Tina Moffat

Department of Anthropology
McMaster University

The Childhood Obesity Epidemic:

Health Crisis or Social Construction?

There has been a meteoric rise over the past two decades in the medical research
and media coverage of the so-called global childhood obesity epidemic. Recently, in
response to this phenomenon, there has been a spate of books and articles in the fields
of critical sociology and cultural studies that have argued that this epidemic is
socially constructed, what Natalie Boero (2007) dubs a postmodern epidemic. As
an anthropologist who has studied child nutrition and obesity in relation to poverty
and the school environment, I am concerned about both the lack of reflexivity
among medical researchers as well as critical scholars treatment of the problem as
entirely socially constructed. In this article I present both sides of this debate and
then discuss how we can attempt to navigate a middle course that recognizes this
health issue but also offers alternative approaches to those set by the biomedical
agenda.
Keywords: [obesity, childhood, epidemic, social constructivism]

Only when childhood obesity becomes high on the public agenda will the
necessary research funds from government and private agencies become
available.
J. O. Hill and F. L. Trowbridge, Childhood Obesity, 1998
I argue that the obesity epidemic is a new breed of what I call
postmodern epidemics, epidemics in which unevenly medicalized
phenomena lacking a clear pathological basis get cast in the language and
moral panic of traditional epidemics.
Natalie Boero, All the News Thats Fat to Print, 2007

The previous two quotes epitomize the diametric positions of biomedical health
professionals and critical theorists regarding the so-called childhood obesity epi-
demic. The first is a call to arms on the part of obesity researchers to make childhood
obesity a high-profile public issue to garner resources for research, and presumably
intervention as well; the second is a constructivist position, critical of the discursive
production of the child obesity epidemic. There has been a meteoric rise in studies
MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 24, Issue 1, pp. 121, ISSN 0745-5194,
online ISSN 1548-1387.  C 2010 by the American Anthropological Association. All rights re-

served. DOI: 10.1111/j.1548-1387.2010.01082.x

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2 Medical Anthropology Quarterly

of childhood obesity in the medical literature, with the concomitant creation of new
journals devoted to the issue such as Pediatric Obesity; simultaneously there has
been intense interest in the topic on the part of the media. Social constructionists,
located in critical sociology and cultural studies, are challenging the conceptualiza-
tion of obesity as an epidemic and, in some cases, the biological basis of childhood
obesity and its associated health risks.
Anthropologists using the biocultural approach have been conspicuously quiet
about the childhood obesity epidemic, either ignoring it or working on the mar-
gins of medical sciences, investigating the social, cultural, economic, and environ-
mental dimensions of the issue (e.g., Brewis 2003; Brewis and Gartin 2006; Crooks
1998, 1999, 2000, 2003; Gallo et al. 2005; Galloway 2006, 2007; for a review of
biocultural perspectives on obesity see Ulijaszek and Lofink 2006). My own work on
child nutrition and obesity, like that of my colleagues cited above, has been situated
in the politicaleconomic and environmental dimensions of the problem to inves-
tigate local determinants of poverty and childhood obesity (Moffat and Galloway
2007, 2008; Moffat et al. 2005). Writing prior to the construction of the obesity
epidemic, Ritenbaugh (1987) critically challenged biomedical definitions of obe-
sity by characterizing the medicalization of obesity as a culture-bound syndrome.
Apart from Ritenbaugh, however, anthropologists have been largely complicit with
medical professionals, as we have not considered the way in which childhood obesity
has been conceptualized nor the implications of this current framework for preven-
tion and intervention. At the same time, by not critically assessing the contestation
of the epidemic by our colleagues in social sciences and humanities, we miss an
opportunity to advance a multidisciplinary research agenda.
In this article, I outline the construction of childhood obesity as a social problem
in Canada and the United States and then turn to an analysis of the more recent
contestation of the childhood obesity epidemic by critical scholars vis-a-vis ` the
medical profession and the media.1 I briefly outline criticisms presented thus far in
the social constructivist literature: the characterization of childhood obesity as an
epidemic; the individualization of the phenomenon resulting in victim blaming;
the conflation of the categories overweight and obese; the promotion of the
epidemic for capitalist exploitation; and stigmatization of women, ethnic minorities,
and those of low socioeconomic status (SES).
Finally, I address the contestation of the childhood obesity epidemic by con-
trasting it with the perspectives of biomedical health professionals. I argue that the
parties involved must begin to hear each others views. An open debate could result
in the navigation of a new path that reframes the issue and facilitates attempts to
lower the prevalence of childhood overweight and obesity.

