obesity epidemic essay

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• Published: 27 February 2019

Obesity: global epidemiology and pathogenesis

• Matthias Blüher 1  

Nature Reviews Endocrinology volume  15 ,  pages 288–298 ( 2019 ) Cite this article

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The prevalence of obesity has increased worldwide in the past ~50 years, reaching pandemic levels. Obesity represents a major health challenge because it substantially increases the risk of diseases such as type 2 diabetes mellitus, fatty liver disease, hypertension, myocardial infarction, stroke, dementia, osteoarthritis, obstructive sleep apnoea and several cancers, thereby contributing to a decline in both quality of life and life expectancy. Obesity is also associated with unemployment, social disadvantages and reduced socio-economic productivity, thus increasingly creating an economic burden. Thus far, obesity prevention and treatment strategies — both at the individual and population level — have not been successful in the long term. Lifestyle and behavioural interventions aimed at reducing calorie intake and increasing energy expenditure have limited effectiveness because complex and persistent hormonal, metabolic and neurochemical adaptations defend against weight loss and promote weight regain. Reducing the obesity burden requires approaches that combine individual interventions with changes in the environment and society. Therefore, a better understanding of the remarkable regional differences in obesity prevalence and trends might help to identify societal causes of obesity and provide guidance on which are the most promising intervention strategies.

Obesity prevalence has increased in pandemic dimensions over the past 50 years.

Obesity is a disease that can cause premature disability and death by increasing the risk of cardiometabolic diseases, osteoarthritis, dementia, depression and some types of cancers.

Obesity prevention and treatments frequently fail in the long term (for example, behavioural interventions aiming at reducing energy intake and increasing energy expenditure) or are not available or suitable (bariatric surgery) for the majority of people affected.

Although obesity prevalence increased in every single country in the world, regional differences exist in both obesity prevalence and trends; understanding the drivers of these regional differences might help to provide guidance for the most promising intervention strategies.

Changes in the global food system together with increased sedentary behaviour seem to be the main drivers of the obesity pandemic.

The major challenge is to translate our knowledge of the main causes of increased obesity prevalence into effective actions; such actions might include policy changes that facilitate individual choices for foods that have reduced fat, sugar and salt content.

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Obesity Epidemic: Causes and Solutions

Since the 1980s, the prevalence of obesity in the United States has increased dramatically. Data collected by the Centers for Disease Control and Prevention show rising obesity across the nation, state-by-state . 1

Figure 7.17. Each year since 1990, the CDC has published maps of the United States in which states are color-coded based on the percentage of their population estimated to be obese. The maps show a clear increase in the prevalence of obesity between 1990 and 2010.

The methods used by the CDC to collect the data changed in 2011, so we can’t make direct comparisons between the periods before and after that change, but the trend has continued. Every year, more and more people in the U.S. are obese.

Figure 7.18. The prevalence of obesity among U.S. adults has continued to rise between 2011 and 2018.

These trends are unmistakable, and they’re not just occurring in adults. Childhood obesity has seen similar increases over the last few decades—perhaps an even greater concern as the metabolic and health effects of carrying too much weight can be compounded over a person’s entire lifetime.

Figure 7.19. Between 1999 and 2016, the prevalence of obesity in both children and adults has risen steadily.

While obesity is a problem across the United States, it affects some groups of people more than others. Based on 2015-2016 data, obesity rates are higher among Hispanic (47 percent) and Black adults (47 percent) compared with white adults (38 percent). Non-Hispanic Asians have the lowest obesity rate (13 percent). And overall, people who are college-educated and have a higher income are less likely to be obese. 2 These health disparities point to the importance of looking at social context when examining causes and solutions. Not everyone has the same opportunity for good health, or an equal ability to make changes to their circumstances, because of factors like poverty and longstanding inequities in how resources are invested in communities. These factors are called “ social determinants of health . ” 3

The obesity epidemic is also not unique to the United States. Obesity is rising around the globe, and in 2015, it was estimated to affect 2 billion people worldwide, making it one of the largest factors affecting poor health in most countries . 4 Globally, among children aged 5 to 19 years old, the rate of overweight increased from 10.3 percent in 2000 to 18.4 percent in 2018. Previously, overweight and obesity mainly affected high-income countries, but some of the most dramatic increases in childhood overweight over the last decade have been in low income countries, such as those in Africa and South Asia, corresponding to a greater availability of inexpensive, processed foods. 5

Despite the gravity of the problem, no country has yet been able to implement policies that have reversed the trend and brought about a decrease in obesity. This represents “one of the biggest population health failures of our time,” wrote an international group of researchers in the journal  The Lancet  in 2019 . 6 The World Health Organization has set a target of stopping the rise of obesity by 2025. Doing so requires understanding what is causing the obesity epidemic; it is only when these causes are addressed that change can start to occur.

Causes of the Obesity Epidemic

If obesity was an infectious disease sweeping the globe, affecting billions of people’s health, longevity, and productivity, we surely would have addressed it by now. Researchers and pharmaceutical companies would have worked furiously to develop vaccines and medicines to prevent and cure this disease. But the causes of obesity are much more complex than a single bacteria or virus, and solving this problem means recognizing and addressing a multitude of factors that lead to weight gain in a population.

At its core, rising obesity is caused by a chronic shift towards positive energy balance—consuming more energy or calories than one expends each day, leading to an often gradual but persistent increase in body weight. People often assume that this is an individual problem, that those who weigh more simply need to change their behavior to eat less and exercise more, and if this doesn’t work, it must be because of a personal failing, such as a lack of self-control or motivation. While behavior patterns such as diet and exercise can certainly impact a person’s risk of developing obesity (as we’ll cover later in this chapter), the environments where we live also have a big impact on our behavior and can make it much harder to maintain energy balance.

Environment

Many of us live in what researchers and public health experts call “ obesogenic environments. ” That is, the ways in which our neighborhoods are built and our lives are structured influence our physical activity and food intake to encourage weight gain . 7 Human physiology and metabolism evolved in a world where obtaining enough food for survival required significant energy investment in hunting or gathering—very different from today’s world where more people earn their living in sedentary occupations. From household chores, to workplace productivity, to daily transportation, getting things done requires fewer calories than it did in past generations.

Figure 7.20. Some elements of our environment that may make it easier to gain weight include sedentary jobs, easy access to inexpensive calories, and cities built more for car travel than for physical activity.

Our jobs have become more and more sedentary, with fewer opportunities for non-exercise thermogenesis (NEAT) throughout the day. There’s less time in the school day for recess and physical activity, and fears about neighborhood safety limit kids’ ability to get out and play after the school day is over. Our towns and cities are built more for cars than for walking or biking. We can’t turn back the clock on human progress, and finding a way to stay healthy in obesogenic environments is a significant challenge.

Our environments  can also impact our food choices. We’re surrounded by vending machines, fast food restaurants, coffeeshops, and convenience stores that offer quick and inexpensive access to calories. These foods are also heavily advertised, and especially when people are stretched thin by working long hours or multiple jobs, they can be a welcome convenience. However, they tend to be calorie-dense (and less nutrient-dense) and more heavily processed, with amounts of sugar, fat, and salt optimized to make us want to eat more, compared with home-cooked food. In addition, portion sizes at restaurants, especially fast food chains, have increased over the decades, and people are eating at restaurants more and cooking at home less.

Poverty and Food Insecurity

Living in poverty usually means living in a more obesogenic environment. Consider the fact that some of the poorest neighborhoods in the United States—with some of the highest rates of obesity—are often not safe or pleasant places to walk, play, or exercise. They may have busy traffic and polluted air, and they may lack sidewalks, green spaces, and playgrounds. A person living in this type of neighborhood will find it much more challenging to get adequate physical activity compared with someone living in a neighborhood where it’s safe to walk to school or work, play at a park, ride a bike, or go for a run.

In addition, poor neighborhoods often lack a grocery store where people can purchase fresh fruits and vegetables and basic ingredients necessary for cooking at home. Such areas are called “ food deserts ”—where healthy foods simply aren’t available or easily accessible.

