Darlene McNaughton. Critical Public Health. Volume 21, Issue 2, 2011.
In recent decades overnutrition and obesity have been presented as a looming threat to the health and wellbeing of children and infants, most notably in western industrialised societies. However, this threat is not simply limited to ‘children’ who are ‘over fed’ by their ‘parents’. Increasingly, maternal overweight and obesity are said to inhibit conception, cause recurrent miscarriage, pose a serious threat to the development and health of the foetus and have long-term implications for the future wellbeing of the child. Parental responsibility looms large in these discourses, in which women in particular are held responsible for the future (fat free) health of their offspring from the womb to the tomb. In this article, it is argued that core assumptions at the heart of obesity science have been taken up uncritically in medical arenas focused on conception, pregnancy and reproduction and that this is providing new opportunities for the surveillance, regulation and disciplining of ‘threatening’ (fat) female bodies. It is shown that although all women of a reproductive age are being brought under the gaze of this deeply punitive medico-moral discourse, it is the bodies, lives and bedrooms of marginalised women that are singled out as posing the greatest ‘risk’ to their offspring and then targeted for even greater degrees of health/State intervention and surveillance.
Introduction
An increasing body of evidence suggests that obesity does indeed beget obesity: children of obese parents have a stronger tendency towards obesity … the vicious spiral of obesity is rapidly spiralling upwards as this tendency is passed from parent to child (Reece 2008, p. 24).
We must look at the womb to understand what is producing today’s obesity (Leibowitz quoted in Taylor 2009, p. 1).
As many commentators have noted, the culture of public health policy, practice and research has shifted in recent decades and increasingly focuses on the regulation of private behaviour, rather than public projects and infrastructure (Petersen 1996, 1997, Petersen and Bunton 1997, Petersen and Lupton 1997). During this period, obesity and overweight have become a central focus of the politics of private regulation (Petersen and Lupton 1997, p. 9). In the context of an alleged global obesity epidemic, fatness is increasingly understood as dangerous and debilitating—an unhealthy state of being that places the individual at much greater risk of a growing list of ailments ranging from diabetes to cancer. Since the mid 1990s, the central trope of most obesity discourse, public health messaging and media commentary is ‘be alarmed’: because we are getting fatter at a disturbing rate, being overweight or obese has serious health consequences and everyone is at risk.
Within this discourse, fatness and overnutrition have also been consistently presented as a looming threat to the health and wellbeing of children, most notably in western industrialised societies (Austin 1999, Campos 2004, Gard and Wright 2005, Campos et al. 2006, Murray 2008). Public health campaigns unfailingly emphasise the short- and long-term risks of fatness in children, the scale of the issue, the changeable nature of behaviours purported to produce fatness and the role of parents in inflicting their ‘unhealthy’ habits on their innocent offspring. In some quarters, there are increasing calls for legislation to control or criminalise those who ‘abuse’ their children through ‘over feeding’ or expose them to unhealthy dietary behaviours (Bell et al. 2009). Although fathers and more rarely same sex partners are implicated in these statements, gender stereotypes about responsibility for feeding children are very much at play and invariably, these inadequate or irresponsible parents are cast as mothers and as overweight or obese.
However, the alleged threat posed by fatness or overnutrition is not simply limited to children who are ‘over fed’ by their parents (read parent). Concerns regarding maternal obesity during pregnancy, foetal obesity and infant feeding are becoming more commonplace in scholarly research and popular commentary. Increasingly, maternal fatness is said to inhibit conception, cause recurrent miscarriage, pose a serious threat to the development and health of the foetus and have long-term implications for the future wellbeing of the child. Parental responsibility also looms large in these discourses, in which women in particular are held responsible for the future (fat free) health of their offspring from the womb to the tomb.
In this article, it is argued that core assumptions at the heart of obesity science regarding the scale of the obesity problem, the nature of the risk and where responsibility for health should fall, have been taken up uncritically in medical arenas focused on conception, pregnancy and reproduction. This in turn is providing new and disturbing opportunities for the surveillance, regulation and disciplining of ‘threatening’ (fat) female bodies while at the same time perpetuating a number of taken for grant medico-moral assumptions about individuals and the causes of fatness.
