embodied largeness: a significant women’s health issue

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Nursing Inquiry 2001; 8(2): 90– 97

Feature

Embodied largeness: a significant women’s health issue Blackwell Science, Ltd

Jenny Carryer School of Health Sciences, Massey University, Palmerston North, New Zealand Accepted for publication 25 January 2001

CARRYER J. Nursing Inquiry 2001; 8: 90–97 Embodied largeness: a significant women’s health issue This paper describes a three-year long research project in which nine large-bodied women have engaged in a prolonged dialogue with the researcher about the experience of being ‘obese’. The study involved an extensive review of the multidisciplinary literature that informs our understandings of body size. The literature review was shared with participants in order to support their critical understanding of their experience. An examination of a wide range of literature pertinent to the area of study reveals widespread acceptance of the notion that to be thin is to be healthy and virtuous, and to be fat is to be unhealthy and morally deficient. The experience of participants raised questions as to how nursing could best provide health-care for large women. According to the literature review, nurses have perpetuated an unhelpful and reductionist approach to their care of large women, in direct contradiction to nursing’s supposed allegiance to a holistic approach to health-care. This paper suggests strategies for an improved response to women who are concerned about their large body size. Key words: feminist research, nursing practice, obesity/fatness, women’s health.

This paper arises from the completion of a three-year feminist research project. The study examined the experience of women who are living in a large body within a social context which pathologises and stigmatises fatness. I will briefly describe the study design and the research process. In presenting the findings I will also discuss the possible contribution of the information and insights generated by this study toward improving nursing’s contribution to this significant area of health need. The literature review performed prior to and during the research process encompassed the literature, psychology, nutrition, the social sciences, women’s studies, medicine and popular media writings. In addition, a full review was done of every relevant nursing article from 15 years prior to the research period. Based on the literature review and the research findings, I plan to debunk the accuracy and usefulness of the medical explanation of ‘obesity’ as a disease. I will argue for an improved nursing response to large women as

Correspondence: Professor Jenny Carryer, School of Health Sciences, Massey University, Palmerston North, PB 11–222, New Zealand. E-mail:

patients or clients and a more useful nursing contribution to primary health-care in the related context. This will be argued from the perspective of developing improved congruence between nursing’s theoretical stance and the manifestation of that theory into practice. Initially I argue that the incongruence of nursing practice in this area arises from our obedience to medicine even when, as will be shown, medical understanding and practice is flawed (Hirsch 1994; Rosenbaum et al. 1997; Ernsberger and Koletsky 1999).

THE INVESTIGATION PATH AND FINDINGS Over a period of 2 years, a series of five semistructured interviews was conducted with nine women who were visibly and self-identified as well above currently accepted norms for female body size. The women responded to an advertisement for appropriate participants. The research process was participatory with interviews taking the form of an emerging dialogue. I asked questions, but also encouraged participants to direct the focus of questioning. In addition, I shared my own reading and growing knowledge as the research progressed. © 2001 Blackwell Science Ltd

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The interviews were transcribed and subjected to thematic analysis. The analysis was discussed and shared with the women, who provided ongoing critique of the emerging themes. Analysis generated the concept of embodied largeness. This included a range of experiences involved in battling a body that would not stay small. The women described their automatic recourse to reduction dieting and their vigorous, vigilant and repeated dieting against a steady increase in body weight. Private obsession with monitoring food intake was accompanied by alienation from the social world of food. The women also described considerable suffering as demonstrated here by one participant: I was at a family gathering of my husband’s and my daughter knocked over a cup of boiling hot tea on my leg. I had trousers on and I just sat there and I didn’t do anything about it although it was burning me, actually all my skin came off, because I was so self conscious … whereas if I’d been skinny I probably would have whipped my trousers off … borrowed a pair, but whose could I borrow — they were all skinny.

The research also revealed that being large precluded good health. This was attributed not to body size per se but to the self- and socially imposed restrictions that prevent large women from relaxation, recreation, exercise and a sense of safety and deservedness when accessing health-care. At the conclusion of data analysis I arrived at a clear understanding of large body size as a socially constructed disability as made clear by this participant: You see it seems to me that being overweight is like a trap, because being overweight makes it harder and more painful to exercise, it makes it more difficult to get involved to get out and do things and it makes it more difficult to be taken seriously in terms of health care. But all of those things, not taking your health care seriously, not enjoying your life and getting out and not exercising are quite detrimental to health in themselves, it’s like a vicious circle that we get trapped in, that all large women get trapped in.