Another concept useful in discussions of obesity risk is “food insecurity.”  Food security means “access by all people at all times to enough food for an active, healthy life.” 8  Food insecurity   means an inability to consistently obtain adequate food. It may seem counter-intuitive, but in the United States, food insecurity is linked to obesity. That is, people who have difficulty obtaining enough food are more likely to become obese and to suffer from diabetes and hypertension. This is likely related to the fact that inexpensive foods tend to be high in calories but low in nutrients, and when these foods form the foundation of a person’s diet, they can cause both obesity and nutrient deficiencies. It’s estimated that 12 percent of U.S. households are food insecure, and food insecurity is higher among Black (22 percent) and Latino (18 percent) households. 3

What about genetics? While it’s true that our genes can influence our susceptibility to becoming obese, researchers say they can’t be a cause of the obesity epidemic. Genes take many generations to evolve, and the obesity epidemic has occurred over just the last 40 to 50 years—only a few generations. When our grandparents were children, they were much less likely to become obese than our own children. That’s not because their genes were different, but rather because they grew up in a different environment. However, it is true that a person’s genes can influence their susceptibility to becoming obese in this obesogenic environment, and obesity is more prevalent in some families. A person’s genetic make-up can make it more difficult to maintain energy balance in an obesogenic environment, because certain genes may make you feel more hungry or slow your energy expenditure. 2

Solutions to the Obesity Epidemic

Given the multiple causes of obesity, solving this problem will also require many solutions at different levels. Because obesity affects people over the lifespan and is difficult to reverse, the focus of many of these efforts is prevention , starting as early as the first years of life. We’ll discuss individual weight management strategies later in this chapter. Here, we’ll review some strategies happening in schools, communities, and at the state and federal levels.

Support Healthy Dietary Patterns

Interventions that support healthy dietary patterns, especially among people more vulnerable because of food insecurity or poverty, may reduce obesity. In some cases, studies have shown that they have an impact, and in other cases, it’s too soon to know. Here are some examples:

• Implement and support better nutrition standards for childcare, schools, hospitals, and worksites. 9
• Limit marketing of processed foods, especially ads targeted towards children.
• Provide incentives for supermarkets or farmers markets to establish businesses in underserved areas. 9

• Place nutrition and calorie content on restaurant and fast food menus  to raise awareness of food choices. 9 Beginning in 2018, as part of the Affordable Care Act, chain restaurants with more than 20 locations were required to add calorie information to their menus, and some had already done so voluntarily. There isn’t yet enough research to say whether having this information improves customers’ choices; some studies show an effect and others don’t. 10 Many factors influence people’s decisions, and the type of restaurant, customer needs, and menu presentation all likely matter. For example, some studies show that health-conscious consumers choose lower calorie menu items when presented with nutrition information, but people with food insecurity may understandably choose higher calorie items to get more “bang for their buck”. 11 Research has also shown that adding interpretative images—like a stoplight image labeling menu choices as green or red as shorthand for high or low nutrient density—can help. And a 2018 study found that when calorie counts are on the left side of English-language menus, people order lower-calorie menu items. Putting calorie counts on the right side of the menu (as is more common) doesn’t have this effect, likely because the English language is read from left to right. 12 Some studies have also found that restaurants that implement menu labeling offer lower-calorie and more nutrient-dense options, indicating that menu labeling may push restaurants to look more closely at the food they serve. 10,13

Figure 7.22. As of 2018, restaurant chains and some other food vendors are required to list calorie counts on their menus. Would these make you pause before ordering?

• Increase access to food assistance programs and align them with nutrition recommendations. For example, in 2009, the U.S. Department of Agriculture revised the food packages for the Women, Infants, and Children (WIC) program to better align with the Dietary Guidelines for Americans. The new packages emphasized more  fruits, vegetables, whole grains, and low-fat dairy and decreased the availability of juice. After this change, there was a decrease in the obesity rate of children in the WIC program. Similar progress may be made by increasing access to the Supplemental Nutrition Assistance Program (SNAP) in order to reduce food insecurity. Many farmers’ markets now accept SNAP benefits for the purchase of fresh fruit and vegetables. 3
• Tax sugary drinks, such as soda and sports drinks, which contribute significant empty calories to the U.S. diet and are associated with childhood obesity. Local taxes on soda and other sugary drinks are often controversial, and soda companies lobby to prevent them from passing. However, early research in U.S. cities with soda taxes show that they do work to decrease soda consumption. 3 In the U.S., soda has only been taxed at the local level, and the tax has been paid by consumers. The United Kingdom has taken a different approach: They started taxing soft drink manufacturers for the sugar content of the products they sell. Between 2015 and 2018, the average sugar content of soda sold in the U.K. dropped by 29 percent. 14

Support Greater Physical Activity

Increasing physical activity increases the energy expended during the day. This can help maintain energy balance, thus preventing weight gain. It may also help to shift a person into negative energy balance and facilitate weight loss if needed. But simply adding an exercise session—a run or a trip to the gym, say—often doesn’t shift energy balance (though it’s certainly good for health). Why? Exercise can increase hunger, and there’s only so many calories a person can burn in 30 or 60 minutes. That’s why it’s also important to look for opportunities for non-exercise activity thermogenesis (NEAT); that is, find ways to increase movement throughout the day.  

• P rioritize physical education and recess time in schools. In addition to helping kids stay healthy, movement also helps them learn.
• Make neighborhoods safer and more accessible for walking, cycling, and playing.
• When safe, encourage kids to walk or bike to school.
• Build family and community activities around physical activity, such as trips to the park, walks together, and community walking and exercise groups.
• Facilitate more movement in the workday by encouraging walking meetings, movement breaks, and treadmill desks.
• Find ways to move that are enjoyable to you and fit your life. Yard work, walking your dog, playing tag with your kids, and going out dancing all count!

Figure 7.23. There are lots of ways to increase physical activity, including walking to work, playing with friends, and going for a bike ride.

VIDEO:  “ James Levine: ‘I Came Alive as a Person’ “  by  NOVA’s Secret Life of Scientists and Engineers, YouTube (April 24, 2014), 3:04 minutes. This short video explains some of the research on NEAT and efforts to increase it in our lives.

VIDEO:  “ The Weight of the Nation: Poverty and Obesity”  by HBO Docs, YouTube (May 14, 2012), 24:05 minutes. 

VIDEO: “ The Weight of the Nation: Healthy Foods and Obesity Prevention”  by HBO Docs, YouTube (May 14, 2012), 31:11 minutes.  These segments from the HBO documentary series, “The Weight of the Nation,” explore  some of the causes and potential solutions for obesity.

References:

• 1 CDC. (2019, September 12). New Adult Obesity Maps. Retrieved October 30, 2019, from Centers for Disease Control and Prevention website: https://www.cdc.gov/obesity/data/prevalence-maps.html
• 2 CDC. (2019, January 31). Adult Obesity Facts | Overweight & Obesity | CDC. Retrieved October 30, 2019, from https://www.cdc.gov/obesity/data/adult.html
• 3 Trust for America’s Health. (2019). The State of Obesity: Better Policies for a Healthier America . Retrieved from https://www.tfah.org/report-details/stateofobesity2019/
• 4 Swinburn, B. A., Kraak, V. I., Allender, S., Atkins, V. J., Baker, P. I., Bogard, J. R., … Dietz, W. H. (2019). The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. The Lancet , 393 (10173), 791–846. https://doi.org/10.1016/S0140-6736(18)32822-8
• 5 UNICEF. (2019). The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world . New York.
• 6 Jaacks, L. M., Vandevijvere, S., Pan, A., McGowan, C. J., Wallace, C., Imamura, F., … Ezzati, M. (2019). The obesity transition: Stages of the global epidemic. The Lancet Diabetes & Endocrinology , 7 (3), 231–240. https://doi.org/10.1016/S2213-8587(19)30026-9
• 7 Townshend, T., & Lake, A. (2017). Obesogenic environments: Current evidence of the built and food environments. Perspectives in Public Health , 137 (1), 38–44. https://doi.org/10.1177/1757913916679860
• 8 Pan, L., Sherry, B., Njai, R., & Blanck, H. M. (2012). Food Insecurity Is Associated with Obesity among US Adults in 12 States. Journal of the Academy of Nutrition and Dietetics , 112 (9), 1403–1409. https://doi.org/10.1016/j.jand.2012.06.011
• 9 CDC. (2019, June 18). Community Efforts | Overweight & Obesity | CDC. Retrieved October 30, 2019, from https://www.cdc.gov/obesity/strategies/community.html
• 10 Bleich, S. N., Economos, C. D., Spiker, M. L., Vercammen, K. A., VanEpps, E. M., Block, J. P., … Roberto, C. A. (2017). A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior. Obesity (Silver Spring, Md.) , 25 (12), 2018–2044. https://doi.org/10.1002/oby.21940
• 11 Berry, C., Burton, S., Howlett, E., & Newman, C. L. (2019). Understanding the Calorie Labeling Paradox in Chain Restaurants: Why Menu Calorie Labeling Alone May Not Affect Average Calories Ordered. Journal of Public Policy & Marketing , 38 (2), 192–213. https://doi.org/10.1177/0743915619827013
• 12 Dallas, S. K., Liu, P. J., & Ubel, P. A. (2019). Don’t Count Calorie Labeling Out: Calorie Counts on the Left Side of Menu Items Lead to Lower Calorie Food Choices. Journal of Consumer Psychology, 29(1), 60–69. https://doi.org/10.1002/jcpy.1053
• 13 Theis, D. R. Z., & Adams, J. (2019). Differences in energy and nutritional content of menu items served by popular UK chain restaurants with versus without voluntary menu labelling: A cross-sectional study. PLOS ONE , 14 (10), e0222773. https://doi.org/10.1371/journal.pone.0222773
• 14 Public Health England. (2019). Sugar reduction: Report on progress between 2015 and 2018 . Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832182/Sugar_reduction__Yr2_progress_report.pdf