Framing obesity as risky
As many commentators have shown, discussions of health risk also serve as part of the increasing surveillance functions of modern medicine, which shifts the medical gaze from the individual to the population at large and encourages individuals to adopt increasing vigilance over their own bodies and behaviours (Armstrong 1995, Lupton 1995). Presenting obesity as a serious health ‘threat’ of epidemic proportions is, among other things, an exercise in power, disciplining and surveillance (Foucault 1994) in which ‘new forms of governance are creating problematic social conditions [i.e. unsatisfactory parenting, mothering] in which the state can ‘reasonably’ intervene’ (Evans et al. 2008, p. 11). Fatness is a highly visible and deeply stigmatised physical characteristic that cannot be hidden in the same way as smoking or drinking and this makes it open to considerable surveillance and judgement (Saguy and Riley 2005, p. 913), particularly in the context of a medical encounter.
Within the discourses examined here, epidemiology and biomedical research are the primary source of expertise and knowledge regarding obesity and are characterised by a belief in law-like mathematical regularities in the population (Hacking 1990, Lupton 1995, Gard and Wright 2005). National and international obesity statistics are consistently held up in this literature as ‘evidence’ that an increasing BMI equals greater risk from a number of diseases, when, in fact, any data correlating obesity prevalence with disease incidence is, at best, ‘an indication of a possible link between body size and health for a population’ rather than an undeniable truth (Gard and Wright 2005, pp. 101-102). Despite the certainty expressed in these discourses and in public health circles that ‘fat is a killer’, we do not actually know exactly how dangerous it is to be overweight as many critics have shown (Austin 1999, Campos 2004, Gard and Wright 2005, Campos et al. 2006, Murray 2008). The ideology of fatness as unhealthy and as an entirely controllable and avoidable risk to life long (i.e. fat free) health is also ubiquitous in the body of literature under examination. Here, ‘healthiness’ acts a metaphor for self-control, self-denial and willpower and as a moral discourse (Crawford 1994, p. 1352). Indeed, when overeating and inactivity are constructed as avoidable, ‘fat bodies are read as evidence of both preventable illness and moral failings’ (Saguy and Riley 2005, p. 885).
Despite the inconclusive state of the evidence on obesity and its impact on ‘health’, public health campaigns, media reports and the medical literature urge parents to vigilantly monitor their own and their children’s weight (see Campos 2008 for a discussion). As I have previously argued (Bell et al. 2009), mothers are particularly singled out in obesity discourse as responsible for the body size and weight of their offspring. In contemporary biomedical and public health discourse, a mother’s work patterns (Anderson et al. 2003, Zhu 2007) and feeding practices (Rising and Lifshitz 2005) have both been deemed a source of ‘risk’ for childhood obesity—an argument that serves to reinforce traditional gender roles and stereotypes. As Lee (2008, p. 468) has noted, mothering in modernity is understood as ‘both the private responsibility of individual mothers, and also a matter of public scrutiny and intervention, with mothering practices defined as ‘good’ or ‘bad’ in expert and policy discourses’. Of course, ideals about what constitutes a ‘good’ or ‘bad’ mother are deeply cultural, shaped by larger structural forces and underwritten by a range of classist, racist and sexist assumptions. They are also linked to discourses of risk, where in a ‘good’ mother resists or avoids any action or activity that might be potentially ‘unhealthy’ for the child (Lee 2008, p. 468).
Breastfeeding (doomed if you do, doomed if you don’t)
While maternal feeding practices more generally have received considerable notice in the obesity literature, breastfeeding has been a particular focus of attention. Breastfeeding is a practice that has received substantial support from primary care and public health sectors in recent decades. Given its raised status as the most appropriate way to feed one’s child it can be crucial to a woman’s identity as a ‘good’ mother (Schmeid and Lupton 2001), and women who choose not to breastfeed, or find they are unable to do so, face considerable challenges in maintaining a positive ‘maternal’ identity (Lee 2008).