In keeping with the critical focus of feminist research, the study also involved an examination of the various discourses (including medicine and nursing) which explain large body size in particular ways, and thus constitute the understanding of large women themselves and the beliefs and practices of health professionals. During extensive, reflexive and reciprocal interviewing, the nine participants shared the ongoing critique of social and medical understandings of body size with myself as a researcher who is similarly positioned as a large woman. At many intervals throughout the project I shared my emerging understanding with women in Australia, Canada, the USA and throughout New Zealand. Sharing with larger © 2001 Blackwell Science Ltd, Nursing Inquiry 8(2), 90–97

groups of women provided excellent and reassuring feedback that the data analysis from nine women had a high degree of fit and credibility with women from many other locations. This extends the notion of face validity of data as first proposed by Lather (1991). At times this process was quite overwhelming as it continually surfaced the degree of absorption and pain that is present in most women’s engagement with body size. During the course of the research, I also engaged in feminist focused discussion groups. Here my emerging interpretations were subjected to rigorous debate and critique as they were when shared with women as described above. This was particularly important to ensure that as a feminist researcher I retained a critical analysis not just of the women’s experience but also of the context in which they lived that experience. I had long been nervous of the potential reification of experience that has characterised interpretive work, as noted by Allen (1996) and Scott (1991). They have argued that investigating experience has often omitted an examination of how that experience came to be. Allen suggests that experience can retain a positivist notion as some type of incontestable evidence, and he advises retaining the idea that experience is in itself an interpretation and even that interpretation is open to challenge and reinterpretation. Because participants were to some extent involved in the analytical process, they also continued to engage with my growing understanding. This meant coming to view body size as a discursive field in which medicine’s flawed understanding (Hirsch 1994; Rosenbaum et al. 1997; Ernsberger and Koletsky 1999) was a dominant discourse that influenced all other sources of understanding. For almost all of the participants the research was personally satisfying. They gained increased knowledge, a sense of not being alone with, or personally culpable for, their experience of largeness and some degree of resolution of their life-long body battle. One participant wrote of her feelings of relief following the research process, ‘If I am naturally large, which I am, why, why should I spend all of this wonderful short lifetime wishing to be someone else. Your research has empowered me’ (emphasis in the original). This study raised many theoretical and methodological issues, but in this paper I wish to confine the discussion to considering how it can inform the practice issues of nursing. The concerns I raise have been generated by my own reflection on participant experience, and the extensive multidisciplinary literature review which has also raised a number of theoretical questions. In particular, I noted the pervasive influence of medicine on social- and literaturebased responses to the issue of body size. 91

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THE INFLUENCE OF MEDICINE ON PERCEPTIONS OF BODY SIZE

THE RELATIONSHIP OF BODY SIZE TO HEALTH

The literature review revealed that dominance of medical discourses as the accepted explanation of the human health and illness experience consistently acts to obscure other more useful means of understanding. In the area of body size the dominance is particularly profound because of the embeddedness of medical discourses in both popular media sources and the literature of other health disciplines, especially nursing. Almost without exception, any article about body size and health, even when written by nurses, uses medical beliefs as the point of reference from which all else follows. What is more, the medical doctrine is accepted without criticism or even reflection (Carryer 1997). The history of medical understanding of the ‘disease’ obesity is characterised by marked shifts in explanatory models. Researchers can now identify the inaccuracy of previous apparently scientific explanations for the presence of excess bodily fat, and those who are more thoughtful also recognise that present understandings may still be similarly flawed or at least incomplete (Hirsch 1994). The basic premise has always involved an assumption of hyperphagia (overeating) and much time has been spent trying to determine the role of the mind in directing the ‘obese person’ to eat more than they need. There is now growing agreement that this has been a very limited, inaccurate and futile approach to a much more complex issue (Hirsch 1994). Research related to the genetic inheritability of body size has been available since the 1920s, but health professionals rarely acknowledge such influence. There is now evidence to indicate that as much as 80% of the variance in the bodymass index is attributable to genetic factors (Hirsch 1994). Hereditability is now understood to cover a range of factors including distribution of body fat, resting metabolic rate, changes in energy expenditure in response to overeating, food preferences and physical activity levels. This is not a complete explanation, as there is clearly a complex interaction between genetic contribution and environmental manipulation. Medicine has actively supported several interacting notions about body weight, all of which are incomplete, inaccurate and work to reinforce each other on the basis of shared inaccuracy. Cogan and Ernsberger (1999) suggest that these false assumptions are that people can change their weight at will, that dieting works and improves health, that dieting is good for the dieter and fatness equals disease and that thinness equals health.