Image Credits

• Figure 7.17. “Obesity Trends Among U.S. Adults, BRFSS, 1990-2010” by Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention is in the Public Domain
• Figure 7.18. “Prevalence of self-reported obesity among U.S. adults in 2011 and 2018”  by Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention is in the Public Domain
• Figure 7.19. “Trends in obesity prevalence”  by National Center for Health Statistics is in the Public Domain
• Figure 7.20. Elements of obesogenic environment: “wocintech”  by WOCinTech Cha  is licensed under CC BY 2.0 ; “Perfect timing”  by Tamara Menzi , Unsplash is in the Public Domain, CC0 ; “Vending machines”  by Purchase College Library  is licensed under CC BY-NC 2.0
• Figure 7.21. Farmers markets. “group of people standing near vegetables”  by Megan Markham  is in the Public Domain, CC0 ; “Veggies at Corvallis Farmers Market” by Friends of Family Farmers is licensed under CC BY-ND 2.0
• Figure 7.22. Menu labeling. “Ballpark Calorie Counting”  by Kevin Harber  is licensed under CC BY-NC-ND 2.0
• Figure 7.23. Increasing physical activity. “Early bird” by Jorge Vasconez  is in the Public Domain, CC0 ; “boy running to the future”  by Rafaela Biazi  is in the Public Domain, CC0 ; “people riding bicycles inside bicycle lane beside skyscraper” by Steinar Engeland  is in the Public Domain, CC0

Economic and social circumstances, such as poverty and racism, that impact health.

Built environments that promote weight gain by encouraging food intake and limiting physical activity.

Areas where healthy foods simply aren’t available or easily accessible.

Having consistent access to enough food for an active, healthy life.

Having inconsistent access to enough food for an active, healthy life.

Nutrition: Science and Everyday Application, v. 1.0 Copyright © 2020 by Alice Callahan, PhD; Heather Leonard, MEd, RDN; and Tamberly Powell, MS, RDN is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Impakter Essay: The Obesity Epidemic

Convergence of Culture, Commerce, and Communications

An epidemic of obesity has been acknowledged for several years in the US, with creeping increases in the age ranges affected—down to young children—and now across borders, as more countries adopt unhealthy American dietary patterns.(1) While obesity by itself is not a fatal condition, it is a chronic state intimately linked to various adverse health sequelae, including diabetes; metabolic syndrome; cardiovascular disorders such as high blood pressure, heart attacks, and strokes; cancer; and premature death. It is also thought to exert a disproportionate financial burden on an already taxed health care system, while simultaneously contributing to the wealth of pharmaceutical companies, which consistently target the production of new drugs to treat the expanding array of chronic health conditions.

Why change one’s diet and implement an exercise regimen when a new proton-pump inhibitor may treat the heartburn or acid reflux that inevitably follows indulgence (or overindulgence) in standard American fare? While the pharmaceutical industry is not a causative agent in the prevalence of obesity—though surely an exacerbating factor—the modern American diet is unquestionably a key ingredient in the insidious and alarming obesity rise. This phenomenon is dynamic, though, and characterized by a convoluted etiologic pathway fueled by cultural constructs, the avarice endemic in unfettered capitalism, and inadequate communications at the societal/media and clinical levels. Indeed, as Turner aptly noted, “[…] ‘medical’ problems typically [have] significant social and economic dimensions.(2)

While all may have an equal opportunity to become obese, some segments of the population are apparently more equal than others and more than equal to the task. That is to say, significant disparities in obesity have emerged along demographic lines. At the same time, variations among different segments of the population have been reported with regard to standards of body size, beauty, and health. Such cultural differences may play a role in rendering what appears to be an intractable societal challenge as even more problematic. In many cases, such body ideal divergences from mainstream or majority preferences occur among minority populations, which disproportionately earn lower incomes.

An added element in this mix is the evident stacking of the culinary deck against lower-income individuals by the billion-dollar food industry, as the most affordable foods tend to be the least healthy. Are larger body ideals among lower-income individuals the result of the greater likelihood that such people will tend to put on weight due, in large part, to economic exigency and convenience? The availability of and access to more accurate information regarding nutrition and related health practices are also less common or likely among the poor. In addition, the communication of honest, insightful information pertaining to the central but hardly salubrious role of the food industry in the American diet and health landscape is compromised at the national media level, and, in many cases, inadequate at the clinical level, as physicians may shy away from acknowledging weight issues, fail to address the topic in a sensitive or even culturally competent manner, and/or lack sufficiently broad knowledge of nutrition.

Photo Credit : Flickr/ Keoni Cabral , CC by 2.0 

The obesity epidemic.

Obesity isn’t just for the United States anymore. The numbers of obese individuals have been expanding as fast if not faster than their bellies and the increasing use of Western- or American- food systems, netting more processed, affordable, and marketable food products, is cited as a primary factor.(2)

By far, and in numerous ways, the American processed food system is a more reliable export than democracy or anything else purportedly leaving these shores. The changes that occurred in the US to transform a country fed mostly by thousands of family farms into a highly mechanized system dominated by far fewer corporate factory farms can be traced to the post-World War II period, in which the search for ways to reduce food costs for a burgeoning middle class population contributed to an eventual sea change. Over the course of decades, Americans have increasingly consumed packaged, processed “edible food-like substances,” in the words of Michael Pollan, author, journalist, professor of journalism, and food system expert.(3) Gradually, Americans also began consuming larger average portion sizes at each meal, with the encouragement of fast-food, other chain restaurants, and food manufacturers.

After World War II, what had been rare items in the home became nearly ubiquitous in the 1950’s as television became a dominant mode of entertainment. While it has evolved (or, arguably devolved), the TV remains a popular instrument around which people congregate, increasingly for rented or streamed movies and “reality” shows. At the same time, the US economy has segued from a manufacturing base to a services orientation. Such a change helped usher in an era in which fewer adults exercise during the course of their work day and home life.

A sedentary lifestyle is another important component in the rise in obesity. Unfortunately, children have not been immune to any of these societal trends. In addition, they have been victimized by universal economic mismanagement (or worse) that has resulted in substantial cutbacks in school budgets, limiting physical education and recess time and thus important opportunities for exercise.

Food industry influence on the United States Department of Agriculture nutrition pyramid recommendations as well as lobbying by the industry to protect makers of frozen pizza and French fries also negatively impact the healthfulness of foods on many public school lunch menus. Legislation passed by the US House of Representatives before the 2011 Thanksgiving recess, in fact, abandoned plans to eliminate the classification of pizza as a vegetable and reduce the frequency of allowable French fry servings in the federally-funded school lunches that feed roughly 32 million children.(4) This action is testament to the strength of the food industry when parents and other activists have tried to get government to act on findings that reducing children’s access to low-nutrient, energy-dense foods at school may succeed as one approach to reducing the average body mass index (BMI) in children.(5) After all, the prevalence of obesity among children has led to myriad disconcerting study results and predictions of much earlier onsets of the obesity-related disorders seen in adults.

Portion Size

Changes in the typical portion sizes in the average American meal have also played an important role in augmenting the girth of the average US citizen. In one of the seminal studies of changes in portion sizes, Young and Nestle culled data from food manufacturers on current and past practices, surveyed modern publications, and directly weighed servings. They found that portion sizes began to expand in the 1970’s, increased acutely in the 1980’s, and have continued to rise, in excess of federal standards and commensurately with body weights.(6)

A parallel and likely contributor to this disturbing trend has been a spike in the frequency with which people eat away from home. Also associated with the increase in portion size is the high energy density of the average diet.(7) The elevation in energy intake in the average diet, particularly in the US but increasingly elsewhere, has been aggravated by a decline in energy output, either in the form of exercise or through the course of one’s daily work activities. Theoretically, at least, this represents an area ripe for simple interventions in the form of substituting healthier, less energy-dense foods such as fruits and vegetables.

