This is one in a series of articles. For more on this subject visit The Daily Meal Special Report: Is Our Food Killing Us? Diet, Nutrition, and Health in 21st Century America.
In almost every TV sitcom, feel-good childhood flick, and youth novel there is the token “fat kid." Think about it. In the wholesome 1950s family show Leave it to Beaver, it was Robert "Rusty" Stevens, the Beaver’s slovenly friend who constantly cut sports and over-ate leftovers. In the 1985 film The Goonies, it was the loveable Chunk, who even in the face of imminent danger would daydream about food. More recently, the “fat” role was somewhat demonized in the Harry Potter series with the main character's lazy, spoiled cousin Dudley. Such characters aside, though, having or being an overweight child is no laughing matter.
Officially, obesity in children is defined as a body fat level that is over 30 percent for girls and 25 percent for boys. Unlike adults, children are measured on the Body Mass Index (BMI) scale according to their age and gender, as their height is frequently changing. For children between two and 19 years-old, Centers for Disease Control Growth Charts define those with a BMI at or above the 85th percentile and below the 95th percentile for children of the same age and sex as overweight; those with a BMI at or above the 95th percentile are classified as obese.
But BMI isn’t the only way to determine whether or not a child is obese.
“BMI is best used as a screening tool to determine if a child over the age of two is underweight, healthy weight, overweight, or obese,” explains Deborah Orlick Levy, M.S., R.D., and Carrington Farms health and nutrition consultant. “Depending on the results, further diagnostic testing may be required. In order to have an accurate assessment, a health care provider would need to use other techniques, such as triceps skinfold measurements, full nutritional assessment, family history, activity records, and other quantifiable medical data.”
The “cost” of childhood obesity isn’t just unhappy children. Among other things, according to the CDC, “Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. In a population-based sample of five- to 17-year-olds, 70 percent of obese youth had at least one risk factor for cardiovascular disease.”
The CDC also reports that children who are obese are likely to grow up to be obese adults and are at risk for issues like heart disease, Type 2 diabetes, stroke, several types of cancer, and osteo-arthritis. Beyond that, studies indicate that “the direct and indirect costs of obesity are more than $190 billion annually and preventing as few as five percent of new cases of chronic conditions, including obesity and related complications, would reduce Medicare and Medicaid spending by nearly $5.5 billion a year by 2030.” There are also reports that indicate that by 2030, half of all adults (115 million adults) in the United States will be obese.
The times, they are a changin’, however. Recently, the New York Times reported that obesity rates for children between two and five years of age have plummeted 43 percent in the last decade. The same study further claims that it appears that the obesity “epidemic” may be over, with Americans showing no drastic increase in obesity overall since 2003.
“Lack of awareness in the past few years has contributed to obesity rates,” explains certified nutritionist Deborah Enos. “There is so much wonderful nutritional information available now — and increased internet access for low-income Americans — and that has led to the drop in obesity rates. We haven’t seen the same in the older groups because that age group is very hard to reach with high levels of influence among group members.”
For some, the term “epidemic,” when applied to childhood obesity, was vastly misused in the first place. Paul Campos, who authored the controversial book The Obesity Myth: Why America’s Obsession with Weight is Hazardous to Your Health, has publicly criticized our perception of obesity and weight. In an interview with the Boston University School of Public Health, he stated that the decline in obesity rates was basically an indication of, well, nothing.“Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. In a population-based sample of five- to 17-year-olds, 70 percent of obese youth had at least one risk factor for cardiovascular disease,” according to the CDC.
“Like most of these reports that come out about weight, I think it’s important to contextualize,” Campos said. “Obesity among preschoolers, as an indicator, was just invented a few years ago by the CDC — not based in science, but just an arbitrary definition. Basically, they took the 95th percentile of the height-weight chart from the 1960s and 1970s and treated that as a definition of childhood obesity. So it’s kind of a made-up definition. And I have trouble seeing a decline in a made-up definition as a big deal.”
Needless to say, not everyone shares his view.
“Think about it," says Enos. “How many overweight kids were in your classes in elementary school? Maybe one or two? How about today? I see about 10 to 20 percent of kids in elementary school that are well above a healthy weight for their age group. Do I call it an epidemic? If not an epidemic, it certainly is a very disturbing trend.”
Marion Nestle, Paulette Goddard Professor in the Department of Nutrition, Food Studies, and Public Health at New York University, believes that the facts speak for itself.
“This depends on how you define epidemic. The word is convenient to use as a more attention-getting description of the increasing prevalence. This is a question of word choice. The basic fact is that obesity among children ages 2 – 19 has tripled since 1980.”
It isn’t easy to pin down exactly what caused this, well, trend. For Deborah Levy, the answer is twofold.
“First, these kids are less active,” she explains. “Years ago, kids would ride bikes to go to friends' houses; today they are driven everywhere. Kids also used to have a gym class at school almost every day of the week. Now, gym classes are only a couple of days a week. Our tweens and teens spend more time on the computer, cell phone, playing hand-held games, and watching TV than playing ball or jumping rope outside. Next, portion sizes of the foods kids choose to eat often are growing in size. For example, bagels are twice the size of what they used to be and pizza slices are much larger as well. So, when kids don’t realize what portion sizes should be and think they can enjoy a bagel or two slices of pizza, what they don’t realize is they may be taking in the equivalent of two bagels or four slices of pizza in calorie and fat content.”
Learn The Facts
Over the past three decades, childhood obesity rates in America have tripled, and today, nearly one in three children in America are overweight or obese. The numbers are even higher in African American and Hispanic communities, where nearly 40% of the children are overweight or obese. If we don't solve this problem, one third of all children born in 2000 or later will suffer from diabetes at some point in their lives. Many others will face chronic obesity-related health problems like heart disease, high blood pressure, cancer, and asthma.
Jennifer E. Phillips , . Dana L. Rofey , in Global Perspectives on Childhood Obesity , 2011
The myriad health risks associated with childhood and adolescent obesity include cardiovascular complications such as hypertension, dyslipidemia, insulin resistance, and chronic inflammation [1, 2] . Obesity, along with the accompanying cardiovascular risk factors, has been shown to track from childhood into adulthood [3–5] . In contrast to the many well-established physical health consequences, the psychological correlates of obesity in childhood are less clear [6, 7] . However, overweight and obese youth are often the targets of bias and stereotyping by peers [8–10] , teachers [11, 12] , and parents  and growing evidence documents several psychological comorbidities related to childhood obesity [9, 14–16] . Thus, similar to long-term physical consequences, the negative impact of obesity-related stigma may have lasting effects on emotional well-being.
Body Mass Index
How do you know if your child is overweight?
Using their height, weight, and age, you figure out their body mass index (BMI) using a:
And then plot their body mass index on a BMI growth chart.
According to the CDC, the current BMI definitions are:
- Underweight: less than the 5th percentile
- Healthy weight: 5th to less than the 85th percentile
- Overweight: 85th to less than 95th percentile
- Obese: Equal to or greater than the 95th percentile
This is a very recent change, as kids in the 85th to less than 95th percentile used to be called at risk for becoming overweight, and those at or above the 95th percentile were defined as being overweight.
Understanding the Childhood Obesity Epidemic
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“Doctor, is my child overweight?” “Oh no, it is just baby fat and he’ll grow out it.” Does your son or daughter have excess weight or obesity? Is it indeed just baby fat, and will they outgrow it?
Pediatric obesity is now of epidemic proportions in the United States. Pediatric overweight and obesity now affects more than 30 percent of children, making it the most common chronic disease of childhood.
