If you want to see something really scary, go to the Web site of the Centers for Disease Control and Prevention in Atlanta, which has been tracking the rise in obesity. You can see the obesity epidemic spreading like cancer, metastasizing across the country from 1985-2005. It looks as though an alien force or a conquering army is taking over the United States, state by state, year by year.
Almost two-thirds of adults are overweight (body mass index, or BMI, between 25 and 30) or obese (BMI over 30). (To calculate your BMI, click here for adults, here for kids.) Worse, a study in the Annals of Internal Medicine that followed 4,000 people over 30 years found that nine out of 10 men and seven out of 10 women will eventually become overweight. And it's not just adults. Since 1970 the percentage of kids who are overweight or obese has risen almost fourfold, from 4.2 percent to 15.3 percent. New CDC figures released today and published in the Journal of the American Medical Association suggest that the rise in childhood obesity may have leveled off—the latest numbers are approximately the same as the last time the survey was done—but it's not clear yet whether the upward trend has been permanently stalled or whether it is just a statistical artifact.
According to the U.S. Department of Health and Human Services, obesity may account for 300,000 premature deaths a year, almost as many as deaths from cigarette smoking. People who are obese have a 50 to 100 percent increased risk of premature death from all causes compared to those who are not overweight, including heart disease, diabetes, high blood pressure, gallbladder disease, sleep apnea, osteoarthritis and some cancers.
Even though today's numbers offer some hope, it's much too early to assume that the problem has been solved—this may still be the first generation in which kids have shorter lifespans than their parents. According to former U.S. surgeon general Richard Carmona, "As we look to the future and where childhood obesity will be in 20 years … it is every bit as threatening to us as is the terrorist threat we face today. It is the terrorist threat from within."
Well, it doesn't have to be this way. Childhood obesity is almost completely preventable. We don't have to wait for a new drug or technology; we just have to put into practice what we already know. Clearly, genes have changed little, if at all, in the past 40 years. What's changed is our diet and lifestyle. If we caused it, we can reverse it.
Dr. Risa Lavizzo-Mourey decided to do something about it. Under her leadership as president and CEO of the Robert Wood Johnson Foundation, the group has committed $500 million to reverse the rise in childhood obesity. I spoke with Lavizzo-Mourey recently, after she gave the chancellor's health policy lecture at the University of California at San Francisco. Excerpts:
Five hundred million dollars is a lot of money. Why?
Risa Lavizzo-Mourey: The foundation has set as a goal to begin reversing the epidemic of childhood obesity by 2015. But we aren't delusional. In order to reverse the rise in childhood obesity, we are going to need a body of evidence that can fuel a social movement that is like none other that we've had to address in the past. We have to take evidence to action. Rather than looking at multiple different approaches, we have taken the view, based on our history of working on tobacco and other public health areas, that the environment, and policies that shape that environment, matter. If we're going to permanently roll back the epidemic of childhood obesity, we've got to change the environment in which kids grow up, learn their health habits, and make choices. That's an enormous challenge, and succeeding will require the deep engagement of parents, schools, industry, government and media, at the macro level neighborhood by neighborhood, because the problem is most severe in the most communities, urban and rural. But we have to do it.
What's changed in our society in the past 25 years that's causing the obesity epidemic?
Almost everything in our society has changed to get us to the point where we have a massive energy gap between calories we consume and calories we burn each day. The gap for overweight teenagers is roughly 1,000 calories. For all children it's a more manageable number—more like 165 calories.
Why has this energy gap been increasing?
Many fast-food and other restaurants increased portion sizes. It didn't cost them that much more, and they were able to drive sales and profitability. And people are eating out more often. In 1962 we spent roughly 27 percent of our food budget away from home, and now in 2002 it's in excess of 46 percent. That's important because both adults and kids eat more calories on days when they eat in a restaurant—anywhere from 200 to 800 more calories a day. One would hope that with all this extra eating and portion sizes that our kids would be more active. But in fact they are more sedentary than ever, spending 366 more minutes sitting per week than they did in 1981. And what are they doing? Mostly they're watching TV, playing videogames, and using their computers. And when kids are sitting and watching TV, they have a higher probability of taking in more calories. Less than one half of kids get the recommended amount of physical activity. By the time they get to be adolescents, that is down to a pathetic 8 percent. The single most available way for kids to build physical activity back into their daily lives is to include time and resources for recess and physical education in schools. We also need to provide more convenient and safe places where children and adolescents can be active in their own neighborhoods. We are more focused as a nation on getting slimmer than we've ever been. We spend a huge amount of money on this. But this energy gap persists because it's so difficult for us to choose healthy lifestyles as the default, given some of the social issues that exist.
