When John and Katherine Smith watched the casket containing their teenage son Roger descend into his grave, they naturally looked around for someone to blame. But there was no murderer, no smoking gun per se. Instead, there were super-duper-sized sodas and fastfood quadrupleburgers, a kitchen pantry filled year-round with Halloween candy, and pancake-and-bacon breakfasts too numerous to mention. Simply put, Roger, 19, a Type 2 diabetic, had eaten himself to death.
An exaggeration? For today, perhaps. But if trends continue, this faux newspaper story will soon be real.
The problem of childhood obesity is, pardon the pun, getting bigger. Childhood obesity plagues America; about one in six children are overweight and another one in six are on the verge. Unless something changes, almost all of these overweight kids will grow up to become overweight or obese adults. Diabetes looms, social and economic problems are in the forecast; the potential ramifications spill on and on. Childhood obesity is the seminal health issue of the twenty-first century and inexcusably so. It's not a contagious disease. Few people inherit it. It is in large part reversible and certainly preventable. And yet, there it is, in every day-care center, school yard and college cafeteria throughout the land (and a whole lot of other lands, too).
How can we as a society prevent childhood obesity and how can we reverse it when it occurs? Or put another way, is it really as simple as not drinking sugared soda?
Sizing Things Up
It's not looking good out there on the playground. In fact, it hasn't looked good for quite a while.
Over the past 30 years, the numbers of overweight children have increased sharply, following a similar trend among adults. Data from two U.S. National Health and Nutrition Examination surveys show that for children aged two to five years, the percentage of those who are overweight rose to 13.9% by the 2003-2004 study from 5% in the 1976-1980 version. Such prevalence increased to 18.8% — nearly one in five — of children aged six to 11, up from 6.5%, and for those aged 12-19, prevalence increased to 17.1% from 5%.
Some 20% of American children are expected to be obese by 2010, and that figure will eventually translate into even higher percentages of obese adults; for the record, 33% of American adults aged 20-74 are now obese, up from 15% three decades ago.
If it's any solace, and it shouldn't be, North America isn't alone in its weight troubles. Type 2 diabetes, a proxy for obesity, is raging throughout Asia, Australia, the Pacific islands, Latin America, Africa and Europe. The World Health Organization says the number of overweight adults now exceeds 1 billion, with 30% of them obese. In some developing nations, as many as half of adults suffer from diabetes. If there were people in Antarctica, they would probably have diabetes, too.
Why is childhood obesity — or rather, obesity in general — exploding? Many experts blame the American Dream. As poor nations industrialize and accrue wealth, free time becomes increasingly limited and treasured, just as food choices multiply. The classic American middle-class lifestyle beckons, with its culinary combination of drive-thru convenience, good (albeit faked) taste and hefty "value" portions. It's no shame to admit that a giant bag of fried and seasoned tortilla chips — on sale — really does taste good, or that, when pressed for time, you've pulled your car in for FastFoodLand's #17 combo special (upgrade to a 64 oz. soda for only pennies more; why not?).
But there is a price to this: a small bowl of fish or vegetables with rice becomes nostalgia. Home cooking, more traditional and additive-free but also more time-consuming, goes by the wayside, along with much stronger control over ingredients and amounts. Add in decreased exercise as economies abandon agrarian roots, and the equation is an easy one: the more food you eat that's bad for you, the fatter you get.
Guided by their increasingly heavy parents, children are no exception.
The Damage
An obese child, in and of him-or herself, may seem just fine — even well adjusted — on the surface. But inside his or her body, trouble is beginning. The damage isn't confined to medical issues; count the potential for psychological problems in there, too. And no child lives in a vacuum; obesity also leads to rising healthcare costs in wider society. Here are a few examples of collateral damage from childhood obesity.