Pediatric obesity is not just a cosmetic problem it is a real health problem that can be associated with significant issues in childhood and in adulthood. Therefore, parents of overweight young children should not just ignore this issue, but should actively seek out help to determine why their child is overweight and what they can do to help rectify the situation.
Understanding Obesity in Children
When infants are born, they have comparatively more fat however, this is normal and appropriate. This relatively greater amount of fat provides the infant with some nutritional reserve when they are most vulnerable and adjusting to life outside the womb. This greater amount of fat decreases as the infant grows older and throughout the first several years of life.
Around five years of age, children have the lowest amount of fat and have the lowest body mass index (BMI) – a relationship between weight and height. If a child is getting overweight between two and five years of age, this is not normal and it is not just “baby fat.” Likewise, after five years of age, an overweight child should not be treated as if it is just “baby fat” and told they will outgrow it and not to worry.
In reality, if your child has excess weight or obesity, you do have a cause for worry. The earlier in the child’s life that you make changes a child’s lifestyle in regards to nutrition and physical activity, the easier it is.
Measuring Obesity in Children
You may be confused with the many new terms related to obesity. There is good reason for this confusion as there is controversy over the definitions related to obesity. For adults more than 18 years of age, the definitions are based on BMI. BMI can be calculated using pounds, inches or kilograms and meters using the following formulas:
Using pounds and inches:
BMI = Weight in pounds x 703
(Height in inches) x (Height in inches)
Using kilograms and meters:
BMI = Weight in kilograms
(Height in meters) x (Height in meters)
The normal range of BMI for adults is 18.5-24.9. A BMI of less than 18.5 is considered underweight. A BMI between 25 and 29.9 is considered overweight while a BMI of 30 and over is considered severe obesity. Some also define morbid obesity as a BMI greater than 40.
For children, BMI is calculated in the same fashion as for adults, but there are no absolute numbers of BMI defining normal and overweight. Instead, you have to calculate BMI and plot it on a BMI curve and find the percentile for a child. There is a BMI curve for males and a separate one for females, ages two to 18 years.
The exact definition does not matter as much as knowing what the BMI percentile of the child is and if it is normal or abnormal, increasing or decreasing. For simplicity sake, we will use excess weight and obesity interchangeably.
For children less than two years of age there is no BMI curve available. Instead, you can plot the measurement on the “weight for length curve” that can be found on the “growth curve” used by healthcare providers. Normal weight is when this measurement falls between the five and 95 percentiles. A child with a “weight for length” that plots less than five percent is considered underweight and greater than the 95 percent is considered overweight.
Causes of Childhood Obesity
Changes in the living environment (how we live, eat and act) is the major factor that has contributed to the current problem. There have been several dietary changes that have transpired over the last 20 to 30 years which have contributed to obesity.
One major factor is the frequency with which people eat out. It is now estimated that approximately 40 to 50 percent of every dollar that is spent on food is spent on food outside the home (i.e. restaurants, cafeterias, sporting events, etc.). When people eat out they tend to eat a larger quantity of food (calories) than when they eat at home. Also, foods that are consumed in restaurants tend to have more fat (higher caloric density) which in turn contributes to excessive intake of calories. This also tends to be true for meals purchased in the school cafeteria. Providing children with money to buy their lunch at school also poses another potential problem.
Portion sizes have also increased. This is true for packaged foods and fast food restaurants. Take french fries for example. A portion size is actually 12 french fries. Most fast food restaurants have small or medium french fries, but sell more large or extra-large french fries. People do not think that a large order may actually be two or three portions.
Also, soda sizes have significantly increased. The average serving size of a soda was 6 and a half ounces in 1950, and increased to 12 ounces in the 1960’s and 20 ounces in the 1990’s. Currently, 24 and 32 ounce sodas are marketed, with a 32 ounce soda containing approximately 400 calories. The consumption of soda by children has increased throughout the last 20 years by 300 percent. Fifty to more than 80 percent of children consume at least one soda per day and 20 percent of children consume more than four per day. Scientific studies have documented a 60 percent increase risk of obesity for every regular soda consumed per day.
Box drinks, juice, fruit drinks and sports drinks present another significant problem. These beverages contain a significant amount of calories and it is estimated that 20 percent of children who are currently overweight are overweight due to excessive caloric intake from beverages.
Another major factor in contributing to the pediatric obesity epidemic is the increased sedentary lifestyle of children. School-aged children spend most of their day in school where their only activity comes during recess or physical education classes. In the past, physical education was required on a daily basis. Currently, only eight percent of elementary schools and less than seven percent of middle schools and high schools have daily physical education requirements in the U.S.
Children are also more sedentary outside of school, which is due to increased time spent doing sedentary activities such as watching television, playing video games or using the computer. Only 50 percent of children, 12 to 21 years of age, regularly participate in rigorous physical activity, while 25 percent of children report no physical activity. The average child spends two hours a day watching television, but 26 percent of children watch at least four hours of television per day.
Studies indicate that when children watch more than two hours of television per day there is a significant increased risk of obesity as well as high blood pressure. Studies have also determined that children who eat in front of the television consume higher fat and salt containing foods and less fruits and vegetables than children who do not eat in front of the TV.
- Only eight percent of elementary schools, and less than seven percent of middle schools and high schools, have daily physical education requirements in the U.S.
- Only 50 percent of children, 12 to 21 years of age, regularly participate in rigorous physical activity
- Twenty-five percent of children, 12 to 21 years of age, report no physical activity
- The average child spends two hours a day watching television
- Twenty-six percent of children watch at least four hours of television per day
Correlation Between Childhood Obesity and Adulthood Obesity
Pediatric obesity is a real and very significant health problem that is associated with adverse effects on health in childhood as well as adulthood. There is a high likelihood of a child with obesity becoming an adult with obesity. This risk increases as the child gets older.
The risk that a five year-old child with obesity remains affected by obesity as an adult is approximately 50 percent. This increases to more than 80 percent for an adolescent with obesity. On the other hand, the risk of a normal weight child becoming affected by obesity as an adult is only seven percent.
Childhood obesity also has adverse effects on health during childhood. The most common consequence of childhood obesity is the psychosocial effect. It has been shown that adolescents with obesity have higher rates of poor self esteem, and this negative self image may carry over into adulthood. There may also be increased rates of depression in children who are overweight.
Our society also discriminates against individuals with obesity, females more so than males. It has been documented that females with obesity have lower acceptance rates for college than non-overweight females with the same grades and standardized test scores. The National Longitudinal Survey of Youth study noted that female adolescent with obesity as young adults had less education, less income, higher poverty rate and decreased rate of marriage as compared to non-overweight adolescent females.
Health Risks of Childhood Obesity
There are multiple medical conditions associated with obesity in childhood. The most common include insulin resistance (the first step towards developing diabetes), hypertension, liver problems and hyperlipidemia (elevated cholesterol and/or triglyceride). While these typically do not cause many problems in childhood, some children will develop diabetes or severe liver disease, including cirrhosis. Other problems that can occur include joint problems, menstrual problems, gallbladder disease, sleep apnea and headaches.
Treating Childhood Obesity
Treatment of pediatric obesity is a family affair and needs to be directed at the family, not just the child. This is extremely important since the home environment and family support are important factors when trying to address pediatric obesity. If the child is the only one making changes in their life, they are less likely to be successful and are then made to feel different. Likewise, parents who do not make healthier changes in their lives are likely to undermine the child’s attempts.
Prior to addressing the treatment of childhood obesity, you must first assess the readiness of the child and the family to make changes. If the child is very depressed, this needs to be addressed prior to working on the child’s weight problem. If a depressed child attempts weight-loss and is unsuccessful, this may worsen their depression or lower their self-esteem.
