the childhood obesity epidemic. health crisis or social construction

8/14/2019 The Childhood Obesity Epidemic. Health Crisis or Social Construction

1/21

Tina MoffatDepartment of AnthropologyMcMaster University

The Childhood Obesity Epidemic:Health Crisis or Social Construction?

There has been a meteoric rise over the past two decades in the medical researchand media coverage of the so-called global childhood obesity epidemic. Recently, inresponse to this phenomenon, there has been a spate of books and articles in the eldsof critical sociology and cultural studies that have argued that this epidemic issocially constructed, what Natalie Boero (2007) dubs a postmodern epidemic. Asan anthropologist who has studied child nutrition and obesity in relation to povertyand the school environment, I am concerned about both the lack of reexivityamong medical researchers as well as critical scholars treatment of the problem asentirely 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 thishealth 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 thenecessary research funds from government and private agencies becomeavailable.

J. O. Hill and F. L. Trowbridge, Childhood Obesity, 1998

I argue that the obesity epidemic is a new breed of what I callpostmodern epidemics, epidemics in which unevenly medicalized

phenomena lacking a clear pathological basis get cast in the language andmoral panic of traditional epidemics.

Natalie Boero, All the News Thats Fat to Print, 2007

The previous two quotes epitomize the diametric positions of biomedical healthprofessionals and critical theorists regarding the so-called childhood obesity epi-demic. The rst is a call to arms on the part of obesity researchers to make childhoodobesity a high-prole public issue to garner resources for research, and presumablyintervention 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 studiesMEDICAL 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

1


2/21

2 Medical Anthropology Quarterly

of childhood obesity in the medical literature, with the concomitant creation of newjournals devoted to the issue such as Pediatric Obesity ; simultaneously there hasbeen 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 childhoodobesity and its associated health risks.

Anthropologists using the biocultural approach have been conspicuously quietabout 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; Crooks1998, 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 onchild nutrition and obesity, like that of my colleagues cited above, has been situatedin the politicaleconomic and environmental dimensions of the problem to inves-tigate local determinants of poverty and childhood obesity (Moffat and Galloway2007, 2008; Moffat et al. 2005). Writing prior to the construction of the obesityepidemic, Ritenbaugh (1987) critically challenged biomedical denitions of obe-sity by characterizing the medicalization of obesity as a culture-bound syndrome.Apart from Ritenbaugh, however, anthropologists have been largely complicit withmedical professionals, as we have not considered the way in which childhood obesityhas been conceptualized nor the implications of this current framework for preven-tion and intervention. At the same time, by not critically assessing the contestationof 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 problemin Canada and the United States and then turn to an analysis of the more recentcontestation of the childhood obesity epidemic by critical scholars vis- ` a-vis themedical profession and the media. 1 I briey outline criticisms presented thus far inthe social constructivist literature: the characterization of childhood obesity as anepidemic; the individualization of the phenomenon resulting in victim blaming;the conation of the categories overweight and obese; the promotion of theepidemic 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 theparties involved must begin to hear each others views. An open debate could resultin the navigation of a new path that reframes the issue and facilitates attempts tolower 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 thestudy of the construction of social problems. Spector and Kitsuse (1987), in theirbook Constructing Social Problems , argue that all social problems are constructedand 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 descriptionof the construction of childhood obesity as a social problem, beginning with its


3/21


4/21


Health organizations around the world followed suit. For example, the U.S. Na-tional Institutes of Health (NIH) recognized the importance of obesity research in2003 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 (NIH2004). Another statement in the press release reads that HHS Secretary Tommy G.Thompson has targeted obesity as a major priority of the Department, and isquoted as stating: There is no doubt that obesity is an epidemic that must bestopped. This plan gives us a clear focus for confronting obesity with science-basedresearch approaches (NIH 2004). Note the use of children and the epidemicin these quotes to highlight the need for immediate and serious action. Not onlydid the NIH give recognition and legitimacy to this issue, but also it increased itsfunding 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 recognizedas an ofcial and legitimate medical and societal problem, backed by research fundsfrom 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 publishedscholarly 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 obesityepidemic as a postmodern epidemic, epidemics in which unevenly medicalizedphenomena lacking a clear pathological basis get cast in the language and moralpanic of traditional epidemics (Boero 2007:41). I begin with Boeros use of theterm traditional epidemics. Martin and Martin-Granel (2006) trace the semanticshifts in the use of epidemic from Homers Odyssey, used nonmedically as whois in the country through to Hippocratess (430 B.C.E.) use of the term to meana collection of medical syndromes. Today, we are familiar with the 19th centuryattribution of an epidemic to a specic genus and species of a microorganism, andmore recently these microbes have been dened by molecular markers. Martinand Marin-Granel (2006), however, note the late-20th-century application of theterm epidemic to noninfectious diseases such as cancer and heart disease, and evento social problems such as crack cocaine addiction. Here epidemic is used as ametaphor, and it is to this metaphoric usage that critical theorists object.

What makes the use of the metaphor of the epidemic dangerous? Saguy andRiley (2005) argue that the use of the epidemic as a metaphor creates a senseof general chaos and moral panic, or shame and blame that is particularly acutearound children. In fact, they warn that it could even invoke the abridgement of civilliberties, as epidemics can do by prompting quarantine or the prohibition of certain


5/21


6/21


ignorant mother has been employed discursively in the public health discoursefor at least a century. (For studies of historical examples of this discourse see Balland Swedlund [1996], Moffat and Herring [1999], and McElhinny [2005], amongothers.)