PHYSICAL ISSUES: THE BELLY OF THE BEAST
Just because they are children doesn't mean obese youths are exempt from the same ills that plague obese adults, particularly heart disease and Type 2 diabetes. Will an obese child suffer a stroke, or come down with weight-related osteoarthritis, ovarian cancer, and/or gallbladder problems? Probably not — today. But since it's so hard to lose the weight once you've gained it, it's all the more important to stop childhood obesity in its tracks, before these weight-related illnesses kick in.
Moreover, their age isn't necessarily protecting obese children from these ills — right now. Some 60% of overweight children have one or more risk factors for heart disease, such as high cholesterol or high blood pressure. Atherosclerosis begins in childhood, with arterial-wall thickness and decreased flexibility of blood vessels.
Diabetes, meanwhile, is one of the most common chronic illnesses in school-age children. Type 2, which is weight-related, is a sizable and growing problem among U.S. children, according to the nation's Centers for Disease Control. Hard-and-fast prevalence numbers are hard to come by, but many cases are undiagnosed due to testing issues. This, and the seriousness of diabetes itself, only underscores how imperative it is to combat childhood obesity, a proxy for diabetes now and later. Diabetes has no cure, whatever age it's first suffered. Complications include heart disease, strokes, blindness, kidney damage, infections, amputations, and more. Drilled down to its essence, it means reduced life expectancy and reduced enjoyment of the time you have left.
As with adults, children's weight-related medical problems start in the belly. As children grow, they will naturally gain weight, in the absolute sense. But not all weight gain is created equal. American children and teens are putting the pounds on in their bellies, not just in their arms and legs, and it's not muscle, either. Researchers recently found that the belly fat of children and teenagers has increased more than 65% since the 1990s, just a decade ago, directly in line with rising obesity rates.
Belly fat, unfortunately, is the most dangerous kind, raising the risk of heart disease and diabetes. Abdominal and visceral fat, the kind found surrounding our internal organs, is more demonstrably linked with disease than general body fat; waist circumference is an even better predictor of ill health than the body mass index, which factors in height with weight.
The youngest of the young — the most vulnerable, the most dependent on others for decision-making — are on a collision course with danger. In a November 2006 examination of federal government health-and-fitness survey data, published in the journal Pediatrics, researchers found that between the 1988-1994 data and the 1999-2004 data, the largest relative increase in the prevalence of abdominal obesity occurred among two- to 5-year-old boys, 84%.
On the other end of the age and sex spectrum, 18- to 19-year-old girls were hardly exempt, with the prevalence of abdominal obesity rising 126% among them in the same time period. Presumably, some of that obesity can be written off as the "Freshman 15." Studies show that college students, on average, gain three to 10 pounds by the time they hit their junior year. Most of this happens before the December holiday vacation of their freshman year, as students succumb to their first taste of freedom (two bowls of ice cream or three?). But the Freshman 15 isn't a new phenomenon, and that only makes the dramatic rise in prevalence more curious and vexing. The reasons, in the end, are somewhat immaterial; the students will have their day of reckoning down the line.
The "great news" about belly fat for children is that the damage is potentially reversible. "Kids, teens and adults who have early stages of atherosclerosis in their arteries can have a healthy cardiovascular system again," said Dr. Stephen Cook, one of the researchers, from the University of Rochester School of Medicine and Dentistry in New York. "Older adults who have plaque buildup have a much harder battle, especially if the plaque has calcified."
PSYCHOLOGICAL ISSUES: DEPRESSION'S IMPRESSION
The hit a child's psyche takes from years of obesity may in the end be more enduring and cruel than the impact on his or her physical health. Self-esteem and peer relationships are bound to suffer; what better target for a bully than the heaviest, most plodding children on the playground?
"Overweight and obese children suffer more relational problems (withdrawal of friendship or being the target of rumors and lies) and overt problems (name-calling, teasing, hitting, kicking or pushing)," than normal-weight children do, the newsletter Pediatrics for Parents concludes.
According to the Iowa Youth Risk Behavior Survey, obesity also leads to alarming rates of desperate weight-loss practices, such as vomiting, fasting, and use of laxatives and diuretics.