Similarly, if there is a lot of stress in the family at that time it is not ideal to try and tackle yet another major issue. In some situations where there is significant depression or stress, it may be most appropriate for the child and the family to seek counseling to address these issues. In addition, if parents express little concern regarding their child being overweight, they are not ready to make the necessary changes.
Treatment of pediatric obesity is not accomplished by just dieting. You need to address multiple aspects of the child’s and the family’s lifestyle, nutrition and physical activity patterns. Prior to discussing any treatment plans, you first must determine what the desired goals are. If your child is overweight, or at risk for becoming overweight, it is important to work with your healthcare provider to develop an individualized plan of care that includes realistic goals and action steps.
The goals of treatment of pediatric obesity can be divided into three major areas: behavioral goals, medical goals and weight goals. The behavioral goals are to promote lifelong healthy eating and activity behaviors. Medical goals are to prevent complications of obesity in childhood and potentially adulthood, as well as improve or resolve existing complications of obesity. The weight goals are dependent on the child’s age and the presence or absence of associated co-morbidities.
Taking the First Steps
The first step for all overweight children is to establish weight maintenance. For children two to seven years of age with a BMI between 85-95 percent, weight maintenance is the primary goal. This is because the child will be growing taller and they have the time as well as the ability to “grow into their weight.” For those with a BMI greater than 95 percent and no associated complications, weight maintenance is still the overall goal. For those whose BMI is greater than 95 percent and have an associated co-morbidity, weight-loss should be strived for after weight maintenance is achieved. Children seven to 18 years of age with a BMI between 85-95 percent and who have no complications, weight maintenance is reasonable. However, close follow-up is needed to ensure that they are not becoming more overweight or develop a complication of obesity.
For those who have an associated co-morbidity and/or whose BMI is greater than 95 percent, weight-loss should be strived for after weight maintenance is achieved. When weight-loss is desired, it needs to be stressed that gradual weight-loss is preferable to rapid weight-loss. It is better to make gradual changes that can be maintained over time, resulting in gradual weight-loss. Ideally, you should not try to lose more than one to two pounds per week.
Parents and Treating Childhood Obesity
Parents are of vital importance in the treatment of pediatric obesity. Parents act as role models for their children regarding nutrition and physical activity. It is extremely important for an overweight child to see the parents being an example of what they want their child to do. Treatment needs to be family-based and individualized. By obtaining a good dietary, physical and lifestyle history, areas of potential concern for that child and family can be identified and then addressed.
Here are tips to help change a family’s lifestyle, nutrition habits and activity level:
Eat as a family.
Slow down the eating process.
Have special family time that is physically active.
Limit eating out or getting take-out food.
Pack lunch for school instead of buying lunch.
Do not have a television in the child’s bedroom.
Limit computer time to a maximum of 1-2 hours per day.
Do not eat in front of the television.
Do not use food as a reward.
Eat healthy, well balanced meals and snacks.
Plan meals and snacks in advance.
Offer the child a choice of healthy foods to eat.
Limit intake of calories from beverages.
Eat appropriate portion size for the child’s age.
Limit calorically dense foods (i.e. high fat, high sugary foods).
Limit treats, but do not eliminate them.
Encourage daily physical activity.
Have a variety of physical activities that can be done.
Be physically active with others.
Limit sedentary activity.
Three Major Areas of Treatment
Treatment of pediatric obesity needs to focus on three major areas: lifestyle, nutrition and physical activity. As you approach the treatment of obesity, it is important this is done in a gradual and stepwise fashion. Once some problem areas are identified, you may consider discussing a few of them and then ask the child to pick one to work on at that time. If you present a long list of things that the child and family need to change, they may feel overwhelmed and are likely to not make any attempt.
In addition, once one or two issues are agreed upon, close follow-up is required to monitor changes, as well as to give positive reinforcement for change in behavior even if no weight is lost. The greater the period of time between appointments with the primary care provider the less likely they are to be successful. Once the initial behavior change has been successfully accomplished, the child and family should move on to the next desired change, but at the same time continue to monitor the initial change.
Medicationsand Childhood Obesity
There are a number of medications both over-the-counter and prescription that are available for the treatment of obesity. These are not frequently used in the initial phase of treatment of pediatric obesity however, the primary treatment modality is behavior modification and lifestyle changes. Some children with significant obesity, especially those associated with other co-morbidities, may benefit from pharmacologic therapy as well. This should be done only under the direction of a physician knowledgeable in the area of pediatric obesity
Surgery and Treating Childhood Obesity
Bariatric surgery (weight-loss surgery) for adults with severe obesity is now being done with increased frequency. This surgery is safe and effective, but is to be used only for those with morbid obesity who meet specific criteria. At this time bariatric surgery should be considered investigational and should only be done in institutions with a comprehensive pediatric weight management program and by surgeons experienced with this type of surgery in children.
About the Author:
Lisa Saff Koche, MD, is the Medical Director for Spectra Healthcare and an Associate Clinical Professor at the University of South Florida in Tampa. Dr. Koche has practiced in obesity for seven years with aggressive medical management as well as complete medical support for bariatric surgery patients.
The nation’s childhood obesity epidemic: Health disparities in the making
We have not always been a nation in the midst of an obesity epidemic. In the 1960s and 1970s only 13 percent of U.S. adults and 5 to 7 percent of U.S. children were obese. Today, 17 percent of our children, 32 percent of adult males, and 36 percent of adult females are obese. Although obesity has increased across all racial and ethnic groups, it affects some groups more than others. Black (50 percent) and Hispanic women (45 percent) have the highest adult obesity rates. Among children, Black adolescent girls (29 percent) and Mexican-American adolescent boys (27 percent) are most affected (Flegal, Carroll, Ogden, & Curtin, 2010 Ogden & Carroll, 2010a, 2010b).
Obesity kills it is now the second leading cause of death in the U.S.and is likely to become the first (Mokdad, Marks, Stroup, & Gerberding, 2004). Unless this epidemic is successfully addressed, life expectancy will actually decline in the U.S. (Olshansky et al., 2005). Not only do obese individuals die earlier, but their quality of life is severely compromised they are far more likely to suffer from diabetes and its complications — kidney failure, blindness, leg amputations — as well as stroke, breast and colorectal cancer, osteoarthritis and depression (Jebb, 2004).
Obesity often begins in childhood and is linked to psychological problems, asthma, diabetes and cardiovascular risk factors in childhood. Because many obese children grow up to become obese adults, childhood obesity is strongly linked to mortality and morbidity in adulthood (Reilly et al., 2003). Because obesity disproportionately affects certain racial and ethnic minority groups in both child and adult populations, it underlies many of the health disparities facing our nation.
This rapid increase in obesity is not the product of changing biology or genes it is the product of an obesogenic environment that promotes inactivity and overeating. How did this happen? As a society, we have changed the types and quantities of food we eat, reduced physical activity, and engaged in more passive leisure-time pursuits.
In 1975, 47 percent of women with children under age 18 worked outside the home in 2009, 72 percent did so and among women with children 6 to 17 years of age, 78 percent were employed (U.S. Bureau of Labor Statistics, 2010). With more time spent working outside the home, there was less time for home activities including food preparation. It will come as no surprise that the per capita number of fast-food restaurants doubled between 1972 and 1997, and the number of full-service restaurants rose by 35 percent (Chou, Grossman, & Saffer, 2004). In the 1960’s, only 21 percent of a family’s food budget was spent on dining out (Jacobs & Shipp, 1990). In 2008, it was 42 percent (U.S. Bureau of Labor Statistics, 2011). One national survey found that 30 percent of children ages 4 to 19 years of age ate fast food daily (Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2003). Fast food and convenience food is inexpensive but high-calorie and low in nutritional value. Available per capita calories increased from 3,250 calories per day in 1970 to 3800 calories per day in 1997 (Chou et al., 2004). Fast-food restaurants are more common in ethnic-minority neighborhoods (Fleischhacker, Evenson, Rodriguez & Ammerman, 2011) and the fast food industry disproportionately markets to ethnic minority youth (Harris, Schwartz, & Brownell, 2010).