Obesity Trends, Acculturation to the US, and Demographic Disparities

Rises in cardiovascular events, diabetes, and cancers are expected as a result of rising prevalence of obesity throughout the world, which, consequently, is expected to burden health systems worldwide.(8) Moreover, as in the case of global climate change, in which the poorest countries are expected to suffer first and worst, dire forecasts have been issued regarding the likely effects of the obesity epidemic on low- and middle-income nations, where incessant urbanization fosters the simultaneous scourges of a sedentary lifestyle and diets rich in processed fats and sugars. In Nepal, for example, Vaidya and colleagues point to the additional burden of prevalent infectious diseases juxtaposed with the increasing incidence of obesity-related chronic noncommunicable conditions such as diabetes and cardiovascular disease.(9) Such an additional burden—the confluence of infectious and chronic disease—is not uncommon among lower-income groups even in wealthier countries, including the US. For such cases, people must trust the expertise of interventional radiologists for treatment.

Indeed, the forecast for the US is far from rosy. Since the 1960’s, obesity prevalence in the US has increased from 13 percent to 32 percent.(10) Moreover, treatment for obesity-related diseases costs public and private health services in the US an estimated $147 billion annually.(11) Some have predicted that most people will be obese in coming decades, with economic burdens on the healthcare system reaching into the hundreds of billions.(12)

Startlingly, multiple teams of researchers have predicted that if present trends continue, all Americans will be overweight or obese by 2050.(12, 13) While such a scenario should elicit concern among policymakers, physicians, and, really, most Americans, the data are even more stark for certain demographic groups where distinct disparities can be seen. Among the 66 percent of American adults who are overweight or obese and 16 percent of children and adolescents, with 34 percent at risk of overweight, disproportionately affected are minority and low-income groups at all ages.(10) Latinos, the largest minority in the US and expected to comprise 25 percent of the US population by 2050, is one such group.(14)

Since the 1960’s, obesity prevalence in the US has increased from 13 percent to 32 percent.

Evidence suggests that acculturation is linked to poor dietary patterns in obesity among Latinos, though more research is needed to elucidate health disparities compared to the general population.(14, 15) Adopting the prevalent dietary and other lifestyle patterns seemingly pervasive in the US appears to add, over time, a significant obstacle besides weight, adapting to a new country and scaling the hurdles of an increasingly thorny immigration environment to newcomers. That is, second- and third-generation Hispanic- and Asian-American families tend to weigh more than first-generation immigrants.(16) A disturbing health disparity that may or may not be mediated by overweight, but may certainly pertain to acculturation and diet was reported in 2009. The study, using nationally representative data over a 35-year period (up to 2004) of 49,574 adults aged 20-74 years, revealed ethnic disparities in diabetes prevalence, with a 33.3% increase of the condition in non-Hispanic whites, a 60% increase in non-Hispanic blacks, and a 227.3% increase over the study period in Mexican-Americans among normal and overweight groups.(17)

Significant differences have also been reported between black men and women in the US as well as black women and white women. Among individuals over the age of 20 as reported in the National Health and Nutrition Examination Survey (NHANES) in 2005-2006, 52.9% of non-Hispanic black women were found to be obese compared with 37.2% of non-Hispanic black men and 32.9% of non-Hispanic white women, with the highest rates of extreme obesity in non-Hispanic black women (13.7%) as compared to 6.7% among white women and 5.9% among black men.(18)

Obesity does not exist in a vacuum nor do these disparities. That is, the obesity epidemic and related disparities are dynamic, multifactorial phenomena informed by the food system, increasingly sedentary lifestyles, disparate access to accurate nutrition information, gender, age, ethnicity, education, socioeconomic status, environment, genetic background, cultural attitudes, beliefs, and behaviors.

Cultural Disparities in Body Image and Obesity

Among such elements, differences among ethnic groups regarding beliefs and attitudes about body image in turn inform the discussion on obesity disparity as its degree of importance within certain demographic groups may not match majority opinion or the prevailing thoughts exhibited by the medical establishment. Among African-American women, for example, the perceived ideal body size is substantially larger than that idealized by Caucasian women.(19-21) It is not surprising, then, that white women in the US report body dissatisfaction at a significantly lower average BMI than do black women.(22) Another factor in this phenomenon is suggested by a recent study comparing the self-perceptions of African-American women and European-American women, average age 72 years, in which African-American participants were more likely to underestimate body shape and size.(23)

Within the Hispanic population in the US, Latinas from the Caribbean are believed to idealize a thinner figure than women from Mexico and Central America.(24) Have larger body ideals emerged in certain segments of the population in association with or because these demographic groups are more likely to be among the poorest and, therefore, most likely to be subsisting on the least expensive, most accessible food, which also happens to be the most processed, least healthy foods most associated with propagating obesity? If there were no health implications related to obesity, and thus no burdens incurred by society, it would be fair to ask whose right is it to cast judgment on culturally variable body size and shape ideals. Given the strong association with numerous health risks, what is the responsibility of the physician in health encounters with obese patients, generally, and with those representing demographic groups who are more likely to prefer larger body sizes? What is required of the physician in this scenario?

The Clinical Setting

It is clear that there is no one universal ideal for body shape. Stoutness has been viewed as a sign of wealth and health in various cultures through history. Until the 1990’s introduction of television, featuring American shows starring thin, attractive people, in the Pacific archipelago nation of Fiji, a heavier frame was aspired to and perceived as a sign of health and physical capability.(25) The encroachment of American views of attractiveness have negatively impacted the body images of adolescent girls in Fiji. Such problems are rife in the West as well and add an additional psychological layer to the intricate business of understanding obesity and how to treat it in the clinical setting. Increasingly unattainable body shapes and sizes in women depicted in the major media confer a deleterious effect on body image of many, especially young women.

While such images are more often associated with the anorexia nervosa and the compulsion for thinness, the larger point is that such public images may affect one’s self-image and psychological make-up and can paradoxically contribute to self-comfort, which may include indulging in unhealthy foods on the pathway to obesity.

In visits with a doctor, it is natural and necessary for the physician to issue a prescribed course of behavior change, whether it is taking a medication or eating more fruits and vegetables, to remedy a particular health condition. The subject of obesity may be uncomfortable for some physicians to broach.(26) Worse yet, evidence has emerged over the last decade of widespread biases against obesity in employment settings, educational venues, interpersonal relationships, and even among health care workers at all levels.(27)

As always, cultural competence and sensitivity exhibited in such a scenario would best serve the patient, and the physician, as the practitioner tries to chart a course for enhancing health. However, the pervasive stigma pertaining to obesity acts as a barrier for some patients, rendering them disinclined to even seek medical services. Implicit in such an exchange is the role of behavioral change and responsibility on the part of the patient, who may or may not view their weight as problematic. Aside from views on body shape and size that diverge from the currently dominant standard, just how responsible are individuals in contemporary society for the obesity epidemic when experts are predicting that all people will be obese in a few decades? Can physicians talk about obesity without euphemism or paternalism and manage not to call a patient fat? Is it feasible for a doctor not to studiously avert this subject while focusing, instead, simply on divining a patient’s unhealthy dietary patterns and charting a course for improvement while eschewing or downplaying a reliance of anthropometric measures of size and weight?

Commodity programs as laid out by the farm bill have subsidized federal dollars to famers for growing corn, soybeans, and wheat, all of which have been cited by numerous authorities as key ingredients in products that contribute to obesity.

In the Photo: Commodity programs laid out by the farm bill have subsidized federal dollars to famers for growing corn, soybeans, and wheat. 

The farm bill, the influence of the food industry, and communicating health messages.

The multiple factors related to the food industry converge with socioeconomic tendencies and related health proclivities to exacerbate wellness disparities, with poor and minority communities, as would be expected, experiencing disproportionate suffering.

The farm bill is the main legislative guideline for agricultural and food policy enacted by the US federal government every five years, on average. For several years, the commodity programs as laid out by the farm bill have subsidized federal dollars to famers for growing corn, soybeans, and wheat, all of which have been cited by numerous authorities as key ingredients in products that contribute to obesity and related disorders.(28) No such funds are provided for growing fruits and vegetables.

The net effect economically is the maintenance of an artificially low price for the supported commodity crops, and derivative products, and comparably higher prices for the fruits and vegetables that health authorities aver are essential for supporting health. As stated above, the net population effect is that the least healthy foods, including the vast array of processed, packaged products containing reformulated derivatives of the primary commodity crops, are rendered the least expensive, and thus the most affordable and likely to be purchased by people of moderate or meager means. There are no subsidies for broccoli, for instance, or other foods that are more likely cultivated by smaller and, in some cases, organic farms but not multibillion dollar companies forever “creating” new allegedly edible concoctions.

The food system today is vastly different from what it was 60 to 100 years ago in the US and the health of the public, particularly the poorest segments, has changed proportionately, measurably, and visibly as a result.