Depression is an issue, one that becomes more acute as children enter puberty, itself adversely stimulated at an earlier age by obesity. While experts aren't quite sure which occurs first, the depression or the obesity, a study reported in Pediatrics found that the longer a child is overweight, the more prone he or she is to depression and other mental-health disorders. If that's not bad enough, a study reported in the April 9, 2003, issue of the Journal of the American Medical Association that obese children were more than five times as likely as healthy kids to have an impaired quality of life. Think of it this way: "Obese children reported scores that were as bad as cancer patients in each and every domain of life," according to Jeffrey Schwimmer, the University of California, San Diego, pediatric gastroenterologist who conducted the study. "The likelihood of significant quality-of-life impairment was profound for obese children."
Meanwhile, a recent report from the University of Michigan's Mott Children's Hospital found that girls who were fatter at age three and who gained weight during the next three years, reached puberty — as defined by breast development — by age nine, earlier than has historically — and healthily — been the case. "Earlier onset of puberty in girls has been associated with a number of adverse outcomes, including psychiatric disorders and deficits in psychosocial functioning; earlier initiation of alcohol use, sexual intercourse and teenage pregnancy; and increased rates of adult obesity and reproductive cancers," the study said.
ECONOMIC ISSUES: BIG NUMBERS
Obesity carries with it enormous economic costs. A child's obesity may not be as costly as an adult's; after all, morbidity costs — the value of income lost from decreased productivity, restricted activity, absenteeism and bed days, as the CDC has it — don't really apply. For the time being. But with so many obese and overweight children becoming adults of similar stature, economic issues are real, especially for productivity-challenged societies. And direct medical costs do apply to children, including preventive, diagnostic and treatment services. In the year 2000, obese and overweight people cost the state of California $22 billion, including indirect costs, according to a World Bank expert.
Or, as Dr. Philip James, the British chairman of the International Obesity Task Force, put it late last year: "We are not dealing with a scientific or medical problem. We're dealing with an enormous economic problem that, it is already accepted, is going to overwhelm every medical system in the world."
So, given the medical, psychological and economic ramifications of obesity, and the sure odds that the increase in childhood obesity will lead to increased numbers of obese adults, we as a society have a moral and financial imperative to stop childhood obesity now. Diet soda, anyone?
What Can Be Done About It?
Unfortunately, it is going to take a lot more than changing carbonated-beverage drinking habits to stem the tide of childhood obesity. Luckily, some of the world's best brains are applying themselves to the matter, and there's no shortage of ideas. No individual concept is going to work by itself; abstinence — an extremely low-calorie diet — would seem to be the best bet, lovely in theory, but hardly practical. So the trick is going to be changing our mindsets, how we live, across the zillion areas that go into making a child obese.
A recent controlled, community-wide experiment in Somerville, Massachusetts, a town of 78,000 people west of Boston, shows the value in a broad approach. As the Wall Street Journal recently reported, Somerville has transformed itself into a petri dish for antichildhood- obesity ideas over the past five years, and for good reason: among the town's first-, second- and third-graders, an unusually high 44% were already overweight or at risk of becoming so, based on their body-mass index. Somerville's public schools nearly doubled the amount of fresh fruit available at lunch; added a nutrition and exercise curriculum featuring fun taste tests; and buttressed after-school offerings with yoga, dance and soccer.
Meanwhile, privately owned restaurants in the town were switching to low-fat milk and — unheard of, really — reverting back to smaller portion sizes, in exchange for special mention by the town government. Exercise was a key part of the plan: crosswalks were repainted to encourage walking, health fairs were held, pedometers given away, a community fun run organized. City employees were reimbursed for gym memberships and numerous bicycle racks were added at schools and on the streets of the town.
The experiment has worked. As published in the May 10 issue of Obesity, Somerville's school children gained less weight than children in two control communities in the same area. The difference, statistically significant, translated into preventing about a pound of excess weight gain annually among children who lean toward the heavy side. Multiply that pound across a child's first 18 years, and it could be the difference between graduating high school overweight and graduating at a normal weight, lead study author Christina Economos, an assistant professor at nearby Tufts University, told the newspaper.
