To set the problem in these terms is to imagine a different sense in which vital phenomena, in their multiplicity and indeterminacy, are political.
—Monica Greco, “The Politics of Indeterminacy and the Right to Health”
Obstacles to physical and mental flourishing require other frames for elaborating contexts of doing, being, and thriving.
—Lauren Berlant, “Slow Death”
Within the dominant logics and epistemologies of the Western imaginary, fatness and the vital materiality of fat itself have been viewed negatively. Fat bodies are “constructed (and discriminated against) as being unhealthy, ugly, and ‘out of place,’” and the substance of fat is defined as that which must be expelled from the body—precisely because it is seen as surplus and negative waste.1 Fatness has become synonymous with deviance in this cultural context, and bodies that are designated as fat are “fragmented, medicalized, pathologized, and transformed into abject visions of the horror of flesh itself.”2
These views on fat are largely based on biomedical claims about the health risks of being “overweight” or “obese”—terms and normalizing categories that are themselves open to questioning.3 However, such views are also associated with moral and aesthetic judgments that are made concerning what a fat body is said to represent, such as laziness, lack of control, asexuality, and undesirability. In distinction, what is taken as the ideal or normative body is a “tight and ‘bolted down’ form,” in other words, “a body that is protected against eruption and whose internal processes are under control.”4 Such ideas can inarguably be attributed to post-Enlightenment binaries that position control/chaos, order/disorder, bounded/unbounded, and self/body as oppositional categories. Within such a context, fat bodies are equated with bodily chaos and being out of bounds, and the “fat self” is seen—based on Cartesian logic—to have lost authority over the body it is meant to master.5 Beyond being viewed negatively, fat has been associated with the failure to thrive: that is, as that which prevents the body and life itself from flourishing and, ultimately, as that which portends death.6 Indeed, as Le’a Kent has noted, “the fat body represents the corporeality and inevitable death of all bodies. . . . The fat body is linked with death, and allowing fat into the body is thought to inevitably court death.”7
This threat to life is governed in the biomedical and broader social sphere through a diverse range of practices and interventions that comprise biocultures of anti-obesity. This chapter explores how initiatives within biocultures of anti-obesity are ostensibly concerned with life-making and proposes that such efforts (whether practical or rhetorical) are predicated on the affirmation to thrive: to flourish, to improve, to be healthy. In the context of obesity, this is a regulatory affirmation that calls for the individual to adopt an entrepreneurial subjectivity: to be strong, to eat well, and to make good choices.8 What we show, however, is that this supposedly positive affirmation supports a negative social reality—that is anti/against fatness—in which those who are deemed as fat or obese are positioned as failed social subjects. Moreover, anti-obesity interventions create or sustain deathly conditions that actually curtail life or threaten vitality itself. Namely, the practices we analyze do little to address the structural conditions marked by racism and economic disadvantage that contribute to escalating levels of obesity in the United States, and they often enable or are complicit in industry/private-sector exploitation that produces fatness or capitalizes on people who are demarcated as fat.
Despite the seeming overdetermination of fat materiality in anti-obesity discourse and interventions, fat has no ontological status. Rather, the way fat signifies—the meaning it accrues and the status it holds—depends on the domain in which it comes to be known and operate. Calling on the quote with which the chapter opens, fat must be understood, then, as a vital phenomenon that is multiple and indeterminate. In exploring the multiplicity of fat materiality and how fat is viewed, we shift away from obesity governance to examine a second case study related to fat: the relatively new deployment of fat/adipose tissue in biocultures of stem cell science.
In this biocultural context, fat has moved from being a category of surplus waste to an object of biovalue. For Catherine Waldby, biovalue refers to “the yield of vitality produced by the biotechnical reformulation of living processes,”9 while Nikolas Rose uses the term to refer to “the value extracted from the vital properties of living processes.”10 Fat is distinct from other forms of excess body material, such as ova, sperm, and embryos, precisely because where it is deemed excessive, it is usually pathologized. It is also distinct, however, from other forms of pathologized bodily waste (such as feces, urine, and pus) because of its potential utility in a therapeutic context.11 Fat becomes biovalue in the domain of regenerative medicine because its very vitality—its live-ness, malleability, and capacity—can be harnessed and redeployed, and this takes place because the adipose-derived stem cells (ADSCs) found in fat tissue have been identified as biological material that enables life to thrive.
The affirmation to thrive is clearly also at work in this domain. What we see, however, is a perverse reversal. In biocultures of anti-obesity, the affirmation to thrive is predicated on the eradication of fat—through entrepreneurial subjectivity. In biocultures of stem cell therapy, however, the affirmation to thrive works to affirm life through the animation of fat and the growth it enables. An epistemological shift occurs wherein fat is valued as a potential form of entrepreneurial materiality that can facilitate life-making. But, though the thriving enabled by fat—through stem cell proliferation—represents a new horizon in the biomedical fostering of life, we show that it also solidifies inequitable distributions of life based on economic access; it converts the body into a speculative asset; and it can threaten life itself. Ultimately, what becomes evident is that fat—and specifically the fat cell—is differently valued according to the body in which it is located and the biocultural arena in which it circulates. Furthermore, fat at once represents the impediment to and means through which to thrive, and in both domains or biocultural arenas, fat kills, or is said to kill—but offers the material ground for exploitation. In concluding the chapter, we ask, how might we work against the death effects of the affirmation to thrive and pursue more inclusive and socially accountable ways to thrive?
