CHAPTER 1. The Myth of the Childhood Obesity Epidemic
ANAMARIE Regino is a twenty-five-year-old in Albuquerque, New Mexico, who looks a lot like every other twenty-five-year-old on TikTok. She posts videos of her dogs and her tattoos. She lip-syncs and tries out new ways to wear eyeliner. And she participates in sassy memes: “Soooo … this whole meme that’s going around with ‘decade challenge’?” she says in a video from 2019. “I just want to say: I think I won that.” Then Anamarie’s current lipsticked smirk is replaced by a photo of her from 2009. In both shots, Anamarie is fat. In fact, in other recent TikTok videos and Instagram posts, Anamarie proudly describes herself as fat, affectionately calls out her double chin, and uses hashtags like #PlusSize and #BBW (short for “big, beautiful woman”). But this video is also tagged #WeightLossCheck, because in the 2009 photo, Anamarie is significantly larger than her adult self. Twelve-year-old Anamarie has a half-hearted smile, but her dark bangs are swept over most of her face. It is the classic awkward “before” shot.
It’s not, however, the most famous photo ever taken of Anamarie. That photo, shot by Katy Grannan when Anamarie was just four years old, first ran in a 2001 New York Times Magazine story and is now archived in the National Portrait Gallery’s Catalog of American Portraits. Anamarie’s body became part of our historical record when she was removed from her parents’ custody by the state of New Mexico because she weighed over 120 pounds at age three, and social workers determined that her parents “have not been able or willing” to control her weight.
The case made international headlines, with Anamarie’s parents telling their story to Good Morning America and to Lisa Belkin of the New York Times Magazine, for the article that accompanied Grannan’s portrait. Anamarie’s mother, Adela Martinez-Regino, had long been concerned about her daughter’s appetite and her rapid growth, and then, her delayed speech and mobility. She sought help from medical professionals repeatedly from the time Anamarie was just a few months old, and multiple tests ruled out any known genetic cause, such as Prader-Willi syndrome, a rare chromosomal disorder that causes children to never feel fullness. But Anamarie continued to grow. And doctors grew frustrated by what they perceived to be a dangerous pattern: Anamarie would lose weight when undergoing their intensive medical regimens, including prescription liquid diets that provided her no more than 550 calories per day. But she would regain the weight when the protocol ended and she was once again left in her family’s care. To the doctors, the risks to Anamarie lay not in their use of aggressive weight loss tactics on a toddler but in what happened when her family let her eat. “They treated her for four years, doctor after doctor. Not one of them could help. Then they took her away for months, and they still couldn’t tell me what was wrong,” Martinez-Regino told Belkin. “They’ve played around with her life like she was some kind of experiment. […] They don’t know what’s wrong, so they blame us.”
Martinez-Regino also reported that when Anamarie was taken from her parents, they had to listen to their daughter screaming for them as a nurse wheeled her away. During her months in foster care, Anamarie lost some weight and got new glasses but also stopped speaking Spanish (her father’s native language) and was understandably traumatized by the separation from her parents. The state’s decision to take custody of Anamarie was immediately controversial: “If this were a wealthy, white, professional family, would their child have been taken away?” Belkin asked in her piece, noting how often doctors and social workers perceived a language barrier with the Regino family, even though English was Anamarie’s mother’s first language. As a nation, we debated the question in op-eds, on daytime talk shows, and at water coolers: Should a child’s high body weight be viewed as evidence of child abuse?
Anamarie Regino wasn’t the first or the last child to be removed from parental custody due to her weight. In 1998, a California mother was convicted of misdemeanor child abuse after her thirteen-year-old daughter, Christina Corrigan, died weighing 680 pounds. A handful of similar cases popped up in Indiana, New York, Pennsylvania, and Texas over the subsequent decade, according to a report published in Children’s Voice, a publication of the Child Welfare League of America. And in 2021, a British case made international headlines when a judge ordered two teenagers into foster care because their parents had failed to make them wear their Fitbits and go to Weight Watchers meetings. A 2010 analysis published in the DePaul Journal of Health Care Law by a legal researcher named Cheryl George summarizes one prevailing cultural attitude on such tragedies:
Parents must and should be held accountable for their children’s weight and health. Parents can be a solution in this health care crisis, but when they are derelict in their duties, they must be held criminally responsible for the consequences of their actions.