Now the question is whether the experiment, which made partners out of government institutions, schools, restaurateurs, a nearby university, parents and, crucially, the children themselves, is sustainable.
Calories In
The first line of attack in the anti-childhoodobesity movement, ultimately, has to be food. After all, when you reduce childhood obesity to its essence, food is what it's all about. Unfortunately, eating less and eating better go completely against the grain in the U.S., a country devoted to excess and the inalienable personal right to be as excessive as you want. A trip through a medium-sized urban supermarket yields more than 300 different varieties of snack food on sale; try keeping your average kid away from crackers and potato chips. This includes multiple flavors of various snacks, so the situation may not be as atrocious as it looks, but these "foods," laden with fats and chemicals, aren't particularly nutritious in any flavor. This supports the idea that while wellconsidered choice is a wonderful thing for individuals, too much choice, and uninformed choice, in particular, may not be so wonderful for society at large.
As witnessed in the Somerville experiment, portion sizes do matter, and boy, does America love big portions, of food and drink. We are the charter members of the Clean Plate Club, and the clubhouses are the ubiquitous chain restaurants that surround every shopping mall, interstate interchange, prosperous suburb and tourist attraction.
Numerous studies have shown that the more you are served, the more you eat, and the more you eat, the more you are likely to weigh, especially when restaurateurs emphasize taste over health in choosing ingredients. It's a great thing that New York City, for example, has banned the use of certain trans-fats in restaurants, but what were those fats doing in the food in the first place? Making it taste better. Why have the soft-drink companies made 20 oz. bottles the standard, and not the 12 oz. size that used to be ubiquitous? Presumably, the bigger the size, the more they charge, the more profit they make (67% more if they can get you to buy as many 20- ounce bottles of soda as you used to buy 12-ounce bottles, at the same cost per ounce).
Up against these challenges, eating and drinking less of the unavoidable bad stuff can be as important for a child as eating better. Parents have to lead the way and be more aware of how they are contributing to their children's weight problems, even inadvertently so. Yes, parents can say no to certain foods. But that's just the beginning. Recent research done by Brian Wansink and Jeffrey Sobal of Cornell University shows that people aren't generally aware of why they make the food decisions they do, including how much they eat. One Wansink-Sobal study showed that participants ate 31% more food as a result of being given an exaggerated environmental clue, such as a large bowl. Of those who ate more because of the bowl, 21% denied they ate more, 75% blamed it on something other than the bowl, like hunger, and only 4% were willing to admit the bowl did them in. Smaller bowls = portion control.
Parents aren't alone in the fight, of course; what a child eats in school can have great bearing on his or her weight. Most public schools are open about 180 days a year. If children eat lunch in their school cafeteria every day, as many do, that's 180 meals a year, or roughly 16% of their annual meal intake (this excludes food eaten not at meals but at other times, which will more often include cookies, cakes and the like, than apples and celery sticks). If a child eats his or her breakfast at school too, as many children from poor families do, then we're at 33% of annual meal intake. The upshot is that what schools serve has a large say in childhood-obesity issues.
To be sure, schools have never been under so much pressure to revamp their menus, and many are. The Somerville experiment is an example of this, and how it can work well when real community-wide effort is applied, covering both the school day and other hours. In Britain, a campaign led by celebrity chef Jamie Oliver led to a government-backed overhaul of school catering. But there are hurdles. Take the vending machines so ubiquitous in American schools. The machines may actually avoid dispensing fully loaded sugared soda, but even so, they aren't necessarily stacked with bottles of water. In 2007 former New York Governor Eliot Spitzer had some suggestions for this. He proposed that before students are allowed to buy Gatorade or other sports drinks at school, they must have "engaged in vigorous athletic activity lasting for more than one hour." He also wanted to make sure high-school students can only get hot chocolate if it's held to 180 calories or less per eight-ounce serving, and only at breakfast, metabolically speaking the highlight of a person's day. High-school vending machines, he said should offer only products that are "non-nutritive-sweetened, noncaffeinated, noncarbonated, nonfortified beverages that contain less than five calories per serving." And he wanted timers put on vending machines so that they work only after the school day ends. Good ideas, all. But will they pass through New York State legislature?