The per capita consumption of high fructose corn syrup — the mainstay of soft drinks and other sweetened beverages — has increased from 38.2 pounds in 1980 to 868 pounds in 1998 (Chou et al., 2004). In 1942, annual U.S. production of soft drinks was 90 8 oz. servings per person in 2000, it was 600 servings (Jacobson, 2005). Soft drinks and juice drinks make up six percent of all calories consumed for 2 to 5 year olds, 7 percent for 6 to11 year olds, and more than 10 percent for 12 to 19 year olds. While children 2 to 11 years old get more of their calories from milk than soda, the opposite is true for youth 12-19 years old. Female teens get 11 percent of their total calories from sodas or juice drinks but only six percent of their calories from milk (Troiano, Brefel, Carroll, & Bialostosky, 2000).
Sodas and other sweetened beverages are readily available in our nation’s schools. Vending machines are placed in almost all of the nation’s middle and high schools (Weicha, Finkelstein, Troped, Fragala, & Peterson, 2006) and are in approximately 40 percent of our elementary schools (Fernandes, 2008). Both school vending machine and fast food restaurant use have been associated with increased sugar sweetened beverage intake in youth (Weicha et al, 2006). When vending machines are placed in elementary schools, black children are more likely to purchase a soft drink from these machines (39 percent) compared to white children (23 percent) (Fernandes, 2008).
Not only have our dietary habits changed, but our energy expenditure has changed as well. During the second half of the twentieth century, there was a wholesale movement of Americans from the cities to the suburbs one half of all Americans now live in the suburbs. Low density neighborhoods were attractive, but these homogeneous residential enclaves, with no mixed-use commercial access, meant that a car was required to buy a newspaper or a quart of milk. The U.S. turned into a nation of drivers only 1 percent of all trips are on bicycles and 9 percent are on foot. Approximately 25 percent of all U.S. trips are less than one mile but 75 percent of these are by car (Frumkin, 2002). It is not surprising that measures of county sprawl have been associated with both minutes walked and obesity (Ewing, Schmid, Killinsworth, Zlot, & Raudenbush, 2003).
Opportunities for physical activity used to be a common component of each child’s school day. Unfortunately, these opportunities are declining especially in our nation’s secondary schools. While 87 percent of schools require physical education in grade eight, this declines to 47 percent in grade 10, and only 20 percent in grade 12. A minority of youth participate in intramural sports or activity clubs (<20 percent) or varsity sports (
35 percent). Further, ethnic minority youth and those from poverty backgrounds are significantly less likely to participate in any type of sport or activity club (Johnson, Delva, & O’Malley, 2007).
In 1969, approximately half of U.S. children walked or biked to school, and 87 percent of those living within one mile of their school did so. Today, less than 15 percent of U.S. school children walk or bike to school (Centers for Disease Control, 2005) among those who live within one mile of their school, only 31 percent walk, and for those living 2 miles or less from the school, only two percent bike to school. A third of U.S. children go to school on a bus and half are taken by private vehicle (Centers for Disease Control, 2002).
Not only are Americans spending more time in their cars driving to work or school or to meet their daily shopping needs, but their leisure time activities have become more sedentary. Television sets are found in almost every U.S. household and many children have TVs in their bedrooms. A recent report by the Kaiser Family Foundation (Rideout, Foehr, & Roberts, 2010) noted the explosion in media content use of all types (TV, music/audio, computer, video games, and cell phones) from more than six hours per day in 1999 to more than seven hours per day in 2009. Most notable were the large discrepancies found between minority and majority youth Black and hispanic youth average > nine hours of media use per day compared to six hours among white children. Numerous studies have documented the link between sedentary leisure activities and poorer physical and psychological health further, intervention studies have shown that lowering the amount of time spent in sedentary activities is associated with reductions in children’s body mass index (Tremblay et al., 2011).
A number of critics have argued that U.S. farm subsidies have resulted in mega farms producing so much corn and soybeans that the price of high-fructose corn syrup, hydrogenated fats from soybeans, and corn-based feed for cattle and pigs is kept artificially low. This, in turn results in low prices for fast food, corn-fed pork and beef and soft drinks. In contrast, no such subsidies exist for fresh fruits and vegetables, which are produced in much lower quantities at higher cost to the American public (Fields, 2004). Even the government’s food assistance programs for the poor appear to have an impact on childhood obesity. While the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the School Breakfast and National School Lunch Program seem to have a positive impact on obesity in young children, the Supplemental Nutrition Assistance Program (Food Stamps) may have a negative impact, especially in cities where the cost of food is high (Kimbro & Rigby, 2010) the authors suggest that providing subsidized meals may be a more effective way to assure high quality nutrition in poor children. Food stamps, while providing a wider array of food choice, may negatively impact childhood obesity especially when the family lives in an area with high food prices, encouraging purchase of cheaper calorie-dense, less nutritious foods. Other critics have argued that the government’s subsidies for highways have promoted the use of the automobile over public transportation. The U.S. government spends most of its transportation dollars on highways (U.S. Department of Transportation, 2012), and the U.S. has the highest number of vehicles per capita in the world (United Nations, 2007). Further, traffic concerns are one of the primary reasons parents do not allow their children to walk or bike to school (Centers for Disease Control and Prevention, 2002, 2005). Some have argued that the No Child Left Behind policy has resulted in decreased access to recess and physical education in our nation’s schools, as teachers and school districts focus on high stakes testing (Anderson, Butcher, & Schanzenbach, 2010). America’s childhood obesity epidemic is a product of multiple changes in our environment that promote high-calorie, poor quality dietary intake and minimal physical activity. Although our obesogenic environment is affecting all Americans, in many respects, it is disproportionately affecting ethnic minorities and those who live in poorer communities. As psychologists, we are trained to understand the multiple factors that determine human behavior. We understand that there is no single simple explanation for this epidemic nor can we solve it with a single intervention. Instead, psychologists are needed at every level — in our communities and schools, in the health care system, among policy makers, and working with children and their families — if we are to successfully combat this major threat to our nation’s health.
Suzanne Bennett Johnson, PhD, ABPP, is an APA fellow and distinguished research professor at Florida State University (FSU) College of Medicine. She was director of the Center for Pediatric and Family Studies at the University of Florida Health Science Center until 2002, when she became the chair of the Department of Medical Humanities and Social Sciences at FSU College of Medicine, the first new medical school to be established in 25 years. Thanks to continued research funding from the National Institutes of Health (NIH), her work has focused on medical regimen adherence, childhood diabetes, pediatric obesity and the psychological impact of genetic screening on children and families. She has received awards for her research contributions from the Society of Pediatric Psychology, the Association of Medical School Psychologists, and the American Diabetes Association. She is currently president of the American Psychological Association.
Bowman, S.A., Gortmaker, S.L., Ebbeling, C.B., Pereira, M.A., & Ludwig, D.S. (2003). Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics, 113, 112-118.
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School lunches and weight gain
Are you concerned about lunch at school and if it might contribute to weight gain in your child? The American Academy of Pediatrics reports that children get a third to half of their daily calories at school, so healthy options at the cafeteria or in the lunch box are important.
