How to Tackle the Childhood Obesity Epidemic

Look around anywhere in America and the reality assaults you: we are simply too big. Nowhere is the evidence for this more striking than the Centers for Disease Control and Prevention's color-coded obesity map. Between 1990 and 2008 the country morphs from a sea of pleasant blue, representing an obese population of less than 19 percent, to an alarming patchwork of tan, orange, and maroon, where the stats range from 21 percent obese in Connecticut to 32.8 percent in Mississippi.

The epidemic is most alarming among American children: rates have tripled among kids ages 12 to 19 since 1980, with one third of America's youth now overweight or obese and almost 10 percent of infants and toddlers dangerously heavy. Obese kids, defined by a body-mass index at or above the 95th percentile for children of the same age and sex, are at risk for developing conditions in childhood once monopolized by adults: high blood pressure, high cholesterol, and type 2 diabetes. And many are stigmatized and suffer from low self-esteem, which can lead to depression. If current trends continue, nearly one in three kids born in 2000—and one in two minorities—will develop type 2 diabetes in their lifetime, according to the American Diabetes Association. The disease is linked to heart attack, stroke, blindness, amputation, and kidney disease. Indeed, a study published last month found that obese children are more than twice as likely to die prematurely as adults than kids on the lower end of the weight spectrum. In the U.S., new government data show an overall plateau of high BMIs in kids over the last 10 years—a hopeful sign. But "even without further increases in childhood obesity, the toll of the epidemic will mount for decades to come," says Harvard's Dr. David Ludwig, director of the Optimal Weight for Life program at Children's Hospital Boston.

This goes way beyond fitting into our jeans or airline seats: the estimated annual cost of obesity in the United States is $147 billion. The problem even threatens our national security—being overweight is the No. 1 reason recruits are turned away from the military. Not so long ago, a lack of personal willpower was blamed. Today, obesity is considered a public-health threat, the toll of a toxic environment that endangers the well-being of our children and their future.

It's not just us, either. "Globesity" has consumed much of the planet, with more than 1 billion adults overweight or obese. And while we're not the fattest—Nauru, Micronesia, and a handful of other countries beat us—we're very close to the top of the list. Urbanization, modernization, technology, and the globalization of food markets, which includes the exportation of Coke and burgers, has created a crisis of "epidemic proportions," in the words of the World Health Organization.

But it's America that has become the world's preeminent fat-making machine. To dismantle it we need a coordinated, comprehensive plan of attack, one that pairs individual responsibility with a social construct that fosters good nutrition and a healthy lifestyle. We need to be surrounded by food that makes us well, not sick. We need schools and workplaces that reward us for exercising our bodies, not just our brains. "If you want people to make the right choices, they need to have the right choices to make," says Dr. William Dietz, director of the CDC's Division of Nutrition, Physical Activity, and Obesity. We need forceful and well-enforced policies, a government that invests dollars in improving the diet of school kids and puts limitations on the advertising that targets them. We need Americans to perceive obesity as a personal threat to themselves and to their children, not as somebody else's problem. We have a long way to go.

We got here through multiple innovations, many of them meant to improve, not corrupt, our lifestyles. Fast food is a quick fix for hungry working families. Cars and buses get kids to school faster than sidewalks. We have grown used to a world order of speed and convenience.
But with our processed diets come fat, sugar, and calories. And a lot of it. When McDonald's opened in the 1950s, a soda weighed seven ounces, according to a study in the Journal of the American Dietetic Association; today, 7-Eleven serves a behemoth 44-ounce Super Big Gulp, which has its own fan club on Facebook. Burger King's signature Whopper packs almost 700 calories. And research shows that the more we're served, the more we eat.

High-calorie, low-nutrient foods are ubiquitous—at gas stations, at airports, and at school, where it matters most for kids. The National School Lunch Program, signed into law in 1946 by President Harry Truman, was designed to feed hungry children who needed extra calories. Today it serves 31 million kids, most of whom don't. School meals, which are subsidized by the government, are subject to nutritional standards, but that doesn't always translate to apples and cucumbers. Almost 42 percent of schools do not offer any fresh fruits or raw vegetables on a daily basis.

Kids supplement, and often substitute, their lunches with "competitive foods." Vending machines, some stocked with cookies and sodas, exist in 17 percent of elementary schools, 82 percent of middle schools, and 97 percent of high schools. Most states have extremely weak standards or none at all when it comes to competitive foods, says Margo Wootan, director of nutrition policy at the Center for Science in the Public Interest. Mary Story, director of the Robert Wood Johnson Foundation's Healthy Eating Research, asks a simple question: if the average school day is only about six hours, why do snack foods or beverages need to be sold at all? If they are, she says, they should come from the food groups lacking in children's diets today: fruits, vegetables, low-fat and nonfat dairy, and whole grains.