A Natural History of the Construction of the Childhood Obesity Epidemic

I begin by approaching childhood obesity using a natural history model for the
study of the construction of social problems. Spector and Kitsuse (1987), in their
book Constructing Social Problems, argue that all social problems are constructed
and that it is useful in and of itself to analyze how they are constructed, re-
gardless of whether or not the claims are true. The following is a description
of the construction of childhood obesity as a social problem, beginning with its
 The Childhood Obesity Epidemic 3

definition as a harmful condition, followed by the public and official recognition of

the epidemic.
Although obesity has been scrutinized intensely by physicians since the beginning
of the 20th century (Hamin 1999; Stearns 1999), it is only in the past 25 years or so
that childhood obesity has been viewed as a medical condition that merits attention
on a societal and global scale. A search of Medline database from 1980 through
to 2008 using the keywords child and obesity with English language and
humans as delimiters resulted in 10,668 articles7,119, or two-thirds of them,
were published between 2000 and 2007. Through this period a rise in the prevalence
of childhood overweight and obesity was reported in Australia (Booth et al. 2003),
Canada (Tremblay and Willms 2000), the UK (Rudolf et al. 2001), and the United
States (Troiano et al. 1995), among other nations of the postindustrial world, with
some studies attributing increases in childhood obesity to such sociological phe-
nomena as television viewing (Gortmaker et al. 1996) and fast food consumption
(Bowman et al. 2004). For the most part, the medical literature has highlighted the
risk of obese children growing up to become obese adults with all of the associated
health risks such as cardiovascular disease, hypertension, dyslipidemia, type 2 dia-
betes mellitus, among others (Barness et al. 2007). More recently, however, there
has been a plethora of research documenting health risks during childhood linked to
obesity such as the rising incidence of type 2 diabetes among youth (Hannon et al.
2005), asthma and sleep apnea (Deane and Thomson 2006), and hypertension and
dyslipidemia (Chien-Chang et al, 2009).
Although an analysis of the medias portrayal of the childhood obesity epidemic
is beyond the scope of this article, it is important to note that in the late 1990s
health professionals actively publicized and created a publicpolitical issue of child-
hood obesity, and their main conduit was the print media. As Boero (2007:42)
points out, in the New York Times alone between 1990 and 2001 there were 750
articles published on the obesity epidemic (incl. adults), more than those printed
on either smoking, the AIDS pandemic, or pollution. There were even examples of
health professionals and journalists working together, for example, in medical jour-
nal cum magazine publications such as Science with articles written by physicians
aimed at the general public. There were also journalistic pieces such as Lechkys
(1994) publication in the Canadian Medical Association Journal in which she inter-
views a bariatric surgeon and specialist in childhood obesity who views childhood
obesity as a major public health problem. Thus, although the media quickly fol-
lowed and reflected the medical construction of the childhood obesity epidemic,
health professionals actively used the media to put the issue on the publicpolitical
agenda.2
At around the same time as the beginning of the media hype about obesity,
and more specifically childhood obesity, the epidemic was recognized by NGOs.
In 1995, the International Association for the Study of Obesity (2008), an NGO,
created the International Obesity Task Force (IOTF). The mission of the IOTF is to
inform the world about the urgency of the problem and to persuade governments
that the time to act is now (IOTF 2008). These organizations worked with the
World Health Organization, which in 2000 published a report entitled Obesity:
Preventing and Managing a Global Epidemic (WHO 2000). Globesity, as it was
dubbed, was now more than just a problem of the so-called developed nations.
4 Medical Anthropology Quarterly

Health organizations around the world followed suit. For example, the U.S. Na-
tional Institutes of Health (NIH) recognized the importance of obesity research in
2003 with its Obesity Research Task Force.3 In the press release about the cre-
ation of the task force, the former NIH director Dr. Elias Zerhouni states: We
are pleased about this focused effort to identify research opportunities in obesity.
We are especially concerned about the serious problems we see emerging in over-
weight children. Many of these are problems that we used to see only in adults (NIH
2004). Another statement in the press release reads that HHS Secretary Tommy G.
Thompson has targeted obesity as a major priority of the Department, and is
quoted as stating: There is no doubt that obesity is an epidemic that must be
stopped. This plan gives us a clear focus for confronting obesity with science-based
research approaches (NIH 2004). Note the use of children and the epidemic
in these quotes to highlight the need for immediate and serious action. Not only
did the NIH give recognition and legitimacy to this issue, but also it increased its
funding considerably. NIH funding for obesity research has increased from just
$50 million in 1993 to just over $400 million in 2005 (Spiegel and Nabel 2006).
Thus, at the beginning of the 21st century the obesity epidemic was recognized
as an official and legitimate medical and societal problem, backed by research funds
from leading international and national organizations.

Contestation of the Childhood Obesity Epidemic

I now turn to an examination of critical scholars contestation of the childhood
obesity epidemic summarized as points of critique garnered from recently published
scholarly journal articles. The following main criticisms are presented below.

