We’ve heard the statistics, we’ve seen the evidence. There are more ‘fat’ children in Malta than most places in the world. Do we really need to worry about very overweight or obese children?

There are arguments to be made for letting individuals with ‘fat bodies’ simply be. The key one being that one ought to be free to live in, and through, the body they please.

There are two important arguments against this, however. The first one is the solid, reliable bio-medical data linking excess body fat (especially in adulthood) to pathological conditions which ultimately compromise quality of life, may go on to impact on the individual’s economic activities, and whose clinical management inevitably puts a strain on public health resources.

The second is that, given the dominant aesthetic preference for the slim body shape, fat people are outsiders – some are affectionately teased and given positive attention, often valued as the jokers of the group, while others are victims to more vicious taunting with inevitable low self-esteem in its tow.

The key point hardly needs to be made here – being heavily overweight tends to be stigmatised, and dealing with stigma is always traumatic at every level.

These two arguments bring one key facet of the debate into focus: the murky fluid overlaying of medical and social issues.

Being ‘obese’ is a medical condition, clearly defined and measured, with pathological consequences predicted. The importance of prevention is framed within bio-medical discourse highlighting physical and physiological negative impacts on quality ­­­of life.

The cost of managing these issues, and loss of individual activity which impacts on national productivity are also there in the subscript.

‘Being fat’, however, is a social issue – the lived experience of obese individuals is what it is because of dominant shared social practices, beliefs and aspirations.

This medical/social overlap doesn’t stop there – it becomes even moreinteresting when the focus shifts to social interactional dynamics that have a direct impact on the medical (pathological) consequences in bodily function.

And this is where children become important in the debate. Research has repeatedly shown that public health campaigns encouraging healthy lifestyles and mindful eating patterns are very good at getting their message across.

What they are less effective at, however, is changing behaviour.

Individuals know what should or ought to be done in order to avoid unhealthy weight gain, however they choose to ignore it.

When focusing on children this becomes more complex because children learn how to view their body/self through interaction with their significant others and they also rely on them for their physical needs.

Analysing this issue with children leads to interesting data. Recent research by Black et al published in the British Journal of General Practice highlights the fact that parents tend not to recognise obesity in their own young children.

The young child goes from being ‘sweet’ to ‘fat’, and is left to create personal coping strategies for the taunting and social exclusion that often follows

These adults may well know all the factual ‘diet and healthy lifestyle’ information, however, this can’t kick into playif they can’t see that there is an ‘obesity issue’. My own research in this field carried out locally is in synchrony with this.

One clear finding is that lay epidemiology (or pattern of illness as defined by lay beliefs) plays an important role here. The chubby, rounded body shape in very young children in my data, was not a source of medical concern to the mothers and grandmothers interviewed. Indeed it was often valued as symbolic evidence of successful mothering.

The very young children in my study (4-5 years) had very interesting stories to tell related to this –the key one is that they didn’t have any ‘fat’ children in their class, while their Body Mass Index calculations threw up very different evidence. Sociologically, this apparent contradiction is very interesting.

Most of these young children were quick to claim that ‘fat=ugly/bad’, however they couldn’t recognise ‘fatness’ in their young classmates, nor in themselves.

These very young children were still mainly socialising within their protective family environment, surrounded by caring, doting adults whose main preoccupation was to see that their child was feeding well and was happy and content.

The rounded body shape in this social context is a source of much praise and attention, eliciting remarks such as “God bless you” or “How sweet” – often promptly followed by offers of sweet or savoury treats.

The extreme of this argument is that interpersonal dynamics actually encourage the very chubby body shape in young children – they are valued aesthetically, they please their loving mothers who enjoy feeding them.

It appears that ‘fatness’ only becomes visible to these very young children once it has been pointed out, usually initially by an adult or older child. Once the label is in place, however,it sticks.

Caring adults now become acutely aware of the potential teasing or social isolation that ‘being fat’ may entail once their child moves away from the protective family environment, into the rough and tumble of the school playground – and this is where the goalposts are switched. The young child goes from being “sweet” to “fat”, and is left to create personal coping strategies for the taunting and social exclusion that often follows.

These are sociological aspects of everyday life. They have, however, important effects on body physiology which may go on to impact on the individual’s health.

There is more.

Grandmothers – precious and much loved – are often an essential source of regular child care in the early years. Their close collaboration with the mother as main mentor when caring for very young babies is shown to have an empowering effect within medical consultations.

Accounts of doctors’ advice to cut down on milk feeds being ignored were well described by some of my participants, where the idea that ‘mother knows best’ dominates when it comes to what the young baby needs.

The grandmothers’ influence also has an important impact in the longer term. When the child is older, the mother may well be concerned about her child’s weight status, however her inability to control the ‘nanna’s treat’ ritual was also very clear in my study.

This becomes more complex when the grandmother is the main and preferred source of pre-school childcare and the mothers’ loss of control over the child’s consumption of high calorie sweet or savoury treats is an accepted negative consequence in child care negotiations.

The medical arguments for changing eating and lifestyle habits are powerful. However they hover in the background within the individuals’ lived experiences of everyday life, until the social realities are such that they become relevant.

The challenge is to bring that time frame forward to the very early years of childhood.

This is definitely not a call to ‘demonise’ the loving praise and attention that chubby young children attract, the practise of ‘cooking as loving’ or offering treats by doting parents and grandparents. Normative categorical statements are certainly not the aim here.

It would be useful, however, to recognise that these sociological issues – simple realities of everyday life – are an important part of the debate on encouraging optimum health in our population.

Gillian Martin is a medical sociologist.