Coinciding with a recent national report suggesting that ‘90% of UK born children are being formula fed after 6 months of age’ (Lee 2008, p. 469), research into the ‘protection’ breastfeeding might confer against obesity is becoming increasingly common, with media reports on these studies including headlines such as ‘Mums encouraged to breast feed in public to fight childhood obesity’(Ely Standard 2008). However, evidence of the protective effects of breastfeeding against overweight and obesity is far from convincing. For example, one study found that:
The prevalence of obesity was significantly lower in breastfed children, and the association persisted after adjustment for socio-economic status, birthweight, and sex. The adjusted odds ratio for obesity (BMI >98th percentile) was 0.70 (95% CI 0.61-0.80). Our results suggest that breastfeeding is associated with a reduction in childhood obesity risk (Armstrong and Reilly 2002, p. 2003).
Although results such as these are statistically weak and rather inconclusive (Beyerlein et al. 2008), similar surveys of women and their infants are being undertaken at a furious rate, with most concluding that overweight and obese women should be specifically targeted for breastfeeding (Buyken et al. 2008). Yet, some researchers are arguing that ‘the increased glucose and insulin levels in the breast milk of mothers with diabetes may actually increase the risk of subsequent obesity in childhood’ and that ‘rather than being causally related to later protection against obesity, the presence of breast-feeding may actually be a marker for other factors related to leanness’ (Toschke et al. 2002, pp. 765-766; see also Braegger 2003).
Many of these epidemiological studies collect data on the fat status of women through the documentation of their BMI before, during and after pregnancy, on how many women breastfeed and for how long (Armstrong and Reilly 2002, Arenz et al. 2004). Some of these studies suggest that overweight or obese women, notably women of colour, are not breastfeeding as much as their thin counterparts (Liu et al. 2009, p. 175). According to one study, obese women were less likely to initiate breastfeeding and ‘women who were obese before pregnancy fed for 2 weeks less than their normal-weight counterparts’ (Li et al. 2003, p. 931). These results have the capacity to further stigmatise fat women, especially as they make no effort to examine why the participants did or did not breastfeed (e.g. returning to work, shame, lactation problems, etc.) or to explore the broader socio-economic, cultural or political contexts that might have been at play.
As Petersen and Lupton (1997) have noted, the positioning of women as producing ill health in their children has long been a central element of public health initiatives and biomedicine more broadly. In the future, fat post-partum women who cannot breast feed, who struggle to but find it too painful, choose not to in the first instance or are advised against it because they are diabetic are going to have to work even harder than their thin compatriots to keep their identity as a good mother secure.
A search for origins
More recently, research into the origins of obesity has extended its gaze to pregnant women, whose eating habits are suspected of influencing the weight and health of their future offspring (Catalano and Ehrenberg 2006, Wu and Suzuki 2006, Rodriguez et al. 2008). Underwriting this literature is a view that fat women will be fat mothers and have fat babies: ‘Nutrition in the womb is central for foetal development … a mother’s pre-pregnancy or early pregnancy birth weight is a likely determinate of the birth weight of her child and that infant birth weight is a likely predictor for adolescent and adult weight’ (Smith et al. 2008, p. 178).
One paper, entitled Maternal and child obesity: the causal link, encapsulates some of the key assertions regarding maternal weight and future child health and the ‘cycle of obesity’ (Oken 2009). The authors write:
High maternal weight entering pregnancy increases risk for obesity and cardiometabolic complications among offspring … higher maternal gestational weight gain is associated with higher weight and consequent risk for obesity and elevated blood pressure among children … and that while these ‘associations’ are partly mediated by shared genes and behaviour, the abundance of human evidence, supported by extensive … animal studies, suggests that intrauterine exposure to an obese intrauterine environment programs offspring obesity risk by influencing appetite, metabolism and activity levels (Oken 2009, p. 361).