To be fair, though, there is a literature written by biomedical professionals whohave conceived of obesity as an environmental disease, akin to notions of structuralviolence in anthropological literature (Farmer 2004). For example, Kelly Brownelland Marion Nestle, well-known public health and nutrition professionals, arguethat children are being raised in a toxic environment in which the food industrypromotes inexpensive, convenient, high-density and low-nutrient food (Brownelland Battle Horgen 2004; Nestle and Jacobson 2000), and in which physical activityis 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., Franket al. 2004). Saguy and Riley (2005) counter that the toxic environment frame-work, while removing some of the blame from the individual onto corporations, isstill couched in morality and blaming, since a toxic environment cannot polluteindividuals without their consent (2005:288). I do not believe the authors whodescribe the toxic environment imply this at all; indeed the very point of usingthis 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 andresources. 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 makesgood economic sense for low-income families because, per calorie intake, it ischeaper 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 beless safe have a higher prevalence of maternal (Brudette et al. 2006) and childhoodoverweight (Lumeng et al. 2006), and children living in low-income neighborhoodsin 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 Conation of Overweight and Obese Children

Like any disease entity the matter of how to categorize, measure, and report it iscontested. Childhood obesity like adult obesity has been for the most part measuredby the Body Mass Index (BMI), a quick, convenient, and noninvasive measureemployed 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 overweightand obesity, including enhanced muscularity, large head size, and high torso-to-legratio, which may result in a falsely elevated BMI; this is particularly a concern forchildren under three years of age (Roberts and Dallal 2001). There are more precisemeasures of fat, including waist measurements to estimate abdominal fat thickness,


7/21

The Childhood Obesity Epidemic 7

and fat thickness at various points of the body, as well as direct measures of fatusing high-tech equipment in laboratories. However, these methods, particularlydirect measures, are expensive, time consuming, and invasive. BMI, though justan 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 (CDC2007). 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 forchildren are unknown, because, apart from a small sample of youth who experiencecardiovascular 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 classication of risk of child overweight and the 95th andabove for child overweight (Kuczmarski et al. 2002). There has been, however,an effort to internationally standardize the classication of childhood overweightand 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 obeseclassications of children at each year of age that match those of the 25 and 30BMI cutoffs set for adults (Cole et al. 2000). At present both sets of cutoffs are usedin prevalence studies with the 85th and 95th percentiles more commonly used inNorth 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. Indoing this, de Vries (2007) argues, overweight and obesity become conated. It isoften forgotten that a much smaller percentage of children above the 85th percentileare obese or morbidly obese and that the health risks associated with overweight areless severe and less numerous than those associated with obesity (de Vries 2007).Thus, overweight children are unnecessarily pathologized, when they may just behealthy 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 overweightinevitably become obese. Note that the CDC substitutes the word overweightfor obese when referring to children; however, children at or over the 85th andbelow 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 clinicalsetting, as it could precipitate emotional problems or unhealthy dieting. But evenin population studies, when overweight and obesity are reported together as onecategory, it heightens the extent of the obesity problem. Indeed, one alarmist reportpredicts an increase in pediatric obesity, such that life expectancy in the UnitedStates will be shortened by two to ve years by midcentury (Ludwig 2007:2325). Infact, recent prevalence data indicates that overweight and obesity among adults didnot increase from 200304 to 200506 in the United States (Ogden et al. 2007). Westill await reports of the youth data for the same time period. This is not to say thatwe should be complacent or assume that this leveling off of overweight and obesitywill continue. Nonetheless, it begs the question of whether dire predictions aboutfuture obesity-associated morbidity and mortality are valid at this point in time.


8/21


The Promotion of the Epidemic for Monetary Prot

The rise in societal concern over weight loss over the last 30 years has spawneda multibillion dollar diet industry, including weight-loss programs and diet food(Austin 1999). The construction of the obesity epidemic has helped to promotethis industry, but perhaps a less obvious nancial benet has accrued to the medicalresearch industry, where large grants can be garnered for studying obesity, partic-ularly if there are potential pharmaceutical applications. There is also prot to bemade from bariatric surgery for adults and clinics and camps to treat obese children.Although some critics might argue that the epidemic was constructed to increaseprots (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 awider capitalistic health care system (see Singer and Baer 1989 for further discussionof 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). 5In 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 anumber of studies indicating the association of childhood obesity with low house-hold income and food insecurity (Alaimo et al. 2001; Casey et al. 2001; Crooks1998, 1999, 2000; Mei et al. 1998; Wang 2001). Thus, women and children of lowSES bear the brunt of the so-called obesity epidemic.

In addition to the association of obesity with low SES, there is also a focus onchildhood obesity among ethnic minorities, with a documented higher prevalence,for example, of overweight among Hispanic and African Americans (Gordon-Larsenet 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 someresearchers suggest that cultural factors such as family environment exist aboveand 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 hasto consider both compositional (individual measures) and collective (neighborhoodenvironment) dimensions of SES when considering health disparities among racialethnic minorities. Collective measures of SES may be more meaningful in consideringobesity among racialethnic groups, where factors such as lower access to qualityfood and opportunity for physical activity could offset individual or family gainsfrom increased SES.