Biocultures of Anti-obesity and the Abject Matter of Fat
The World Health Organization has declared obesity a global epidemic. In a recent fact sheet, the organization claimed that in 2016, more than 1.9 billion adults aged eighteen years and older were overweight. Of these, more than 650 million were obese. Thirty-nine percent of adults aged eighteen years and older were overweight in 2016, and 13 percent were obese.12 The Centers for Disease Control and Prevention (CDC) has estimated that 39.8 percent of adults and 18.5 percent of children are currently obese in the United States.13 Both organizations claim that the worldwide prevalence of obesity more than doubled between 1980 and 2014. Adding further complexity to U.S. figures, data from the National Health and Nutrition Examination Survey 2009–10 stated that more than two in three adults are considered to be overweight or obese; more than one in three adults are considered to be obese; more than one in twenty adults are considered to have extreme obesity; about one-third of children and adolescents ages six to nineteen are considered to be overweight or obese; and more than one in six children and adolescents ages six to nineteen are considered to be obese.14
Fat alarmism is presumably due, in no small part, to the fact that fat has been provisionally associated with a raft of medical conditions, such as type 2 diabetes, heart disease, high blood pressure, nonalcoholic fatty liver disease, osteoarthritis, multiple types of cancer (including breast, colon, endometrial, and kidney cancers), and stroke.15 As early as 2001, this alarmism led then U.S. Surgeons General C. Everett Koop and David Satcher to declare a national “war against obesity,” to avert what they announced as the three hundred thousand “excess deaths” related to fat.16 To launch the war, they and the Health and Human Services Secretary held a press conference and, to motivate everyone watching, stated that “all Americans—as their patriotic duty—should lose 10 pounds.”17 In 2006, Surgeon General Richard Carmona vilified persons classified as “obese” as “domestic bioterrorists,” thereby situating the “obese” individual as a legitimate “enemy target” in the “war”—a war that resonated within a larger nationalist, patriotic narrative post-9/11.18 And, in an act that cemented the mounting panic over fatness, the American Medical Association passed Resolution 420 in 2013, which was short and to the point: “that our American Medical Association recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”19 This new label—“disease state”—is predicted to affect the way obesity is identified and treated and was deemed an appropriate classification because of the heightened prevalence of obesity, its threat to health, and increases in obesity-related health care expenditure, which is said to average $200 billion annually in the United States.20
These various forms of moral and medical panic over obesity have been reflected in what the American Medical Association called for: a proliferation of interventions and processes that aim to manage the problem of obesity and promote weight-related well-being—to administer fatness. Such interventions ostensibly labor to optimize the life of individuals and populations in and against the threat of fat. Collectively, they can be said to endeavor to make the population live more, and thereby they act as instantiations of the affirmation to thrive. In the first instance, all individuals are encouraged to thrive through regulating themselves in relation to what is viewed as excess weight—to affirm their own life through monitoring and minimizing the risks associated with fat. We see such incitements daily—and hear them in thunderous symphony21—on our televisions, in food advertising, in public service announcements related to health, and in our doctor’s offices. As Pirkko Markula has noted, individual citizens are now asked to take on primary responsibility for health in the face of fatness: “to locate themselves within the BMI [Body Mass Index] scale, to confess to being fat and to seek the appropriate bodily discipline (diet and exercise) to avoid becoming an economic burden for society.”22 Put another way, the American ideal of what Kathryn Pauly Morgan has called “carnal governmentality” is “a vigilant community of disciplined (and self-disciplining), compliant individuals—totalized by being sorted mathematically [and] . . . weighed and measured into discrete categories of normalcy and hierarchies of obesity-pathology.”23
Should individually led forms of prevention fail, one key way of intervening against obesity is via the biomedical approach, which focuses on biological factors of obesity. More generally, in the biomedical realm, genetic and early life factors are examined in relation to obesity, as are prenatal nutrition, biofood activities, and the role of fat tissue itself. Epidemiology, a branch of biomedical science, concentrates on regional prevalence of obesity, secular trends, risk factors, burden of illness related to obesity, and possible determinants. Importantly, the biomedical approach defines obesity via the BMI scale (a measurement system that has been widely criticized) and views “abnormal feeding behavior” as the primary cause of obesity.24 For instance, the National Institutes of Health states,
Overweight and obesity result from an energy imbalance. The body needs a certain amount of energy (calories) from food to keep up basic life functions. Body weight tends to remain the same when the number of calories eaten equals the number of calories the body uses or “burns.” Over time, when people eat and drink more calories than they burn, the energy balance tips toward weight gain, overweight, and obesity.25
In response, biomedical approaches concentrate on nonsurgical and surgical treatment methods to reduce weight. These methods include the use of anti-obesity pharmaceutical agents (“diet pills” like orlistat and sibutramine), the monitoring of diet, and—as an intervention of last resort—obesity surgery (gastric banding, bypass, and sleeve surgeries). Such biomedical protocols both biopolitically administer the population and discipline individual bodies: they are offered both as ways to regularize the mass of bodies that comprise the population and as techniques to “correct” and normalize the singular body.