A detailed explanation of the food system is beyond the scope of this paper, but the summary treatment of farm subsidy issues warrants additional elements. That is to say, like the multilayered obesity epidemic itself, the roles of the farm bill, farm subsidies, and the concomitant commodity crop overproduction are hardly simple.

Researchers at Food and Water Watch suggest that a more responsible federal supply management program that lowers overproduction and stabilizes prices and supplies is necessary to reverse the effects of deregulation accompanied by the enforcing of anti-trust law and regulating the marketing of junk food to children.(29) Attempts are underway to propose new nutrition standards on foods and beverages marketed directly to children. Not surprisingly, the industry has created a new lobbying group, deceptively named the “Sensible Food Policy Coalition” to combat more restrictive federal standards, even though the federal Interagency Working Group on Food Marketed to Children (which is comprised of the Federal Trade Commission, Food and Drug Administration, Centers for Disease Control and Prevention, and the United States Department of Agriculture) are proposing non-binding, self-regulatory, voluntary standards.(30)

Food Industry Influence, Oprah’s Beef with the Beef Industry, and Communicating Health

When the subject of communication of health facts, media manipulation and lobbyist dissembling arises, high fructose corn syrup often is not far behind. The rise in portion sizes since the 1970s has been accompanied by a parallel increase in the consumption of beverages (i.e., primarily sodas and fruit juices) containing high-fructose corn syrup (HFCS), which rose 135% between 1977 and 2001, according to the Organic Consumers Association.(31) Over the 20-year period between 1970 (when HFCS was introduced) and 1990, the consumption of HFCS rose 1000% and is now the near-universal source of sweeteners used in sodas.(32) Fructose is approximately 20 times sweeter than sucrose (table sugar), which is twice as sweet as glucose (a simple sugar into which carbohydrates break down), and is processed only in the liver, unlike other sugars, so its presence does not trigger the pancreas to release appetite-suppressing insulin. Nevertheless, the Corn Refiners Association is hard at work trying to imbue in the public consciousness, through various advertisements, the notion that fructose and sugar are equivalent. “Sugar is sugar,” says their ad campaign, and they are petitioning the FDA for a name change from HFCS to corn sugar.(33)

The overarching point here is that a well-funded lobbying group is able to widely broadcast its message, with no edifying or clarifying messages proffered by major news media. The public, bombarded by a surfeit of distracting news and infotainment already, must take the time to seek out accurate health data. The least well-off of any nation’s citizens are too beset by daily struggles to delve deeply enough for such information and are much more likely to absorb mainstream media communications and, worse, the unhealthy standard diet.

Billionaire Oprah Winfrey, during the height of her wildly popular talk show, had Howard Lyman, a former Montana rancher as a guest. Lyman was a fourth-generation rancher who radically changed his work style by shifting to organic farming in response to a cancer scare and then became a vegetarian after another health crisis (ultimately becoming vegan). He had begun researching mad cow disease in 1990 after its advent in the United Kingdom. He appeared on Winfrey’s show on April 16, 1996 and discussed cattle farm practices, including the feeding of protein derived from rendered cattle to other cows, prompting the host to renounce hamburger consumption. Four Amarillo, Texas ranching families and their cattle companies sued Winfrey and Lyman for causing cattle prices to plummet, costing the cattle companies approximately US$11M. Two years and a fortune, for most people, in legal fees later, Winfrey and Lyman were acquitted.(34) But the prospect of being taken to court for offering cogent evidence that discourages people from purchasing big-money food products may well be one key element in a climate chilly to a free, open, and sophisticated discourse on the relative salutary merits of food. Indeed, the food industry lobby responded by pushing for food libel or “food disparagement” laws, which have since been enacted in 13 US states, including, of course, Texas.(35)

Paternalism is just one of the charges lobbed at the Danish government for its controversial “fat tax” enacted in 2009 and partially phased in as of July 2011. The new taxes increase the cost of manufacturing products or marketing foods likely to harm the environment and human health, including ice cream, candy, sugar-sweetened sodas, and foods that include saturated fats. As Marion Nestle, author and New York University professor of nutrition, food studies, and public health, noted on her website, the Danes want to ameliorate their health, as measured by an obesity rate that has risen from 9.5% to 13.4% in the last decade, though this rate has not been this relatively low in the US since the 1970’s and is below the European average of 15%.(36) She plans to closely monitor the effects of the new taxes in Denmark, but cautions that the effects of health taxes there will have less impact on the poor given the relatively low income disparity. Thus, the tax may not provide sufficient incentive to alter unhealthy dietary patterns. Nestle also admonishes that while implementing a sin tax is one approach to affecting the food environment to benefit public health, more stringently regulating the production of unhealthy foods might be more effective. Undeniably, enhanced regulation would be a boon to public health. But, the food industry would not brook such maneuvers and government is more beholden to corporations than the general public.

This dynamic is reinforced by the well-meaning but timid initiative instituted by First Lady Michelle Obama, the “Let’s Move!” campaign. Critics charge that the program has focused almost exclusively on prevention and not treatment, thus disproportionately ignoring minority children. Lee and Lee note that 20 percent of African-American and Mexican-American children are obese, as compared to 15% of white children in the US.(37) In addition, though the first lady has no official role in the government, she and her program fail to meaningfully address or challenge the truly hegemonic role of the billion-dollar food industry and its leading role in the obesity epidemic.

In the Photo: Diet, exercise programs and more fails to address the food industry and its role in obesity. 

Salient aspects of the epidemic and the role of the physician.

This has by no means been an exhaustive treatment of what is a profoundly complicated phenomenon. Volumes have been and continue to be written on several of the discrete subjects referenced in this discussion. The encompassing message here, though, is that such topics are not truly distinct. That is, multiple complex, inextricably linked economic, political, sociocultural, and personal factors influence and propel the ongoing national obesity epidemic. Structural violence is patently perpetrated by the food industry, abetted by a passive media and with complicity of a cowed government, from which many participants return to industry or for whom they seek lobbying positions after leaving government service in a revolving door relationship that reeks of conflict of interest.

The world of commerce offers few, if any, genuine solutions and, in fact, profits significantly over the portly status quo. The pharmaceutical industry has attempted to be a player to benefit from expanding waistlines, but has not succeeded in finding an elixir for weight loss. Of course, the weight loss/fitness industry has flourished parallel to the epidemic, but remains a peripheral issue when juxtaposed with food supply and dietary patterns. In other words, the industry thrives without putting a dent in the obesity epidemic. Further, buying exercise equipment or joining a gym are relegated to the backburner, if that, for those lacking the financial wherewithal to afford such extravagances. And one need not spend money to exercise.

While US culture has become increasingly sedentary, suggesting self-selection among those who have participated in the ubiquitous fitness industry, exercise pertains to fitness, whereas diet relates to fatness or girth. In this realm, the billion-dollar food industry largely fails consumers of all demographic groups, but particularly those least able to spend money on anything but the least expensive items and those who are least likely to learn ways to feed themselves and their families cheaply but healthfully.

What qualifies as communications media in the modern age has never been more diverse and stratified. Nevertheless, mainstream or corporate mass media continue to hold sway and remain the most likely sources of information, via television, radio, and newspapers (which have declined noticeably in recent years juxtaposed with the advent of the Internet and dwindling resources resulting in significant layoffs and even closings of various, especially foreign bureaus).

Unfortunately, the messages conveyed through such media regarding food and nutrition lacks depth and insight when treated in a news-oriented format or, in the case of advertising, largely attempts to sell unhealthy choices to a mostly unsuspecting populace so burdened by economic hard times, in many cases, that the lowest priced processed foods cannot help but sound appealing.

Among savvier individuals who know they are being sold a false bill of goods, awareness has dawned that one must research to learn how the food system really works, what foods and kinds of diets are most conducive to sustainable good health, and how to regularly obtain such provisions. Such work is unlikely among the majority of the populace and the fruits of such research already available on numerous websites, at least, struggle to find a larger audience. After all, even in an expensive but losing cause in a lawsuit against billionaire Oprah Winfrey, the beef industry, and its brethren, cast an intimidating, well-funded pall over those inclined to speak out.

The inflation of prices of healthy foods, in relation to the subsidized ingredients of processed ones, actual healthy food choices, and ways to access these items represent an elephant in the room that the billion-dollar food industry strongly dissuades the media and political class from genuinely acknowledging to the populace.

