Childhood Obesity in America: Biography of an Epidemic
Harvard University Press, 2014
320 pp., $47.50
Childhood Obesity in America
In a study conducted in 1961, 10- and 11-year old boys and girls in the fifth and sixth grades were given six drawings of children and asked to rank the children from the one they liked best to the one they liked least. The drawings depicted one healthy child with no visible disabilities, one with crutches and a leg brace, one sitting in a wheelchair with a blanket covering both legs, one with no left hand, one with a facial disfigurement, and one child who was obese. Children tended to select the healthy child as the one they liked best and the obese child as the one they liked least. This study was replicated in 2003 with a new sample of children. In 2003, the difference in average ranking between the healthy child and the obese child was 40.8 percent greater than in 1961, and over 70 percent of the children in the study ranked the obese child lowest or second-lowest. If the same study had been conducted in 1900, it is likely that the outcome would have been much different.
At the beginning of the 20th century, childhood obesity was rare and had little medical or social significance. Being a hefty child was a good thing. It meant that you had access to nutrition, that your mother was taking good care of you, and that you drank your milk. Even extreme obesity was seen as a temporary state that would resolve itself as the child grew. Fast-forward to the present: childhood obesity has a very different meaning, medically, socially, and culturally. Childhood obesity is now at best a medical issue and at worst a death sentence, a sign of a future burdened with heart disease, type two diabetes, hypertension, social rejection, and early death. Obesity is also now a sign of failure, failure of personal self-regulation and of failure as a culture. So how did we as a society end up where we are now? As the book's title and subtitle suggest, Laura Dawes takes a historical approach and examines childhood obesity in the United States over the last 100 years.
The first section of the book emphasizes the measurement and diagnosis of childhood obesity, beginning with the difficulties that medical professionals and researchers have had in quantifying children's body size. Dawes explains that professionals have come to realize that obesity needs to be addressed as an excess of fat mass rather than overall body mass. Unfortunately, this causes problems for researchers. Body-mass index (BMI), a measure based on the relationship between height and weight, has great epidemiological utility. The ease of measurement of BMI has led to its wide use in the assessment of population trends in childhood obesity. However, it does not accurately assess actual body fat. The development of new techniques such as skin calipers and hydrostatic weighing have made the measurement of body fat, as opposed to body weight, easier, but these new techniques are more expensive and time-consuming than simply stepping on a scale. Complicating the issue further is the question of how to figure out which children are at a healthy weight and which children are not. Dawes explains that the answer to this question has changed over time as views on childhood obesity have shifted from positive to negative and as children have become increasingly overweight. The size of the "average" child may no longer be the size of a healthy child.
Next, Dawes takes the reader on a journey through the history of theories about the etiology of childhood obesity, how these theories have affected who is blamed when a child is fat, and how treatments have shifted with each change in who is blamed. Every significant change in theory has implicated an increasing number of people with regard to both the causes and the treatment of childhood obesity. Endocrinal, biological, genetic, psychological, familial, metabolic, behavioral, social, environmental, and cultural explanations are all addressed in this section, and each with impressive clarity. The notion that childhood obesity is a biological problem that can be fixed with a drug is the explanation that has the longest history. Biological theories first focused on endocrine disruption, then metabolic theories, and finally hormonal imbalances. With each change in definition came a change in treatment and new hope that a drug would finally solve the issue. However, the drugs generally have done more harm than good, and on top of that, childhood obesity has continued to become more common.
By the 1940s, new theories about the causes of childhood obesity overlaid these biological explanations. Now, not only could childhood obesity be a biological issue, it could also be a familial and emotional issue. Dawes explains how these psychological and familial explanations developed, and how focus of treatment changed accordingly. Two decades later, the focus had shifted yet again. According to the new model—still largely in place—childhood obesity was caused by energy imbalance. Children were eating too much and moving too little. Not surprisingly, another shift in treatment occurred and behavioral modification treatment became the most common approach. With this shift, the children's dieting movement began, and treatments implicating energy balance became the gold standard.