A study from the U.S. Food and Drug Administration (FDA) found that school lunch guidelines put in place are improving students' eating habits. The new guidelines aimed to provide students with more fruits, vegetables, whole grains, fat-free or low-fat milk, and lower amounts of salt and saturated fats.
The FDA found that there was a 4% decline in the total lunch calories. Calories from fat fell 18% and salt consumption decreased 8%. However, students who received free and reduced-price lunches were more likely to choose entrees with higher levels of fat. This is a concern as this group is most likely to have obesity-related health risks.
Bottom line for school lunches? Talk to your child about selecting healthy food choices at school, help them learn what food is healthy versus unhealthy, mirror that practice at home, and talk about what they ate at school each day.
QUESTION 3: What are the biological and cultural factors associated with racial/ethnic differences in childhood obesity?
Biological factors may, in part, mediate racial/ethnic and SES differences in childhood obesity. For example, low SES or discrimination by race or ethnicity may result in increased stress. Stress has a direct effect on the hypothalamic-pituitary-adrenal axis, resulting in elevation of plasma cortisol, which has been implicated in the development of obesity (29). The relationships between stress and illness differ markedly by race/ethnicity, in part due to differences in exposure to social and environmental stressors the degree to which the environment, SES, and discrimination are appraised as stressful culturally appropriate strategies for coping with stress biological vulnerability to stress and the expression of stress as illness (30). While these relationships are plausible, they are not fully understood.
Race/ethnicity may have underlying genetic components however, self-identified race/ethnicity is complicated by genetic admixture (31). Whether genetic differences across populations are associated with obesity development also remains unclear. A “thrifty genotype” may confer an advantage in an energy-poor environment, which would become disadvantageous in an energy-dense environment because it would predispose to increased accumulation of adipose tissue. The genes or gene variants that would support this hypothesis have not been identified.
One possible contributor to racial/ethnic disparities in the metabolic comorbidities of obesity may be related to different patterns of fat distribution. African American adults and children have less visceral and hepatic fat than white and Hispanic individuals (32). Another possibility is that there are fundamental metabolic differences by race or ethnicity. Racial and ethnic differences in resting metabolic rate have been found (33) but may partly be due to differences in fat-free mass or organ mass and have not been shown to account for weight gain over time within populations (34). Some differences in insulin secretion and response among racial/ethnic groups have been found. African American and Hispanic children have lower insulin sensitivity than white children. African Americans have higher circulating insulin levels than whites, due to not only a more robust β-cell response to glucose but also decreased clearance of insulin in the liver. Hispanics also have lower insulin sensitivity than whites, after controlling for BMI and body composition, and have higher insulin levels in compensation for their relative insulin resistance (35).
There are differences in lipids and lipoproteins related to race/ethnicity (36). African Americans have lower rates of basal lipolysis than whites (37). This could be a metabolic risk factor for both the development of obesity and the risk of obesity-related comorbidities. African Americans also have lower levels of adiponectin than white subjects during childhood and adolescence, which may help explain their increased risk of diabetes and cardiovascular disease despite having less visceral adiposity (38). In summary, there is circumstantial evidence for biological differences in obesity development and the occurrence of comorbidities by race/ethnicity however, the relationships are far from definitive.
Culture is a system of shared understandings that shapes and, in turn, is shaped by experience. Culture provides meaning to a set of rules for behavior that are normative (what everyone should do) and pragmatic (how to do it). Culture, unlike instinct, is learned is distributed within a group in that not everyone possesses the same knowledge, attitudes, or practices enables us to communicate with one another and behave in ways that are mutually interpretable and exists in a social setting. Among the shared understandings embodied by a culture are those pertaining to obesity, including understanding of its cause, course, and cure, and the extent to which a society or ethnic group views obesity as an illness. Illness is shaped by cultural factors governing perception, labeling, explanation, and valuation of the discomforting experiences (39). Because illness experience is an intimate part of social systems of meaning and rules for behavior, it is strongly influenced by culture.
As with race and ethnicity, culture is a dynamic construct in that shared understandings change over time as they are shaped or informed by the experience of individual members of a group or the entire group. For instance, beliefs relating the normative and pragmatic rules for engaging in health-promoting behavior (diet and exercise) or leisure activity (watching television or playing video games) will change as individual members of an ethnic group experience and come to value innovative practices, while losing interest in and thereby disvaluing traditional practices.
Cultural variation in the population is maintained by migration of new groups, residential segregation of groups defined by their culture and ethnicity, the maintenance of language of origin by the first and, to a lesser degree, the second generation of immigrants, and the existence of formal social organizations (religious institutions, clubs, community or family-based associations). In contrast, globalization and acculturation simultaneously promote cultural change and cultural homogeneity. Globalization, a social process in which the constraints of geography on social and cultural arrangements recede, can affect obesity through the promotion of travel (e.g., migration of populations from low-income to high-income countries), trade (e.g., production and distribution of high-fat, energy-dense food and flow of investment in food processing and retailing across borders), communication (promotional food marketing), the increased gap between rich and poor, and the epidemiologic transition in global burden of disease (40). Acculturation (changes of original cultural patterns of one or more groups when they come into continuous contact with one another) can affect obesity by encouraging the abandonment of traditional beliefs and behaviors that minimize the risk of overweight and the adoption of beliefs and behaviors that increase the risk of overweight.
With both acculturation and globalization there are changes in preferences for certain foods and forms of leisure/physical activity, as well as educational and economic opportunities. These changes may differ by ethnic groups. For instance, first-generation Asian and Latino adolescents have been found to have higher fruit and vegetable consumption and lower soda consumption than whites. With succeeding generations, the intake of these items by Asians remains stable. In contrast, fruit and vegetable consumption by Latinos decreases while their soda consumption increases, so that by the third generation their nutrition is poorer than that of whites (41). Acculturation to the U.S. is also significantly associated with lower frequency of physical activity participation in 7th-grade Latino and Asian American adolescents (42).
In much of the world, traditional diets high in complex carbohydrates and fiber have been replaced with high-fat, energy-dense diets. Rural migrants abandon traditional diets rich in vegetables and cereal in favor of processed foods and animal products. In the U.S. and abroad, globalization has been linked to fewer home cooked meals, more calories consumed in restaurants, increased snacking between meals, and increased availability of fast foods in schools (43). Similarly, there have been changes in patterns of physical activity linked to risk of obesity in both adults and children worldwide, including increased use of motorized transport, fewer opportunities for recreational physical activity, and increased sedentary recreation (44).
Culture is believed to contribute to disparities in childhood obesity in numerous ways. First, body image development occurs in a cultural context, and ethnic/cultural groups differ in their shared understandings as to valued and disvalued body image. For instance, perceived ideal body size for African American women is significantly larger than it is for white women, and African American men are more likely than non-Hispanic white men to express a preference for larger body size in women (45). The mean BMI at which white women typically express body dissatisfaction is significantly lower than that for African American women (46).
Given that women typically assume primary responsibility for the care, feeding, and education of children, including the transmission of shared cultural understandings, the beliefs that women possess with respect to their own body image have implications for their perception of and response to the body image of their children. This pattern may vary by ethnicity. For instance, non-Hispanic white mothers’ dietary restraint or their perceptions of their daughters’ risk of overweight can influence their young daughters’ weight and dieting behaviors (47). In contrast, Latinas tend to prefer a thin figure for themselves but a plumper figure for their children (48). Even within the Latino population in the U.S., however, there are important cultural variations, with Latinas from the Caribbean preferring a thinner body size than Latinas from Mexico and Central America (49).