George acknowledged the “fear and anxiety” caused when a child is removed from parental custody but quickly dismissed that as a priority, quoting an earlier article on the subject: “If a child remains with his or her parents in order to affirm the ‘attachment,’ we may be overlooking the looming morbid obesity problem,” she wrote. Never mind that removing custody in an effort to address this “morbid obesity” overlooks a child’s emotional and developmental needs, as well as several basic human rights.
A New Mexico judge dismissed charges against Anamarie’s parents after a psychiatric evaluation of Martinez-Regino found no evidence of psychological abuse. But the family was left to sort through the wreckage of those harrowing months, while continuing to seek answers that doctors could not provide to explain Anamarie’s accelerated growth. And Anamarie’s story embedded itself in our national consciousness. She became a kind of “patient zero” for the war on childhood obesity. Even Belkin’s piece, which is largely sympathetic to the family, frames Anamarie’s body as the problem. Belkin makes sure to emphasize how this toddler’s weight made her unlovable, describing Anamarie’s “evolution from chubby to fat to horrifyingly obese” in family photos, and noting that Martinez-Regino “knows that the sight of her daughter makes strangers want to stare and avert their eyes at the same time.” Having a fat child was framed as the ultimate parental failure. Anamarie’s story confirmed that our children’s weight is a key measure of our success as parents, especially for mothers.
Nowhere in the public conversations around Anamarie’s early childhood was there ever any attempt to understand what Anamarie herself thought of her body or the treatment she received because of it. Today, her social media makes it clear that she’s proud to have lost weight but also proud to still identify as fat, and maybe also still working it all out. (Anamarie—quite understandably—did not respond to my interview requests.) But in the late 1990s and early 2000s, our anxiety about the dangers of fatness in children far outstripped any awareness of their emotional health.
Today, this conversation has evolved, but only so far: We want our kids to love their bodies, but we also continue to take it for granted that fat kids can’t do that. A child’s high body weight is still a problem to solve, a barrier to their ability to be a happy, healthy child. This thinking is the result of a nearly forty-year-old public health crusade against the rising tide of children’s weight. We’ve been told—by our families, our doctors, and voices of authority, including First Lady Michelle Obama—that raising a child at a so-called healthy body weight is an essential part of being a good parent.
But when we talk about the impossibility of raising a happy, fat child, we’re ignoring the why: It’s not their bodies causing these kids to have higher rates of anxiety, depression, and disordered eating behaviors. Even when high weight does play a role in health issues, as we’ll explore in Chapter 2, it’s often a corresponding symptom, a constellation point in a larger galaxy of concerns. The real danger to a child in a larger body is how we treat them for having that body. Fat kids are harmed by the world, including, too often, their own families. And our culture was repulsed by fat children long before we considered ourselves amid an epidemic of them. “It is easy for us to assume today that the cultural stigma associated with fatness emerged simply as a result of our recognition of its apparent health dangers,” writes Amy Erdman Farrell, PhD, a feminist historian at Dickinson College, in her 2011 book, Fat Shame: Stigma and the Fat Body in American Culture. “What is clear from the historical documents, however, is that the connotations of fatness and of the fat person—lazy, gluttonous, greedy, immoral, uncontrolled, stupid, ugly, and lacking in will power—preceded and then were intertwined with explicit concern about health issues.” To understand how we’ve reached this anxious place of wanting our kids to love their bodies, but not wanting them to be fat, we have to first go backward and understand the making of our modern childhood obesity epidemic. And we need to see how it has informed, and been informed by, our ideas about good mothers and good bodies.