Beyond empirical data that indicates associations between obesity and ethnic mi-norities, however, there are stereotypes originating in the eugenics movement of theearly 20th century. At that time, as Saukko (1999) explains, obesity was conatedwith notions of constitutional soft or slack personalities of new immigrant groupsto the United States such as Italians and Jews. It is thus understandable that de Vries


9/21


(2007) voices concern about the further social marginalization of poor and ethnicminorities in the construction of the childhood obesity epidemic. The author states:In this way, the call to take political action against childhood obesity apparentlyequals 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 werecognize the biological consequences of social inequalities and barriers. As Krieger(2004:350) expounds in her glossary of embodiment in social epidemiology, ourliving bodies tell stories about our lives, whether or not these are ever consciouslyexpressed. 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 playsout variously in different contexts. Far from being just a problem of socioeconomi-cally disadvantaged children in Western nations, childhood obesity is fast becomingan issue for children living in economically developing countries, because of majorshifts in diet resulting in greater intakes in fat and sweeteners and declines in phys-ical activity associated with modernization (Popkin and Gordon-Larsen 2004). Inthese cases it is the children of middle and higher socioeconomic families who areconsuming energy-dense foods and expending less energy (Dasgupta et al. 2008;Wang 2001).

The challenge in doing research on socioeconomic determinants of obesity is thetrap of falling into discourse that plays into stereotyping and stigmatizing of vulner-

able groups. It calls for a reexive and sensitive approach, but not the disappearanceof this type of research altogether.

Medical Perspectives on Childhood Obesity

There has been little reection by the biomedical community on the use of the termepidemic to describe the rising prevalence of obesity. Most biomedical professionalswould probably acknowledge that although the use of the term is metaphoric, itis apt. Several medical researchers, moreover, have employed the term epidemicquite literally and have made claims about the rise in global obesity as havingepidemic attributes, such as a theory of obesity as a contagion running throughobese individuals social networks (Christakis and Fowler 2007). There is even atheory 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 concernedabout the very opposite societal tendency, apathy. Indeed, they fear that obesity isnot pathologized enough and that there is a growing societal normalization of childhood overweight and obesity. I base this observation, in part, on discussions Ihave 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 haveshifted (and will continue to shift in greater numbers) from the so-called normalBMI 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 theright, and with this shift there has been a decline in our ability to recognize obesity.


10/21


11/21


and the possible abridgement of civil liberties. For the most part the reaction tothe childhood obesity epidemic has been measured. Although there have beensuggestions in the United States to conduct BMI screening in schools, only Arkansashas 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 criteriafor successful screening programs in schools outlined by the American Academyof Pediatrics (Nihiser et al. 2007). Moreover, it may have unintended harmfulconsequences and could waste scarce resources that could otherwise be put tohealth 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 theplea by health care professionals for the manufacture of larger, stronger, and there-fore safer car seats for heavier preschoolers (Triletti et al. 2006) to the popularityof baggy hip-hop clothing fashions that are geared to a larger body size, albeit aimedat the male gender (Gross 2005). This acceptance may be, in part, because of theSize Acceptance Movement or Fat Liberation activists, who have attempted to createmore awareness about the stigma and suffering of larger people and the need to bemore accepting of diverse body sizes (Mitchell 2005; Sobal 1999). Although theselatter movements are not mainstream, the spirit of them is reected in the recentNEW Dove Soap advertising campaign Real women have real curves (2009). Thistrend 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 apublic health perspective. An epidemic of cholera or whooping cough, for example,

requires the use of tools, such as isolation and antibiotics or vaccination campaignsthat can immediately be employed. Ideally, public health creates strategic plans inadvance of epidemics so that healthcare professionals may act swiftly, and hopefullyeffectively, in stemming the outbreak. 6 Childhood obesity, however, has no suchquick solutions; although there have been a plethora of childhood obesity preventionprograms and subsequent evaluations, recent reviews of such interventions indicatethat there is limited evidence on which to base best practices (Boon and Clydesdale2005; Livingstone et al. 2006). The lack of effectiveness of prevention programs hasrecently been acknowledged in an opinion piece in the journal Obesity Reviews. Theauthors state: it is time to admit that we as obesity experts do not have sufcientand effective strategies to prevent overweight (Mueller and Danielzik 2006:88).These critics argue further that childhood obesity is part of larger societal andglobal forces that require multifaceted solutions that are thoughtful and directed atchanges in social and economic policy, the environment, and our cultural milieux(Livingstone et al. 2006; Mueller and Danilzik 2006). These types of interventionsdiffer from responses to acute infectious disease epidemics. Conversely, the specterof 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 societyto prevent a further rise in childhood obesity. Thus, to get out of the quick-x orthe situation is out of control mindsets, we must abandon the epidemic metaphor.

The second useful criticism of the treatment of childhood obesity is the conationof overweight and obesity discussed above. Longitudinal studies are required to fol-low children between the 85th and 95th percentiles into adolescence and adulthoodto determine how many of them become obese, as prospective studies to date do


12/21


not differentiate between overweight and obese children (e.g., Deshmukh-Taskar2006). Moreover, we require further research to understand the health risks orlack 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 isinversely correlated with metabolic syndrome, independent of abdominal fat (Leeet al. 2005). Further research is needed to understand the relationship between bodyfat and tness, as it may prove to be more benecial to promote cardiorespiratorytness over weight reduction in childhood obesity intervention programs.