Calories Out
The flip side of "calories in" is "calories out." In the general discussion about obesity in the U.S., food gets most of the attention; you're much more likely to see a bestseller about a diet than you are one about a hot exercise program. The truth is, it may not matter exactly what exercise a child does, as long as he or she is doing enough of it to burn a meaningful amount of calories.
Children, like adults, need to enjoy exercise — to not even consider it exercise — or a lack of interest results. While children are pretty adept at creating their own fun, the onus is still on adults to guide leisure-time activity in a way that encourages physical exertion (and not endless hours in front of an electronic device). It's not like we're talking about whole afternoons at the playground, either. British and U.S. researchers recently completed a study of 5,500 children, with an average age of 12, who wore a motion-sensor device. The study found, logically, that those who exercised more were less likely to be obese, but also that short bursts of intense activity seemed to be the most helpful. Children who did only 15 minutes a day of moderate exercise were 50% less likely than inactive children to become obese, the researchers reported in PLoS Medicine, the Public Library of Science journal.
West Virginia, the state with the worst childhood-obesity problem in America, is really stepping out in its bid to turn back the tide. The state has embraced a popular dancing video game called "Dance Dance Revolution." The audience-participation game, watched on a TV, provides just that short burst of intense activity found to be most helpful. A 24-week study of 50 overweight or obese children, aged seven to 12, showed that those who played the game at home for at least 30 minutes five days a week maintained their weight and even experienced a reduction in risk factors for heart disease and diabetes. Another 12 children who didn't play the game for the first half of the trial period added an average of six pounds during that time, then picked up the game and saw their weight stabilize. West Virginia now plans to develop after-school clubs — in all its public schools — devoted to the game.
Public & Corporate Policy
While West Virginia, a state government, appears to be enlightened, it's in the minority when it comes to childhood obesity. Mike Huckabee, the former Republican governor of Arkansas, another state with a serious childhood- obesity problem, is one of the few politicians who seems to be willing to go the extra mile in search of a solution. In 2005, Huckabee, in conjunction with Ruder Finn client Gerber Products Company, Wal-Mart, and the state of Arkansas, launched a successful educational initiative aimed at the youngest of children. The state put its weight behind the "Healthy Arkansas: Better State of Health Guidebook," free for all citizens, while endorsing a program to provide two days of nutrition counseling at all Wal-Mart supercenters throughout Arkansas. The nutrition days gave parents one-on-one access to nutrition counselors.
Huckabee, to be sure, was able to move on his priorities thanks to a state tobacco-settlement windfall, but again, he had to have his priorities right in the first place. For Huckabee, who had been obese himself before losing 100 pounds, the program was personal. "We must address the first two years, when children's eating habits are established," he said.
Gerber, in fact, has taken a very proactive role in addressing childhood obesity, particularly the 0-2 age group that represents the core market for its nutritionally focused foods. Its latest program, partnering with celebrity Alison Sweeney, focuses on communication with parents, after surveys found a disconnect between what parents want to know about nutrition and what they really do. For instance, 91% of mothers of toddlers said nutrition is the most important factor in their choice of food for their child, but only 43% of moms know calories for a child should be about half the amount for adults. And only half of the poll respondents were serving their children the recommended servings of vegetables a day, and only 43% were serving the proper quantity of fruits.
Governments and corporations, along with parents, non-governmental organizations and the community at large can do much more to fight childhood obesity, whether on the food side or the exercise side. For the federal government, it doesn't seem to be too much of a priority. If it wanted to, Washington could tax foods and drinks that are contributing to obesity and diabetes, as a disincentive to consumption. Such a stick, in the end, might prove more conducive than a carrot; while Huckabee can rally a state to fight childhood obesity, national campaigns, even successful ones, can't get traction. The Institute of Medicine has found that national efforts to combat childhood obesity have been uncoordinated, unevaluated, and sometimes unfunded — in short, failing.
