One of the main findings of our interviews was that adolescents and mothers acknowledge the role of early life experiences in obesity development. Interestingly, subjects do not blame either emotional problems or biophysiological processes as single causes of obesity. In fact, adolescents and mothers easily accept that the process of obesity development has both emotional and biophysiological causes, both of which are part of the biomedical model of obesity development. Our findings also showed that low-income obese adolescents and their mothers perceive obesity to be a heritage caused by family genes, side effects of medication use, and stressful life events. Eutrophic adolescence, however, emphasize the role of unhealthy diets on obesity development. Among high-income adolescents, those who are obese attribute it to genetic factors and emotional problems, whereas those who are eutrophic mention unhealthy diets and lack of physical activity as the main causes of obesity (
). Table 3 presents only answers that were provided by at least five of 10 adolescent–mother pairs.
Reasons for obesity etiology reported by adolescent and their mothers (N = 80)
Initially, we selected two groups of the main categories for in-depth analysis. The first group, entitled Family Meals and Fat: Heritage and Identity, discusses how family memories and traditions, as well as genetic factors, create a family identity that influences the food people eat. The second group, entitled Sociocultural Pressures, Unwanted Effects, and Life Events, discusses the role of peer pressure, aesthetics, and stressful events in determining what people eat and how they want to look.
Family, meals and fat: heritage and identity
The messages given by health professionals and media about healthy eating and lifestyle relate to a series of complex concepts on food, obesity, and fat that were pointed out in respondents' statements. One convincing answer was about the importance of family habits, acquired through family meals, in determining current eating patterns. Adolescents and mothers of both income strata emphasized the importance of pleasurable eating and the social benefits of family meals. Daily meals are composed of dishes such as “Grandma's meat,” “Dad's beans,” or the “Son's french fries.” Adolescents and their mothers do not report being concerned with the health consequences of this type of traditional family eating. In fact, these traditional meals are clearly identified as positive much more than negative.
The common idea of genetics as the origin of obesity was initially upheld among high- as well as low-income obese adolescents of both sexes. Having obese parents and relatives was given as an explanation for current nutritional status. Respondents also mentioned that future generations were likely to continue experiencing the problem, because it is a “family issue.”
In the lower-income segment, the way in which food is prepared and offered is not seen as an explanation for obesity occurrence. Low-income people in our sample mentioned that food is “for filling the stomach,” whereas among high-income families, the “nibbling” concept was mentioned several times. The genetic inheritance reference—“tendency to gain weight”—disregards, in part, the responsibility of the individual and the family for the mode of preparation, type of cooking, and nutritional quality. Daniel (BMI, 35.6 kg/m2; low-income) has lunch and dinner with the family. He likes pasta and fried food prepared by his mother and calls himself “chubby since childhood.” Because the father is “fat”, the family believes that “the entire side of his family is like that.” Because of this, the family has never worried about the child's weight, and besides being like the father, “He does everything a thin person does and never had health problems.” The association between biology and weight o fatness strengthens the adolescent's belonging to the group (“took after my family”). In this sense, biology reaffirms an important link between the family and the subject. Another finding from this discourse is that fatness is understood as a disease only when a clinical alteration is diagnosed.
To extenuate the current standards of weight and height, low-income families reinforce the importance of being naturally what they are. They refute the way they believe high-income people eat: “nibble and waste food to maintain appearances instead of eating heartily.” Family members of this group also recognized economic achievements by food abundance. Many parents' stories involved food deprivation. Being able to eat much or at any time is also a sign of prestige, economic, and social power for adolescents. Having a healthy body is not considered the same as being thin.
In the high-income segment, heredity is considered a part of the biological process that the young obese should resist and overcome with effort and support. Genetics is seen as a complicating factor, but not as a definitive one. A male adolescent explained, “I don't blame genetics; I blame myself for not taking care of myself.” The idea that the individual should react to the environment works as an ally in the weight loss process, which is established as soon as boys feel aesthetically and affectively rejected by girls, and vice versa. All of them mentioned daily menu changes: unhealthy food being replaced with healthier options. Some mothers reported adopting the same diet.
