Diet and physical activity play a role in body size, but they are not the only factors. Lessons from abroad point to three ways the United States can improve health policy around childhood obesity by taking culture into account.
The spread of body positivity is at an all-time high. Celebrities and influencers are celebrating larger bodies. Models of a variety of sizes are promoting beauty and consumer products. And a flood of social media posts and TV shows urge us to love our bodies as they are.
Despite this positive rhetoric, weight bias and fat shaming remain rampant. Thinness is a Western ideal that has had enormous influence around the world, spread first through colonization and echoed today through social media and pop culture. It's an ideal that has racist roots: during the slave trade, middle and upper class white women were told to eat “as little as was necessary in order to show their Christian nature and also their racial superiority” in the words of sociologist Sabrina Strings. Body size became associated with discipline and self-control and used to suggest who did and did not deserve freedom.
Childhood Obesity and Weight Discrimination
While unintentional, anti-fat attitudes have also made their way into public health policy. Take efforts to address childhood obesity: there is no shortage of interventions that concentrate on diet and exercise, based on conventional wisdom that weight gain results from more calories consumed than expended. But this focus on individual behavior feeds into biases that being overweight is the result of a lack of self-discipline or a moral failing.
While improving nutrition and levels of physical activity is beneficial, such a singular approach fails to acknowledge that individual food and lifestyle choices are embedded in larger environmental, economic, and social contexts—including a global food system that supplies the market with cheap, convenient, and hyper-palatable, ultra-processed products.
Learning from the World
Diet and physical activity play a role in body size, but they are not the only factors, and often not the most important. Recognizing this, different interventions across the world are shifting their efforts toward promoting health for all body sizes and taking a holistic approach to improve childhood nutrition.
Looking for global insights into the cultural contexts of size and health, our report identified three key areas in which the United States can improve health policy around childhood obesity.
We must recognize that:
Food is More than Nutrition
Cultural values, historical legacies, personal tastes, and financial constraints frame our food choices. Brazil recognizes this insight with its innovative dietary guidelines. The guidelines are simple and culturally appropriate, depicting plates with natural, unprocessed foods regularly eaten by all social classes, including traditional Brazilian foods. The guidelines also provide advice on how to eat, for example avoid snacking, eat at the same time every day, and eat with others as a way of strengthening social bonds and reinforcing healthy eating habits. Imagine if the 2025 U.S. dietary guidelines focused more on cultural aspects of eating than on nutrient balance; what could that look like?
Health is More than Weight
Large bodied patients overwhelmingly report that their caregivers focus on weight to the exclusion of other conditions. Yet, in recent years, the limitations of body mass index (BMI) as a diagnostic measure have become clear. Not all individuals—classified as obese by BMI are ill—a sizable percentage have healthy metabolic measures. In fact, a 2016 study found that half of those in the “overweight” and a quarter of those in the “obesity” categories had healthy metabolic measures, while over 30 percent of those in the “normal” weight category had unhealthy metabolic measures. This classification of fat as unhealthy has spurred decades of weight discrimination, feeding into shame and stigma that have resulted in lasting psychological trauma for large-bodied kids. In Japan, annual checkups include a battery of laboratory tests in addition to body size measures to assess risk of obesity. Japan recognizes that a high BMI is just one risk factor that, depending on the individual physiology, may or may not need to be treated. Imagine if the U.S. looked beyond BMI to classify how weight impacts health—how could that change our understanding of a patient’s actual needs?
Diet is More than Individual Choice
Low wages, long work hours, school food programs, restricted access to healthy food, and the built environment all interact in different ways to create diets that are more likely to be calorie dense and nutrient poor. We need to look at these underlying social, environmental and economic systems that produce overweight and obesity together. In the Netherlands, the Amsterdam Healthy Weight Programme is working across government units, including housing and schools, with the business sector and local food entrepreneurs, and in partnership with local neighborhood and civic groups to advance an integrated approach to child weight. It’s a 20-year “marathon” that launched in 2013 and advocates for a reasonably paced run towards healthy living, rather than a sprint to lose weight. Imagine if the U.S. overcame policy silos and took a whole systems approach to addressing inequalities associated with poor nutrition—could we then ensure every kid grows up healthy and at a healthy weight?
What we label “obesity” is produced by interrelated systems in which human biology interacts with environments, social norms, economic structures, and historical legacies. To effectively improve child nutrition, we must de-center the role of the individual, look beyond weight, and have policies and interventions that take into account the cultural contexts and colonial legacies that produce community environments that can contribute to obesity.
As we do so, we must center the voices and lived experiences of those most directly affected by these policies and interventions. In reality, there is no universally ideal body nor a single size for good health. As we take steps to improve children’s diets and address the health risks associated with certain types of fat, it is crucial that we avoid shaming and blaming those with large bodies. All body types deservethe best possible health and healthcare.