A second key way of intervening into and administering obesity is through the public health approach, which generally draws on biomedical framings and understandings of fatness. This approach provides a population-based account of obesity (calling on epidemiological evidence) and pursues public policy changes that are important in the attempt to reduce the toll of poor diet, physical inactivity, and extreme weight: such efforts are clearly biopolitical in that they represent the calculated management of life of the masses that comprise the population.26 The public health approach concentrates primarily on prevention via public education around making positive food choices, exercise protocols, and general lifestyle choices. But public health authorities have also taken a more hands-on governing approach, stressing the need for food labeling, and in certain jurisdictions (such as New York City), they have succeeded in placing taxes on foods that are deemed to contribute to the rise of obesity. Intersecting with public health initiatives are state interventions against both childhood and adult obesity, which constitute a third form of obesity administration. For instance, in 2008, the Georgia State Senate passed a bill mandating that schoolchildren be weighed twice a year by school officials, New York City sends home “fitnessgrams,” and Philadelphia delivers “obesity report cards” to the parents of schoolchildren (six states in total have laws that require individualized assessment of children). In extreme cases, the state has forcibly removed children from their parents’ custody, using fatness alone as evidence of parental neglect (two reputable cases would be the Alexander Draper and Anamarie Regino cases).27 A final key way obesity is administered is via the diet and fitness industry that supports weight reduction. This industry is composed of proprietary weight reduction diets, diet facilities, food companies, pharmaceutical companies, diet and fitness book and magazine companies, personal trainers and health clubs, exercise programs, personal chefs, and so on. Estimates calculate the annual revenue of the U.S. weight loss industry at $72 billion per year (as of 2018), highlighting both the reach of weight administration and its financialization.28
While many of these interventions may attempt to move toward mitigating unhealthiness and death, they simultaneously advance and compromise the ability to thrive in a general sense and to reduce obesity more specifically. Such compromise can be seen in the very individualization of obesity—where fat and fatness are situated in biocultures of anti-obesity as only-ever-abject and as the materialization of individual failure. There are two important points to be made here, then: corpulence can never be imagined or circulate in the social sphere in a benign sense, and the healthy body—now only interpellated as slim—has come to signify the morally worthy citizen. It is due to these two notions that, as Lauren Berlant has argued, “the epidemic concept is not a neutral description, but always a contribution to ongoing mechanisms of social distinction. Who’s degenerate, who’s competent, and who’s out of and in control.”29 And it is precisely because both the supposed origin and answer to this epidemic is the atomized subject that obesity is individualized.
This individualization of obesity (and fatness more generally) is clearly evident in biomedical approaches, where the individual’s eating practices and body become governable and targets of intervention. The body, here, is divorced from its social context and subject to a form of power that, as Michel Foucault claims, is “centered on the body as a machine: its disciplining, the optimization of its capabilities, the extortion of its forces, the parallel increase of its usefulness and its docility, its integration into systems of efficient and economic controls.”30 Thus, while biomedicine operates at the level of population in the case of obesity (to regularize the social body en masse through inaugurating and disseminating practices of normalizing governmentality, such as the BMI), it more tangibly operates at the level of individual subjects to discipline the body and its size. Yet, biomedical approaches—which generally operate as adjuncts to lifestyle interventions (exercise, changing eating habits, etc.)—curtail vitality in myriad ways and threaten the ability to thrive in the same moment that they supposedly offer the means by which to eradicate fat. For instance, the weight loss pharmaceutical orlistat (Xenical), sold also in a low-dose form over the counter in the United States (as Alli), was marketed in the early 2000s under the slogan “Lose Weight. Gain Life.” But the drug compromises daily life through its most common side effects, which include oily rectal discharge; passing gas with oily discharge; urgent need to have a bowel movement; oily or fatty stools; increased number of bowel movements; being unable to control bowel movements.31 The drug also dissolves other fat-soluble substances in the body, including vitamins A, D, E, K, and beta-carotene, depleting the body over time; it has the potential long-term effects of producing kidney and liver damage; and it has been found to produce (in rats) high numbers of aberrant crypt foci colon lesions, which are believed to be one of the earliest precursors of colon cancer.32 Similarly, the weight loss drug sibutramine (Reductil) has the following side effects: dry mouth, nausea, strange taste in the mouth, upset stomach, constipation, trouble sleeping, dizziness, drowsiness, menstrual cramps/pain, headache, flushing, and joint or muscle pain. It also paradoxically increases appetite and was withdrawn from the market in 2010 in a number of countries (including the United States) because of findings that it significantly increased cardiovascular disorders, resulting in excess deaths.
Surgical biomedical approaches to obesity are no less troubling. What are collectively known as bariatric surgeries (including gastric bypass, adjustable gastric banding, and sleeve gastrectomy) commonly result in what is known as dumping syndrome, a condition stemming from corporeal changes after these surgeries and marked by “dizziness, palpitations, lightheadedness, nausea, and the sudden urge to vomit or defecate in response to foods with high carbohydrate content or sugar.”33 And, while weight loss is reported in most cases, acute complications associated with bariatric surgeries (which occur in 5 to 10 percent of patients, depending on the procedure, patient risk, age, and condition) include hemorrhage, obstruction, anastomotic leaks, infection, arrhythmias, pulmonary emboli, and rhabdomyolysis. Longer-term complications included neuropathies due to nutritional deficiencies, internal hernias, anastomotic stenoses, and emotional disorders.34 Despite these complications and death effects, bariatric surgeries are generally characterized in terms of “biomedical success,” and while this success might be attributed to surgical skill, it still unilaterally requires individual postoperative compliance and ongoing discipline, which situates any failure to lose weight or the regaining of fat—the failure to thrive—as internal to the individual.