The Characterization of Childhood Obesity as an Epidemic

As quoted at the beginning of this article, Natalie Boero characterizes the obesity
epidemic as a postmodern epidemic, epidemics in which unevenly medicalized
phenomena lacking a clear pathological basis get cast in the language and moral
panic of traditional epidemics (Boero 2007:41). I begin with Boeros use of the
term traditional epidemics. Martin and Martin-Granel (2006) trace the semantic
shifts in the use of epidemic from Homers Odyssey, used nonmedically as who
is in the country through to Hippocratess (430 B.C.E.) use of the term to mean
a collection of medical syndromes. Today, we are familiar with the 19th century
attribution of an epidemic to a specific genus and species of a microorganism, and
more recently these microbes have been defined by molecular markers. Martin
and Marin-Granel (2006), however, note the late-20th-century application of the
term epidemic to noninfectious diseases such as cancer and heart disease, and even
to social problems such as crack cocaine addiction. Here epidemic is used as a
metaphor, and it is to this metaphoric usage that critical theorists object.
What makes the use of the metaphor of the epidemic dangerous? Saguy and
Riley (2005) argue that the use of the epidemic as a metaphor creates a sense
of general chaos and moral panic, or shame and blame that is particularly acute
around children. In fact, they warn that it could even invoke the abridgement of civil
liberties, as epidemics can do by prompting quarantine or the prohibition of certain
 The Childhood Obesity Epidemic 5

rights such as crossing national borders. Murray (2008) goes further to describe it
as fat panic, arguing:

The notion of the epidemic exemplifies the function of disciplinary medicine

as Foucault understands it. It has powerful, productive implications, many
of which remain tacit. If, for example, a community is in the grip of an
infectious disease epidemic, it is expected and understood that all members
of this community will take rigorous steps to protect themselves and their
families from, and to prevent the spread of, the pathogen that threatens not
only their own bodies, but the body politic more generally. [Murray 2008:9]

Perhaps the more pressing concern, however, according to de Vries (2007) is

the medicalization of obesity that goes along with the use of the term epidemic.
By analogy, if childhood obesity is an epidemic then obesity must be a disease.
Indeed, as de Vries (2007) points out, there has been a subtle shift in the medical
literature in the characterization of obesity as a risk factor for a number of diseases,
such as heart disease and diabetes, to obesity as a disease unto itself. De Vries
(2007) argues that as a society we tend to medicalize that which we find morally
unacceptable. Defining obesity as a disease is also a practical way to get coverage
of obesity treatment by medical insurance, as in 2004 when U.S. Medicare declared
obesity a disease and therefore subject to coverage (U.S. Department of Health and
Human Services 2004). Whatever the reason for conceiving of obesity as a disease,
however, it affects the way we treat and categorize children, as all obese children
become patients who must be cured (deVries 2007).

The Individualization of the Phenomenon

Saguy and Riley (2005) point out that medicalization of obesity and the framing
of it as a disease may or may not remove blame from the individual, depending on
which disease model is employed. Studies of the molecular underpinnings of obesity
(Friedman 2003) and individual variation in such behaviors as appetite control, for
example (Carnell and Wardle 2008), reduce the blame on the individual, because
if obesity is a result of an inherited disposition, to a large extent this behavior is
out of ones control. However, a lifestyle model of disease squarely places obesity
among diseases such as heart disease and AIDS, where personal choices and
risky behavior are considered the major causal factors. In the medical literature,
childhood obesity is frequently framed as a lifestyle disease that can be reduced or
prevented by behavioral changes to diet and physical activity level (e.g., Driskell
et al. 2008; Rodearmal et al. 2007).
As Boero (2007:55) points out, children themselves are never blamed for obesity
but, rather, their caregivers, and more often their mothers. In this literature the
childhood obesity epidemic has been constructed as an epidemic of unrestricted
indulgence in sweet or high-fat food (e.g., Brekke et al. 2007; Van Horn 2005) and
too much TV viewing and computer use (e.g., Dubois et al. 2008; Gortmaker et al.
1996). In addition, mothers are often blamed for the poor eating habits of their
children, with associations sought between obese mothers and their children (e.g.,
Contento et al. 2005; Powers et al. 2006). This is not an isolated example, as the
6 Medical Anthropology Quarterly