Where you live has an impact on whether or not you can choose a healthy lifestyle. If you live in a more affluent area, you have twice as many supermarkets as if you live in a poor area. And proximity to a supermarket is directly proportional to your ability to get affordable, healthy food. Also, in California 51 percent of Latino children and 58 percent of African-American adolescents report eating in fast-food restaurants every day, compared with 36 percent of white children. Where you live also has an impact on your access to physical activity sites. If you have more recreational facilities close to you, then you have a higher likelihood of getting the recommended amount of physical activity and not being overweight. If you live in an affluent area, chances of having a recreational facility within a mile of your house are pretty high. As socioeconomic levels decrease, the chances of having a recreational facility close to where you live are the smallest. Another factor is that the price of fruits and vegetables has risen a lot faster than the price of fat, salt and sugar. For many Americans, their real income has stayed the same or gone down. So if you only have a dollar or two for a meal, you can buy a lot more calories in the form of junk food than healthy food as the default choice.
What does the foundation plan to do to address these big issues?
We plan to begin three new flagship programs. Healthy Kids, Healthy Communities will provide direct support to communities working to reshape their environments in ways that promote healthy living and prevent childhood obesity. We will fund 10 leading communities this summer and release a call for proposals by the end of this year to fund 90 more. We are launching the Robert Wood Johnson Foundation Center to Prevent Childhood Obesity at the University of Arkansas for Medical Sciences to provide information and resources to policymakers and community activists. It will be up and running by mid-September. We will launch a program to support experienced local advocates working with low-income communities of color. Communities Creating Healthy Environments will fund advocacy efforts in 20 communities.
Also, social networks are going to be a critical part of understanding this epidemic and reversing it. I was having a conversation with a U.S. senator not too long ago who said, "You know, Risa, the problem with using policy solutions to address this obesity epidemic is that there is no secondhand smoke. There's no reason why I should care whether the person next to me is overweight or not." But there is. There's a financial cost to all of us.
Also, a recent study in the New England Journal of Medicine found that your probability of being obese is higher if you associate with other people who are also obese. This study tracked over 12,000 people in strong social networks and found that a person's chance of becoming obese increased by 57 percent if he or she had a friend who became obese during a given time interval. In a way, obesity is contagious. But so is losing weight.
I've been advising some of the large food companies to make more healthful foods and to promote healthier lifestyles. What are your thoughts about the role of industry?
If we're really going to reduce this epidemic, we're going to have to engage industry. They make the food we eat. They are committed, many of them, to improving the food supply. I'm not in favor of demonizing the food industry. But for every $100 we may spend to try to make a healthy, active environment for kids, industry spends $10,000 advertising to them. They need to advertise only healthy foods to kids. I have some hope that this kind of approach might work, because about two years ago President Clinton and the Alliance for a Healthier Generation negotiated an agreement between beverage manufacturers and schools to meet guidelines for what would be shipped to schools. And they have been on track with meeting those guidelines. A year later they were able to demonstrate that the calories shipped to schools were reduced by 41 percent. If you have bottled water in front of you and you're thirsty, you're more likely to choose that instead of a sugary drink.
Also, we need to reform our farm policy. We know that what we produce on the farm gets into the food supply and gets consumed. And we have a farm policy—and a new farm bill—that's much more heavily weighted toward the economic outcomes of our policy than the health outcomes. How do we get more fruits and vegetables produced as compared to seed oils and other crops that can be used to produce sugars and fats? Working together, we can begin to imagine a new world where kids go to schools where the food is healthy, where they are able to exercise and play, where they can be active in their neighborhoods, and they can have a new appreciation for ways of having fun that don't involve having a screen in front of them.