The valorization of a thin, healthy, and muscular body in this group as indicators of education, discipline, beauty, and self-control stood out in the practice of encouraging children to exercise and consult a health professional. Wealthy obese girls were less likely to engage in exercise because of they were ashamed of their body. They were constantly dieting to look thinner, hardly went out, and had low self-esteem. Boys did not mind being vain, desiring more muscles, and having less fat. Of the 20 high-income obese respondents, 14 (nine boys and five girls) had lost enough weight to change nutritional status from 11 to 15 years of age. Among the 20 low-income obese adolescents, only one girl was no longer classified as obese in that period.
Family members of obese adolescents from the lower-income group are also theoretically supportive when their children want to lose weight. However, because they consider genetics (gene family) to be main reason for obesity, they eventually weaken the adolescent's desire to resist traditional diets. We noticed that in this group, diets rarely changed, with only a modest increase in the report of eating vegetables. For these mothers, fighting against genetics in favor of a thin body pattern will require more obstacles than those faced by children without a family history of obesity. Weight loss diets are seen as punishment more than as a positive lifestyle choice. A mother of a low-income adolescent on a weight loss diet reported that her daughter concealed eating popcorn with condensed milk. Another mother, also of low-income, understood her daughter's grief over the weight scale. After the girl lost and regained 33 kg, she tried to convince herself that she didn't mind her fatness. Despite the daughter's discontentment with her image, the mother proudly described her consumption: “[My husband] buys food every week. A lot of food comes into our home! [What kind of food?] Pizza, pastry, lasagna, those heavy things [strong], soda, cake.” These statements clearly show that speaking about lifestyle changes and obesity with this group is to overlook a process of family achievements, identity, and class habitus in favor of what is not always a prestigious standard for all.
Mothers of high-income male and female adolescents adopted different strategies to ensure the success of a diet, by providing one or more foods associated with the pleasure of the previous diet. One of them said, “You can take away other things but not Coca-Cola! You have to identify these pleasure things. You associate diet with starvation; suffering … it should not be that way!”.
Sociocultural pressures, unwanted effects, and life events
After exhausting claims about intergenerational transmission of fat in the body, some mothers in the lower-income group also pointed out the causal relation between weight in adolescence and events in childhood. The use of natural fortifiers (herbs and plants mixture, ferrous sulphate, and phosphoric acid) and vitamins prescribed by them or by doctors are some examples. Luana had weight and height lower than other neighborhood children. Her mother, who was from a humble family, used to be questioned by other mothers about the daughter's supposed prematurity in childhood. Feeling pressed and given the comparisons with “bigger” children, she decided to give Luana a traditional tonic before meals. Ten years later, in adolescence, the daughter pointed out the consequences of the medicine: “It's because of the medicines that I took as a child!” The mother agrees: “It's not because she eats, she's fat. It's because she took a lot of vitamin fortifier when she was a little girl.”
However, adolescents and their mothers do not always agree about the etiology of obesity. Obese girls from both income groups tended to blame their mothers for excessive concerns with undernutrition in infancy and childhood, and stated that these concerns were responsible for their being obese as adolescents. Among high-income boys, however, mothers were more likely to blame themselves, stating that current unhealthy diet patterns were responsible for the fact that their adolescents were obese.
A “large” or “strong” body—which some would call fat—may actually be desirable by families. That is how most low-income obese boys saw themselves or wanted to be seen. “Chubby boys,” as they described themselves, wished to reduce the belly and shape the arm muscles. For them, the size of the belly or waist circumference was what defined fat and risk of disease. Unlike what the nine high-income, formerly obese boys said, losing weight would not be enough to gain admiration and feel good. Shaping muscles with exercise would be also needed.
Girls and boys from low-income families often reported that a beautiful body “must have flesh”; a skinny woman or man is as rejected as an obese one (because of a sagging belly or because the person does not walk “normally”). Low-income eutrophic girls reported great efforts to gain weight—“look hot.” They wanted to have a body like models or popular singers, who wear scanty clothes to project shapely bodies with aesthetic intervention. For the wealthiest income group, this slender body pattern fit into the “disgusting,” “fat,” and “ugly” categories.
