COMMENTARY

Weighty Matters: Public Health Aspects of the Obesity Epidemic: Part IV -- Obesity Worldwide, Pathological Underweight, and Gluttony

Martin Donohoe, MD, FACP

Disclosures

March 19, 2008

Introduction

Previous articles in this series on the public health aspects of the obesity epidemic have covered various contributors and consequences to this health problem in the United States. This piece discusses obesity worldwide, as well as the related topics of pathologic underweight and gluttony.

Obesity Worldwide

America's weight problem is occurring in the midst of a global epidemic of overweight and obesity.[1] Although the world's underfed population has declined slightly to 1.1 billion, the number of overweight people has surged to match that figure.[2] Individuals who move from countries with lower rates of cancer and more healthy diets (such as many Southeast Asian nations) within a generation adopt a less healthy American diet. As a result, they become more overweight/obese and suffer higher rates of cancer and obesity-related illnesses.[3] Americanization of food choices and portion sizing, particularly through the cultural export of fast-food outlets, have made obesity a significant health problem in both developed and developing nations throughout the world.

The flip side of the obesity epidemic in the United States is that many individuals suffer from abnormal self-image, particularly regarding their weight. The prevalence of eating disorders has risen in the United States and in developing countries, a possible consequence (in part) of the Western media's depiction of the "ideal," excessively thin woman.

As many as 66% of women and 52% of men have reported feelings of dissatisfaction or inadequacy regarding their body weight.[4] Sixty percent of girls in grades 9-12 are trying to lose weight, compared with 24% of boys.[4] The number-one wish of girls aged 11-17 is to lose weight.[5] Women are more likely to judge themselves as overweight when they are not, whereas men are the opposite.[6] Women who desire to lose weight are more likely to do so in the hopes of improving their appearance, whereas men who wish to lose weight are more likely to be concerned about their future health and fitness.[7]

Body-image distress is now classified as a psychological disorder. Five percent to 10% of females have an eating disorder such as anorexia nervosa or bulimia.[4] Male and female high school athletes are especially at risk for unhealthy weight-control behaviors, such as restricting food intake, vomiting, overexercising, using diet pills, inappropriately taking prescribed stimulants or insulin, and using nicotine.[8] Some adolescents dehydrate by restricting fluid intake, spitting, wearing rubber suits, taking daily steam baths and/or saunas, and using diuretics or laxatives.[8]

Consequences of abnormal weight-loss behaviors include delayed maturation, impaired growth, menstrual irregularities or loss of menses, increased rates of infection, eating disorders, and depression. Alternatively, such behaviors can be a sign of depression or verbal, physical, or sexual abuse.[9,10]

Media images have contributed to a misguided perception of the "ideal" body. Today, models weigh 23% less than average women; in 1986 it was only 8%.[11] Modeling schools for teens create unrealistic expectations. Only a very "select" few models achieve financial success (of these select few, beginners earn $1500 per day, those in the top tier $25,000 per day, and supermodels $100,000 or even more per day).

Food insecurity and hunger. Ironically, although the United States is the wealthiest nation, prone to overconsumption of natural resources and plagued by an epidemic of obesity, our country also faces an increasing maldistribution of wealth and significant levels of poverty and hunger.[12] The US Department of Agriculture estimates that 12% of US households suffer from food insecurity (limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable food in socially acceptable ways), and that another 4% face outright hunger (the uneasy or painful sensation caused by the recurrent lack of access to food).[13] Twenty-five percent of children live in poverty, and 4 million go hungry each day.[14] At the same time, American households waste over $43 billion worth of food per year, 3 times as much as in 1985.[12] Worldwide, hunger-related causes kill as many people in 2 days as were killed in the atomic bombing of Hiroshima.[12]

Gluttony. A bizarre trend likely to be seen by the rest of the world as typical of American "affluenza" and overconsumption of resources is the recent dramatic increase in the number and popularity of eating contests. The most (in)famous of such events is Nathan's Annual Fourth of July Hot Dog Eating Contest -- the World Cup of food bolting -- in which past winners have consumed over 50 frankfurters and buns in just 12 minutes.[15] The International Federation of Competitive Eating sponsors more than 150 other annual gorgefests, involving such foods as chicken wings, oysters, and jalapenos, which it promotes through its official newsletter, The Gurgitator.[15]

Conclusions

Obesity is a growing health problem, not just in the United States but worldwide. The final article in this series will describe treatments for obesity and analyze public health approaches to combating this epidemic.

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