A SHORT HISTORY OF FATPHOBIA
Just as we think of childhood obesity as a modern problem, we often frame fatphobia as a modern response and wax poetic about the days of yore when fat was seen as a sign of wealth, status, and beauty. But when historians dig back through old periodicals, newspapers, medical records, and other historical documents, they find plenty of evidence of anti-fat bias throughout Western history. The ancient Greeks celebrated thin bodies in their sculptures, art, and poetry. By the 1500s, corsets made from wood, bone, and iron were designed to flatten the torsos of the European aristocracy. And early novels like Don Quixote and the plays of Shakespeare are full of fat jokes and fat characters played as fools. For the purposes of understanding our modern childhood obesity epidemic, it’s most helpful to see how Western anti-fatness intensified at the end of the late nineteenth century and then strengthened in the early decades of the twentieth century. This happened in response to the end of American slavery and increasing rights for women and people of color, as Sabrina Strings traces in her seminal work, Fearing the Black Body. In Fat Shame, Farrell notes that for much of the nineteenth century, fatness was attached to affluence and social status “and as such, might be respectable […] but also might reveal gluttonous and materialistic traits of specific, unlikeable, and even evil individuals. By the end of the 19th century, fatness also came to represent greed and corrupt political and economic systems.” Around the same time, advances in medicine and sanitation led to a decrease in infant mortality and infectious disease death rates. This meant that by the early 1900s the scientific world could begin to consider the ill effects of high body weight in a more concerted way. And scientists brought their preexisting associations of fat with sloth and amorality to this work.
The template for our modern body mass index was first designed as a table of average heights and weights in the 1830s by a Belgian statistician and astronomer named Lambert Adolphe Jacques Quetelet. Quetelet set out to determine the growth trajectory of the life of the “Average Man,” meaning his white, Belgian, nineteenth-century peers. He never intended his scale to assess health. But in the early 1900s, the American life insurance industry began using his work to determine what they called an “ideal weight” for prospective clients based on their height, gender, and age. How closely you matched up to this ideal determined whether you qualified for a standard life insurance policy, paid a higher premium, or were denied coverage. And as the medical world was connecting these first dots between weight and health, we see the unmistakable presence of anti-fat bias. “A certain amount of fat is essential to an appearance of health and beauty,” wrote nutrition researchers Elmer Verner McCollum and Nina Simmonds in 1925. “It is one indication that the state of nutrition is good. [… But] we all agree that excessive fat makes one uncomfortable and unattractive.” Health and beauty were synonymous to these researchers, and many other medical experts of the late nineteenth and early twentieth centuries.
Much of the early scientific work around weight was rooted in the racist belief that fat bodies were more primitive because they made white bodies look more like Black and immigrant bodies. Black women, in particular, were (and still are) stereotyped as a “mammy” (a fat and asexual maternal caretaker of white families), a hypersexual “Jezebel,” or, more recently, a “welfare queen” (a fat, amoral, single mother whose existence endangers the sanctity of the white family). The almost exclusively white and predominantly male fields of medicine and science were eager to find “proof” of white people’s superiority to other racial groups and made broad generalizations about racial differences in body size and shape (as well as facial features, skull size, and so on) to build their case.
In 1937, a Jewish psychiatrist named Hilde Bruch set out to challenge the theory of fatness as a sign of racial inferiority by studying hundreds of Jewish and Italian immigrant children in New York City. She examined their bodies (with a particular focus on height, weight, and genital development). She visited their homes to observe children eating and playing, and she interviewed their mothers extensively. And Bruch determined that there was nothing physically wrong with the fat kids in her study—which could have been a huge breaking point in our cultural understanding of weight and health. But although she disputed the notion that fat white immigrants and fat people of color were biologically inferior to thin white Americans, Bruch still framed fatness as a matter of ethnicity: “Obesity occurs with greater frequency in children of immigrant families than in those of settled American background,” she declared in a 1943 paper. And instead of blaming physiology, Bruch blamed mothers. Her papers on childhood obesity explain the children’s fatness as “a result of the smothering behavior of their strongwilled immigrant mothers,” writes Farrell. “These mothers simultaneously resented and clung to their children, trying to make up for both their conflicting emotions and poor living conditions by providing excessive food and physical comfort. Bruch described the fathers of these fat children as weak willed, often absent, and ‘yearning’ for the love that their wives devoted to the children.”