Medicine subscribes simplistically to the notion that good health must include bodily slenderness and defines large body size as an illness labelled as ‘obesity’. It has been well argued (Hirsch 1994; Rosenbaum et al. 1997) that the relationship between body size and health is at best poorly understood and that there is limited support for medicine’s contentions about the universal desirability of weight loss. Assumptions about the negative effects of largeness are consistently overemphasised and have entirely obscured a number of actual health benefits conferred by so-called obesity. As Ernsberger and Koletsky (1999) argue, a substantial number of very large, longitudinal studies showed that overweight increased morbidity risk only when it was extreme and moderate levels of overweight do not increase risk (Allison et al. 1996; Bender et al. 1998). Conversely, nursing understands health as a multifaceted, multileveled state of wellness which incorporates physical and emotional well-being expressed through satisfying engagement with work, relationships and leisure or relaxation. Defining the concept ‘health’ has engaged the thoughts and writing of nurse scholars for many years ( Jones and Meleis 1993). Consensus has been reached that, for nursing at least, health is considerably more than the absence of disease. During the period when nursing focused on conceptualising health, it was defined variously as a state, an entity, a process, a goal or an equilibrium (Tripp-Reimer 1984). The intersections of power and knowledge which allow a medical discourse to pervade nursing and popular discourses leave almost no space for the large woman to understand herself in any way other than as physically compromised and socially undesirable. There is literally no other location in which she may stand. Accordingly, women make the assumption themselves, as do most health professionals, that striving to be thin is the single most health-promoting activity that a large woman can undertake (Carryer 1997). There are significant health consequences from body size but they are different from what is commonly held to be true.

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Consequences of contemporary beliefs and practices about large body size Participants in the research project described how they constrain a large number of lifestyle and other choices because they perceive their large bodies to be either unsuited or unacceptable for many settings. In particular, they withdraw from exercise participation, sit on the sidelines in recreational pursuits and feel hesitant in many social areas because © 2001 Blackwell Science Ltd, Nursing Inquiry 8(2), 90 – 97

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of real or imagined stigmatisation. One participant described her reluctance to risk embarrassment: I was just thinking when the family was away at Christmas time and everybody was out canoeing, which I would quite like to have a go at. But I thought if I have any trouble getting into or out of that canoe or I tip it over.

The women described enduring a difficult preoccupation with food induced by chronic engagement with reduction dieting, yet despite repeated diets they watch their weight continue to rise. They often avoid seeking health-related consultation for fear of criticism. They interpret and internalise the social meanings ascribed to fatness and have difficulty perceiving themselves as sexually desirable. Finally, all of these feelings are overlaid with a strong sense of their personal culpability because thinness is socially understood, and medically argued, as possible for all. I will now explore some of these findings in more detail, focusing on the manner in which they impede access to good health.

Chronic reduction dieting The participants had all dieted extensively and conscientiously. Several had lost and regained up to 60 kg of weight during the course of their adult lives: I started dieting and I remember that I wanted to get to 65 kg, ideal weight, but I think I was 70 kg or something crazy and I remember getting on the scales at work all the time and dieting and really doing it hard, you know ... and then of course because I got so small I could only get bigger ... I got bigger, to 9 stone then I wasn’t 8 stone anymore. So I dieted and that sort of started it all I guess. I guess I would have one serious diet a year. Lose a bit and gain up again.

Information relating to the problematic nature of reduction dieting has been well documented for many years ( Bennet and Gurin 1982; Atrens 1988; Wooley and Garner 1991; Leibel et al. 1995; Erdman 1996; Cogan and Ernsberger 1999). There are now well-developed explanations for the chronic failure of reduction dieting which bear no relation to the will-power of the dieter. The cost to chronically dieting women, in terms of loss of energy, irritability and nutritional deprivation, appears to be neither acknowledged nor researched to any degree. Women, especially young or pregnant women, have particular nutritional needs, especially the need for calcium and iron intake (Kirkley and Burge 1989). A New Zealand study (LINZ Survey 1995) has reported consistently low iron levels in women compared with levels in the normal range for men. There is also growing awareness of the problem of calcium-related diminished bone density in women, leading © 2001 Blackwell Science Ltd, Nursing Inquiry 8(2), 90–97

to osteoporosis in older women and the sequelae of lifelimiting hip and other fractures. The women in the study reported a degree of eating consciousness that is present whether they are dieting or not. While constantly handling food in the process of caring for others, they are also aware of its forbidden nature for themselves. Ogden (1992) also documents the altered relationship to food described by dieters. This includes obsessing about ‘forbidden food’, following one dietary lapse by eating excessively to compensate for the sense of failure, and feeling bad about themselves and their eating after consuming a high-calorie meal. Women in the study also reported the weariness and physical fatigue associated with chronic dieting, especially when combined with work and domestic responsibilities. Yet they live in a discursively saturated environment from which they glean that they are greedy and eat too much. Simultaneously, they grapple with the physiological and psychological consequences of dieting, and it is virtually impossible for them to know how, or even what it is, to eat normally.