Although US doctors have not been traditionally trained in nutrition, the opportunities for continuing education abound for clinicians. In addition, medical school curricula are continually expanding to include training on complementary and alternative medicine as well as nutrition. But it is incumbent upon the physician to do more, sometimes by doing less. There is a certain subset of the obese population that shies away from medical appointments either from shame or fear of potential humiliation or memories of past embarrassing experiences. In fact, such fears may have only been stoked recently by news that a University of Pennsylvania orthopedic surgeon, who performs stand-up comedy on an occasional basis and writes a humor column for a medical trade magazine, was reprimanded for offering fat jokes that insulted and provoked concern among several readers.(38)

In the clinical setting – and in the broader public space – doctors best serve their patients and themselves by presenting an open, nonjudgmental demeanor that reveals itself as culturally competent while acknowledging or implying clinical confidence but personal fallibility.

In terms of the obese patient who displays no significant comorbidities, the physician would ideally leave any personal biases aside, understand the profound anxiety that the patient may be experiencing in even following through with an appointment, and choose language carefully but comfortably in discussing dietary patterns. Indeed, a detailed history, including food diary, would be important information for the practitioner to obtain in order to ferret out the contributing causes of the patient’s condition. Such an encounter may be complicated by a patient presenting with little or no concern about their weight or beliefs that their body matches, resembles, or approaches a cultural ideal, not of the unattainable images proffered by the culture at large, but in certain minority communities. One’s medical history and dietary patterns remain important to discuss in this context, but the physician may act most appropriately by listening to the patient’s thoughts while approaching care simply through an attempt first to help the patient include healthier food choices, drinking more water rather than soda, for instance, and, perhaps, incorporating some exercise and addressing financial constraints sensitively. People who are overweight can also take weight management supplements like Revitaa pro to help them lose weight naturally.

In the Photo: The role of the physician is significant as the practitioner is to work on behalf of her or his patients and to understand the complex obesity epidemic. 

This whole discussion is predicated on a pejorative perspective of obesity, of course, as espoused by the medical community and reported on widely in various media, and is a viewpoint that I have absorbed as a member of this culture. Native Fijians were living healthier, heavier but active lives, without concomitant body image issues or the chronic diseases of the West before the introduction of US TV programming. There is more than one way, and perhaps what we view as obesity in the West and now much of the rest of the word must still be placed in the proper context.

The data on sedentary lifestyles of the overweight and obese do suggest multiple comorbidities and complications. But in individual circumstances, there may be various etiologic factors at play, including cultural, genetic, socioeconomic, and behavioral—suggesting a relativity in the risks of obesity to individuals—that require understanding and sensitivity from the physician in order to address. Such an encounter may result in adjusting the realistic parameters in which weight and body dimension change might be even be sought or expected. In any case, the physician should heed Kagawa-Singer and Blackhall’s words that “culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying,” while remembering that culture is but one of many factors that contribute to obesity and might not be implicated strongly in a patient’s presentation or body image.(39)

With such a multitude of factors in mind, the practitioner and patient are best served by less rigidity in terms of hewing to anthropometric measures of size and weight while more attention is focused more holistically on the patient’s life circumstances. In order to help patients improve their lives, it is incumbent upon the physician to meet the individual more than halfway. That is, to make every effort to try to understand the patient’s perspective, which in some cases might mean a compromise in the behavioral change sought by the physician and what the patient is willing or able to exhibit. The successful practitioner might, ideally, receive favorable word of mouth that might prompt or attract a visit from obese individuals who would otherwise be resistant to making a medical appointment.

The salient features of the obesity epidemic and the inherent role of the physician as healer combine to place a potentially significant onus on the practitioner to work at multiple levels on behalf of her or his patients and to fully understand the larger, multifaceted obesity context. Despite the confluence of societal movements far beyond the control of the individual, it is up to the individual to combat or decide to combat one’s own overweight or obesity.

At the individual level, the clinician must certainly play the role as outlined above, which ideally would include the use of some or all of the Kleinman questions (40). At the macro level, cultural competence and awareness might impel physicians to advocate for changes to the food system. Understandably, some doctors rail that they don’t even have enough time in the average patient visit to ask the Kleinman questions. But if enough medical voices were to rise in unison demanding universal health care, for instance, numerous tides might turn. Neither on a global nor individual level is this effort simple. But it is clearly a battle to be waged on multiple fronts.

1. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, Gortmaker SL. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011 Aug 27:378(9793):804-14.

2. Turner L. Bioethics, social class, and the sociological imagination. Camb Q Healthc Ethics. 2005 Fall;14(4);374-8.

3. Pollan M. In Defense of Food. New York, NY: Penguin Press, 2008.

4. Baertlein L, Abbott C. The House of Representatives dealt a blow to childhood obesity warriors on Thursday by passing a bill that abandons proposals that threatened to end the reign of pizza and French fries on federally funded school lunch menus. Reuters News Service, November 18, 2011.

5. Fox MK, Dodd AH, Wilson A, Gleason PM. Association between school food environment and practices and body mass index of US public school children. J Am Diet Assoc. 2009 Feb;109(2 Suppl):S108-17.

6. Young LR, Nestle M. The contribution of expanding portion sizes to the US obesity epidemic. Am J Public Health. 2002 Feb;92(2):246-9.

7. Ledikwe JH, Ello-Martin JA, Rolls BJ. Portion sizes and the obesity epidemic. J Nutr. 2005 Apr;135(4);905-9.

8. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011 Aug 27;378(9793):815-25.

9. Vaidya A, Shakya S, Krettek A. Obesity prevalence in Nepal: public health challenges in a low-income nation during an alarming worldwide trend. Int J Environ Public Health. 2010 Jun; 7(6):2726-44.

10. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6-28.

11. Trogdon JG, Finkelstein EA, Feagan CW, Cohen JW. State- and payer-specific estimates of annual medical expenditures attributable to obesity. Obesity (Silver Spring). 2011 Jun 16. [Epub ahead of print.]

12. Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? Estimating the progression and cost of the US obesity epidemic. Obesity (Silver Spring). 2008 Oct;16(10):2323-30.

13. Yanovski SZ, Yanovski JA. Obesity prevalence in the United States—up, down, or sideways? New England Journal Med. 2011;364(11):987-9.

14. Pérez-Escamilla R. Acculturation, nutrition, and health disparities in Latinos. Am J Clin Nutr. 2011 May;93(5):1163S-7S.

15. Mainous AG 3rd, Diaz VA, Geesey ME. Acculturation and healthy lifestyle among Latinos with diabetes. Ann Fam Med. 2008 Mar-Apr;6(2):131-7.

16. Popkin BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: the National Longitudinal Study of Adolescent Health. J Nutr. 1998 Apr;128(4):701-6.

17. Zhang Q, Wang Y, Huang ES. Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among US adults. Ethn Health. 2009 Oct;14(5):439-57.

18. Ogden CL. Disparities in obesity prevalence in the United States: black women at risk. Am J Clin Nutr. 2009 Apr;89(4):1001-2.

19. Caprio S, Daniels SR, Drewnowski A, Kaufman FR, Palinkas LA, Rosenbloom AL, Schwimmer JB. Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment: a consensus statement of Shaping America’s Health and the Obesity Society. Diabetes Care. 2008 Nov;31(11):2211-21.

20. Padgett J, Biro FM. Different shapes in different cultures: body dissatisfaction, overweight, and obesity in African-American and Caucasian females. J Pediatr Adolesc Gynecol. 2003 Dec;16(6):349-54.

21. Powell AD, Kahn AS. Racial differences in women’s desires to be thin. Int J Eat Disord. 1995 Mar;17(2):191-5.

22. Fitzgibbon ML, Blackman LR, Avellone ME. The relationship between body image discrepancy and body mass index across ethnic groups. Obes Res. 2000 Nov;8(8):582-9.

23. Schuler PB, Vinci D, Isosaari RM, Philipp SF, Todorovich J, Roy JL, Evans RR. Body-shape perceptions and body mass index of older African American and European American women. J Cross Cult Gerontol. 2008 Sep;23(3):255-64.

24. Snooks MK, Hall SK. Relationship of body size, body image, and self-esteem in African American, European American, and Mexican American middle-class women. Health Care Women Int. 2002 Jul-Aug;23(5):460-6.

25. Becker AE. Television, disordered eating, and young women in Fiji: negotiating body image and identity during rapid social change. Cult Med Psychiatry. 2004 Dec;28(4):533-59.

26. Neighmond P. Why doctors and patients talk around our growing waistlines. NPR’s Morning Edition, Nov. 14, 2011. Website: http://www.npr.org/blogs/health/2011/11/14/142255024/why-doctors-and-patients-talk-around-our-growing-waistlines. Accessed November 26, 2011.

27. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009 May;17(5):941-64.

28. Public Health Law Center at William Mitchell College of Law Website: http://publichealthlawcenter.org/topics/healthy-eating/federal-farm-bill. Accessed December 5, 2011.