Individualization is also at work in public health approaches to obesity. For instance, in a fact sheet on obesity subtitled “What Can Be Done,” the CDC instructs people to do the following: “eat more fruits and vegetables and fewer foods high in fat and sugar; drink more water instead of sugary drinks; watch less television; support breastfeeding; promote policies and programs at school, work, and in the community to make the healthy choice the easy choice; be more physically active.”35 Lastly, we see the individualization of obesity and efforts to intervene against fatness in governmental efforts to address fatness. Punitive governmental measures to disincentivize weight gain were put in place, for example, in the U.S. health care reform law of 2010 (the Affordable Care Act, ACA), which allows employers to charge obese workers 30 to 50 percent more for health insurance if they decline to participate in a qualified wellness program. The ACA also persuades Medicare and Medicaid enrollees to see a primary care physician about losing weight and funds community demonstration programs for weight loss.36 In such programs, employees who fail particular health biometrics (such as meeting a specific BMI target) incur a penalty or, if they meet the standard, receive a benefit. In another example, the Federal Action Plan of May 2010, released by the White House Task Force on Childhood Obesity (following a memorandum issued by former U.S. President Obama), also largely directed the incitement to eradicate fat—to reduce the tide of escalating obesity rates—at the individual level.37 The plan, which was in part actualized as the Let’s Move! campaign spearheaded by Michelle Obama, laid out five key pillars or action areas. Two of these pillars again stressed personal responsibility in relation to minimizing childhood obesity specifically. The first, “Early Childhood,” mentions the need to reduce chemical “obesogens” (the term given to a host of chemicals that may promote weight gain and obesity), but only in the context of individual activity (such as microwaving plastic baby bottles) and only after noting two behavioral elements—self-regulation regarding preconception weight and prenatal care and self-disciplining in terms of breast-feeding. The second, “Empowering Parents and Caregivers,” stresses that the fundamental responsibility of child health and development rests with the parents (stating “children learn from the choices adults make”). Such language effectively deflects attention away from the limited capacities certain people have to “choose,” which in turn shape consumption, eating, and broader behaviors.38
These various ways of individualizing obesity are problematic because, as we have outlined, they potentially subject people to numerous deathly conditions and forms of punitive administration. More than this, however, the very individualization of fatness ultimately compromises life because it does little to address the impersonal etiologies and structural conditions—broader sociopolitical, geographic, and economic factors—that have led to increasing rates of obesity that affect both individuals and entire communities.
First, what is overshadowed through the relentless forms of individualization outlined here are the ways that fatness and obesity are products of the political economy of food in the United States (and, of course, in numerous other countries throughout the world). As many critical food and fat studies scholars, along with antipoverty and antihunger activists, have insisted, people live in a toxic environment in the United States, where too much food is produced.39 Indeed, there is an infinite supply of what are known as “durable foods” (for example, corn, soy, sugar, wheat) because of the generous support of state agricultural subsidies, and it is these commodities that are then used to produce highly processed, high-caloric “junk.” Served in supersized portions to overworked, time-poor neoliberal subjects—who are confronted daily with a plethora of cheap, easy-to-access, nutrient-deficient food—this junk food is all around us and is “feeding” the nation. In the context of this obesogenic environment, making “good choices” is impossible for many. Moreover, alongside infinite supply, food marketing induces people to eat more, and as Julie Guthman and Melanie DuPuis have noted, in our contemporary context, we are encouraged to consume greater and greater quantities to be ideal neoliberal citizens: “eating becomes the embodiment of that which today’s society holds sacred: consumption. We buy and eat to be good subjects.”40
Second, focusing on fatness and obesity as individual and individualized phenomena obscures the ways they are conditioned by—and often the product of—material deprivation based on race and class (and their intersections). In other words, fatness and obesity can be a predicament of poverty, and as such, they can eventuate as the corporeal effects or the materialization of deprivation. Black Americans and Latinx most particularly bear this bodily burden, highlighting the racialization of fatness in the United States. According to recent figures from the National Institutes of Health, overweight and obesity affect 78.8 percent of Latinx and 76.7 percent of blacks, compared to 66.7 percent of whites. Almost 50 percent of blacks and more than one in three Latinx (39.1 percent) are considered to be obese (as opposed to 34.3 percent of their white counterparts), and extreme obesity affects more than one in ten blacks (13.1 percent), compared to 5.7 percent of whites and 5 percent of Latinx.41
The racial disparities in these figures are the result of complex histories of disenfranchisement, segregation, lack of access to resources, and inadequate allocation of resources related to achieving food security and health optimization more generally. For instance, many lower-income minorities experience impediments to spatial access to food, which manifests in extreme forms as food deserts.42 As the Racial Justice Project has noted, low-income minority communities are less likely to have access to supermarkets than nonminority communities, and what they do have access to—smaller grocery stores—carry less varied and higher-priced items than those found in other communities. In Washington, D.C., for example, “the District’s two lowest income neighborhoods, which are overwhelmingly African-American, have one supermarket for every 70,000 residents compared to 1 supermarket for approximately every 12,000 residents in two of the District’s highest income and predominantly white neighborhoods.”43 Given that limited access to nutritionally rich food potentially impacts rates of obesity (making people hungry, fat, and undernourished44), what we see here again is the way race and racism might “cut” the biopolitical fostering of life. At the same time, recent research in epigenetics—which focuses on the ways environments affect gene expression—has established that obesity might have other racialized etiologies not accounted for by behavioral or food access approaches. Exposure to certain agricultural chemicals (that act as endocrine disruptors), chronic stress and accompanying cortisol circulation (which has been shown to result from experiencing institutional racism), and generationally passed-on malnutrition have all been associated with escalated rates of obesity in minority populations. Epigenetic processes can be heritable across several generations and highlight another form of “letting die.”45 In the context of these factors, we see clearly that minorities have been and continue to be unequally incorporated into biological citizenship, resulting in what Didier Fassin has called “bioinequality” or what Matthew Sparke has theorized as “biological subcitizenship.”46 In such a context, focusing on individual “good choices” only further compounds racialized disparities through stigmatization—if they fail to do so—and overwhelms the reality that, as Berlant has eloquently stated, “morbidity, the embodiment toward death as a way of life, marks out slow death as what there is” for many people of color in the United States.47