Exercise The outcome of many aspects of living in a large body is a decrease in what nurses would regard as health-promoting behaviours. Fear of injury, shame and ridicule are significant deterrents to exercise, especially participation in public recreation such as skiing and swimming. Knowing how one is viewed and thought of by others serves to confine large women to lonely encounters with a miniature trampoline or skipping rope, rather than the more motivating participation in recreational sports. Exercise is almost invariably promoted to women as an activity aimed exclusively at the loss of weight. For example a recent advertisement for a women-only gym invites members to ‘burn fat fast’. The advertisements of gyms aimed at women often offer a reduced joining fee in order to achieve weight loss before summer. Women-only gyms advertise the presence of ‘tummy trimmers’ and ‘butt blasters’, thus employing graphic language to offer the eradication of the demonstrably female portions of a woman’s body.

Stigmatisation Few large women can fail to be aware of the widespread repugnance with which an out-of-control female body is viewed. In the process of interpreting and internalising the meaning of fatness, study participants were found to be taking a deeply stigmatised way of living in the world into their own self-concept: 93

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I think people would make comments about large people where they wouldn’t make comments about disabled people … I think it comes from the fact that large people are perceived to be makers of their own destiny and disabled people are not and so therefore you can’t, you don’t joke about something people don’t have control over. Being a large person we all know how hard it is to have any control what size you are really. It takes so much control if you want to do something, but people seem to think it’s OK to make large jokes.

The experience of bodily largeness is a health-threatening experience. But it is made so by rigid socially and medically condoned requirements for women to inhabit particularly small and artificially restrained bodies. Suggested treatments, diet-triggered disordered eating and prolonged stigmatisation combine to produce a lived experience which on balance may be far more detrimental to health than simply having a larger body than the body currently and somewhat arbitrarily deemed to be normal (Carryer 1997). These research findings stimulated considerable reflection on the contribution that nursing makes and could make in this area.

THE NURSING RESPONSE AS IT IS NOW On the basis of the comprehensive review of nursing literature, I argue that nurses have, in the main, colluded with the unhelpful responses offered to large women. I argue this while recognising that nurses as a largely female profession may find it difficult to stand outside their own discursive positioning as women. My review of nursing literature demonstrated a degree of uniformity about existing nursing responses to women whose body size falls outside accepted norms. Nurses have accepted the premise that a bodily state of largeness is a disease and a disease with such unacceptable consequences that weight must at all costs be reduced. Some literature (Miller 1992) spoke of ‘the obese woman’ in terms which often precluded a caring focus and assumed their wilful responsibility for being large. In the literature I reviewed, a behaviourist focus was predominant and advice was presented which aimed to improve the imagined bad eating habits which are assumed to occur due to lack of willpower, insufficient knowledge, poor motivation and even lack of intelligence. A significant lack of assessment supports false assumptions of excessive eating and a complete lack of awareness of socio-cultural or political analysis exists. There are notable exceptions (MacBride 1988; Rossi 1988; White 1991; Dossey 1995), but they are few and far between. Nursing has increasingly prided itself on the possession of a separate body of knowledge, unique to nursing and entirely separate to medicine (Doheney et al. 1992; Barnum 1998). It is argued that what makes nursing different is that 94

we nurse persons, not parts of people or diseases or even isolated events in people’s lives. We have also prided ourselves on a growing realisation that people cannot be effectively nursed without reference to their environment. This includes family, the wider social sphere or, more ambitiously, the socio-political context in which each individual negotiates their health. In the context of body size, comparing the response in related nursing literature with the need made manifest by the participants in the study reveals a profound schism. The women in this study clearly articulated their suffering and their very real difficulties in reaching their full potential to enjoy life and to be as fully healthy as is possible for them personally. Supervised reduction dieting, referral to diet clinics (professional or entrepreneurial) and complicity with marginalising stereotypes do not fit comfortably with any ethos of nursing we could currently explicate. The women in this study had not sought nursing support for weight management but they had experienced inappropriate care by nurses and doctors in a range of settings. This, combined with the content of the literature, suggests a clear duality of focus with nurses practising within a central contradiction between the servicing of supposedly scientific medicine and the provision of holistic care (Wicks 1995; Davies 1998).

