COMMENTARY

Weighty Matters: Public Health Aspects of the Obesity Epidemic: Part II -- Treatments and Approaches to Combating the Problem

Martin Donohoe, MD, FACP

Disclosures

January 04, 2008

Introduction

This column, the second in a 5-part series focusing on the obesity epidemic, describes the economic consequences of obesity, the "obesity economy," and the roles played by nutrition, exercise, and television.

Economic Consequences of Obesity

In 2003, obesity-attributable national medical expenditures were $75 billion and ranged from $87 million in Wyoming to $7.7 billion in California.[1,2] Half of the healthcare costs associated with obesity are currently covered by Medicare, which now classifies obesity as a disease.[1] Much of the increased costs of healthcare associated with the obese are due to prescription drugs, but complications from surgery are more common and hospital lengths of stay are longer for obese than for normal-weight individuals.[3,4]

The Obesity Economy

Today there is a growing "obesity economy."[5] The plus-size apparel market is worth $17 billion and accounts for 20% of women's clothing sales, up from 11% in 2001. Half of all US women wear size 14 or larger clothing, whereas in 1985 the average size was 8.[5] Companies have sprung up to cater to the morbidly obese, producing XXXL size, oversized autos, furniture, coffins, and specialized medical equipment such as lifts, special chairs, and toilets.

Nutrition, fast food, supersizing, sweeteners, and soda. Major changes in the human diet have contributed to the rise in overweight and obesity. These include the beginning of agriculture more than 10,000 years ago and, more recently, changes in portion size, the spread of fast food franchises since the mid-20th century, the use of artificial sweeteners and trans-fatty acids in processed foods, and current high levels of consumption of sugar- and caffeine-containing sodas.

The contributions of agriculture to nutrition and society. The advent of agriculture, considered a watershed in human societal evolution, brought the benefits of community and local food production but also led to a class-based society with rulers, farmers, artisans, merchants, and soldiers, each with distinct duties and positions in the group hierarchy. It may have hastened, or even brought about, the advent of organized warfare. It also led to dramatic changes in diet and exercise.

Our ancestors expended enormous calories in hunting and gathering. They ingested up to 7000 of the 75,000 different edible plant species on a predominantly vegetarian diet. The wild game they ate, when it was available, was high in protein but very low in fat, unlike today's grain-fed (and antibiotic- and hormone-treated) supermarket meat.[6] Today, humans eat a markedly decreased variety of foodstuffs, and most of the planet relies on just a few crops (wheat, corn, rice) for a large proportion of its calories.[7]

Fast foods and supersizing. In recent decades, portion sizes have grown, as has the size of restaurant dinner plates.[8,9] Americans now spend about one half of their food budgets and consume about one third of their calories outside the home.[10]

Fast food spending has increased 18-fold since 1970.[11] The US food industry produces 3800 calories per person per day, although average caloric need is only 2500 calories per person per day. Fast foods (super-sized, protein-poor, carbohydrate- and fat-rich meals) now comprise 10% of total caloric intake.[12] On any given day, 8% of Americans eat at McDonalds.[13] A typical American eats 30 pounds of French fries per year.[14]

Serving size and the caloric content of typical packaged and fast foods have ballooned over the last 50 years, as the following examples illustrate[15]:

  • In 1954, a Burger King hamburger weighed 2.8 oz. and contained 202 calories. The same regular burger today weighs 4.3 oz. and contains 310 calories.

  • A serving of McDonalds fries was 2.4 oz. and contained 210 calories when the restaurant chain began in 1955. Today, one serving is 7 oz. and contains 610 calories.

  • In 1916, the typical size of a bottle of Coca-Cola was 6.5 fluid oz. and contained 79 calories. Today the typical bottle contains 16 fluid oz. and 194 calories.

  • Some mega-sized fast food burgers on the market today contain well over 1000 calories.

Fast food outlets tend to target poor inner city communities. Meals can be obtained inexpensively and conveniently, which helps consumers working 2 jobs, raising children solo, or lacking inadequate kitchen facilities. The fast food industry directly targets children, producing 20% of Saturday morning television and offering, often in collusion with the motion picture industry, prizes and inducements based on characters that appeal to youngsters.

