Without the technology of measurement, the moralities affixed to body weight simply couldn't adhere (Schwartz 1986). In another sense, as Anna Tsing explains, scale is a rule of analytic distance that can magnetize or distance us from a problem. The national BMI created in 2008 certainly worked in these two senses of scale. It measured changes in bodies based on a standardization of body weight. It also put the previously used American/European index in the spotlight and anchored a series of extensive debates among biomedical experts about the relationship between risk and enumeration. A story of risk emerged at the dynamic interface of bodies, environments, and time. Concerns over obesity demarcated vernacular bodies through numbers, engaged claims about global epidemiological shifts, and accomplished both these moves by foregrounding a body whose temporal malleability enabled the accumulation of fat.
An elderly man pulled up his white kurta with one hand, inserted a one-rupee coin with the other, and stepped onto the scale. The machine whirred awake. Its face spun green and red lights, and a slit in its front shot out a piece of paper. The man stepped off carefully, slid his feet into sandals, and gave the paper a cursory glance. He shared the results with his two companions. "It says 94 kilos, but I'm 64," he said with a chuckle. In a rush along with all the other commuters, the men (with surprising agility) hopped onto the moving train car arriving at that moment, leaving behind the guess-your-weight scale, one of the most ubiquitous features of Mumbai's local train stations. With visual dazzle, these scales print weight on one side of their readout slips and a fortune on the other. The scales measure bodily change at the intersection of curiosity, certainty, entertainment, and diagnosis.
Scales in the city come in multiple forms and are themselves plastic in their ability to give, take, and shift form. On street corners, men sit cross-legged behind bathroom scales, with a cardboard square laid out in front that announces the one-rupee charge for the passerby to step on and weigh in. Alongside human ones, other bodies are constantly being weighed. Vegetables, fruits, meats, and grains dance onto the scale at vendor carts and shops, where every nudge of the finger on the counterweight can add or subtract rupees from the total sale price. Scales have already determined how much of that food arrives at the market. In Manuli, fish is an essential element of life and work, and scales determine a fisher's remuneration for a morning's catch. Through a fast-moving business ritual on the beach, a distributor for the area weighs what each fisher brings in from the sea and credits the man's account by marking a scrap of paper. Only then will the fish make its way to baskets women carry up and down stairs of apartment buildings, calling out as both question and demand the morning's offerings that eaters will eventually absorb. As for human scales, new forms proliferated, too. One day, outside the Glamour movie theater, I noticed that the longstanding guess-your-weight scale by the ticket line was gone, only to be replaced by a machine that purported to measure BMI. In contrast to the playful ambiguity of train station scales, the BMI machine suggested scientific certitude behind a number combining both result and fortune. No spin dials of lights appeared on this scale's face; instead, a digital readout and a clear question printed in English: "Are you overweight?"
The potential for an answer to that question was at the center of India's story of mass metabolic disruption. In mid-November 2008, newspapers reported that millions of Indians suddenly became overweight. Waiting for the local train, I read a headline about this development: "You Just Got Fatter: What Is Overweight for Caucasians Is Now Obese for Indians." I bought several newspapers at a kiosk on the train platform and found other headlines: "Obesity guidelines rejigged for Indians"; "Fat's in the fire, Gov't brings more under 'obese' and 'overweight'"; "Think you are slim? New norms may make you obese"; and the instructive "How to remove BMI," which included suggestions for approximating actress Kareena Kapoor's famous and ever-elusive size 0 (begin the morning with a glass of warm water with a teaspoon of honey and a squeeze of lemon).
Excerpted from Metabolic Living by Harris Solomon. Copyright © 2016 Duke University Press. Excerpted by permission of Duke University Press.
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Table of ContentsAcknowledgments ix
Interlude. Birthday Cakes 27
1. The Thin-Fat Indian 31
Interlude. Mango Madness 65
2. The Taste No Chef Can Give 69
Interlude. The Ration Card 99
3. Readying the Home 105
Interlude. Stamps 141
4. Lines of Therapy 145
Interlude. Waiting Room Walls 187
5. Gut Attachments 193
Conclusion. Metabolic Mumbai 225
What People are Saying About This
"As we travel the streets of Mumbai with Harris Solomon we come to understand the empirical complexity of any too-simple analysis of 'globesity' and discover that India's rising rates of obesity and metabolic disorders cannot be reduced to a problem of overeating. Solomon's writing is vivid, and he represents the dilemmas, resources, and popular cultures of contemporary India with sympathy, occasional humor, and considerable skill. This compelling and thought-provoking book will find eager audiences in medical anthropology, science studies, public health, and South Asian studies."
"Harris Solomon’s deft and beautifully written analysis makes a strong case for absorption as a key concept that will enable new understandings of global health and its politics; food and obesity as generative sites for reflection on complex transformation in urban India; and metabolism as a powerful figure for reanimating debate in science studies, medical and philosophical anthropology, and public health."