Culture influences child-feeding practices in terms of beliefs, values, and behaviors related to different foods (43). Affordability, availability of foods and ingredients, palatability, familiarity, and perceived healthfulness prompt immigrant families to retain or discard certain traditional foods and to adopt novel foods associated with the mainstream culture. Bilingual school-age children from immigrant Mexican households serve as agents of dietary acculturation by rejecting the lower-calorie traditional foods prepared at home and favoring the higher-calorie foods, beverages, and snacks they consume at school or see advertised on television (50) and may resist efforts by their parents to restrict the availability of foods from the mainstream culture.
Cultural patterns of shared understandings influence food consumption in several ways. These shared understandings define which types of food are healthy and which are unhealthy. For instance, Hmong immigrants in California believe that only fresh food is healthy, that anything frozen or canned is not, that school meals are unhealthy for children, and that fruits and vegetables are totally different domains (51). Food is both an expression of cultural identity and a means of preserving family and community unity. While consumption of traditional food with family may lower the risk of obesity in some children (e.g., Asians) (52), it may increase the risk of obesity in other children (e.g., African Americans) (53).
Differences in levels and types of exposure to nutritional marketing may also account for cultural differences in patterns of nutrition. For instance, exposure to food-related television advertising was found to be 60% greater among African American children, with fast food as the most frequent category (54). Marketing strategies for food often target specific ethnic groups. This marketing, in turn, may produce alterations in belief systems as to the desirability of foods high in calories and low in nutrient density.
Culture influences preferences for and opportunities to engage in physical activity. As with nutrition, children model the types of physical activity undertaken by their parents thus, a parent in a culture that views rest after a long workday as more healthy than exercise is less likely to have children who understand the importance of physical activity for health and well-being (55). Compared with their white counterparts, African American adolescents have greater declines in levels of physical activity with increasing age and are less likely to participate in organized sports (56). A study by the Kaiser Family Foundation (57) found longer periods of television viewing among African American children than among non-Hispanic white children, with Hispanic children in between. The relationship between television watching and obesity may vary by race. Henderson (58) found that white girls who watched more television at baseline showed a steeper increase in BMI over early adolescence than girls who watched less, while television viewing was not associated with adolescent BMI change in black girls.
Culture can influence the perception of risk associated with obesity. Studies of Latinos have found that many mothers of obese children believe their child to be healthy and are unconcerned about their child's weight, although these same parents are likely to believe that obese children in general should be taken to a nutritionist or physician for help with weight reduction (50). Among African American parents, there is greater awareness of acute health conditions than of obesity. A study by Katz et al. (59) found that both obese African American girls and their female caregivers were unaware of the potential health consequences associated with their current body size.
Culture can influence the utilization of health services, affecting the likelihood that childhood obesity can be prevented or effectively treated in specific ethnic groups. While ethnic differences in access to services can be attributed to differences in SES (e.g., higher proportions of Latinos lack health insurance or transportation to health care providers), several studies have pointed to differences in use of services even when access is available. Among Latino families, differences in patterns of service use have been found to be related to different beliefs about the cause, course, and cure of an illness, the stigma attached to particular illnesses, and interactions between patients and providers (60).
Finally, culture may influence the manner in which the risk for obesity varies by social status. For instance, cultures vary with respect to which body type is associated with wealth and health, with low-income societies generally believing that a larger body size and high-income societies generally believing that a thinner body is an indicator of wealth and health. Individuals with low SES in low-income countries are at risk of undernutrition. This risk creates a cultural value favoring larger body shapes, a value that may accompany immigrant groups upon their arrival to the U.S. With globalization, however, this cultural value may be diminishing, as low-income countries become increasingly exposed to media images linking wealth with thinness.
In the early 1970s, Finland’s death rate from coronary heart disease was the highest in the world, and in the eastern region of North Karelia—a pristine, sparsely populated frontier landscape of forest and lakes—the rate was 40 percent worse than the national average. Every family saw physically active men, loggers and farmers who were strong and lean, dying in their prime.
Thus was born the North Karelia Project, which became a model worldwide for saving lives by transforming lifestyles. The project was launched in 1972 and officially ended 25 years later. While its initial goal was to reduce smoking and saturated fat in the diet, it later resolved to increase fruit and vegetable consumption.
The North Karelia Project fulfilled all of these ambitions. When it started, for example, 86 percent of men and 82 percent of women smeared butter on their bread by the early 2000s, only 10 percent of men and 4 percent of women so indulged. Use of vegetable oil for cooking jumped from virtually zero in 1970 to 50 percent in 2009. Fruit and vegetables, once rare visitors to the dinner plate, became regulars. Over the project’s official quarter-century existence, coronary heart disease deaths in working-age North Karelian men fell 82 percent, and life expectancy rose seven years.
The secret of North Karelia’s success was an all-out philosophy. Team members spent innumerable hours meeting with residents and assuring them that they had the power to improve their own health. The volunteers enlisted the assistance of an influential women’s group, farmers’ unions, homemakers’ organizations, hunting clubs, and church congregations. They redesigned food labels and upgraded health services. Towns competed in cholesterol-cutting contests. The national government passed sweeping legislation (including a total ban on tobacco advertising). Dairy subsidies were thrown out. Farmers were given strong incentives to produce low-fat milk, or to get paid for meat and dairy products based not on high-fat but on high-protein content. And the newly established East Finland Berry and Vegetable Project helped locals switch from dairy farming—which had made up more than two-thirds of agriculture in the region—to cultivation of cold-hardy currants, gooseberries, and strawberries, as well as rapeseed for heart-healthy canola oil.
“A mass epidemic calls for mass action,” says the project’s director, Pekka Puska, “and the changing of lifestyles can only succeed through community action. In this case, the people pulled the government—the government didn’t pull the people.”
Could the United States in 2017 learn from North Karelia’s 1970s grand experiment?
“Americans didn’t become an obese nation overnight. It took a long time—several decades, the same timeline as in individuals,” notes Frank Hu. “What were we doing over the past 20 years or 30 years, before we crossed this threshold? We haven’t asked these questions. We haven’t done this kind of soul-searching, as individuals or society as a whole.”
Today, Americans may finally be willing to take a hard look at how food figures in their lives. In a July 2015 Gallup phone poll of Americans 18 and older, 61 percent said they actively try to avoid regular soda (the figure was 41 percent in 2002) 50 percent try to avoid sugar and 93 percent try to eat vegetables (but only 57.7 percent in 2013 reported they ate five or more servings of fruits and vegetables at least four days of the previous week).
A playbook for healthy-food activists
How can advocates for a wholesome food environment transform the American eating landscape? By telling their stories, turning time into power, and mobilizing action, says veteran organizer Marshall Ganz, senior lecturer in public policy at the Harvard Kennedy School.
Ganz teaches people how to convert community resources into a force for social change. His approach is grounded in what he terms “public narrative: a story of self, a story of us, and a story of now.” A “story of self” draws on moments of one’s own life experience, which enables others to “get” why one has been called to act. A “story of us” invokes values rooted in shared experience. A “story of now” frames the present as a time of challenge, a choice to be made, and a source of hope.
In the case of the obesity epidemic, a story of self could describe one’s own experience as a young child struggling with overweight or growing up in a fresh-food desert—someone without much chance against a fattening food environment—and where one found the hope to change. “It’s not making the case in terms of data. It’s making the case experientially,” says Ganz. “Unless there’s a human connection, it’s hard for people to engage with the challenge. Values are emotional in content—they are not simply ideas.”
Ganz’s approach bridges the moral ground of experience with action. That could mean firmly asking your city councilors to serve healthy food at official events, shopping only at supermarkets that offer healthy provisions, asking the medical staff to actively support a campaign to have hospitals sell fresh fruit in their cafeterias, leveraging social media to amplify all these demands—and training people in the practice of organizing.