Third, critical scholars are right to interrogate the etiological models used tounderstand childhood obesity as a phenomenon. However, the individualizinglifestyle 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 obesityin the Cecil Textbook of Medicine indicates that in recent years models of obesityhave become more concerned with environmental and social contexts (albeit geneticones as well) and less focused on individual blame and accountability (Chang andChristakis 2002). And although much of the medical literature continues to employa lifestyle approach to epidemiology and health promotion, there is an alternatebody of research within public health that critiques the individualizing lifestyleapproach to health promotion and advances a social epidemiology framework (see,e.g., Krieger 1994; Marmot 2005). There are also biomedical professionals whocritique the lifestyle approach to childhood obesity interventions (see Livingstone

et al. 2006).I conclude this review of the critical literature by considering whether criticaltheorists 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 readersthat evidence for the rise in childhood obesity is equivocal or at least impressivelyoverblown. For example, Boero begins her article stating that she does not denyrising 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 risein 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 latterstatement, however, is countered by a recent metastudy that compares internationaldata sets. The authors found clear evidence of an increase in both overweight andobesity among school-aged children since 1980 in all countries of the world exceptfor Russia and to a lesser extent Poland (Wang and Lobstein 2006). Many of thevalid criticisms and arguments about the social construction of the obesity epidemicbecome 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 phenomenonversus a medical crisis. However, it is also a social problem with real consequencesfor real people. It is clear that framing childhood obesity as an epidemic is not useful.


13/21


I have, as have many others, accepted the construction of the obesity epidemicand parroted the term unquestioningly in journal articles without considering theramications 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 obesityresearch. 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 littlein the way of communication between these groups and no public acknowledgmentby medical professionals of the critique; at the same time critical scholars have notfairly considered biomedical perspectives on childhood obesity. For there to be di-alogue, there must be some common ground, which means an acknowledgment onthe part of critical scholars that there is a biological phenomenon occurring globallythat 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 forchildhood obesity, because even if we abandon the epidemic metaphor some-thing is bound to replace it: as humans we live by metaphors (Lakoff and Johnson1980) and we construct social problems (Spector and Kitsuse 1987). Hence, thequestion is not should we be using a metaphor, but which should we choose toframe this problem? One approach is to treat childhood obesity as a social andenvironmental problem that is in part fueled by a toxic food environment, asmentioned above. Or perhaps we should link it metaphorically to consumption,

not just of food, but of material goods, related to concerns about global warmingand environmental destruction. Here we begin to address larger questions of so-cietal transformation of the economy, 7 food systems, and the environment, issuesto which most social scientists, health professionals, and the general public canrelate.

On a more practical level, anthropologists must establish a research agendathat includes empirical data collection and hypothesis testing as well as criticaland interpretive aspects. Empirical research could entail investigating establishedwisdom such as risk for obesity translates into obesity later in life; while we awaitresults of ongoing prospective studies, more research employing the lifecourseapproach and life histories may be useful, as exemplied by Clarkins (2008) studyof adiposity and height among adult Hmong refugees. It also requires collaborationwith health professionals on research projects where anthropologists can inject somecritical reection on the construction of the social problem of childhood obesity andimplications for prevention and intervention. Although multidisciplinary work ischallenging, because of differences in epistemology and methodology, it is perhapsthe only way to ensure that multiple perspectives are incorporated into the study of childhood obesity.

NotesAcknowledgments . I would like to thank Ann Herring, Tracey Galloway, and Dan Sellenfor their helpful comments on the manuscript, as well as anonymous reviews and the editorsof MAQ for their constructive aid in the preparation of this article.


14/21


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, Irefrain 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 collaborationof scientic 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 Denham2003).

5. Obesity is not stigmatized universally. See, for example, Popenoes (2005) accountof the fat female ideal among Nigerian Arabs.

6. I do not mean to imply that all disease epidemics are easily contained. HIV/AIDSis a case in point, where none of the public health measures described above have beeneffective.

7. For example, the construction of the obesity epidemic has been characterized as aproduct of neoliberalism where the citizen is a consumer that is encouraged to eat and atthe same time discipline him- or herself to achieve thinness amidst this plenty (Guthmanand DuPuis 2006:444).

References Cited

Alaimo, K., C. M. Olson, and E. A. Frongillo Jr.2001 Low Family Income and Food Insufciency in Relation to Overweight in U.S.

Children: Is There a Paradox? Archives of Pediatric Adolescent Medicine 155:11611167.

Atkinson, R. L.2007 Viruses as an Etiology of Obesity. Mayo Clinic Proceedings 82(10):11921198.

Austin, S. B.1999 Commodity Knowledge in Consumer Culture: The Role of Nutritional Health

Promotion in the Making of the Diet Industry. In Weighty Issues: Fatness and Thin-ness as Social Problems. J. Sobal and D. Maurer, eds. Pp. 159182. New York:Aldine de Gruyter.

Ball, H. H., and A. Swedlund1996 Poor Women and Bad Mothers: Placing the Blame for Turn-of-the Century Infant

Mortality. Northeast Anthropology 52:3152.Barness, L. A., J. M. Opitz, and E. Gilbert-Barness

2007 Obesity: Genetic, Molecular, and Environmental Aspects. American Journal of Medical Genetics 143A:30163034.

Boero, Natalie2007 All the News Thats Fat to Print: The American Obesity Epidemic and the

Media. Qualitative Sociology 30:4160.Boon, C. S., and F. M. Clydesdale

2005 A Review of Childhood and Adolescent Obesity Interventions. Critical Reviewsin Food Science and Nutrition 45:511525.

Booth, M. L., T. Chey, M. Wake, K. Norton, K. Hesketh, J. Dollman, and I. Robertson2003 Change in Prevalence of Overweight and Obesity among Young Australians,19691997. American Journal of Clinical Nutrition 77:2936.

Bordo, S.1993 Unbearable Weight: Feminism, Western Culture, and the Body. Berkeley: Univer-

sity of California Press.


15/21


Boutelle, K., J. A. Fulkerson, D. Neumark-Sztainer, and M. Story2004 Mothers Perceptions of Their Childrens Weight Status: Are They Accurate?

