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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 elds 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 reexivity 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 epidemic. The rst is a call to arms on the part of obesity researchers to make childhood obesity a high-prole 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 reserved. DOI: 10.1111/j.1548-1387.2010.01082.x

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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 conceptualization 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 margins of medical sciences, investigating the social, cultural, economic, and environmental 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 Lonk 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 investigate 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 denitions of obesity 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 prevention 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 briey 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 conation 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 contrasting 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, regardless 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

denition as a harmful condition, followed by the public and ofcial 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 phenomena 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 diabetes 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 childhood 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 journal 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 interviews a bariatric surgeon and specialist in childhood obesity who views childhood obesity as a major public health problem. Thus, although the media quickly followed and reected 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 specically 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.

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Health organizations around the world followed suit. For example, the U.S. National 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 creation 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 overweight 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 ofcial 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 specic genus and species of a microorganism, and more recently these microbes have been dened 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

rights such as crossing national borders. Murray (2008) goes further to describe it as fat panic, arguing: The notion of the epidemic exemplies 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 nd morally unacceptable. Dening 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

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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 planning 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 framework, 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 environmental 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. Moreover, 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 (GordonLarsen 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 Conation 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 classied 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

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 percentiles are used to estimate overweight and obesity up to the age 18 years (CDC 2007). Moreover, unlike xed 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 recommended for the classication 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 classication of childhood overweight and obesity, and to align these percentile cutoffs with the adult standards. Thus, the IOTF created a table of sex-specic percentile cutoffs for overweight and obese classications 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 conated. 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 distribution. 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 ve 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.

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The Promotion of the Epidemic for Monetary Prot 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 nancial benet has accrued to the medical research industry, where large grants can be garnered for studying obesity, particularly if there are potential pharmaceutical applications. There is also prot 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 prots (e.g., Campos 2004), I would counter this point with the reminder that profiting 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, particularly 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 household 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 minorities, however, there are stereotypes originating in the eugenics movement of the early 20th century. At that time, as Saukko (1999) explains, obesity was conated 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

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(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 reection 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 marginalized 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 socioeconomically 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 physical 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 vulnerable groups. It calls for a reexive and sensitive approach, but not the disappearance of this type of research altogether.

Medical Perspectives on Childhood Obesity


There has been little reection 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 associated 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 forgotten 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 percentile. 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.

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This concern is reected by a number of articles in medical, nutrition, and obesity 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. pediatricians, 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 reected 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, because 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 underclassication 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 identication 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 identied 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,

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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 therefore safer car seats for heavier preschoolers (Triletti 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 reected 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 sufcient 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-x 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 conation of overweight and obesity discussed above. Longitudinal studies are required to follow 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

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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 nds, 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 tness 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 tness, as it may prove to be more benecial to promote cardiorespiratory tness 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 scholars 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 epidemic. 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 unevenly 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 beginning 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.

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I have, as have many others, accepted the construction of the obesity epidemic and parroted the term unquestioningly in journal articles without considering the ramications 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 epidemic from the scholarly literature and media representations of childhood obesity research. To make progress with this, however, critical scholars must begin a dialogue 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 dialogue, 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 biology 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 something 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 societal 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 exemplied 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 reection 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.

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1. I assume that the construction of the childhood obesity epidemic would vary depending 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 scientic researchers, politicians, activists, journalists, and advertisers. 3. In February 2009, the NIH in conjunction with the Robert Wood Johnson Foundation 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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