For many such commentators, the source of obesity is the womb: the intrauterine environment. For Oken (2009, p. 362) and others, the only way to slow the obesity epidemic and improve the lives and life expectancy of future generations is to ‘interrupt this cycle of obesity’ by intervening throughout a woman’s reproductive life: before she conceives, while she is pregnant and in the years after she has given birth (Gunderson 2009). Although several of these same commentators acknowledge that many of the findings are contradictory, based on animal studies or too weak to show any clear relationship between maternal overweight, foetal or infant obesity and long-term health effects, most call for greater levels of intervention and surveillance of overweight women (Guillaume 1999). Alongside this research are related discussions regarding the possible existence of an ‘obesity gene’ which, like the ‘gay gene’, is attached to commentaries about prenatal genetic diagnosis being used for obesity testing (see LeBesco 2009 for a trenchant critique).
With striking consistency, the literature emerging from reproductive medicine begins with the premise (stated or unstated) that we are in the midst of worldwide obesity epidemic. This, it is asserted, is resulting in more women being overweight or obese prior to, during and after pregnancy, especially women of colour, poor women and those from minority groups (see, e.g. Phelan 2009). The uncritical acceptance of a childhood obesity epidemic leads many to imagine the avalanche of fat women of a reproductive age that is come and the impact this will have on health care systems. Acceptance of the threat of obesity and the risks it is purported to pose, operates not only as a justification for the research itself, but also as a call for urgency in the generation of knowledge and for the development of immediate and earlier interventions into women’s lives (pre-pregnancy) on the part of experts. The discourse constructs itself.
Fat women produce fat (unhealthy) foetuses and infants
In fat-averse societies, pregnancy is one of the few times women (particularly middle class women) are encouraged to eat freely (‘to eat for two’) and gain weight legitimately without the guilt and stigma traditionally attached to an increase in body size. Not anymore. For the nature of a woman’s dietary and exercise habits and the conditions these are thought to create in her womb are coming under greater scrutiny. This focus on the womb is encapsulated in the recent work of Barker and colleagues who suggest that ‘a woman provides her unborn baby with a ‘nutritional forecast’ that guides metabolic development’ and that ‘it is experiences before birth, primarily, that are held to have a permanent legacy’ with regards to the development of obesity and overweight (Barker 2004 cited in Moore and Davies 2005, pp. 341-342).
Although many of these studies commonly assert that a great deal is still not known about the causes of foetal or infant overweight or obesity, the female body is increasingly the site of new research into these questions:
… inadequate or excessive energy intake is not optimal for the developing fetus. Against a history of inconsistent results, several recent studies suggest that in Western settings the balance of macronutrients in a woman’s diet can influence newborn size. Effects appear to be modest, but this relationship may not encapsulate the full significance for health of the child, as there is emerging evidence of associations with long-term metabolic functioning that are independent of birth size (Moore and Davies 2005, p. 341).
Other commentators are less moderate in their assertions, claiming that ‘paediatric obesity has reached critical proportions’ and is contributing to the worldwide obesity epidemic (Lieb et al. 2009). Other epidemiological studies argue that ‘individuals who were small at birth have an increased risk of type II diabetes and cardiovascular disease in adulthood’ and overweight and obesity (Grivetti 1998 cited in Moore and Davies 2005, p. 341). The internal contradictions in this research are notable.
Also significant is that although underweight and overweight are both constructed as a risk for mothers and babies, it is overweight and obese mothers who currently receive the greatest focus in this literature. Although there was historically much interest in underweight mothers and underweight babies, women who are considered underweight or ‘normal’ weight are often excluded from contemporary studies examining the impacts of weight on mothers and offspring, which commonly focus entirely on women identified as overweight or obese in terms of their BMI (<20) (see, e.g. Callaway et al. 2006). This limits the possibility of drawing a broader impression of the effects of weight and diet on foetal, infant or child health and evidences the powerful influence of ideas regarding the threat of obesity in these research areas.