Obesity Research 12(11):17541757.Bowman, S. A., S. L. Gortmaker, C. B. Ebbeling, M. A. Pereira, and D. S. Ludwig

2004 Effects of Fast-Food Consumption on Energy Intake and Diet Qualityamong Children in a National Household Survey. Pediatrics 113(1 Pt. 1):112118.

Boyington, J., and A. Johnson2004 Maternal Perception of Body Size as a Determinant of Infant Adiposity in

an AfricanAmerican Community. Journal of the National Medical Association96(3):351362.

Brekke, H. K., J. van Odijk, and J. Ludvigsson2007 Predictors and Dietary Consequences of Frequent Intake of High-Sugar, Low-

Nutrient Foods in 1-Year-Old Children Participating in the ABIS Study. British Journal of Nutrition 97:176181.

Brewis, A.2003 Biocultural Aspects of Obesity in Young Mexican Schoolchildren. American Jour-

nal of Human Biology 15:446460.Brewis, A., and M. Gartin

2006 Biocultural Construction of Obesogenic Ecologies of Childhood: Parent-Feedingversus Child-Eating Strategies. American Journal of Human Biology 18:203216.

Brownell, K. D., and K. Battle Horgen2004 Food Fight: The Inside Story of the Food Industry, Americas Obesity Crisis, and

What We Can Do about It. Chicago: Contemporary.Brudette, H. L., T. A. Wadden, and R. C. Whitaker

2006 Neighborhood Safety, Collective Efcacy, and Obesity in Women with YoungChildren. Obesity 14(3):518525.

Campos, P. F.2004 The Obesity Myth: Why Americas Obsession with Weight is Hazardous to Your

Health. New York: Penguin.Carnell, S., and J. Wardle

2008 Appetitive Traits and Child Obesity: Measurement, Origins and Implications forIntervention. Proceedings of the Nutrition Society 67:343355.

Carr, D., and M. A. Friedman2005 Is Obesity Stigmatizing? Body Weight, Perceived Discrimination, and Psychologi-

cal Well-Being in the United States. Journal of Health and Social Behavior 46:244

259.Casey, P. H., K. Szeto, S. Lensing, M. Bogle, and J. Weber

2001 Children in Food-Insufcient, Low-Income Families, Prevalence, Health, and Nu-trition Status. Archives of Pediatric Adolescent Medicine 155:508514.

CDC2000 National Health and Examination Survey, 2000. United States: CDC Growth

Charts. Electronic document, http://www.cdc.gov/growthcharts, accessed January15, 2008.

2007 About BMI for Children and Teens. Electronic document, http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm, accessed January15, 2008.

Chaimovitz, R., R. Issenman, and T. Moffat2008 Body Perception: Do Parents, Their Children and Their Childrens Physicians Per-

ceive Body Image Differently? Journal of Pediatric Gastroenterology and Nutrition47(1):7680.


16/21


Chang, V. W., and N. A. Christakis2002 Medical Modeling of Obesity: A Transition from Action to Experience in

a 20th Century American Medical Textbook. Sociology of Health and Illness24(2):151177.

Chien-Chang, L., T. Su, K. Chien, J. Wang, C. Chiang, C. Lin, R.S. Lin, Y. Lee, and F.Sung2009 Elevated Blood Pressure, Obesity, and Hyperlipidemia. Journal of Pediatrics

155(1):7983.Christakis, N. A., and J. H. Fowler

2007 The Spread of Obesity in a Large Social Network Over 32 Years. New England Journal of Medicine 357:370379.

Clarkin, P.2008 Adiposity and Height of Adult Hmong Refugees: Relationship with War-Related

Early Malnutrition and Later Migration. American Journal of Human Biology20:174184.

Cole, T. J., M. C. Bellizzi, K. M. Flegal, and W. H. Dietz2000 Establishing a Standard Denition for Child Overweight and Obesity Worldwide:

International Survey. British Medical Journal 320(7244):12401243.Contento, I. R., P. Zybert, and S. S. Williams

2005 Relationship of Cognitive Restraint of Eating and Disinhibition to the Qualityof Food Choices of Latina Women and Their Young Children. Preventive Medicine40:326336.

Crooks, Deborah L.1998 Poverty and Nutrition in Eastern Kentucky: The Political Economy of Childhood

Growth. In Building a New Biocultural Synthesis: PoliticalEconomic Perspectiveson Human Biology. A. H. Goodman and T. L. Leatherman, eds. Pp. 339358. AnnArbor: University of Michigan Press.

1999 Child Growth and Nutritional Status in a High-Poverty Community in EasternKentucky. American Journal of Physical Anthropology 109:129142.

2000 Food Consumption, Activity, and Overweight among Elementary School Childrenin an Appalachian Kentucky Community. American Journal of Physical Anthropol-ogy 112:159170.

2003 Trading Nutrition for Education: Nutritional Status and the Sale of Snack Foodsin an Eastern Kentucky School. Medical Anthropology Quarterly 17(2):182199.

Dasgupta, P., R. Saha, and M. Nube2008 Changes in Body Size, Shape and Nutritional Status of Middle-Class Boys Bengali

Boys in Kolkata, India, 19822002. Economics and Human Biology 6:7594.Deane, S., and A. Thomson

2006 Obesity and the Pulmonologist. Archives of Disease in Childhood 91:188191.Deshmukh-Taskar, P., T. A. Nicklas, M. Morales, S. J. Yang, I. Zacheri, and G. S.