VERB, a huge Centers for Disease Prevention media campaign promoting exercise in nine- to 13-year-old children, put images of kids playing sports in billboard, TV and magazine ads. Federal researchers found the program worked — even better than expected, with 74% brand awareness — and more children were exercising. But after a five-year run and some $340 million spent, the then-Republican- led House of Representatives wanted to allocate a mere $11.2 million for it in Fiscal 2006, the Senate didn't want it at all, and President Bush didn't push any funding through.
On the state level, there has been some progress. In Pennsylvania, Delaware, Tennessee, South Carolina and elsewhere, schools are now sending home to parents a different kind of report card, where students are graded on their body mass index. Sounds good, except in some ways, the children are being set up to fail. Not only are there psychological ramifications at that age (at any age) of being formally graded on your weight, but the schools themselves aren't always helping, as a January 2007 New York Times story illustrates. In one Pennsylvania school district, for example, the schools distribute obesity report cards at the same time that they're serving funnel cakes and pizza for breakfast, all while denying some students physical education classes for half the school year. To its credit, the school district is no longer serving powdered sugar with the funnel cakes. But as one expert at Yale University told the Times, to successfully change eating habits, schools really need to offer individual counseling and sophisticated nutrition and physical activity assessments.
Corporations, in the end, can help drive a solution with their messaging, if they are willing to risk their bottom lines to do so; a Kaiser Family Foundation report from 2004 cited studies showing that the typical child sees about 40,000 ads a year on television, and that the majority of the ads targeted at children are for candy, cereal, soda and fast food. Many of these ads use children's favorite TV and movie characters to push products.
There is hope, however. The Kellogg Company (another Ruder Finn client) recently announced it would phase out advertising its products to children under the age of 12 unless the foods meet specific nutrition guidelines for calories, sugar, sodium and fat. If Kellogg can reformulate its products to be healthier, it will. While the changes were prompted by a threatened lawsuit over advertising to children, and amid suggestions of possible legislation, it still represents a step in the right direction and shouldn't be taken for granted. A domino effect may, in fact, ensue, where Kellogg and its competitors try to outdo one another to provide healthier food, as opposed to focusing on sugar-based taste to drive sales.
Surgery: The Last Resort
For those teenagers who find losing weight impossible, the medical community has come up with a new last resort. For some time now, surgeons have been able to perform certain gastric bypass operations (rerouting the intestinal tract), but they are now focusing on a specific procedure, gastric banding, also known as lap banding. The lap band is surgically implanted and placed around the upper part of the stomach, effectively limiting the amount of food that can be consumed, reducing appetites and slowing down the digestive process.
While still not de rigeur, the procedure, acceptable in adults, is being tested in older children in a clinical-trial setting at three major U.S. hospitals: New York University Medical Center; New York-Presbyterian's Morgan Stanley Children's Hospital; and the University of Illinois at Chicago Medical Center. NYU's trial results, covering 53 morbidly obese teenagers, were published in the January 2007 issue of the Journal of Pediatric Surgery. The study found that the teens were able to lose 50% of their weight a year after surgery, without experiencing complications requiring a hospital re-admit.
The question, of course, is whether it has to come down to that. The fact that we have let childhood obesity get as far along as it has in society is a three-dimensional indictment of our culture and thus of many of the things we hold dear. Is this just a cost of living in the twenty-first century, or are we prepared as individuals to give up some of our precious freedoms — in practical terms, to eat what we want when we want in amounts we want; in philosophical terms, the right to live our lives free of interference from others — if that's what it takes to improve the common good? Every obvious logical argument argues that the problem of childhood obesity has become so big that something (plural) must be done. Visit those day-care centers, school yards and college cafeterias and the emotional arguments become just as compelling. But are these arguments compelling enough to effect change? Start by asking John and Katherine Smith.