29. Hauter W. If we end farm subsidies, does that mean our food system will be healthy? Food and Water Watch. October 21, 2011. Website Alternet: http://www.alternet.org/health/152827/if_we_end_farm_subsidies,_does_that_mean_our_food_system_will_be_healthy?page=entire. Accessed December 10, 2011.

30. Nestle M. Food Politics website: http://www.foodpolitics.com/2011/09/the-food-industry-vs nutrition-standards-a-first-amendment-issue/. Accessed December 11, 2011.

31. Organic Consumers Association website article “How High Fructose Corn Syrup Damages Your Body, July 20, 200. Website: http://www.organicconsumers.org/articles/article_6210.cfm. Accessed December 11, 2011.

32. Fields S. The fat of the land: do agricultural subsidies foster poor health? Environ Health Perspect. 2004 Oct;112(14):A820-3.

33. O’Brien R. “Sugar is sugar” claims the Corn Refiners Association. But is it? Huffington Post, 9/15/10. Website: http://www.huffingtonpost.com/robyn-o/sugar-is-sugar-claims-the_b_717537.html. Accessed December 11, 2011.

34. Lyons SA. Oprah says free speech prevails in win over Texas beef industry. The Washington Post,vol. 188, issue 8, Friday, February 27, 1998.

35. Coalition for Free Speech Food Speak website: http://cspinet.org/foodspeak/laws/existlaw.htm. Accessed December 11, 2011.

36. Nestle M. On Denmark’s Fat Tax. Food Politics website: http://www.foodpolitics.com/?s=Danish+tax. Accessed December 11, 2011.

37. Lee JM, Lee H. Obesity reduction within a generation: the dual roles of prevention and treatment. Obesity (Silver Spring). 2011 Oct;19(10):2107-10.

38. McCullough M. Penn doctor endures fallout over fat jokes. Philadelphia Inquirer, Oct. 28, 2011.

39. Kagawa-Singer M, Blackhall JL. Negotiating cross-cultural issues at the end of life: “You got to go where he lives.” JAMA. 2001 Dec 19;286(23):2993-3001.

40. Editor note regarding the “Kleinman questions”. Kleinman et al. (1978) proposed eight questions that a healthcare provider could comfortably ask a patient of a different culture. This means that the healthcare provider does not have to know about the patient’s culture but can specifically find out how that culture is reflected in the expression and understanding of the patient’s symptoms and illness.

The eight Kleinman questions are the following:

1. What do you think caused the problem? 2. Why do you think it happened when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your sickness?

Source: Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258.

How a Pope Saved a Forest

An accelerator with a development impact.

Edmund Weisberg

Edmund M. Weisberg obtained his master of science and master of bioethics degrees from the University of Pennsylvania and has several years of experience in medical writing and editing. He has worked with Greenpeace, the International Clinical Epidemiology Network, the American Association for Cancer Research, the University of Pennsylvania, and Johns Hopkins University, where he currently serves as senior science writer in the Department of Radiology. In addition, he was the Managing Editor, as well as a contributing author, for the first two editions of the textbook Cosmetic Dermatology: Principles and Practice, by Dr. Leslie Baumann, and Managing Editor for Dr. Baumann’s Cosmeceuticals and Cosmetic Ingredients, all three of which were published by McGraw-Hill. Their next collaboration, the third edition of Cosmetic Dermatology, is forthcoming. Mr. Weisberg’s essays pertaining to bioethics appear online in Impakter, Voices in Bioethics, and the Rutgers Journal of Bioethics, and his poetry, in Literary Yard, Down in the Dirt Magazine (collected in Outside the Box), Pure Slush, and Danse Macabre. He is also the author of the children’s picture book While You’re at School.

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Obesity Essay

Last updated on: Feb 9, 2023

Obesity Essay: A Complete Guide and Topics

By: Nova A.

11 min read

Reviewed By: Jacklyn H.

Published on: Aug 31, 2021

Are you assigned to write an essay about obesity? The first step is to define obesity.

The obesity epidemic is a major issue facing our country right now. It's complicated- it could be genetic or due to your environment, but either way, there are ways that you can fix it!

Learn all about what causes weight gain and get tips on how you can get healthy again.

On this Page

What is Obesity

What is obesity? Obesity and BMI (body mass index) are both tools of measurement that are used by doctors to assess body fat according to the height, age, and gender of a person. If the BMI is between 25 to 29.9, that means the person has excess weight and body fat.

If the BMI exceeds 30, that means the person is obese. Obesity is a condition that increases the risk of developing cardiovascular diseases, high blood pressure, and other medical conditions like metabolic syndrome, arthritis, and even some types of cancer.

Obesity Definition

Obesity is defined by the World Health Organization as an accumulation of abnormal and excess body fat that comes with several risk factors. It is measured by the body mass index BMI, body weight (in kilograms) divided by the square of a person’s height (in meters).

Obesity in America

Obesity is on the verge of becoming an epidemic as 1 in every 3 Americans can be categorized as overweight and obese. Currently, America is an obese country, and it continues to get worse.

Paper Due? Why Suffer? That's our Job!

Causes of obesity

Do you see any obese or overweight people around you?

You likely do.

This is because fast-food chains are becoming more and more common, people are less active, and fruits and vegetables are more expensive than processed foods, thus making them less available to the majority of society. These are the primary causes of obesity.

Obesity is a disease that affects all age groups, including children and elderly people.

Now that you are familiar with the topic of obesity, writing an essay won’t be that difficult for you.

How to Write an Obesity Essay

The format of an obesity essay is similar to writing any other essay. If you need help regarding how to write an obesity essay, it is the same as writing any other essay.

Obesity Essay Introduction

The trick is to start your essay with an interesting and catchy sentence. This will help attract the reader's attention and motivate them to read further. You don’t want to lose the reader’s interest in the beginning and leave a bad impression, especially if the reader is your teacher.

A hook sentence is usually used to open the introductory paragraph of an essay in order to make it interesting. When writing an essay on obesity, the hook sentence can be in the form of an interesting fact or statistic.

Head on to this detailed article on hook examples to get a better idea.

Once you have hooked the reader, the next step is to provide them with relevant background information about the topic. Don’t give away too much at this stage or bombard them with excess information that the reader ends up getting bored with. Only share information that is necessary for the reader to understand your topic.

Next, write a strong thesis statement at the end of your essay, be sure that your thesis identifies the purpose of your essay in a clear and concise manner. Also, keep in mind that the thesis statement should be easy to justify as the body of your essay will revolve around it.

Body Paragraphs

The details related to your topic are to be included in the body paragraphs of your essay. You can use statistics, facts, and figures related to obesity to reinforce your thesis throughout your essay.

If you are writing a cause-and-effect obesity essay, you can mention different causes of obesity and how it can affect a person’s overall health. The number of body paragraphs can increase depending on the parameters of the assignment as set forth by your instructor.

Start each body paragraph with a topic sentence that is the crux of its content. It is necessary to write an engaging topic sentence as it helps grab the reader’s interest. Check out this detailed blog on writing a topic sentence to further understand it.

End your essay with a conclusion by restating your research and tying it to your thesis statement. You can also propose possible solutions to control obesity in your conclusion. Make sure that your conclusion is short yet powerful.

Obesity Essay Examples

Essay about Obesity (PDF)

Childhood Obesity Essay (PDF)

Obesity in America Essay (PDF)

Essay about Obesity Cause and Effects (PDF)

Satire Essay on Obesity (PDF) 

Obesity Argumentative Essay (PDF)

Obesity Essay Topics

Choosing a topic might seem an overwhelming task as you may have many ideas for your assignment. Brainstorm different ideas and narrow them down to one, quality topic.

If you need some examples to help you with your essay topic related to obesity, dive into this article and choose from the list of obesity essay topics.

Childhood Obesity

As mentioned earlier, obesity can affect any age group, including children. Obesity can cause several future health problems as children age.

Here are a few topics you can choose from and discuss for your childhood obesity essay:

• What are the causes of increasing obesity in children?
• Obese parents may be at risk for having children with obesity.
• What is the ratio of obesity between adults and children?
• What are the possible treatments for obese children?
• Are there any social programs that can help children with combating obesity?
• Has technology boosted the rate of obesity in children?
• Are children spending more time on gadgets instead of playing outside?
• Schools should encourage regular exercises and sports for children.
• How can sports and other physical activities protect children from becoming obese?
• Can childhood abuse be a cause of obesity among children?
• What is the relationship between neglect in childhood and obesity in adulthood?
• Does obesity have any effect on the psychological condition and well-being of a child?
• Are electronic medical records effective in diagnosing obesity among children?
• Obesity can affect the academic performance of your child.
• Do you believe that children who are raised by a single parent can be vulnerable to obesity?
• You can promote interesting exercises to encourage children.
• What is the main cause of obesity, and why is it increasing with every passing day?
• Schools and colleges should work harder to develop methodologies to decrease childhood obesity.
• The government should not allow schools and colleges to include sweet or fatty snacks as a part of their lunch.
• If a mother is obese, can it affect the health of the child?
• Children who gain weight frequently can develop chronic diseases.