Berenson2006 Tracking of Overweight Status from Childhood to Young Adulthood: The Bo-

galusa Heart Study. European Journal of Clinical Nutrition 60:4857.de Vries, J.

2007 The Obesity Epidemic: Medical and Ethical Considerations. Science Engineeringand Ethics 13:5567.

Drenowski, A.2007 The Real Contribution of Added Sugars and Fats to Obesity. Epidemiologic Re-

views 29:160171.Drewnowski, A., and S. E. Specter

2004 Poverty and Obesity: The Role of Energy Density and Energy Costs. American Journal of Clinical Nutrition 79:616.


17/21


Driskell, M., S. Dyment, L. Mauriello, P. Castle, and K. Sherman2008 Relationships among Multiple Behaviors for Childhood and Adolescent Obesity

Prevention. Preventive Medicine 46:209215.Dubois, L., A. Farmer, M. Girard, and K. Peterson

2008 Social Factors and Television Use during Meals and Snacks Is Associated withHigher BMI among Pre-School Children. Public Health Nutrition 11(12):12671279.

Etelson, D., D. Brand, P. Patrick, and A. Shirali2003 Childhood Obesity: Do Parents Recognize This Health Risk? Obesity Research

11:13621368.Farmer, P.

2004 An Anthropology of Structural Violence. Current Anthropology 45(3):305325.Flegal, K. M., C. J. Tabak, and C. L. Ogden

2006 Overweight in Children: Denitions and Interpretation. Health Education Re-search 21(6):755760.

Frank, L. D., M. A. Andresen, and T. L. Schmid2004 Obesity Relationships with Community Design, Physical Activity, and Time Spent

in Cars. American Journal of Preventive Medicine 27(2):8796.Friedman, J. M.

2003 A War on Obesity, Not the Obese. Science 299:856858.Gallo, M. V., L. M. Schell, and Akwesasne Task Force on the Environment

2005 Height, Weight, and Body Mass Index among Akwesasne Youth Mohawk Youth.American Journal of Human Biology 17:269279.

Galloway, T.2006 Obesity Rates among Rural Ontario Schoolchildren. Canadian Journal of Public

Health 97(5):353356.2007 Gender Differences in Growth and Nutrition in a Sample of Rural Ontario

Schoolchildren. American Journal of Human Biology 19(6):744788.Germov, J., and L. Williams

1999 Dieting Women: Self-Surveillance and the Body Perception. In Weighty Issues:Fatness and Thinness as Social Problems. J. Sobal and D. Maurer, eds. Pp. 117132.New York: Aldine de Gruyter.

Gordon-Larsen, P., L. S. Adair, and B. M. Popkin2003 The Relationship of Ethnicity, Socioeconomic Factors, and Overweight in U.S.

Adolescents. Obesity Research 11(1):121129.Gordon-Larsen, P., M. C. Nelson, P. Page, and B. M. Popkin

2006 Inequality in the Built Environment Underlies Key Health Disparities in PhysicalActivity and Obesity. Pediatrics 117(2):417424.

Gortmaker, S. L., A. Must, A. M. Sobol, K. Peterson, G. A. Colditz, and W. H. Dietz1996 Television Viewing as a Cause of Increasing Obesity among Children in the United

States, 19861990. Archives of Pediatric and Adolescent Medicine 150:356362.Gross, J.

2005 Phat. In Fat: The Anthropology of an Obsession. D. Kulick and A. Meneley, eds.Pp. 6476. New York: Penguin.

Guthman, J., and M. DuPuis2006 Embodying Neoliberalism: Economy, Culture and the Politics of Fat. Environment

and Planning D: Society and Space 24(3):427448.Hamin, M. T.

1999 Constitutional Types, Institutional Forms: Reconguring Diagnostic and Thera-peutic Approaches to Obesity in Early Twentieth-Century Biomedical Investigation.In Weighty Issues: Fatness and Thinness as Social Problems. J. Sobal and D. Maurer,eds. Pp. 5374. New York: Aldine de Gruyter.


18/21


Hannon, T. S., G. Rao, and S. A. Arslanian2005 Childhood Obesity and Type 2 Diabetes Mellitus. Pediatrics 116:473480.

Hill, J. O., and F. L. Trowbridge1998 Childhood Obesity: Future Directions and Research Priorities. Pediatrics 101:570

574.International Association for the Study of Obesity2008 Historical overview. Electronic document, http://www.iaso.org/history.asp, ac-

cessed January 15, 2008.International Obesity Task Force (IOTF)

2008 What Is IOTF? Electronic document, http://www.iotf.org/whatisiotf.asp, accessed January 15, 2008.

Ikeda, J. P., P. B. Crawford, and G. Woodward-Lopez2006 BMI Screening in Schools: Helpful or Harmful. Health Education Research

21(6):761769. Jeffery, A. N., L. D. Voss, B. S. Metcalf, S. Alba, and T. J. Wilkin

2005 Parents Awareness of Overweight in Themselves and Their Children: Cross Sec-tional Study within a Cohort. British Medical Journal 330:2324.

Krieger, N.1994 Epidemiology and the Web of Causation: Has Anyone Seen the Spider? Social

Science and Medicine 39(7):887903.2005 Embodiment: A Conceptual Glossary for Epidemiology. Journal of Epidemiology

and Community Health 59:350355.Kuczmarski, R. J., C. L. Ogden, S. S. Guo, L. M. Grummer-Strawn, K. M. Flegal, Z. Mei,

R. Wei, L. R. Curtin, A. F. Roche, and C. L. Johnson2002 2000 CDC Growth Charts for the United States: Methods and Development. Vital

Health Statistics 11(246):1190.Lakoff, G., and M. Johnson

1980 Metaphors We Live By. Chicago: University of Chicago Press.Lechky, O.

1994 Epidemic of Childhood Obesity May Cause Major Public Health Problems, WarnsDoctor. Canadian Medical Association Journal 150(1):7881.