Above all, public narrative rests on sharing stories of hope as well as hurt. “The definition of hope that I like comes from Maimonides, who said that hope is belief in the plausibility of the possible, as opposed to the necessity of the probable,” says Ganz. “To be a realist is to recognize that it is probable Goliath will always win—but that, sometimes, David does.”
Individual resolve, of course, counts for little in problems as big as the obesity epidemic. Most successes in public health bank on collective action to support personal responsibility while fighting discrimination against an epidemic’s victims. [To learn more about the perils of stigma against people with obesity, read “The Scarlet F.”]
Yet many of public health’s legendary successes also took what seems like an agonizingly long time to work. Do we have that luxury?
“Right now, healthy eating in America is like swimming upstream. If you are a strong swimmer and in good shape, you can swim for a little while, but eventually you’re going to get tired and start floating back down,” says Margo Wootan, SD ’93, director of nutrition policy for the Center for Science in the Public Interest. “If you’re distracted for a second—your kid tugs on your pant leg, you had a bad day, you’re tired, you’re worried about paying your bills—the default options push you toward eating too much of the wrong kinds of food.”
But Wootan has not lowered her sights. “What we need is mobilization,” she says. “Mobilize the public to address nutrition and obesity as societal problems—recognizing that each of us makes individual choices throughout the day, but that right now the environment is stacked against us. If we don’t change that, stopping obesity will be impossible.”
The passing of power to younger generations may aid the cause. Millennials are more inclined to view food not merely as nutrition but also as narrative—a trend that leaves Duke University’s Kelly Brownell optimistic. “Younger people have been raised to care about the story of their food. Their interest is in where it came from, who grew it, whether it contributes to sustainable agriculture, its carbon footprint, and other factors. The previous generation paid attention to narrower issues, such as hunger or obesity. The Millennials are attuned to the concept of food systems.”
We are at a public health inflection point. Forty years from now, when we gaze at the high-resolution digital color photos from our own era, what will we think? Will we realize that we failed to address the obesity epidemic, or will we know that we acted wisely?
The question brings us back to the 1970s, and to Pekka Puska, the physician who directed the North Karelia Project during its quarter-century existence. Puska, now 71, was all of 27 and burning with big ideas when he signed up to lead the audacious effort. He knows the promise and the perils of idealism. “Changing the world may have been utopic,” he says, “but changing public health was possible.”
Fat profits: how the food industry cashed in on obesity
W hen you walk into a supermarket, what do you see? Walls of highly calorific, intensely processed food, tweaked by chemicals for maximum "mouth feel" and "repeat appeal" (addictiveness). This is what most people in Britain actually eat. Pure science on a plate. The food, in short, that is making the planet fat.
And next to this? Row upon row of low-fat, light, lean, diet, zero, low-carb, low-cal, sugar-free, "healthy" options, marketed to the very people made fat by the previous aisle and now desperate to lose weight. We think of obesity and dieting as polar opposites, but in fact, there is a deep, symbiotic relationship between the two.
In the UK, 60% of us are overweight, yet the "fat" (and I include myself in this category, with a BMI of 27, slap-bang average for the overweight British male) are not lazy and complacent about our condition, but ashamed and desperate to do something about it. Many of those classed as "overweight" are on a near-perpetual diet, and the same even goes for half of the British population, many of whom don't even need to lose an ounce.
When obesity as a global health issue first came on the radar, the food industry sat up and took notice. But not exactly in the way you might imagine. Some of the world's food giants opted to do something both extraordinary and stunningly obvious: they decided to make money from obesity, by buying into the diet industry.
Weight Watchers, created by New York housewife Jean Nidetch in the early 1960s, was bought by Heinz in 1978, who in turn sold the company in 1999 to investment firm Artal for $735m. The next in line was Slimfast, a liquid meal replacement invented by chemist and entrepreneur Danny Abraham, which was bought in 2000 by Unilever, which also owns the Ben & Jerry brand and Wall's sausages. The US diet phenomenon Jenny Craig was bought by Swiss multinational Nestlé, which also sells chocolate and ice-cream. In 2011, Nestlé was listed in Fortune's Global 500 as the world's most profitable company.
These multinationals were easing carefully into a multibillion pound weight-loss market encompassing gyms, home fitness, fad diets and crash diets, and the kind of magazines that feature celebs on yo-yo diets or pushing fitness DVDs promising an "all new you" in just three weeks.
You would think there might be a problem here: the food industry has one ostensible objective – and that's to sell food. But by creating the ultimate oxymoron of diet food – something you eat to lose weight – it squared a seemingly impossible circle. And we bought it. Highly processed diet meals emerged, often with more sugar in them than the originals, but marketed for weight loss, and here is the key get-out clause, "as part of a calorie-controlled diet". You can even buy a diet Black Forest gateau if want.
We think of obesity and dieting as polar opposities, but there is a deep relationship between the two
So what you see when you walk into a supermarket in 2013 is the entire 360 degrees of obesity in a single glance. The whole panorama of fattening you up and slimming you down, owned by conglomerates which have analysed every angle and money-making opportunity. The very food companies charged with making us fat in the first place are now also making money from the obesity epidemic.
How did this happen? Let me sketch two alternative scenarios. This is the first: in the late 1970s, food companies made tasty new food. People started to get fat. By the 1990s, NHS costs related to obesity were ballooning. Government, health experts and, surprisingly, the food industry were brought in to consult on what was to be done. They agreed that the blame lay with the consumer – fat people needed to go on diets and exercise. The plan didn't work. In the 21st century, people are getting fatter than ever.
OK, here's scenario two. Food companies made tasty new food. People started to get fat. By the 1990s, food companies and, more to the point, the pharmaceutical industry, looked at the escalating obesity crisis, and realised there was a huge amount of money to be made.
But, seen purely in terms of profit, the biggest market wasn't just the clinically obese (those people with a BMI of 30-plus), whose condition creates genuine health concerns, but the billions of ordinary people worldwide who are just a little overweight, and do not consider their weight to be a significant health problem.
That was all about to change. A key turning point was 3 June 1997. On this date the World Health Organisation (WHO) convened an expert consultation in Geneva that formed the basis for a report that defined obesity not merely as a coming social catastrophe, but as an "epidemic".
The word "epidemic" is crucial when it comes to making money out of obesity, because once it is an epidemic, it is a medical catastrophe. And if it is medical, someone can supply a "cure".
The author of the report was one of the world's leading obesity experts, Professor Philip James, who, having started out as a doctor, had been one of the first to spot obesity rising in his patients in the mid-1970s. In 1995 he set up a body called the International Obesity Task Force (IOTF), which reported on rising obesity levels across the globe and on health policy proposals for how the problem could be addressed.
It is widely accepted that James put fat on the map, and thus it was appropriate that the IOTF should draft the WHO report of the late 90s that would define global obesity. The report painted an apocalyptic picture of obesity going off the scale across the globe.
The devil was in the detail – and the detail lay in where you drew the line between "normal" and "overweight". Several colleagues questioned the group's decision to lower the cut-off point for being "overweight" – from a BMI of 27 to 25. Overnight, millions of people around the globe would shift from the "normal" to the "overweight" category.
Professor Judith Stern, vice president of the American Obesity Association, was critical, and suspicious. "There are certain risks associated with being obese … but in the 25-to-27 area it's low-risk. When you get over 27 the risk becomes higher. So why would you take a whole category and make this category related to risk when it isn't?"
Why indeed. Why were millions of people previously considered "normal" now overweight? Why were they being tarred with the same brush of mortality, as James's critics would argue, as those who are genuinely obese?