Bruch’s description of immigrant parents of fat children is a neat precursor to the treatment the Regino family received during Anamarie’s custody case. Anamarie’s father, Miguel, goes unquoted in the New York Times Magazine feature and most other media, while her mother is required to defend herself as a parent and assert herself as an American repeatedly, in the media and with doctors and social workers who assume she can’t understand them. “There were so many veiled comments which added up to, ‘You know those Mexican people, all they eat is fried junk, of course they’re slipping her food,’” the Regino family’s lawyer told Belkin. The social worker’s affidavit recommending that Anamarie be placed in foster care concluded by saying, “The family does not fully understand the threat to their daughter’s safety and welfare due to language or cultural barriers.” Martinez-Regino said such comments showed her that “they decided about us before they even spoke to us.”
So anti-fatness, racism, and misogyny have long intersected with and underpinned one another. Even when a researcher like Bruch set out to challenge one piece of the puzzle, she did so by reinforcing the rest of our cultural biases. The immigrant children she studied weren’t diseased—but their weight was still a problem, and their mothers still held responsible. It would be decades before anyone thought to question either assumption. In 1969 the nascent “fat acceptance” movement took off with the establishment of the National Association to Advance Fat Acceptance (NAAFA). In 1973, two California activists named Judy Freespirit and Aldebaran wrote the first “Fat Manifesto” for their organization, the Fat Underground: “We believe that fat people are fully entitled to human respect and recognition,” they began. A later clause specifies:
We repudiate the mystified “science” which falsely claims that we are unfit. It has both caused and upheld discrimination against us, in collusion with the financial interests of insurance companies, the fashion and garment industries, reducing industries, the food and drug establishments.
These early activists created spaces where fat people could find community and support and begin to understand the way they were treated as a form of chronic oppression. Along with disability rights activists, they operated on the fringes of feminism and queer activism, and their ideas were far from any mainstream conversations about weight.
But around the same time, a handful of researchers began studying fat stereotypes as a way of understanding how we learn and internalize biases. In several studies from the 1960s, researchers showed children drawings of kids with various body types (usually a disabled child, a child with a birth defect, and a child in a larger body) and found that they consistently rated the fat child as the one they liked least. In a 1980 experiment, a public health researcher named William DeJong found that high school students shown a photo of a higher-weight girl rated her as less self-disciplined than a lower-weight subject unless they were told her weight gain was caused by a thyroid condition. “Unless the obese can provide an ‘excuse’ for their weight […] or can offer evidence of successful weight loss, their character will be impugned,” he wrote. In 2012, researchers revisited the picture-ranking experiment from the 1960s with a group of 415 American fifth and sixth graders and found that anti-fat bias had only intensified. They noted, “The difference in liking between the healthy and obese child was currently 40.8 percent greater than in 1961.” So, the farther we come in claiming to understand and care about the health of fat children, it seems, the less we like them. As Anamarie’s mother said in the New York Times Magazine story: “They decided about us before they even spoke to us.”
THE MAKING OF THE MODERN OBESITY EPIDEMIC
In 1988, Colleen was ten years old, living in Highlands Ranch, Colorado. She had never heard of fat acceptance or the Fat Manifesto or early research on anti-fat biases. But she experienced fatphobia every day. At home, family members would make comments like “You look like you’re going to have a baby with that belly” and remind her to suck in her stomach and stand “like a lady,” with her hands clasped in front of her middle, especially when she went up to receive Communion at church. At school, kids teased her mercilessly, calling her “Tank” when she played four-square at recess. When everyone got weighed in her gym class, Colleen recalls stepping on the scale in front of all her classmates and then having to put her weight on an “About Me” poster that was hung in the school hallway. Highlands Ranch is a mostly white, affluent suburb of Denver also known as “The Bubble,” and Colleen thinks its lack of diversity played a role in her experience. “There was a sense of perfectionism and I didn’t fit that ‘perfect’ or ideal body type.”