Indirect links between maternal obesity and health effects in her future offspring are also being made via a focus on gestational diabetes. It has long been recognised that some women develop non-insulin dependent diabetes mellitus (type II) during pregnancy and that for many the condition dissipates after they give birth. However, links are now being made between gestational diabetes and obesity and type II diabetes in offspring. For example, in a commentary from the Journal of the Australian Medical Association entitled ‘Maternal diabetes and obesity may have lifelong impact on health of offspring’ we find the following:
Many obstetricians have traditionally struggled to help diabetic women maintain good blood glucose control during pregnancy. Then, once the infant was born, everyone would give a sigh of relief … We used to think, at least the baby’s out and it’s safe. Well, that baby is not safe. We have set up this child for adverse health downstream—certainly in childhood, and perhaps as an adult … It’s a vicious cycle where an obese insulin-resistant woman has an obese fetus who becomes an obese neonate, who becomes an obese child, who is at greater risk to develop type 2 diabetes … We’ve always assumed that if you would just get up and get a gym membership and not drive to McDonald’s, you would be able to avoid these problems … And maybe to some extent that’s true, but it might also depend on your intrauterine nutrition (Hampton 2004, p. 789).
In this literature, obesity is sometimes referred to as a disease, for example: ‘In addition to being a serious disease in its own right, obesity has also added fuel to a multitude of other diseases and can be socially contagious’ (Fumento cited in Saguy and Riley 2005, p. 892; see also Reece 2008). It is also identified as a cause of diseases like diabetes mellitus, rather than as a symptom (Gard and Wright 2005, p. 95). However, overweight and obesity, like thinness, are not diseases, or diagnosable illnesses (Gard and Wright 2005, p. 25). Framing fat as an avoidable disease and a disease causing agent assists in characterising fat women of child bearing age as irresponsible and dangerous to themselves, to their offspring and to society. They are bad citizens and bad mothers.
Maternal obesity and the unproductive and deadly womb
Women of childbearing age are also a growing object of study into the implications of overweight and obesity on conception, miscarriage, birth defects and foetal and infant development. This research has been appearing in much greater quantities in a range of academic and practitioner-oriented journals from the fields of paediatrics, obstetrics, gynaecology, fertility, reproduction and midwifery.
Maternal fatness is now a central focus in studies on conception, where it is commonly hypothesised that overweight and obesity inhibit conception, including assisted conception with IVF and have a role to play in infertility (Norian et al. 2005, Rajasingham et al. 2009). Again, it is poor minority women of colour who feature most strongly statistically:
Obesity negatively affected CP [clinical pregnancy] in all races studied; however, obese Black and White women had a lower percentage of CPs [clinical pregnancy]. Although both Blacks and Hispanics had a higher incidence of obesity, obesity imposed the greatest negative impact on IVF CP [clinical pregnancy] success in Blacks compared to other races (Norian et al. 2005, p. 249).
To address this, some practitioners are calling for greater use of gastric banding to reduce a woman’s weight before she tries to conceive, but the risks are considerable, given the high mortality rates associated with this procedure. Coustan notes that one study has suggested that ‘gastric banding was more effective than lifestyle intervention in inducing remission of type 2 diabetes in an obese patient’ (2008, p. 2552). He goes on to suggest that
Theoretically, such interventions may reduce the risk of adverse pregnancy outcomes associated with diabetes, hypertension and obesity. However, gastric bypass carries risks including nutritional deficiencies because of decreased nutrient intake as well as decreased fat absorption (Coustan 2008, p. 2552).
Maternal obesity has also become the focus of studies into the causes of stillbirths and in some research is being identified as a significant cause, alongside other factors such as age and IVF, for which there are more compelling data (Lo 2008). In recent media coverage of an Australian study into maternal obesity and still births, it was reported that ‘There could be an epidemic of stillbirths in Australia in the next few years if the nation’s obesity rate continues to soar and more women aged over 35 have children’ (Flenady, 2008). In an interview with the study’s author, it was asserted that:
40% of the 2000 Australian stillbirths a year are preventable if a woman loses any excessive weight, has children earlier and gives up smoking … That’s 800 babies a year which could be saved if we were able to remove these three modifiable factors (Flenady 2008).
In contrast to these alarming and alarmist claims, a meta analysis of studies on the topic concluded that ‘maternal obesity is associated with an increased risk of stillbirth, although the mechanisms to explain this are not clear’ (Chu et al. 2007, p. 223).
Who gets the intervention?