The nursing response: personal care During and following completion of the study, I have inevitably discussed the work with postgraduate students, with registered nurses and medical practitioners in seminars and with women in a wide range of locations. I have received many spontaneous comments about the degree of censure which is expressed privately, and sometimes not so privately, about large women as patients. It is noted that both medical practitioners and registered nurses make such comments. It is known that social stigmatisation and the perception that fatness is wilful and distasteful are present in the attitude of many health professionals (Blumberg and Meleis 1985; Wiese et al. 1992; Hoppe and Ogden 1997). Such negative perceptions must cloud the caring and concern for a patient’s well-being and reduce sensitivity to her distress and embarrassment in situations which inevitably include high levels of bodily exposure to strangers. Nurses and women alike engage in endless self-monitoring of their bodies’ compliance and they jointly look to medicine as an authority on the acceptable body (Connors 1985). It is asking a great deal to require nurses to stand outside their socialisation as women and to practice nursing free from marginalising behaviours, but it is also a requirement that needs to be addressed vigorously. © 2001 Blackwell Science Ltd, Nursing Inquiry 8(2), 90 – 97

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It is important because of the nature of the therapeutic relationship between nurse and client. The essence of such a relationship in nursing is that the client experiences the encounter as a valued and respected person. In a situation where the nurse holds negative evaluations of the client and unrealistic expectations it is likely that the nature of the relationship will be compromised. Participants in my research expressed their feelings of humiliation and frustration at the comments they felt forced to accept without right of reply. In one incident, however, the participant did make a telling reply: Once going into A & E [emergency room] with suspected appendicitis, I was feeling really miserable. They left me there and then poked and prodded around of course and this doctor came in and he said of course you are overweight, and I thought well that was a brilliant deduction, I said ‘so it can’t possibly be appendicitis then, you know it’s just fat?’

The care of large women as patients is an important aspect of the one-to-one direct care provided by nurses. There is also the wider realm of primary health-care which moves beyond personal care to the realm of health promotion, advocacy and political action.

The nursing response: primary health-care The equation of obesity with ill health and the assumption that weight loss must be pursued at all costs is clearly an extremely simplistic response to a problem that is multifaceted. Nursing has a commitment to nursing whole people, mindful of their individuality and mindful of the diverse pathways toward good health. Nurses could reconceptualise ‘obesity’ by moving beyond the simplistic medical behaviour of labelling body size as a disease. Instead we could consider more thoughtfully what it is about body size which most precludes the full achievement of health, and respond accordingly. This response would be multifaceted, involving management of the social response to body size, addressing the achievement of suitable exercise habits and constructive balanced and nurturing diets. This is especially challenging for those whose eating has become disordered and emotionally fraught, through years of ill-advised reduction dieting (Hirschmann and Munter 1995; Erdman 1996). Participants all described an adolescence wherein they felt alone with their body size problems and an adulthood in which they believed their own situation to be both isolated and of their own making. Creating situations where women and adolescent girls may articulate their distress to each other may generate less isolation and more challenge from women whose lives are thus constrained (Carryer 1992). © 2001 Blackwell Science Ltd, Nursing Inquiry 8(2), 90–97