ignorant mother has been employed discursively in the public health discourse
for at least a century. (For studies of historical examples of this discourse see Ball
and Swedlund [1996], Moffat and Herring [1999], and McElhinny [2005], among
others.)
To be fair, though, there is a literature written by biomedical professionals who
have conceived of obesity as an environmental disease, akin to notions of structural
violence in anthropological literature (Farmer 2004). For example, Kelly Brownell
and Marion Nestle, well-known public health and nutrition professionals, argue
that children are being raised in a toxic environment in which the food industry
promotes inexpensive, convenient, high-density and low-nutrient food (Brownell
and Battle Horgen 2004; Nestle and Jacobson 2000), and in which physical activity
is minimal because of reliance on the automobile as a result of poor urban plan-
ning that is not conducive to physically active forms of transportation (e.g., Frank
et al. 2004). Saguy and Riley (2005) counter that the toxic environment frame-
work, while removing some of the blame from the individual onto corporations, is
still couched in morality and blaming, since a toxic environment cannot pollute
individuals without their consent (2005:288). I do not believe the authors who
describe the toxic environment imply this at all; indeed the very point of using
this metaphor is to show that peoples choices are limited when exposed to environ-
mental toxicants and are even more constrained for those with less education and
resources.4
There are also well-recognized structural barriers to healthy eating, one of
the main ones being poverty. For example, Drewnowski and Specter (2004) and
Drenowski (2007) argue that purchasing high-density, low-nutrient food makes
good economic sense for low-income families because, per calorie intake, it is
cheaper than low-density, high-nutrient food such as fruits and vegetables. More-
over, there are several studies that show that neighborhoods that are perceived to be
less safe have a higher prevalence of maternal (Brudette et al. 2006) and childhood
overweight (Lumeng et al. 2006), and children living in low-income neighborhoods
in the United States have reduced access to facilities for physical activity (Gordon-
Larsen et al. 2006).
Thus, within the medical literature there are competing models of the etiology of
obesity as a disease and an epidemic; it is too overly simplistic to characterize all of
the literature as individualizing and blaming.

The Conflation of Overweight and Obese Children

Like any disease entity the matter of how to categorize, measure, and report it is
contested. Childhood obesity like adult obesity has been for the most part measured
by the Body Mass Index (BMI), a quick, convenient, and noninvasive measure
employed in population studies. The BMI is calculated as weight over height squared
(kg/m2 ). Adults are classified as overweight if their BMI is above 25, and obese if
above 30. There are a number of problems with using BMI to classify overweight
and obesity, including enhanced muscularity, large head size, and high torso-to-leg
ratio, which may result in a falsely elevated BMI; this is particularly a concern for
children under three years of age (Roberts and Dallal 2001). There are more precise
measures of fat, including waist measurements to estimate abdominal fat thickness,
 The Childhood Obesity Epidemic 7

and fat thickness at various points of the body, as well as direct measures of fat
using high-tech equipment in laboratories. However, these methods, particularly
direct measures, are expensive, time consuming, and invasive. BMI, though just
an estimate, correlates well with direct measures of fat; it is fast, convenient, and
noninvasive and thus ideal for use in large prevalence studies (Mei et al. 2002).
For children, the use of the BMI is more complicated, as the distribution and
amount of body fat changes as childrens bodies grow and develop; thus, BMI per-
centiles are used to estimate overweight and obesity up to the age 18 years (CDC
2007). Moreover, unlike fixed adult BMI cutoffs, which are related to health risks,
there are no risk-based cutoffs for children. This is because the health risks for
children are unknown, because, apart from a small sample of youth who experience
cardiovascular disease and type 2 diabetes, most problems occur later in adulthood
(Flegal et al. 2006). A statistical cutoff of the 85th percentile and above is rec-
ommended for the classification of risk of child overweight and the 95th and
above for child overweight (Kuczmarski et al. 2002). There has been, however,
an effort to internationally standardize the classification of childhood overweight
and obesity, and to align these percentile cutoffs with the adult standards. Thus,
the IOTF created a table of sex-specific percentile cutoffs for overweight and obese
classifications of children at each year of age that match those of the 25 and 30
BMI cutoffs set for adults (Cole et al. 2000). At present both sets of cutoffs are used
in prevalence studies with the 85th and 95th percentiles more commonly used in
North American studies.
Despite the distinction between the 85th and 95th percentile cutoffs, much of the
literature reports all children above the 85th percentile as overweight or obese. In
doing this, de Vries (2007) argues, overweight and obesity become conflated. It is
often forgotten that a much smaller percentage of children above the 85th percentile
are obese or morbidly obese and that the health risks associated with overweight are
less severe and less numerous than those associated with obesity (de Vries 2007).
Thus, overweight children are unnecessarily pathologized, when they may just be
healthy and chubby (de Vries 2007:63) and at the high end of the normal dis-
tribution. There is a tacit assumption, moreover, that children who are overweight
inevitably become obese. Note that the CDC substitutes the word overweight
for obese when referring to children; however, children at or over the 85th and
below the 95th percentiles of BMI-for-age are said to be at risk for overweight,
implying that their BMI is likely to move up in the percentiles.
Labeling a child overweight may be particularly dangerous in the clinical
setting, as it could precipitate emotional problems or unhealthy dieting. But even
in population studies, when overweight and obesity are reported together as one
category, it heightens the extent of the obesity problem. Indeed, one alarmist report
predicts an increase in pediatric obesity, such that life expectancy in the United
States will be shortened by two to five years by midcentury (Ludwig 2007:2325). In
fact, recent prevalence data indicates that overweight and obesity among adults did
not increase from 200304 to 200506 in the United States (Ogden et al. 2007). We
still await reports of the youth data for the same time period. This is not to say that
we should be complacent or assume that this leveling off of overweight and obesity
will continue. Nonetheless, it begs the question of whether dire predictions about
future obesity-associated morbidity and mortality are valid at this point in time.
8 Medical Anthropology Quarterly