In the discourses on maternal obesity, fat women are scapegoated as irresponsible mothers/parents and citizens who set a poor example, and put their food addictions and bad habits ahead of the health of their offspring and their very capacity to reproduce society. Framing maternal obesity and overweight as the result of risky behaviour also suggests a need for intervention—usually in the form of education and increased surveillance. It also implies and potentially reinforces the view that fat people are stupid or ignorant (Saguy and Riley 2005, p. 886). For example, Dr Xavier Pi-Sunyer, who runs a weight loss clinic and is on the board of Weight Watchers (USA), writes:
Why does the average American woman gain weight with each pregnancy and end up [after] four kids, fifty pounds heavier? Its because nobody alerts her to the fact that this may happen and it many not be good for her to end up fifteen to twenty years later fifty pounds heavier (cited in Saguy and Riley 2005, p. 886).
It is argued here that within these discourses on maternal and child obesity is a shared and increasing concern regarding the ‘problems’ and ‘threats’ posed by the individualised behaviours of women whose actions are constructed as dangerous to the interests of their children, families, communities and nations. In these discourses and in obesity science more broadly, an unhealthy lifestyle is evidenced by higher than average weight, which in turn is read as evidence of a lack of self-control and of personal and civic (because of public health costs) irresponsibility (Saguy and Riley 2005, p. 887). These understandings are embedded in much of the discourse examined here with little or no reflection on the deeply cultural and classist assumptions that underwrite them.
As Petersen and Lupton (1997) note, the enforcement of state-imposed regulations tends to be exercised upon the most stigmatised and powerless groups. In particular, it is women of colour, single mothers and women living in poverty who are most often identified as posing the greatest risk to their offspring and targeted for intervention and surveillance—further stigmatising those who are already marginalised and powerless (Bell et al. 2009). In this literature, there is little recognition of the potential harms that arise from increased state interventions into the lives of these women, let alone consideration of the structural and contextual factors that create risks to health in the first place such as poverty, racism, disenfranchisement, poor housing, etc. This neo-liberal emphasis on individual responsibility is popular because it emphasises personal control over illness rather than requiring major changes in industrial practices, in the economy, or in the government (Saguy and Riley 2005, p. 887).
Conclusion
As many commentators have shown, the true impact of fatness on health is not known and obesity science is permeated with ambiguity and contradiction (Gard and Wright 2005). In this article, I have argued that certain assumptions regarding the inherent dangers of fatness, on conception, pregnancy foetuses, infants and children need to be critically examined. These include but are not limited to assumptions regarding the scale of the obesity epidemic, the nature of the risk and where responsibility for health should fall. These logics are far from neutral or objective (Austin 1999, Campos 2004, Gard and Wright 2005, Campos et al. 2006, Murray 2008). They also affirm certain moral, neo-liberal ideas and values while at the same time rendering invisible the political economy that produces ill health in the first place (poverty, racism, classism, sexism, etc.) (Crawford 1994).
These logics and the medico-moral assumptions that underpin them underwrite the design of studies, the examination of results and in claims about the risks of exposing foetuses, infants and children to food substances and lifestyles said to have the potential to negatively affect their health in the short- and long-term. Furthermore, in a search for the ‘origins’ of obesity, researchers are moving beyond the usual ‘suspect’ environments of the kitchen table, corporations and genetics as the causes of fatness, and turning their gaze to the female body and the womb.
Within these discourses it is asserted and assumed that women who exert self-control and maintain a healthy weight throughout their life are more likely to produce children of a ‘normal weight’ who, according to the core assumptions of obesity science, will be healthier in the long-term. By contrast, those who do not discipline themselves in these ways or do so unsuccessfully are not only less capable of reproducing, but their unhealthy lifestyles, behaviours and state of being can cause the untimely death of their unborn child, or doom those that do survive to a life of overweight, ill health and a shortened life span.
Even more disturbingly, the gaze of this deeply punitive medico-moral discourse is being expanded to encompass all women of childbearing age because of suspicions that their body weight and eating habits before pregnancy influence the future survival and health of their offspring. However, as demonstrated above, it is the bodies, lives and bedrooms of marginalised women that are singled out for even greater degrees of health/State intervention and surveillance and are seen to pose the greatest risk to their future and current offspring.