There is enormous and unrecognised potential for effective health promotion for girls and women. It will not be found in nursing’s current acceptance of the oppressive requirements for women to conform to rigid specifications for body size and limiting definitions and practices of femininity. Nor will it occur while excessive anxiety about food and appearance is deemed to be normal feminine behaviour. It is not health promoting for nurses to comply with behavioural programmes which require some women to gain weight and others to lose it. This is based on arbitrarily imposed norms and in most cases without cognisance of the issues that make body size so problematic for women. I contend that there is sufficient evidence to suggest that nurses should actively and publicly reject reduction dieting as a method of weight control, and work to prevent young women from embarking on a life-long involvement with reduction dieting. I also argue that it is inappropriate to encourage large women to engage in reduction dieting. In so doing we enforce the binary opposition, to diet or not to diet, and avoid looking for the healthier practices which may arise in the gap between these two poles. Nursing needs to address the support that could be offered to women such as those in this study, who have dieted extensively and are now considerably more overweight than they were before they commenced dieting. From a health outcome perspective this is ironic, given that morbidity and mortality consequences only become significant at extreme BMI (body mass index) levels (Cogan and Ernsberger 1999). Some nurse authors (MacBride 1988; Dossey 1995) argue for an approach to large women that does not equate with the traditional practice of supported weight loss. They suggest that genuinely holistic care would mean having multiple criteria for success and this would seem to fit comfortably with the multifaceted experience of body size. Their approach begins, as should all nursing approaches, with a careful and entirely individualised assessment of each woman which attempts to identify what that person wants. Dossey (1995) asks clients to look within themselves for the source of their difficult relationship to food, although at the same time she strongly advocates the need to abandon reduction dieting. Given the hegemonic nature of discursive constructions of femininity, it is difficult for any woman to take up a subject position that stands outside conventional feminine attractiveness with its close links to slenderness. It is challenging for nurses who do view women’s health through a feminist lens to choose to what degree and exactly how this approach will be utilised in practice. Based on the findings of this study, there are particular concerns which characterise the health needs of larger-bodied women. Fears of ill health from excess weight may often be 95

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unrealistic, depending on particular circumstances. There may be considerable pressure from relatives and partners that will need to be examined and dealt with. There may well be inaccurate expectations about reduction dieting and a high sense of personal culpability to explore. There may be withdrawal from participation in exercise and recreation due to bodily shame. As one participant noted: I absolutely love it up the mountain, I love the air, the snow the sensation of skiing and all I could think of [is] what would I wear cause I’ve got nothing that will fit me on the ski field and if I fall over and break my leg, how humiliating to be carried off the mountain by two zippy ski instructors.

There are a variety of possible interventions for a woman who is realistically concerned about her weight. Alteration of the diet may involve increasing complex carbohydrates, fibre, calcium and iron and reducing processed foods, salt, simple sugars and fats. Searching for an appropriate exercise modality which is not too boring, too expensive or impossible to combine with other commitments may be useful for some women. Abernathy and Black (1996) support this process in saying: ‘Indexes associated with high risk in obese persons often return to normal with appropriate physical activities, dietary habits and a small weight loss even when body weight and percentage body fat remain above recommended standards’ (448S). Learning to disengage from reduction dieting may eventually allow healthier eating patterns. It is suggested (Hirschmann and Munter 1995; Erdman 1996) that as the spectre of dieting fades, the former dieter may be able to resume eating in response to hunger and need rather than less appropriate cues. Regaining a relaxed attitude to satisfying hunger and relinquishing eating consciousness may or may not cause weight loss, but it may well prevent further gain. Even more importantly, it will eventually relieve a source of constant anxiety and preoccupation. In relation to improved nursing practice in the area of large body size, I have discussed both the care of large women as patients and the primary health-care of all women. I have suggested that in order to provide a high standard of practice, nurses would need to acknowledge and deal with their personal positioning within the dominant discourses about ‘obesity’ and those pertaining to femininity. As befits the standards of a profession, care must be based on researchderived knowledge about the client group tempered with an approach that is, in the true sense of the word, holistic.

CONCLUSION Despite professing to reject reductionist concepts of health and illness, nursing, in the area of women’s body size, 96

adheres to them somewhat blindly. In the process of proselytising holism (Lawler (1991), nursing has also subverted that from its initial global and population focus to an individual focus in which it has an uncomfortable fit. The consequent philosophical and practical confusion is clearly borne out in the area of this study. In the area of women and body size there is much that could change. I have argued that nursing must reconceptualise body size, reclaiming it from the artificial and unhelpful diagnostic labels provided by medicine. The reconceptualising of body size will involve ignoring arbitrary definitions of normal and abnormal weight. Medical research about body size and health outcomes has been overshadowed by cultural or aesthetic preference for slenderness, creating an excessive and inappropriate demand for bodies to be attractively thin. This creates an opportunity for nursing, with its greater involvement and understanding of the social, to focus on optimising women’s health in both an individual and social sense. There is potential for nursing to focus more directly on constructive nutrition for all people regardless of body size and to promote active rejection of the diet industry. Nurse-led primary healthcare centres could provide a safe space for women of all sizes to access screening and other necessary health encounters. As a discipline we could be challenging stigmatisation and marginalisation on the basis of any stereotype, including body size. Additionally, nursing could play a role in specifically supporting women to negotiate the embodiment of contemporary constructions of femininity. To do this nursing would need to provide political advocacy that challenges the shrinking horizons of normality currently presented to women and enforced by the process of medicalisation.

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