When the bullying reached a breaking point, her parents called a psychologist—and put Colleen on the popular ’90s weight loss plan Jenny Craig. “I remember my mom saying, ‘You need to nip this in the bud right now,’” says Colleen, who is now a forty-two-year-old physician’s assistant, still living in a larger body, and still living in Highlands Ranch, with her husband and eleven-year-old son. “I think she felt that if I was fat at that age, I’d be fat for the rest of my life, and live this horrible life where everyone would make fun of me, and I’d never be accepted.” There was no discussion of consequences for the kids bullying Colleen at school. Her family is white and now upper middle class, but having a fat child still subjected Colleen’s parents, who grew up working class themselves, to stigma and scrutiny. Colleen’s weight was their problem to solve, and her mother, especially, was determined to fix it.
Indeed, by the 1990s, fixing everyone’s weight had become a national project. In 1997, a Boston pediatrician named William Dietz, MD, PhD, joined the front lines of the fight, as director of the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention. “I took the CDC job because I thought that obesity needed to be a national concern, and I couldn’t really do that much about it in an academic setting,” he tells me. Dietz and his colleagues had been warning about a rise in body size for both children and adults since the mid-1980s, based on data collected in the National Health and Nutrition Examination Survey, known as NHANES, which is executed every two years. Data collected beginning in 1971 showed that just 5.2 percent of kids aged two to nineteen met the criteria for obesity then. By the survey begun in 1988, that percentage had nearly doubled, and the 1999–2000 NHANES showed a youth obesity rate of 13.9 percent. That rate has continued to climb, reaching 19.3 percent in the 2017–2018 NHANES. A similar rise in body size was documented for adults: Data collected from 1976 to 1980 showed that 15 percent of adults met criteria for obesity. By 2007, it had risen to 34 percent. The most recent NHANES data puts the rate of obesity among adults at 42.4 percent.
The statistics alone were startling, but Dietz wanted to find an even more effective way to communicate to Americans the scale of the obesity epidemic. One day early in his CDC tenure, while chatting with staffers in a hallway, Dietz suggested they plot the NHANES findings across a map of the United States, to designate which states had become “obesity hot zones,” using a green to red color-coded system. “Those maps, more than anything else, I think, began to, well, transform the discussion of obesity,” Dietz tells me. “Nobody argued thereafter that there wasn’t an epidemic of obesity because those maps were so compelling.”
Dietz’s maps, which are updated every year, and the NHANES numbers are dramatic, unprecedented, and, to some extent, indisputable. Americans are, on average, bigger than we were a generation ago. And our kids are bigger, on average, than we were as kids. We’ll look more at explanations for this rise in body size in Chapter 2. But what I want to note about these numbers now is how they continued to climb even as public health officials were printing their maps and assembling this evidence of their epidemic; even as weight loss became our national pastime. One conclusion we can therefore draw is that the weight loss industry and public health messaging have failed, quite spectacularly, in their quest to make anyone smaller. They may even have had the opposite effect. But it’s also worth looking at these statistics in a little more detail, to see what else they tell us.
The NHANES researchers determine our annual rate of obesity by collecting the body mass index scores of about five thousand Americans (a nationally representative sample) each year. BMI is a blunt tool, never developed to directly reflect health. But it’s useful for tracking populations in this way because it’s easy to calculate by dividing a person’s weight in kilograms by the square of his or her height in meters. From there, researchers can sort people into the categories of underweight, normal weight, overweight, or obese, depending on where they fall on the BMI scale. This entire project of categorizing people by body size—and determining that there is only one “normal” weight range—is flawed and loaded with bias. And to make matters more confusing, the cutoff points for those categories haven’t stayed fixed over the years. A major shift happened in 1998, when the National Institutes of Health’s task force lowered the BMI’s cutoff points for each weight category, a math equation that moved twenty-nine million Americans who had previously been classified as normal weight or just overweight into the overweight and obese categories. The task force argued that this shift was necessitated by research. But just a few years later, in 2005, epidemiologists at the CDC and the National Cancer Institute published a paper analyzing the number of deaths associated with each of these weight categories in the year 2000 and found that overweight BMIs were associated with fewer deaths than normal weight BMIs. (Both the obese and underweight groups were associated with excess deaths compared to the normal weight group, but the analysis linked obesity, specifically, with less than 5 percent of deaths that year.)
Copyright © 2023 by Virginia Sole-Smith