Lee, S., J. L. Kuk, P. T. Katzmarzyk, S. N. Blair, T. S. Church, and R. Ross2005 Cardiorespiratory Fitness Attenuates Metabolic Risk Independent of Abdominal

Subcutaneous and Visceral Fat in Men. Diabetes Care 28:895901.Livingstone, M. B. A., T. A. McCaffrey, and K. L. Rennie

2006 Childhood Obesity Prevention Studies: Lessons Learned and to Be Learned. Public

Health Nutrition 9(8A):11211129.Ludwig, D. S.

2007 Childhood Obesity: The Shape of Things to Come. New England Journal of Medicine 357:23252327.

Lumeng, J. C., D. Appugliese, H. J. Cabral, R. H. Bradley, and B. Zuckerman2006 Neighborhood Safety and Overweight in Children. Archives of Pediatric and

Adolescent Medicine 160:2531.Marmot, M.

2005 Social Determinants of Health Inequalities. Lancet 365:10991104.Martin, P. M. V., and E. Martin-Granel

2006 2500-Year Evolution of the Term Epidemic . Emerging Infectious Diseases12(6):976980.

McElhinny, B.2005 Kissing a Baby Is Not All Good for Him: Infant Mortality, Medicine, and

Colonial Modernity in the U.S.-Occupied Philippines. American Anthropologist107(2):183194.


19/21


Mei, Z., L. M. Grummer-Strawn, A. Pietrobelli, A. Goulding, M. I. Goran, and W. H.Dietz

2002 Validity of Body Mass Index Compared with Other Body-Composition ScreeningIndexes for the Assessment of Body Fatness in Children and Adolescents. American

Journal of Clinical Nutrition 75(6):978985.Mei, Z., K. S. Scanlon, L. M. Grummer-Strawn, D. S. Freedman, R. Yip, and F. L.Trowbridge

1998 Increasing Prevalence of Overweight among U.S. Low-Income Preschool Children:The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance,19831995. Pediatrics 101(1):16.

Mitchell, A.2005 Pissed Off. In Fat: The Anthropology of an Obsession. D. Kulick and A. Meneley,

eds. Pp. 211226. New York: Penguin.Moffat, T., and T. Galloway

2007 Adverse Environments: Investigating Local Variation in Child Growth. American Journal of Human Biology 19(5):676683.

2008 Food Consumption Patterns among Elementary School Children in Hamilton,Ontario. Canadian Journal of Dietetic Practice and Research 69(3):152154.

Moffat, T., T. Galloway, and J. Latham2005 Stature and Adiposity among Children in Contrasting Neighborhoods in the City

of Hamilton, Ontario, Canada. American Journal of Human Biology 17(3):355367.

Moffat, T., and Herring, D. A.1999 The Historical Roots of High Rates of Infant Death in Aboriginal Communities in

Canada in the Early Twentieth Century: The Case of Fisher River, Manitoba. SocialScience and Medicine 48:18211832.

Mueller, M. J., and S. Danielzik2006 Childhood Overweight: Is There a Need for a New Societal Approach to the

Obesity Epidemic? Obesity Reviews 8:8790.Murray, S.

2008 Pathologizing Fatness: Medical Authority and Popular Culture. Sociology of Sport Journal 25(1):721.

National Collaborative on Childhood Obesity ResearchN.d. Home page. Electronic document, http://www.nccor.org/, accessed February 2009.

National Institutes of Health (NIH)2004 U.S. Department of Health and Human Services NIH News. Electronic document,

http://www.nih.gov/news/pr/aug2004/niddk-24.htm, accessed January 15, 2008.Nestle, M., and M. F. Jacobson

2000 Halting the Obesity Epidemic: A Public Health Policy Approach. Public HealthReports 115(1):1224.

NEW Dove Soap Advertising Campaign Real Women Have Real Curves. Electronic doc-ument, http://www.campaignforrealbeauty.com/at3.asp?id=2287, accessed March2009.

Nihiser, A. J., S. M. Lee, H. Wechsler, M. McKenna, E. Odom, C. Reinhold, D. Thompson,and L. Grummer-Strawn.

2007 Body Mass Index Measurement in Schools. Journal of School Health 77(10):651671.

Ogden, C. L., M. D. Carroll, M. A. McDowell, and K. M. Flegal2007 Obesity among Adults in the U.S.No Statistically Signicant Change since

20032004. NCHS Data Brief, No. 1. Hyattsville, MD: National Center for HealthStatistics.


20/21


Popenoe, R.2005 Ideal. In Fat The Anthropology of an Obsession. D. Kulick and A. Meneley, eds.

Pp. 928. New York: Penguin.Popkin, B. M., and P. Gordon-Larsen

2004 The Nutrition Transition: Worldwide Obesity Dynamics and Their Determinants.International Journal of Obesity 28:S2S9.Powers, S. W., L. A. Chamberlin, K. B. van Schaick, S. N. Sherman, and R. C. Whitaker

2006 Maternal Feeding Strategies, Child Eating Behaviors, and Child BMI in Low-Income African American Pre-Schoolers. Obesity 14(11):20262033.