The Promotion of the Epidemic for Monetary Profit

The rise in societal concern over weight loss over the last 30 years has spawned
a multibillion dollar diet industry, including weight-loss programs and diet food
(Austin 1999). The construction of the obesity epidemic has helped to promote
this industry, but perhaps a less obvious financial benefit has accrued to the medical
research industry, where large grants can be garnered for studying obesity, partic-
ularly if there are potential pharmaceutical applications. There is also profit to be
made from bariatric surgery for adults and clinics and camps to treat obese children.
Although some critics might argue that the epidemic was constructed to increase
profits (e.g., Campos 2004), I would counter this point with the reminder that prof-
iting from ill health is not unique to the obesity epidemic and is part and parcel of a
wider capitalistic health care system (see Singer and Baer 1989 for further discussion
of this point).

Stigmatizing Women, the Poor, and Ethnic Minorities

Obesity in the United States is associated with the stigma of gluttony, immorality,
and loss of control, resulting in social discrimination for many obese people, particu-
larly in workplace and health care settings (Carr and Friedman 2005; Sobal 1991).5
In Western countries, women are particularly subject to the thin ideal (Bordo 1993;
Germov and Williams 1999), which renders obese women even more stigmatized.
In North America today, moreover, there is an inverse correlation between SES and
obesity among women (Sobal 1991; Sobal and Stunkard 1989), and there are a
number of studies indicating the association of childhood obesity with low house-
hold income and food insecurity (Alaimo et al. 2001; Casey et al. 2001; Crooks
1998, 1999, 2000; Mei et al. 1998; Wang 2001). Thus, women and children of low
SES bear the brunt of the so-called obesity epidemic.
In addition to the association of obesity with low SES, there is also a focus on
childhood obesity among ethnic minorities, with a documented higher prevalence,
for example, of overweight among Hispanic and African Americans (Gordon-Larsen
et al. 2003; Sorof et al. 2004), as well as immigrant children (Smith et al. 2003).
Low SES is no doubt the major determinant of this association, although some
researchers suggest that cultural factors such as family environment exist above
and beyond socioeconomic ones (Gordon-Larsen et al. 2003; Wang et al. 2007).
However, SES is a complex measure, and as Shavers (2007) points out, one has
to consider both compositional (individual measures) and collective (neighborhood
environment) dimensions of SES when considering health disparities among racial
ethnic minorities. Collective measures of SES may be more meaningful in considering
obesity among racialethnic groups, where factors such as lower access to quality
food and opportunity for physical activity could offset individual or family gains
from increased SES.
Beyond empirical data that indicates associations between obesity and ethnic mi-
norities, however, there are stereotypes originating in the eugenics movement of the
early 20th century. At that time, as Saukko (1999) explains, obesity was conflated
with notions of constitutional soft or slack personalities of new immigrant groups
to the United States such as Italians and Jews. It is thus understandable that de Vries
 The Childhood Obesity Epidemic 9

(2007) voices concern about the further social marginalization of poor and ethnic
minorities in the construction of the childhood obesity epidemic. The author states:
In this way, the call to take political action against childhood obesity apparently
equals a call for political action against the poor and weak individuals in society. I
believe a theoretical reflection on these assertions is necessary (de Vries 2007:64).
Although it is important to be sensitive to social marginalization of women and
children, those of low SES, and ethnic minorities, it is equally imperative that we
recognize the biological consequences of social inequalities and barriers. As Krieger
(2004:350) expounds in her glossary of embodiment in social epidemiology, our
living bodies tell stories about our lives, whether or not these are ever consciously
expressed. Thus, higher prevalence of obesity among children in socially marginal-
ized groups cannot be ignored, as it is an embodiment of social inequalities.
As well, we must consider childhood obesity at the global level, where it plays
out variously in different contexts. Far from being just a problem of socioeconomi-
cally disadvantaged children in Western nations, childhood obesity is fast becoming
an issue for children living in economically developing countries, because of major
shifts in diet resulting in greater intakes in fat and sweeteners and declines in phys-
ical activity associated with modernization (Popkin and Gordon-Larsen 2004). In
these cases it is the children of middle and higher socioeconomic families who are
consuming energy-dense foods and expending less energy (Dasgupta et al. 2008;
Wang 2001).
The challenge in doing research on socioeconomic determinants of obesity is the
trap of falling into discourse that plays into stereotyping and stigmatizing of vulner-
able groups. It calls for a reflexive and sensitive approach, but not the disappearance
of this type of research altogether.