Calories in are not the entire problem. Exercise used to be built into the day; today it is an elite privilege for too many kids. With a focus on standards of learning propelled by the reading- and math-focused No Child Left Behind Act, many schools cannot afford, financially or academically, to offer physical education—even though studies show exercise can improve academic performance. The surgeon general recommends at least 60 minutes of moderate physical activity a day most days of the week for kids; two thirds of high schoolers fail to get it. Too many boys and girls end up wired instead: 8- to 18-year-olds spend an average of seven and a half hours a day multitasking in front of TVs, videogames, or computers.

Our suburban designs, influenced by age-old zoning laws, also work against us. A century ago, residential neighborhoods were separated from workplace factories to spare people from breathing in soot. Fast-forward to 2010: we live in subdivisions and drive to shopping centers and office parks. Biking and walking have been "systematically taken out of our lives," says Jim Sallis, director of the RWJF's Active Living Research program.

We've battled public-health crises before by collecting data, raising public awareness, and passing tough laws. Everybody must now wear seat belts, kids must be buckled into car seats, and drunken driving is an offense punishable by jail. Winning the war on obesity demands the same kind of big-think solution and the determination to take on and also collaborate with powerful interests. It will require time, money, and both individual and political will to undo or rework what got us here.

Aware that it has a public-relations problem, the food industry is taking steps to show it can be part of the solution without help from government regulators. "We have changed the recipes for more than 10,000 of our products to reduce fat, calories, sugar, and sodium," says Scott Faber of the Grocery Manufacturers Association. Salads are now routinely offered at fast-food chains; KFC introduced grilled chicken last year (one grilled wing, 80 calories; one extra-crispy fried, 190). Coke debuted a mini 7.5-ounce can in December. And the beverage industry has substituted high-calorie soft drinks with lower-calorie, more nutritious options in schools, resulting in an 88 percent reduction in calories since 2004.

But those efforts are still aimed more at healthy competition than healthy nutrition. The 100-calorie snack packs of Doritos and Oreos are an attempt to merge both agendas, and while some pediatricians give these products a thumbs up—fewer calories is, after all, a good thing—purists like Dr. Sarah Armstrong, a pediatrician at Duke University Medical Center, want their patients to make better choices, not just eat smaller amounts of the bad stuff. Diet sodas are also double-edged. They save on calories, but they're far from nutritious.

Public-health advocates are taking on Big Food just as their predecessors took on Big Tobacco. Dr. David Kessler, the former head of the FDA, argues that the fattening of America has happened by design as food companies intentionally manufactured irresistible cocktails of sugar, fat, and salt. Manufacturers' efforts to do better don't assuage Kelly Brownell, head of Yale's Rudd Center for Food Policy and Obesity. "The country defaults to giving industry the benefit of the doubt," he says. "Industry says you don't need to regulate us; we'll police ourselves. The tobacco industry abused that with God knows how many lives as a consequence. To expect the food industry to be different may be wishful thinking."

Especially when laudatory efforts are entwined with deceptive information. Earlier this month, FDA Commissioner Margaret Hamburg sent an open letter to the food industry citing violations in food labeling that mislead consumers. Example: particular brands of coconut custard pie, fish fillets, and organic vegetable shortening are promoted as having no trans fat, but fail to disclose the fact that they are high in saturated fat and total fat.

And then there's rampant marketing. Food and drink advertising to children is a $1.6 billion annual effort. The food industry has made an effort to increase ads for healthy foods and reduce the not-so-healthy stuff. But parents and kids are still besieged. The least nutritious cereals are the ones most aggressively and frequently marketed to children, according to a recent Yale study. "I think it's a stretch to say that the First Amendment protects the right of a cereal manufacturer to advertise a sugary breakfast product to a 5-year-old," says Harvard's Ludwig. "These kinds of practices cry out for regulation."

Maybe it would help to adopt a more European approach, increasing our comfort level with government meddling that encourages healthier behavior. Sweden and Norway forbid advertising of any kind to children younger than 12 on commercial TV shows. The French removed more than 22,000 food and drink vending machines from schools and replaced them with water fountains. Denmark banned trans fatty acids in 2003 and plans a tax on saturated fat this year. New York City launched its own local revolution in the United States. As head of the city's Department of Health, Dr. Tom Frieden banned trans fats and forced calorie counts onto restaurant-chain menus. Whether or not this will change eating habits is unclear, but a new study out of Seattle found that parents will choose meals with 100 fewer calories for their kids when they see the numbers. Frieden's approach caught Obama's attention: he appointed him to head the CDC.