In addition to acknowledging how the political economy of food and material deprivation contribute to fatness and obesity, we must be aware of (and contest) the ways that many interventions against the threat of fat can sustain or indeed be complicit in private-sector or industry exploitation of fatness—producing fatness, capitalizing on those demarcated as fat, and/or exacerbating death. Put another way, there is money to be made in making people fat, and fat bodies have become rich sites of financial extraction or points of accumulation within neocapitalist frameworks. Private industry is implicated here in numerous ways. We have already discussed how the food industry is complicit in fattening the nation and sustaining obesity. So, in the most obvious sense, this industry makes money out of creating products that make people fat, but it also then sells products to people that help slim them down—in the form of diet or calorie-restricted foods and beverages. The biggest market here is not the morbidly obese but all those individuals who have been made conscious of their weight through the relentless normalizing technologies and knowledges associated with fatness that pervade biocultures of anti-obesity. The pharmaceutical industry—which funds a great portion of obesity research—sets and lowers “at risk” levels of glucose, cholesterol, and other obesity-related biomarkers, enabling drug manufacturers to sell more medications to more people and exponentially increase profits. The life sciences are making genetics, microbiota, and stem cells, as they relate to obesity, sites of investment.48 Media profits from obesity through creating entertainment: The Biggest Loser, Celebrity Fit Club, Thintervention, Extreme Weight Loss, and Fit to Fat to Fit. The diet industry pumps out new proprietary weight loss regimes and fitness programs at an ever-increasing rate. And, finally, the new bodily forms created through weight loss surgeries have “created a new market for everything from new forms of plastic surgeries to remove post-weight-loss ‘redundant’ skin, nutritional supplements and specialty foods, to beaded medic-alert bracelets and weight-loss surgery scrapbooks.”49
What becomes evident, ultimately, is that the affirmation to thrive in relation to obesity is fraught. The ability to thrive—at both the individual and communal levels—is limited and the lives of many are curtailed, thereby exposing the “death function in the economy of biopower.”50 In neoliberal times, this is only exacerbated by a financial imperative that affirms an altogether different operation: the ability of industry and private-sector businesses to thrive economically—to thrive off fat and forms of premature death.
Biocultures of Stem Cell Therapy: Where Fat Is “Liquid Gold”
The way fat is understood and administered in biocultures of anti-obesity relies on the notion that fat is negative waste that kills and that such fat needs to be eradicated. Yet, paradoxically, in both biomedicine and broader social arenas, fat has undergone a reversal of status. Fat has come to signify something altogether else: it is a substance that can be harvested, harnessed, and redeployed therapeutically to facilitate corporeal repair or the extension—indeed, the proliferation—of life itself. Rather than being a threat, then, fat is viewed as the possible new horizon of life. This epistemological reversal is not, however, a simple inversion of status. Rather, as Catherine Waldby and Robert Mitchell have argued, it is only because a tissue is designated as waste—a part of the body to be expelled—that it can be put to another use.51 In the case of fat, it is only because it is classified as surplus and as a substance that can be wasted that it can be reevaluated and redeployed in another context. Put another way, value is facilitated by the tissue being categorized as waste. It is, then, a perverse reversal, in that fat has to be waste (and wasted) to be valued. Moreover, in biocultures of stem cell science, this value can only be secured once fat has been removed from the body. That is, fat can only be converted into value in abstracted form, and once it is liberated from the body, it can circulate as a form of entrepreneurial material that can be used to make individuals live (more). What we see, then, is that the materiality of fat—as a phenomenon—is multiple and indeterminate, and in certain biomedical contexts, it is called into the service of the affirmation to thrive, as the means through which to thrive, and individuals are encouraged to think of their own fat as that which can affirm life.
The therapeutic use of fat is by no means a new invention. For example, for more than a century, surgeons have used patients’ own fat, along with muscle and skin, to enlarge and reshape breasts following mastectomy. German physician Vincent Czerny performed the first documented case using such methods in 1895, when he transplanted a lipoma (a benign tumor comprising fat tissue) from the lumbar region to reconstruct a breast.52 Since then, in what might be referred to as first-generation deployments of adipose tissue, fat has been redistributed to other parts of the body for therapeutic repair. We see this in forms of fat transfer and fat grafting, where preexisting fat is moved from one part of the body to another. Yet, such uses of fat have been limited in that they can only achieve a point-to-point substitution.
The relatively recent discovery of stem cells in fat tissue has, however, altered the limitation previously associated with fat and has been a eureka moment in biotechnological developments.53 Indeed, new possibilities for life have been found “hidden in a pair of love handles.”54 As UCLA pediatric plastic surgeon Marc Hedrick has noted, “fat is not the tissue we once thought. For too long it was seen as something to be removed and tossed away [following most forms of lipoaspiration]. . . . We weren’t seeing its potential. We now know that it’s not just spare tissue.”55 What is so promising about this discovery is that fat-derived stem cells—what are known as adipose-derived stem cells (ADSCs)—can be used within tissue engineering and regenerative medicine to regenerate injured parts of the body and thus enable corporeal renewal. As such, with the identification of stem cells in fat, the surplus or residual becomes regenerative and emergent, thereby expanding the material and biotechnological possibilities and capacities of fat and exponentially increasing its value.
ADSCs are adult stem cells. Both embryonic stem cells and adult stem cells renew themselves in a process of self-renewal or morphogenesis. However, while embryonic stem cells are pluripotent, meaning that they are “blank” or undifferentiated cells that hold the potential to give rise to any type of cell, adult stem cells have a specific physiological function—to replenish the cells in their home tissues as needed. Adult stem cells are multipotent: these cells can give rise to different kinds of cells in their home tissues through entering normal differentiation pathways, but they do not normally generate cell types outside of their particular tissues or cell lineages. Despite this restricted developmental potential, adult stem cells can be manipulated in vitro to differentiate into different types of cells, including cells of different germ origin; and in vivo, the same changes can be seen when these stem cells are transplanted into a tissue environment other than their tissue of origin.