Some mothers of obese adolescents from both income groups highlighted other concerns about obesity, by mentioning that their sons could face difficulties such as discrimination in the job market, discrimination in social relationships, harmful long-term health consequences of obesity, and the possibility of isolation from friends.
Another key component in the obesity equation is emotional health. Interviewees considered that weight gain may derive from anxiety, depression, or the absence of a family member. For many high-income and low-income families, the death of a close family member, and especially the divorce of parents, caused changes in eating and emotional behavior (e.g., depression). Family members from five low-income and seven high-income adolescents noticed higher food consumption after the parents' divorce, and, in two other cases (both low-income), because of a grandparent's death. This association between eating and emotional disorders 
guaranteed the family that mourning or changes in the house dynamics could be alleviated by food. In low-income families, mothers often adopted the “let him or her eat” as a means of facilitating adaptation into a new neighborhood or low contact with the father. Among the high-income group, going to psychologists was more frequently reported as a means of adapting to changes and losses, resulting from the power of assimilation biomedical discourse.
After the two main sections defined a priori, we decided to devote a short section to the issues of medicalization, popular knowledge, and social problems, summarizing the implications of obesity biomedical discourses on the perception of the population about the problem.
Medicalization, popular knowledge, and social problems
Over the past 3 decades there has been a decrease in malnutrition and absolute poverty rates, and fast economic growth in Brazil 
. The latter provides greater access to and consumption of goods and services 
. In the country, obesity has increased in all age groups [3,28]
, and estimates for future years are alarming 
. Health professionals use media programs to inform the population about how to eat, live, and have a healthy body. This health promotion, primarily focused on diet and physical activity, is based on the disease epidemic or pandemic notion of obesity, and is an example of how social issues permeate body image and diets that, once medicalized, are targeted by biomedical or biopolitical conceptions of social control [10,14,15,38]
It is not surprising that obese and eutrophic adolescents from both family income groups and sex usually mentioned terms such as “metabolism,” “calories,” “carbohydrates,” and “BMI” when talking about obesity, overweight, and fat. These terms, previously used only by health professionals, are now widely employed in the media and other communication channels. Felipe, who is from a high-income family, justified eating two small chocolate bars by saying that the amount of calories in those two bars was not extreme, and therefore he would not become fatter as a result of its consumption. By emphasizing the caloric equation, adolescents were able to minimize being guilty for eating unhealthy foods. Clearly, each family and individual finds a particular strategy to deal with the abundance of information available, depending on the body–health–disease conceptions learned over time. A previous study showed that both researchers and the media are likely to blame individuals more than the environment and genetics factors for obesity development [11,39]
In some conversations, we observed an apparent contradiction: “Genetics is an excuse!” “He or she is obese because he or she eats a lot!” Disregarding the term “genetics” now ratifies the excuse and portrays more subtle social forms of pressure, regulation, and biomedical power on what is good or bad, and normal or abnormal. Body weight becomes a moral issue, emphasizing personal disabilities and responsibilities. Explicitly, eating fattens, and the lack of control causes the weight to exceed. In sequence, mentioning ”to eat a lot” was justified by a lack of willpower, which is frequently attributed as being lazy, unwilling, psychologically or emotionally weak, and slow. Among obese adolescents, these adjectives were clearly enunciated by nine adolescents who had gone on a diet and by five who had not. All of the eutrophic ones pointed to these characteristics. One of them said, “Gluttony and sloth—a near fatal combination.” The notion that obesity is a sign of weakness instead of a genetic or biological issue leads to an individualizing model in which the subject is seen as the only person responsible for his or her own health [5,10,11]
Our report shows that the perceptions about the causes of obesity in adolescents from a middle-income setting vary by gender, socioeconomic position, and nutritional status. Whereas some blame genetics as being responsible for obesity development, others blame unhealthy diets and lifestyles, and others acknowledge the roles of early life experiences and family traditions in the process of obesity development. The challenge of reducing the rising rates of obesity should not be underestimated or taken lightly. Health systems should not expect that the availability of scientific information will automatically lead to behavioral change. A multisectoral and multimethodological approach is urgently needed in the obesity arena if we are serious about tackling it.