I asked James where the science for moving the cut-off to BMI 25 had come from. He said: "The death rates went up in America at 25 and they went up in Britain at 25 and it all fits the idea that BMI 25 is the reasonable pragmatic cut-off point across the world. So we changed global policy on obesity."
James says he based this hugely significant decision, one that would define our global understanding of obesity, partly on prewar data provided by US insurance company Met Life. But this data remains questionable, according to Joel Guerin, a US author who has examined the work produced by Met Life's chief statistician Louis Dublin.
"It wasn't based on any kind of scientific evidence at all," according to Guerin. "Dublin essentially looked at his data and just arbitrarily decided that he would take the desirable weight for people who were aged 25 and apply it to everyone."
I was interested in who stood to gain from his report and asked James where the funding for the IOTF report came from. "Oh, that's very important. The people who funded the IOTF were drugs companies." And how much was he paid? "They used to give me cheques for about 200,000 a time. And I think I had a million or more." And did they ever ask him to push any specific agenda? "Not at all."
James says he was not influenced by the drug companies that funded his work but there's no doubt that, overnight, his report reclassified millions of people as overweight and massively expanded the customer base for the weight-loss industry.
James rightly points out that he needed the muscle of drugs companies to press home the urgency of the unfolding obesity problem as a global public health issue, but didn't he see the money-making potential for the drug companies in defining obesity as an "epidemic"?
"Oh, let us be very clear," he says. "If you have a drug that drops your weight and doesn't do you any other harm in terms of side-effects, that is a multibillion megabuck drug."
Former GSK sales rep Blair Hamrick with Jacques Peretti. Photograph: Brendan Easton/BBC/Fresh One Productions/Brendan Easton
I asked Gustav Ando, a director at IHS Healthcare Group, how important this decision to define obesity as a medical epidemic was for the industry. "It really turned a lot of heads," he said. "Defining it as an epidemic has been hugely important in changing the market perception." The drugs companies could now provide, Ando explained, "the magic bullet".
Paul Campos, a legal expert with a special interest in the politics of obesity, saw the decision to shift the BMI downwards as crucial not just in making a giant new customer base for diet drugs but in stigmatising the overweight. "What had been a relatively minor concern from a public health perspective suddenly was turned into this kind of global panic," he told me. "I think when you look at this issue what you see is a combination of economic interests with cultural prejudice which led to a toxic brew of social panic over weight in our culture."
But guess what? The drugs wheeled out to clean up the "epidemic" didn't turn into the blockbusters the industry had hoped for.
Since the 1950s, the great dirty secret of weight loss was amphetamines, prescribed to millions of British housewives who wanted to lose pounds. In the 1970s, they were banned for being highly addictive and for contributing to heart attacks and strokes. Now drugs were once more on the agenda – in particular, appetite-suppressants called fenfluramines. After trials in Europe, the US drugs giant Wyeth developed Redux, which was approved by the Food and Drug Administration (FDA) in spite of evidence of women developing pulmonary hypertension while taking fenfluramines. Dr Frank Rich, a cardiologist in Chicago, began seeing patients who had taken Redux with the same symptoms. And when one, a woman in Oklahoma City, died, Rich decided to go public, contacting the US news show Today.
"That was filmed in the morning and when I went to my office, within an hour later I got a phone call from a senior executive at Wyeth who saw the Today piece and was very upset. He warned me against ever speaking to the media again about his drug, and said if I did some very bad things would start happening, and hung up the phone."
The Wyeth executive concerned has denied Rich's version of events. But once legal liability cases began, evidence emerged from internal documents that Wyeth knew of far more cases of pulmonary hypertension than had been declared either to the FDA or to patients. Redux was taken off the market and Wyeth set aside $21.1bn for compensation. The company has always denied responsibility.
But with Wyeth out of the game, obesity was now an open door for other drugs companies.
British giant GlaxoSmithKline (GSK) found its antidepressant Wellbutrin had a handy side effect – it made people lose weight. Blair Hamrick was a sales rep for the company in the US tasked with getting doctors to prescribe the drug for weight loss as well as depression, a move that would considerably widen its market and profitability. In the trade, this is called "off-labelling".
"If a doctor writes a prescription, that's his prerogative, but for me to go in and sell it off label, for weight loss, is inappropriate," says Hamrick. "It's more than inappropriate – it's illegal people's lives are at stake."
GSK spent millions bribing doctors to prescribe Wellbutrin as a diet drug, but when Hamrick and others blew the whistle on conduct relating to Wellbutrin and two other drugs, the company was prosecuted in the US and agreed to a fine of $3bn, the largest healthcare fraud settlement in US history.
Drug companies had attempted to capitalise on obesity, but their fingers got burnt.
Still, there was a winner: the food industry. By creating diet lines for the larger market of the slightly overweight, not just the clinically obese, it had hit on an apparently limitless pot of gold.
In the late 1990s the cut-off point for being “overweight” went from a BMI of 27 to 25
There now exist two clear and separate markets. One is the overweight, many of whom go on endless diets, losing and then regaining the weight, and providing a constant revenue stream for the both the food industry and the diet industry throughout their adult lives. (As former finance director of Weight Watchers, Richard Samber, put it to me – "It's successful because the 84% [who can't keep the weight off] keep coming back. That's where your business comes from.") The other market is the genuinely obese, who are being cut adrift from society, having been failed by health initiative after health initiative from government.
As Dr Kelly Brownell, director of the Rudd Centre for food policy and obesity at Yale University, explained, the analogy must now be with smoking and lung cancer: "There's a very clear tobacco industry playbook, and if you put it next to what the food companies are doing now, it looks pretty similar. Distort the science, say that your products aren't causing harm when you know they are."
But the solution to obesity could also follow the cigarette trajectory too, according to Brownell. It was only after a combination of heavy taxation (price), heavy legislation (banning smoking in public places), and heavy propaganda (warnings on packets an effective, sustained anti-smoking advertising campaign and most crucially, education in schools) was brought to bear on a resistant tobacco industry that smoking became a pariah activity for a new generation of potential consumers, and real, lasting change took place. Similar measures, Brownell says, could provide an answer to obesity.
And it's funny, that analogy with smoking. Because deep in the archive at San Francisco University is a confidential memo written by an executive at the tobacco giant Philip Morris in the late 1990s, just as the WHO was defining obesity as a coming epidemic, advising the food giant Kraft on strategies to employ when it started being criticised for creating obesity.
Titled "Lessons Learnt From the Tobacco Wars", it makes fascinating reading. The memo explains that just as consumers now blame cigarette companies for lung cancer, so they will end up blaming food companies for obesity, unless a panoply of defensive strategies are put into action. You might conclude that there was a good reason why the food industry bought into dieting – it was nothing personal, it was just business.
Jacques Peretti presents The Men Who Made Us Thin, 9pm, BBC2, Thursday 8 August.
Use healthy oils (like olive and canola oil) for cooking, on salad, and at the table. Limit butter. Avoid trans fat.
Drink water, tea, or coffee (with little or no sugar). Limit milk/dairy (1-2 servings/day) and juice (1 small glass/day). Avoid sugary drinks.
The more veggies &mdash and the greater the variety &mdash the better. Potatoes and French fries don’t count.
Eat plenty of fruits of all colors
Choose fish, poultry, beans, and nuts limit red meat and cheese avoid bacon, cold cuts, and other processed meats.
Eat a variety of whole grains (like whole-wheat bread, whole-grain pasta, and brown rice). Limit refined grains (like white rice and white bread).
Incorporate physical activity into your daily routine.
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