Adult stem cells have been identified in many organs and tissues, including brain matter, bone marrow, peripheral blood, blood vessels, skeletal muscle, skin, teeth, heart, gut, liver, ovarian epithelium, and testis.56 And, while the stem cells found in bone marrow have been considered the gold standard of adult stem cells, they are difficult to source, and such sourcing is achieved only through complicated and painful procedures. Finding stem cells in fat has, then, altered the terrain of stem cell science, and ADSC technologies/therapeutics are increasingly becoming the focus of clinical trials in regenerative medicine (with the U.S. government registering in excess of 300 national and international clinical trials involving ADSCs in application for a wide variety of pathologies).57 The reasons for this heightened interest are threefold: harvesting stem cells from fat circumvents the ethical minefield associated with using stem cells from embryos—because fat, unlike the embryo, is seen as inconsequential tissue; it is easy to source—liposuction is a relatively common and uncomplicated procedure, and more than four hundred thousand liposuctions are conducted per year in the United States alone, with each yielding between one hundred milliliters and more than three liters of fat;58 and, beyond being expendable, nearly everyone has some fat that they can spare. Moreover, fat has been identified as the richest source of adult stem cells, and these cells have been found not only to generate adipose tissue but also to differentiate successfully—through inducing processes—into bone, cartilage, muscle, skin, and nerves.59
To date, adipose-derived stem cells have specifically been imagined as “breast-making gold,” and breast reconstruction using ADSC therapy was the first major form of applied fat stem cell therapy in humans.60 That ADSC therapeutics developed in the context of breast reconstruction may be due to the fact that breasts are seen as inconsequential to the laboring body; that is, breasts are not required to “work” for the individual’s body to survive.61 It is considerably easier and more strategic, then, to clear regulatory hurdles through conducting stem cell research in relation to breasts rather than other tissue or organs. But despite the fact that breasts are seen as relatively inconsequential within the general taxonomy of corporeal significance, ADSC therapy represents an important way through which individuals might reimagine and materialize the body after breast cancer surgery—by deploying fat to produce an emergent breasted materiality, that is, a breast that arises or emerges from the genesis of cells and the interaction of these cells within the biological organism of the human body.
Two companies have been significant in the development of ADSC therapy in relation to breast reconstruction. The first is the San Diego–based biotech company Cytori Therapeutics, which has developed what it calls the RESTORE procedure.62 This procedure involves harvesting fat through liposuction and injecting this fat into what Cytori calls the Celution system—a patented machine that processes the tissue, extracts the patient’s regenerative cells, and concentrates them into a pellet. These concentrated stem cells are then combined with some of the liposuctioned fat cells to create a liquid suspension, which is then deposited back into the breast site, creating a biological mesh that is subsequently incorporated into preexisting tissue. The RESTORE procedure is heralded as being more successful than traditional fat grafts because the ADSC-rich suspension increases the growth factor signaling at the interface between the newly grafted tissue and the adjacent vascularized tissue, improving overall incorporation.63 A second company pursuing ADSC therapy for breast reconstruction is Neopec Pty Ltd., which is Australian-based and funded by the Victorian State Government. Neopec—whose guiding motto is “natural. individual. forever.”—aims to “entice a woman’s own regenerative capacity to grow living fat as a substitute for breast reconstruction.”64 The technique developed by the company involves implanting a biodegradable synthetic chamber into the mastectomy site, redirecting blood vessels from under the armpit into the chamber, and injecting the chamber with stem cell–rich lipoaspirate, which will grow to fill the space of the chamber over a period of four to six months.65 Both of these technologies endeavor to reimagine materiality and enable a supposed return to normative embodiment through the genesis and animation of form itself.
ADSC technologies are indeed promising: they envision (and actualize) the emergence of life through the very thriving of the stem cells found in fat. Registered clinical trials using ADSCs are in the process of exploring how they might enable soft tissue regeneration, musculoskeletal regeneration, cardiovascular regeneration, and nervous system regeneration. Studies have shown that fat stem cells are effective in treating Crohn’s disease, pulmonary disease, Parkinson’s, and various autoimmune diseases. And, given this potential, Medical and Scientific Advisory Board member Rand McClain sums up the overriding response to this promise of fat: “it really is amazing. The process of extracting stem cells from fat and reintroducing them into the body allows the body the ability, in essence, to heal itself naturally.”66
Despite this promise, however, ADSC technologies simultaneously present a number of contingencies that are obscured in much of the hype. First, and perhaps most importantly, at the same time that ADSCs are being reimagined as that which can foster life, they also threaten. New technologies using stem cells rely on processes of transformation and growth of tissue through regenerating the transformable—the emergent stem cell. Yet, it is precisely this reliance on cellular thriving and transformation that makes the technology risky: cells might grow or proliferate too well, and where the first signs of life can also mark the first sign of death, the excessive vitality of cells might result in the material emergence of cancer.67 In this vein, studies have demonstrated that ADSCs home in on tumor sites when injected intravenously and that ADSCs are tumor promoting. Furthermore, ADSCs have been shown to promote the invasion and metastasis of breast cancer specifically.68 These findings suggest that there should be pause before celebrating fat as the fount of life.