Fast food restaurants tend to be clustered around schools.[16] Furthermore, some US hospitals have regional and national fast food franchises located on the grounds of their main medical centers, thus sending the wrong message to patients and their families about optimal nutrition.[17]

The consumption of fast and junk foods begins early in life. Each day, 3% and 10%, respectively, of US infants and toddlers eat candy; 4% and 23%, respectively, consume sweetened soda beverages.[18] Soft drinks, which account for 20% to 24% of calories for 2- to 19-year-olds, are associated with tooth decay and decreased consumption of healthier alternatives, such as fruits and vegetables.[19]

Americans of all ages are drinking more soda, and a majority of adults drink soda daily. Per capita soda consumption has more than doubled since 1970, from 24 gallons per year to 53 gallons per year.[10] One well-known convenience store chain offers sizes such as "Big Gulp" and "Super Big Gulp."[4]

Seventy percent of soft drinks consumed in the United States contain caffeine as an added ingredient. Evidence suggests that the mood-altering and physical dependence-producing effects of caffeine (a central nervous system stimulant) have contributed to high rates of consumption of caffeinated soft drinks.[20] Soda's addictive properties put imbibers at risk of caffeine-withdrawal symptoms such as headache.

The National School Lunch Program. The National School Lunch Program gives schools more than $6 billion per year to offer low-cost meals to more than 27 million schoolchildren at 99,000 schools and childcare centers.[21] Begun in 1946, the program, administered by the US Department of Agriculture, has the conflicting missions of providing healthy meals to children, regardless of income, and subsidizing agribusiness, shoring up demand for beef and milk.[11] As such, meals emphasize meat and dairy products at the expense of fruit and vegetables, contain high levels of fat, and fail to meet the government's own inadequate nutritional standards, which are out of date with current science and have not been updated since the 1970s.[1,21]

Eighty-one percent of schools serve lunches exceeding 30% fat content, less than 45% serve cooked vegetables other than potatoes (usually French-fried), and less than 10% serve legumes.[21] Overemphasis on milk products may increase long-term risk for breast cancer, particularly if the milk comes from cattle treated with recombinant bovine growth hormone (also know as recombinant bovine somatotropin).[22,23]

Such daily fare does not help to establish good nutritional habits in America's youth. Unfortunately, dramatic changes in the National School Lunch Program are unlikely to occur given the large amounts of political clout wielded (and campaign dollars donated) by the beef and dairy industries, which have former lobbyists in key positions in the Department of Agriculture.[1,21]

Exercise and Television

 

The Institute of Medicine has urged Americans to exercise 1 hour per day, double the 1996 recommendation by the Surgeon General.[24] However, 70% of American adults are not active in their leisure time; 40% are not active at all.[25] One third of children do not participate in the minimum recommended level of moderate or vigorous physical activity, and the number taking part in physical education courses has dropped significantly, in part due to school funding cuts.[1]

Neighborhoods with high levels of minorities and individuals of low socioeconomic status have a paucity of facilities that enable and promote physical activity, such as parks and gymnasia.[26] Perception of one's neighborhood as less safe is also associated with an increased risk of overweight in children, likely due to fear of exercising outdoors.[27] Lack of exercise has effects beyond obesity, as participating in daily physical education is associated with better school attendance, more positive attitudes about school, and better academic performance.[1]

Instead of exercising, many youth spend their time watching television and using other electronic media such as the Internet and video games. The average youth spends 67% more time watching TV per year than he/she spends in the classroom.[28] Thirty-two percent of children aged 2-7 years have televisions in their rooms, as do 65% of children aged 8-18 years, which diminishes parental control over viewing time and content.[29]

Increases in television viewing are associated with increased calorie intake among youth, especially of calorie-dense low-nutrient foods of the type promoted on TV.[30] Businesses spend an estimated $13 billion annually marketing food and drinks in the United States, much of it on television advertising[31] American children are exposed to approximately 40,000 food advertisements per year, 72% of which promote candy, cereal, and fast food.[32] Convenience/fast foods and sweets comprise over 80% of foods advertised during children's programming.[33] African-American-oriented television airs far more junk food ads targeted at kids than general-oriented networks.[34]

Neither the Federal Trade Commission nor the Federal Communications Commission has the authority to limit such advertising, despite the fact that children are vulnerable to exploitive advertising messages and unable to discern truth from fiction in ads.[35] The American Academy of Pediatrics, which argues that children are cognitively and psychologically defenseless against advertising, has called for severe restrictions on advertisements for junk food aimed at children.[36]

Intriguingly, overweight and obese characters on television represent less than half of their percentages in the general population.[37] Such characters are less likely to be considered attractive, to interact with romantic partners, or to display physical affection, no doubt perpetuating stereotypes and contributing to the poor self-image many overweight individuals face.[37] In the real world, the overweight and obese, especially women, suffer from various forms of stigmatization. For instance, overweight and obese women get fewer promotions and face more job discrimination, whereas heavyset men do not.[21]

Conclusion

Poor nutrition, lack of exercise, and excessive television viewing have all been associated with obesity.

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