Medical Perspectives on Childhood Obesity

There has been little reflection by the biomedical community on the use of the term
epidemic to describe the rising prevalence of obesity. Most biomedical professionals
would probably acknowledge that although the use of the term is metaphoric, it
is apt. Several medical researchers, moreover, have employed the term epidemic
quite literally and have made claims about the rise in global obesity as having
epidemic attributes, such as a theory of obesity as a contagion running through
obese individuals social networks (Christakis and Fowler 2007). There is even a
theory of viruses as an etiology of obesity (Atkinson 2007).
In contrast to critical scholars descriptions of moral panic and alarmism asso-
ciated with the obesity epidemic, biomedical health professionals are concerned
about the very opposite societal tendency, apathy. Indeed, they fear that obesity is
not pathologized enough and that there is a growing societal normalization of
childhood overweight and obesity. I base this observation, in part, on discussions I
have had with health professionals who have opined that as a society we have for-
gotten what childrens bodies looked like in the past because so many children have
shifted (and will continue to shift in greater numbers) from the so-called normal
BMI range, between the 15th to the 85th percentiles, to BMIs above the 85th per-
centile. Thus, the normal range of variation, or bell curve, has been skewed to the
right, and with this shift there has been a decline in our ability to recognize obesity.
10 Medical Anthropology Quarterly

This concern is reflected by a number of articles in medical, nutrition, and obe-

sity research journals that investigate caregivers ability to accurately recognize an
overweight or obese child relative to reference standards (e.g., Boutelle et al. 2004;
Boyington and Johnson 2004; Etelson et al. 2003; Jeffrey et al. 2005). These studies
have all found that caregivers consistently underestimate the BMI of their children.
One study even went beyond caregivers to consider childrens own perceptions of
their body size as well as their pediatricians perceptions of their patients body size;
the authors found that a large proportion of all of the participants (incl. pediatri-
cians, although to a lesser extent) did not accurately categorize childrens BMI when
using verbal and picture descriptions of various body types (Chaimovitz et al. 2008).
All of the authors who have done this type of research on body perception concur
that without recognition and acknowledgment of overweight or obesity, there can
be no treatment. Jeffrey et al. (2005) suggest that caregivers either do not want to
admit there is a weight problem or have become desensitized to overweight and
obesity, as it is now the norm.
This latter concern is reflected in the construction of the 2000 CDC childhood
growth reference (CDC 2000). The latest child growth reference was constructed
using data from the National Health Examination Surveys (NHES) conducted in
the United States between 1963 and 1994 (Roberts and Dalal 2001). The previous
1977 National Center for Health Statistics (NCHS) child growth reference did not
have BMI charts, only weight-for-height and weight-for-age charts; however, be-
cause BMI is a better indicator of relative weight, the 2000 CDC reference includes
BMI charts for children of ages two to 20 years. Of note is that the CDC did not
use the National Health and Nutrition Examination Surveys (NHANES) III data,
collected from 1988 to 1994, for the construction of the BMI percentiles for children
over six years of age, because of: the marked increase in the weight of children
six years and older in NHANES III compared to previous surveys. The inclusion of
NHANES III data would have shifted the percentiles up and resulted in a relative
underclassification of the prevalence of overweight (Roberts and Dalal 2001:33).
Thus, the most recent BMI data were excluded so that their use would not
obscure the identification of obesity among children today.
Far from concerns about alarmism, then, the biomedical community is worried
about a collective amnesia for the body type characterized by lower average BMIs
that prevailed prior to the 1990s, and it is actively taking measures to prevent this
from happening in clinical diagnosis and population health research. Clearly, the
perspective of biomedical professionals is diametrically opposed to that of critical
scholars, and although there may be no hope of reconciliation, a consideration of
both sides is warranted.

What Can We Learn from Critical Theorists, and Where Is Skepticism Warranted?
Critical scholars have begun to critique and question the authority of medical experts
in their construction of the so-called obesity epidemic, and I have so far identified
and commented on some of the main criticisms salient in the literature. I now turn to
highlighting the usefulness and problematic features of several of the key criticisms.
To begin, framing the rise in childhood obesity as an epidemic is problematic
although I do not believe it will create an atmosphere of alarmism, moral panic,
 The Childhood Obesity Epidemic 11