Ritenbaugh, C.1987 Obesity As a Culture-Bound Syndrome. Culture, Medicine and Psychiatry 6:347

361.Roberts, S. B., and G. E. Dallal

2001 The New Childhood Growth Charts. Nutrition Reviews 59(2):3136.Rodearmal, S. J., H. R. Wyatt, N. Stroebele, S. M. Smith, L. G. Ogden, and J. O. Hill

2007 Small Changes in Dietary Sugar and Physical Activity As an Approach to Pre-venting Excess Weight Gain: The America on the Move Family Study. Pediatrics120(4):E869E879.

Rudolf, M. C. J., S. Pinki, J. H. Barth, and J. Walker2001 Increasing Prevalence of Obesity in Primary School Children: Cohort Study. British

Medical Journal 322:10941095.Saguy, A. C., and K. W. Riley

2005 Weighing Both Sides. Morality, Mortality, and Framing Contests over Obesity. Journal of Health Politics, Policy and Law 30(5):869921.

Saukko, P.1999 Fat Boys and Goody Girls: Hilde Bruchs Work on Eating Disorders and the

American Anxiety about Democracy, 19301960. In Weighty Issues: Fatness andThinness as Social Problems. J. Sobal and D. Maurer, eds. Pp. 3152. New York:Aldine de Gruyter.

Schell, L. M., and M. Denham2003 Environmental Pollution in Urban Environments and Human Biology. Annual

Review of Anthropology 32:111134.Shavers, V. L.

2007 Measurement of Socioeconomic Status in Health Disparities Research. Journal of the National Medical Association 99(9):10131023.

Singer, M., and H. Baer

1989 Toward an Understanding of Capitalist and Socialist Health. Medical Anthropol-ogy 11(2):97107.

Smith, T. K., B. Bogin, M. I. Varela-Silva, and J. Loucky2003 Economic and Anthropological Assessments of the Health of Children in Maya

Immigrant Families in the U.S. Economics and Human Biology 1(2):145160.Sobal, J.

1991 Obesity and Socioeconomic Status: A Framework for Examining the Rela-tionship between Physical and Social Variables. Medical Anthropology 13:231247.

1999 The Size Acceptance Movement and the Social Construction of Body Weight. InWeighty Issues: Fatness and Thinness as Social Problems. J. Sobal and D. Maurer,eds. Pp. 209230. New York: Aldine de Gruyter.

Sobal, J., and A. J. Stunkard1989 Socioeconomic Status and Obesity: A Review of the Literature. Psychological

Bulletin 105:260275.


21/21


Sorof, J. M., G. Lai, J. Turner, T. Poffenbarger, and R. J. Portman2004 Overweight, Ethnicity, and the Prevalence of Hypertension in School-Aged Chil-

dren. Pediatrics 113(3):475482.Spector, M., and J. I. Kitsuse

1987 Constructing Social Problems. New York: Aldine de Gruyter.Spiegel, A. M., and E. G. Nabel2006 NIH Research on Obesity and Type 2 Diabetes: Providing the Scientic Evidence

Base for Actions to Improve Health. Nature Medicine 12:6769.Stearns, P. N.

1999 Children and Weight Control: Priorities in the United States and France. InWeighty Issues: Fatness and Thinness as Social Problems. J. Sobal and D. Maurer,eds. Pp. 930. New York: Aldine de Gruyter.

Sui, X., M. J. LaMonte, J. N. Laditka, J. W. Hardin, N. Chase, S. P. Hooker, and S. N.Blair

2007 Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults. Journal of the American Medical Association 298(21):25072516.

Tomes, N.2002 Epidemic Entertainments: Disease in Popular Culture in Early-Twentieth-Century

America. American Literary History 14(4):625652.Tremblay, M. S., and J. D. Willms

2000 Secular Trends in the Body Mass Index of Canadian Children. Canadian MedicalAssociation Journal 163(11):14291433.

Triletti, L. B., W. Shields, D. Bishai, E. McDonald, F. Reynaud, and A. Gielen2006 Tipping the Scales: Obese Children and Child Safety Seats. Pediatrics 117:1197

1202.Troiano, R. P., K. M. Flegal, R. J. Kuczmarski, S. M. Campbell, and C. L. Johnson

1995 Overweight Prevalence and Trends for Children and Adolescents. Archives of Pediatric and Adolescent Medicine 149:10851091.

Ulijaszek, S., and H. Lonk2006 Obesity in Biocultural Perspective. Annual Review of Anthropology 35:337360.

U.S. Department of Health and Human Services2004 HHS Announces Revised Medicare Obesity Coverage Policy. Electronic doc-

ument, http://www.hhs.gov/news/press/2004pres/20040715.html, accessed January15, 2004.

Van Horn, L.2005 Liquid Sweets and Candy Treats? Is That All There Is? Journal of the American

Dietetic Association 105(2):191.Wang, Y.

2001 Cross-National Comparison of Childhood Obesity: The Epidemic and the Re-lationship between Socioeconomic Status. International Journal of Epidemiology30:11291136.

Wang, Y., H. Liang, L. Tussing, C. Braunshweig, B. Cabellero, and B. Flay2007Obesity and RelatedFactors among Low Socio-Economic Status Minority Students

in Chicago. Public Health Nutrition 10(9):927938.Wang, Y., and T. Lobstein

2006 Worldwide Trends in Childhood Overweight and Obesity. International Journalof Pediatric Obesity 1:1125.

WHO2000 Obesity: Preventing and Managing the Global Epidemic. Report of a WHO con-

sultation. World Health Organization Technical Report Series 894:ixii, 1253.

the childhood obesity epidemic. health crisis or social construction

Documents