Second, such technologies convert the body and the fat it stores into speculative assets. We see this in the sense that ADSC technologies enable individuals to optimize the body and give what Waldby and Mitchell refer to as a “gift of self to self”—by investing a part of their body in their own future and relying on their own corporeal resources for that future.69 This reliance on the self is part of a broader operation that Rose names “the ethic of active citizenship that has taken place in advanced liberal democracies.”70 Within this ethic, “the maximization of lifestyle, potential, health, and quality of life has become almost obligatory . . . [and individuals are encouraged to] adopt an active, informed, positive, and prudent relation to the future.”71
That fat has offered this opportunity—new forms of self-reliance and the maximization of life—is particularly evident in the emergence and proliferation of “fat banks,” where individuals can store harvested surplus fat through cryopreservation. The premise of this banking is that stored fat can be reanimated at a later point for a range of therapeutic applications—such as repeated breast reconstruction revisions—or it can be kept (supposedly indefinitely) until ADSC research is developed into future clinical practices. Fat banking is, then, a future-oriented storing of promise, as seen in the language deployed by the banks themselves. For example, American CryoStem refers to the fat banking service it provides as “bioinsurance”; BioLife Cell Bank calls on the individual to “Preserve your cells. Preserve yourself”; and a fat bank called Liquid Gold markets its facility through the slogan “invest/save/withdraw.” Advanced Cosmetic Surgery of New York makes a more ambitious and forceful claim: “Storing your Adult Stem Cells has the potential of one day SAVING YOUR LIFE!” (it is only in the disclaimer at the bottom of the page that we are informed that “medical treatments using adult stem cells are still under development”).72
With fat banking, the promise and value of fat are spectacularly financialized, showing that subjects are being called on to “pay good money to buy back . . . [their] own bodily waste after it [has] . . . been processed through the infrastructure of commodity capitalism.”73 BioLife Cell Bank, as a case in point, previously offered two major banking packages—a “fat (adipose) banking package” and a “stem cell banking package”—with pricing for processing and storing starting at around $2,000 per year.74 Corporations are thus also employing adipose tissue as a speculative asset and converting the (always potentially) latent corporeal capital of fat into economic capital, a fact that is perhaps most clearly evidenced by the explosion of stem cell clinics worldwide and the burgeoning of stem cell tourism. The National Stem Cell Foundation of Australia refers to such practices as a form of “cowboy culture,” in that biotech companies and biomedical practitioners are reaping huge financial profits from therapies that are currently often unregulated and unproven.75 Promising to cure a range of pathologies—from stroke, muscular dystrophy, and spinal cord injury to Alzheimer’s—these clinics (which are featured on stem cell tourism routes in, for instance, locales like Kazakhstan, China, Mexico, and Argentina) prey on people desperate for a cure and willing to pay up to $400,000 for a chance of recovery.76 Fundamentally, however, fat and the body are positioned in ADSC technologies as speculative assets of and for the individual. This framing, in turn, individualizes disease—as the property of particular bodies—and positions the solution to disease as also residing in the individual’s body. The risk in such a framing is that attention will be redirected away from looking at broader social etiologies of disease and finding clinical solutions that would benefit (and be accessible by) wider publics.
Third, and related to the preceding point, ADSC technologies encourage and enable the conversion of the liberal subject into the entrepreneurial neoliberal market actor—one who can direct their own restoration, through fat. Problematically, this means that fat gets to be valued and remediated only by those already privileged within circuits of capital and broader relations of power. To take breast reconstruction using fat as a case in point (given that it is currently one of the main applications for fat technologies), the teleological end goal of realizing the (always vexed) promise of corporeal repair is conditioned from the outset by racial disparities in breast cancer incidence rates, diagnosis, and survival. According to the U.S. National Center for Health Statistics, death rates from breast cancer among African American women were 39 percent higher than they were among white women in 2015—representing the lowest five-year survival across all racial groups.77 This trend continues and can be largely attributed to lower frequency of mammograms and early screening, lack of insurance and/or access to health care, and the “unequal receipt of prompt, high-quality treatment.”78 If health is unable to be divorced from patterns of structural racism and social and economic disenfranchisement, and minority women are dying at increased rates, then corporeal repair is always already a foreclosed dream for some. This dream is further delimited by the fact that even if women survive the disease, there are discrepancies in terms of options to access breast reconstruction technologies—and specifically those using fat. Significant predictors of immediate reconstruction are white race and private insurance. Significant predictors of no reconstruction are diabetes, obesity, black race, and Medicaid.79 Cost is also clearly prohibitive: the average cost of reconstruction surgery involving autologous fat transfer procedures runs $50,000 to $100,000 (without insurance), and, while ADSC technologies for breast reconstruction are not yet commercially available, it is anticipated that their price tag will be at least that of—if not more than—traditional methods. As such, the potential to pursue repair or restoration—to thrive through fat—needs to be understood as a privilege enjoyed by a largely white, upper-middle-class, insured population.80
Other Frames of Being, Doing, and Thriving
Biocultures of anti-obesity and biocultures of stem cell science are diametrically opposed in their approach to fat and in how they epistemologically order and value fat. In the first biocultural arena, fat is said to kill. In the second, it is said to offer the possibility of corporeal renewal and life extension through fat stem cell proliferation. The affirmation to thrive is predicated in the first arena on the idea that individuals must eradicate fat through entrepreneurial activity, yet in the second, the affirmation to thrive is based on harnessing and redirecting the cellular potential of fat as entrepreneurial material—to reproduce life, whether that be of the cell itself or of the patient/body more generally. In both contexts, however, thriving is contoured by ideologies and discourses of self-reliance, individual responsibility (in light of declining state support and increasing privatization), and self-enhancement/optimization. As we have explored in numerous ways throughout the preceding chapters, these logics condition contemporary approaches to health: health has become increasingly individualized and that which individuals must be responsible for; individuals are encouraged to maximize their lives through established and emerging biomedical and broader health protocols; and, connected to this, individuals are increasingly encouraged to consume health-related (or purportedly health-enhancing) goods and services to be ideal citizens—to exercise “choice” as a form of freedom, while at the same time expanding markets.81
Additionally, in both biocultural arenas, the affirmation to thrive can curtail life and be deadly. In biocultures of anti-obesity, biomedicalized governance of fatness can and does endanger the health and well-being of individuals demarcated as “fat”—whether that be through the effects of biomedical interventions themselves or through forms of punitive administration. The individualization of obesity—and the entrepreneurial subjectivity advanced in anti-obesity initiatives—obscures broader sociopolitical, environmental, geographical, and economic etiologies of fatness and facilitates their continuation. Additionally, the lucrative market in fat production/fatness facilitates the “letting die” of many. In biocultures of stem cell science, calls to exploit the entrepreneurial materiality of fat individualize the body as a speculative asset, deepen and secure inequitable distributions of life chances, and potentially invite the material threat of cancer. Within the context of such let-die operations, the question remains, how might we work against these logics and practices and pursue other ways to thrive?