and the possible abridgement of civil liberties. For the most part the reaction to
the childhood obesity epidemic has been measured. Although there have been
suggestions in the United States to conduct BMI screening in schools, only Arkansas
has adopted this program, and an evaluation report written by the CDC recommends
that BMI is not a useful screening tool, as it does not meet all of the criteria
for successful screening programs in schools outlined by the American Academy
of Pediatrics (Nihiser et al. 2007). Moreover, it may have unintended harmful
consequences and could waste scarce resources that could otherwise be put to
health promotion programs in schools (Ikeda et al. 2006; Nihiser et al. 2007).
In fact, there are signs of acceptance of larger body sizes for childrenfrom the
plea by health care professionals for the manufacture of larger, stronger, and there-
fore safer car seats for heavier preschoolers (Trifiletti et al. 2006) to the popularity
of baggy hip-hop clothing fashions that are geared to a larger body size, albeit aimed
at the male gender (Gross 2005). This acceptance may be, in part, because of the
Size Acceptance Movement or Fat Liberation activists, who have attempted to create
more awareness about the stigma and suffering of larger people and the need to be
more accepting of diverse body sizes (Mitchell 2005; Sobal 1999). Although these
latter movements are not mainstream, the spirit of them is reflected in the recent
NEW Dove Soap advertising campaign Real women have real curves (2009). This
trend may be indicative of resistance by the general public to the alarmist aspects of
the obesity epidemic that warrants further research.
Rather, the problem with the epidemic framework is that it is not useful from a
public health perspective. An epidemic of cholera or whooping cough, for example,
requires the use of tools, such as isolation and antibiotics or vaccination campaigns
that can immediately be employed. Ideally, public health creates strategic plans in
advance of epidemics so that healthcare professionals may act swiftly, and hopefully
effectively, in stemming the outbreak.6 Childhood obesity, however, has no such
quick solutions; although there have been a plethora of childhood obesity prevention
programs and subsequent evaluations, recent reviews of such interventions indicate
that there is limited evidence on which to base best practices (Boon and Clydesdale
2005; Livingstone et al. 2006). The lack of effectiveness of prevention programs has
recently been acknowledged in an opinion piece in the journal Obesity Reviews. The
authors state: it is time to admit that we as obesity experts do not have sufficient
and effective strategies to prevent overweight (Mueller and Danielzik 2006:88).
These critics argue further that childhood obesity is part of larger societal and
global forces that require multifaceted solutions that are thoughtful and directed at
changes in social and economic policy, the environment, and our cultural milieux
(Livingstone et al. 2006; Mueller and Danilzik 2006). These types of interventions
differ from responses to acute infectious disease epidemics. Conversely, the specter
of an epidemic evokes a sense of helplessness, a state of being out of control,
contagion running wild. However, there are changes we can contemplate as a society
to prevent a further rise in childhood obesity. Thus, to get out of the quick-fix or
the situation is out of control mindsets, we must abandon the epidemic metaphor.
The second useful criticism of the treatment of childhood obesity is the conflation
of overweight and obesity discussed above. Longitudinal studies are required to fol-
low children between the 85th and 95th percentiles into adolescence and adulthood
to determine how many of them become obese, as prospective studies to date do
12 Medical Anthropology Quarterly

not differentiate between overweight and obese children (e.g., Deshmukh-Taskar

2006). Moreover, we require further research to understand the health risks or
lack thereof associated with being overweight but not obese. As a recent study of
people over 60 years of age finds, being physically active is a better predictor of
longevity, regardless of the BMI category or body fat distribution (Sui et al. 2007).
Moreover, there is some evidence that cardiovascular fitness among young men is
inversely correlated with metabolic syndrome, independent of abdominal fat (Lee
et al. 2005). Further research is needed to understand the relationship between body
fat and fitness, as it may prove to be more beneficial to promote cardiorespiratory
fitness over weight reduction in childhood obesity intervention programs.
Third, critical scholars are right to interrogate the etiological models used to
understand childhood obesity as a phenomenon. However, the individualizing
lifestyle approach may not be as prevalent in the medical literature as critical schol-
ars posit. A sociological analysis of the evolution of medical modeling of obesity
in the Cecil Textbook of Medicine indicates that in recent years models of obesity
have become more concerned with environmental and social contexts (albeit genetic
ones as well) and less focused on individual blame and accountability (Chang and
Christakis 2002). And although much of the medical literature continues to employ
a lifestyle approach to epidemiology and health promotion, there is an alternate
body of research within public health that critiques the individualizing lifestyle
approach to health promotion and advances a social epidemiology framework (see,
e.g., Krieger 1994; Marmot 2005). There are also biomedical professionals who
critique the lifestyle approach to childhood obesity interventions (see Livingstone
et al. 2006).
I conclude this review of the critical literature by considering whether critical
theorists acknowledge that there is any biological basis to the so-called obesity epi-
demic. Several of the authors previously cited in this article indicate to their readers
that evidence for the rise in childhood obesity is equivocal or at least impressively
overblown. For example, Boero begins her article stating that she does not deny
rising weight and associated health problems but goes on to state that it is an un-
evenly medicalized phenomenon lacking a clear pathological basis (Boero 2007:41;
emphasis added). De Vries (2007:85) questions the empirical data supporting a rise
in childhood obesity, arguing that we only have prevalence data back to the be-
ginning of the 1990s that is not substantial enough to be unequivocal. This latter
statement, however, is countered by a recent metastudy that compares international
data sets. The authors found clear evidence of an increase in both overweight and
obesity among school-aged children since 1980 in all countries of the world except
for Russia and to a lesser extent Poland (Wang and Lobstein 2006). Many of the
valid criticisms and arguments about the social construction of the obesity epidemic
become less credible when they are accompanied by attempts to falsify claims of
rising childhood obesity.