Now Frieden and others support a tax on sugar-sweetened beverages. Brownell's calculation: a penny per ounce on soda could reduce consumption by 23 percent, which would ultimately save about $50 billion over 10 years in health-care costs. A controversial federal soft-drink tax was considered as a way to help pay for health-care reform. Last fall President Obama said, "It's an idea that we should be exploring." But a coalition led by the beverage industry spent millions lobbying against it, arguing that it would burden working families. And, fearing the "food police," many constituents don't like it either. The idea may be gaining momentum at the local level, however; a handful of states have introduced soda-tax legislation and New York City Mayor Michael Bloomberg said it "makes sense" as a way to build state revenue.

Ludwig believes a tax would also level the playing field against government subsidies on abundant commodities like corn and soy. High-fructose corn syrup, synthesized from corn, is a main ingredient in a multitude of sweetened drinks and snacks. "We've got a cheap calorie environment, where a lot of the calories are coming from added fats and added sugars that are derived from these few crops," says Dr. David Wallinga of the Institute for Agriculture and Trade Policy in Minnesota. "What we don't have is a policy encouraging the production of fruits and vegetables and other healthy foods." Price does have some sway over the salivary glands: a new study out of the University of North Carolina at Chapel Hill, which followed participants over 20 years, finds that young adults eat less pizza and soda as the cost for these items goes up. And here's the really good news: their weight and risk for diabetes go down.

It took decades after the surgeon general's 1964 report on the hazards of tobacco for anti-smoking laws to go into effect. And there is, of course, one major and critical difference between tobacco and food: you can live without smoking, but you will die without eating. Which makes tackling childhood obesity such a complicated challenge.

An entire cultural shift is required, starting with nutrition education. Showing children the government's food pyramid is fine, but it's not enough. Kids need to learn which items to choose in the lunch line, says CSPI's Wootan, and someone needs to show them what a plate of colorful, nourishing food looks like. Schools must get the funding they need to fix ovens and buy mixers and salad bars so their meal staff can do more than reheat processed foods. Educators must figure out creative ways to incorporate exercise into the day, even if it means blasting music over the PA system for 10 minutes every morning and afternoon for all-school dance time.

Nutritionists and community organizations must team up to reinvent the way families cook, especially in poor and undernourished neighborhoods—the "food deserts," where corner bodegas sell candy bars and white bread. In her hometown Alabama shrimping village, Surgeon General Regina Benjamin taught people to shift from frying to broiling. Gumbo can be less greasy and "still taste very good," says Benjamin. Workplaces should offer an area for pumping or breast-feeding, which has been shown to reduce the risk of obesity, perhaps because breast-fed babies may be better at regulating how much they eat. Parents should eat with their kids as often as possible and set limits on TV, computer, and videogame use. Above all, they should demand healthful foods and environments for their children.

First lady Michelle Obama is being careful not to alienate anyone—from the food lobby to beleaguered parents trying their best. She's investing $400 million in the eradication of food deserts, but she isn't giving anybody a pass on individual responsibility. She's growing fresh fruits and veggies on the White House lawn, but isn't banning the occasional burger and fries. Will her approach be aggressive enough? It's hard to know. But it is ambitious.

With her initiative comes the president's executive order for a Task Force on Childhood Obesity, which requires government departments that have often been at cross-purposes to work together. The president's appointments signal a seriousness about public health. And his higher-ups are not afraid to concede their personal fat demons. Benjamin has acknowledged her own weight struggle, which, she told NEWSWEEK, started in her 40s. So has Agriculture Secretary Tom Vilsack. He says he can't forget the cartoon his mother put on the fridge to discourage him from snacking when he was an overweight child: a heavyset kid wearing a beanie cap, busting out of his britches. "Every time I opened the refrigerator door, I had to look at that guy," he told a crowd at the National Press Club.

Now he's calling on Congress to increase meal-reimbursement rates so that schools can buy higher-priced healthier foods, including whole grains, fruits, and vegetables. He's asking for a stronger link between local farmers and cafeterias, and the authority to set standards on competitive foods. The American Academy of Pediatrics, partnering with the first lady, is urging its doctors to write exercise and eating "prescriptions" for their patients. "Just as we give immunizations," says AAP president Judith Palfrey, "we're going to give healthy eating and exercise advice at every visit." Benjamin says she is planning to travel the country to educate schools and communities about nutrition and physical activity "anywhere we can get the message out." Americans are trying—the multibillion-dollar diet industry attests to that—but they need help, she says. Her personal goal: a hike to the top of Mount Kilimanjaro by 2011.

Talk about a steep climb. Childhood obesity is so vast, so complex, so entrenched. We must all join the journey. "When we come together as a nation and really commit ourselves, we can do it," says Robert Wood Johnson Foundation CEO Risa Lavizzo-Mourey. "If we can get that kind of resolve, we'll be able to create a legacy of healthy children and a healthier nation." Our future depends on it.

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