In the first instance, it will be necessary to question and work against the largely economic premise of what underscores the discourse of the “obesity epidemic” and its accompanying governing strategies: those financial logics that both propel escalating levels of obesity, on one hand, and benefit from those levels, on the other. In the second instance, finding other ways to thrive will also, as Kathleen LeBesco has noted, require looking “more closely at paths to wellbeing that abstain from the kind of carrot and stick model that beats down those it preemptively deems unhealthy.”82 One such possible path is the Health at Every Size (HAES) movement, which works against the pathologizing biomedical model of obesity. The movement advances principles like promoting bodily diversity, valuing pleasurable and individually appropriate forms of physical activity that are not aimed solely at weight loss, and “eating in a flexible and attuned manner that values pleasure and honors internal cues of hunger, satiety, and appetite, while respecting the social conditions that frame eating options.”83 In supporting such commitments, HAES seeks to broaden typical definitions of health—in relation to weight—beyond the restrictive terrain on which it now rests. One such example is the HAES-affiliated I STAND photo campaign. Developed by Marilyn Wann, individuals take photographs of themselves standing up to negative fat discourse to challenge and change anti-fat social prejudice—particularly against children.84
Another possible path is to view eating as what Berlant has called “self-medication,” while at the same time reworking what self-medication means.85 To self-medicate in relation to food is not, in this understanding, directed toward “health at any cost” or health as the end point or teleological goal of human subjectivity—where it is viewed as an individual attribute, as located in the body, and as fixed and measurable in relation to a norm. Rather, self-medicating through food might be a way to make things better, to define health in terms of affirming comfort, belonging, conviviality, and enjoyment. Understood in this way, self-medicating is not a negative. Rather, as Berlant notes, “it extends being in the world enjoyably and, usually, undramatically.”86 A tangible example here would be to think about health through culinary care as an alternative way to thrive. Emily Yates-Doerr and Megan A. Carney have examined how Latin American kitchens are such sites of culinary care—sharing stories of how women redefine food and feeding as pleasure, where pleasure is “both a means to and expression of health.”87 Their study outlines how women care for and through food: preparing food might be a way to nourish social ties, a way to build strong relationships, a means through which to support local growers and know the conditions under which food is grown. Individual needs and individualized notions of health do not structure these motivations. Instead, they are driven by expansive understandings of health and thriving as linked to families, communities, and lands. In preparing and offering food, they work against the neoliberal framing of what it means to thrive: rather than privileging self-reliance, they promote care for others; rather than focusing on individual responsibility, they imagine and actualize the capacity to thrive as a group commitment; and rather than giving primacy to the idea of self-enhancement, the women in this study explicate how communal support and nourishment are fundamental to well-being.
In relation to fat stem cell science, recall that the use of ADSC therapies or technologies runs the risk of materializing or exacerbating cancer—promoting the thriving of cells toward life in the same moment that they potentially inaugurate the cellular thriving toward death. More broadly, we have outlined how within biocultures of stem cell science, the potential to thrive is viewed as an individual pursuit, a way of optimizing the health of the singular atomized subject who is able to pay for such services. More ethical ways of thriving in relation to fat stem cells are also imaginable, however, but they would rely on first finding ways to mitigate the threat of cancer and would require extensive further investigation as to the broader efficacy of fat stem cell science and therapeutics. If, however, these limitations were overcome, would it not be possible to pursue forms of stem cell altruism rather than harvesting and harnessing these stem cells only for individual use? For instance, if there is so much supposed excess fat, we could conceive of donor services, where those who were interested could gift their fat to others. Along these lines, we could establish fat-banking commons, where gifted fat is stored for communal use—enabling unwanted fat to enter into the circulation of exchange so that those who were in need of ADSCs could access a wider pool of cell reserves. Such possibilities have already been advanced. Indeed, ADSC therapies have been positioned as a potential way to combat rising levels of obesity in the population, with the American Heart Foundation predicting that “future citizens may undergo liposuction to remove excess adipose tissue in ‘fat drives’” similar to existing blood drives.88 To be truly communal, however, such efforts would need to be kept out of the hands of private entities or actors—such as pharmaceutical companies and their investors—who could convert this altruistic gifting into a vehicle of wealth generation: it would require that fat be democratized and made public as a reimagined nonprofit tissue reserve. In each of these scenarios, we see a different understanding of “fat liberation” that works against thinking of fat and health as the property of the individual. And, instead of conceptualizing ADSCs only as the means to optimization, we could conceive of fat stem cells as enabling new forms of ethical conviviality.
If, as we have explored, the dominant affirmation to thrive in relation to fat is regulatory, individualizing, life-threatening, and that which secures inequitable distributions of health, it becomes imperative to find other frames of being, doing, and thriving. Like dominant modes, the alternative versions of thriving that we have outlined here are underscored by a commitment to vitalizing and maintaining sustainable lives. They are distinct, however, in that they share a more expansive understanding of what constitutes life, propose ways to cultivate life that are dispersed across collectives, and advance more socially accountable ways of thriving.