Conclusion: Is There a Middle Path?

Childhood obesity has been framed in extremes: a socially constructed phenomenon
versus a medical crisis. However, it is also a social problem with real consequences
for real people. It is clear that framing childhood obesity as an epidemic is not useful.
 The Childhood Obesity Epidemic 13

I have, as have many others, accepted the construction of the obesity epidemic
and parroted the term unquestioningly in journal articles without considering the
ramifications of the framework for prevention and intervention (e.g., Moffat et al.
2005). We can and should be more vocal about banishing the phrase obesity epi-
demic from the scholarly literature and media representations of childhood obesity
research. To make progress with this, however, critical scholars must begin a dia-
logue with biomedical professionals. At this point in time, there appears to be little
in the way of communication between these groups and no public acknowledgment
by medical professionals of the critique; at the same time critical scholars have not
fairly considered biomedical perspectives on childhood obesity. For there to be di-
alogue, there must be some common ground, which means an acknowledgment on
the part of critical scholars that there is a biological phenomenon occurring globally
that may well have some dire health consequences.
Medical and biocultural anthropologists who cross the chasm between biol-
ogy and the social sciences can potentially play key roles in bridging these camps.
On a theoretical level we can contribute to providing alternative metaphors for
childhood obesity, because even if we abandon the epidemic metaphor some-
thing is bound to replace it: as humans we live by metaphors (Lakoff and Johnson
1980) and we construct social problems (Spector and Kitsuse 1987). Hence, the
question is not should we be using a metaphor, but which should we choose to
frame this problem? One approach is to treat childhood obesity as a social and
environmental problem that is in part fueled by a toxic food environment, as
mentioned above. Or perhaps we should link it metaphorically to consumption,
not just of food, but of material goods, related to concerns about global warming
and environmental destruction. Here we begin to address larger questions of so-
cietal transformation of the economy,7 food systems, and the environment, issues
to which most social scientists, health professionals, and the general public can
relate.
On a more practical level, anthropologists must establish a research agenda
that includes empirical data collection and hypothesis testing as well as critical
and interpretive aspects. Empirical research could entail investigating established
wisdom such as risk for obesity translates into obesity later in life; while we await
results of ongoing prospective studies, more research employing the lifecourse
approach and life histories may be useful, as exemplified by Clarkins (2008) study
of adiposity and height among adult Hmong refugees. It also requires collaboration
with health professionals on research projects where anthropologists can inject some
critical reflection on the construction of the social problem of childhood obesity and
implications for prevention and intervention. Although multidisciplinary work is
challenging, because of differences in epistemology and methodology, it is perhaps
the only way to ensure that multiple perspectives are incorporated into the study of
childhood obesity.

Notes

Acknowledgments. I would like to thank Ann Herring, Tracey Galloway, and Dan Sellen
for their helpful comments on the manuscript, as well as anonymous reviews and the editors
of MAQ for their constructive aid in the preparation of this article.
14 Medical Anthropology Quarterly

1. I assume that the construction of the childhood obesity epidemic would vary depend-
ing on national context and cultural notions of body fat, children, and childhood; thus, I
refrain from commenting on it beyond these two countries.
2. Tomes (2002) explores the roots of exploitation of news and entertainment of deadly
infectious diseases in the early-20th-century United States that occurred via collaboration
of scientific researchers, politicians, activists, journalists, and advertisers.
3. In February 2009, the NIH in conjunction with the Robert Wood Johnson Founda-
tion created the National Collaborative on Childhood Obesity Research (n.d.).
4. An example of an environmental toxicant that disproportionately affects those of
lower socioeconomic status is childhood lead poisoning and exposure (Schell and Denham
2003).
5. Obesity is not stigmatized universally. See, for example, Popenoes (2005) account
of the fat female ideal among Nigerian Arabs.
6. I do not mean to imply that all disease epidemics are easily contained. HIV/AIDS
is a case in point, where none of the public health measures described above have been
effective.
7. For example, the construction of the obesity epidemic has been characterized as a
product of neoliberalism where the citizen is a consumer that is encouraged to eat and at
the same time discipline him- or herself to achieve thinness amidst this plenty (Guthman
and DuPuis 2006:444).

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