Obesity Argumentative Essay Topics

Do you want to write an argumentative essay on the topic of obesity?

The following list can help you with that!

Here are some examples you can choose from for your argumentative essay about obesity:

• Can vegetables and fruits decrease the chances of obesity?
• Should you go for surgery to overcome obesity?
• Are there any harmful side effects?
• Can obesity be related to the mental condition of an individual?
• Are parents responsible for controlling obesity in childhood?
• What are the most effective measures to prevent the increase in the obesity rate?
• Why is the obesity rate increasing in the United States?
• Can the lifestyle of a person be a cause of obesity?
• Does the economic situation of a country affect the obesity rate?
• How is obesity considered an international health issue?
• Can technology and gadgets affect obesity rates?
• What can be the possible reasons for obesity in a school?
• How can we address the issue of obesity?
• Is obesity a chronic disease?
• Is obesity a major cause of heart attacks?
• Are the junk food chains causing an increase in obesity?
• Do nutritional programs help in reducing the obesity rate?
• How can the right type of diet help with obesity?
• Why should we encourage sports activities in schools and colleges?
• Can obesity affect a person’s behavior?

Health Related Topics for Research Paper

If you are writing a research paper, you can explain the cause and effect of obesity.

Here are a few topics that link to the cause and effects of obesity.Review the literature of previous articles related to obesity. Describe the ideas presented in the previous papers.

• Can family history cause obesity in future generations?
• Can we predict obesity through genetic testing?
• What is the cause of the increasing obesity rate?
• Do you think the increase in fast-food restaurants is a cause of the rising obesity rate?
• Is the ratio of obese women greater than obese men?
• Why are women more prone to be obese as compared to men?
• Stress can be a cause of obesity. Mention the reasons how mental health can be related to physical health.
• Is urban life a cause of the increasing obesity rate?
• People from cities are prone to be obese as compared to people from the countryside.
• How obesity affects the life expectancy of people? What are possible solutions to decrease the obesity rate?
• Do family eating habits affect or trigger obesity?
• How do eating habits affect the health of an individual?
• How can obesity affect the future of a child?
• Obese children are more prone to get bullied in high school and college.
• Why should schools encourage more sports and exercise for children?

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Topics for Essay on Obesity as a Problem

Do you think a rise in obesity rate can affect the economy of a country?

Here are some topics for your assistance regarding your economics related obesity essay.

• Does socioeconomic status affect the possibility of obesity in an individual?
• Analyze the film and write a review on “Fed Up” – an obesity epidemic.
• Share your reviews on the movie “The Weight of The Nation.”
• Should we increase the prices of fast food and decrease the prices of fruits and vegetables to decrease obesity?
• Do you think healthy food prices can be a cause of obesity?
• Describe what measures other countries have taken in order to control obesity?
• The government should play an important role in controlling obesity. What precautions should they take?
• Do you think obesity can be one of the reasons children get bullied?
• Do obese people experience any sort of discrimination or inappropriate behavior due to their weight?
• Are there any legal protections for people who suffer from discrimination due to their weight?
• Which communities have a higher percentage of obesity in the United States?
• Discuss the side effects of the fast-food industry and their advertisements on children.
• Describe how the increasing obesity rate has affected the economic condition of the United States.
• What is the current percentage of obesity all over the world? Is the obesity rate increasing with every passing day?
• Why is the obesity rate higher in the United States as compared to other countries?
• Do Asians have a greater percentage of obese people as compared to Europe?
• Does the cultural difference affect the eating habits of an individual?
• Obesity and body shaming.
• Why is a skinny body considered to be ideal? Is it an effective way to reduce the obesity rate?

Obesity Solution Essay Topics

With all the developments in medicine and technology, we still don’t have exact measures to treat obesity.

Here are some insights you can discuss in your essay:

• How do obese people suffer from metabolic complications?
• Describe the fat distribution in obese people.
• Is type 2 diabetes related to obesity?
• Are obese people more prone to suffer from diabetes in the future?
• How are cardiac diseases related to obesity?
• Can obesity affect a woman’s childbearing time phase?
• Describe the digestive diseases related to obesity.
• Obesity may be genetic.
• Obesity can cause a higher risk of suffering a heart attack.
• What are the causes of obesity? What health problems can be caused if an individual suffers from obesity?
• What are the side effects of surgery to overcome obesity?
• Which drugs are effective when it comes to the treatment of obesity?
• Is there a difference between being obese and overweight?
• Can obesity affect the sociological perspective of an individual?
• Explain how an obesity treatment works.
• How can the government help people to lose weight and improve public health?

Writing an essay is a challenging yet rewarding task. All you need is to be organized and clear when it comes to academic writing.

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• Organize your thoughts.
• Pen down your ideas.
• Compose a perfect essay that will help you ace your subject.
• Proofread and revise your paper.

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7.5: Obesity Epidemic - Causes and Solutions

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• Page ID 39986

• Alice Callahan, Heather Leonard, & Tamberly Powell
• Lane Community College via OpenOregon

Since the 1980s, the prevalence of obesity in the United States has increased dramatically. Data collected by the Centers for Disease Control and Prevention show rising obesity across the nation, state-by-state. 1

The methods used by the CDC to collect the data changed in 2011, so we can’t make direct comparisons between the periods before and after that change, but the trend has continued. Every year, more and more people in the U.S. are obese.

These trends are unmistakable, and they’re not just occurring in adults. Childhood obesity has seen similar increases over the last few decades—perhaps an even greater concern as the metabolic and health effects of carrying too much weight can be compounded over a person’s entire lifetime.

While obesity is a problem across the United States, it affects some groups of people more than others. Based on 2015-2016 data, obesity rates are higher among Hispanic (47 percent) and Black adults (47 percent) compared with white adults (38 percent). Non-Hispanic Asians have the lowest obesity rate (13 percent). And overall, people who are college-educated and have a higher income are less likely to be obese. 2  These health disparities point to the importance of looking at social context when examining causes and solutions. Not everyone has the same opportunity for good health, or an equal ability to make changes to their circumstances, because of factors like poverty and longstanding inequities in how resources are invested in communities. These factors are called “ social determinants of health. ” 3

The obesity epidemic is also not unique to the United States. Obesity is rising around the globe, and in 2015, it was estimated to affect 2 billion people worldwide, making it one of the largest factors affecting poor health in most countries . 4 Globally, among children aged 5 to 19 years old, the rate of overweight increased from 10.3 percent in 2000 to 18.4 percent in 2018. Previously, overweight and obesity mainly affected high-income countries, but some of the most dramatic increases in childhood overweight over the last decade have been in low income countries, such as those in Africa and South Asia, corresponding to a greater availability of inexpensive, processed foods. 5

Despite the gravity of the problem, no country has yet been able to implement policies that have reversed the trend and brought about a decrease in obesity. This represents “one of the biggest population health failures of our time,” wrote an international group of researchers in the journal The Lancet in 2019. 6  The World Health Organization has set a target of stopping the rise of obesity by 2025. Doing so requires understanding what is causing the obesity epidemic; it is only when these causes are addressed that change can start to occur.

Causes of the Obesity Epidemic

If obesity was an infectious disease sweeping the globe, affecting billions of people’s health, longevity, and productivity, we surely would have addressed it by now. Researchers and pharmaceutical companies would have worked furiously to develop vaccines and medicines to prevent and cure this disease. But the causes of obesity are much more complex than a single bacteria or virus, and solving this problem means recognizing and addressing a multitude of factors that lead to weight gain in a population.

At its core, rising obesity is caused by a chronic shift towards positive energy balance—consuming more energy or calories than one expends each day, leading to an often gradual but persistent increase in body weight. People often assume that this is an individual problem, that those who weigh more simply need to change their behavior to eat less and exercise more, and if this doesn’t work, it must be because of a personal failing, such as a lack of self-control or motivation. While behavior patterns such as diet and exercise can certainly impact a person’s risk of developing obesity (as we’ll cover later in this chapter), the environments where we live also have a big impact on our behavior and can make it much harder to maintain energy balance.

Environment

Many of us live in what researchers and public health experts call “ obesogenic environments. ” That is, the ways in which our neighborhoods are built and our lives are structured influence our physical activity and food intake to encourage weight gain. 7 Human physiology and metabolism evolved in a world where obtaining enough food for survival required significant energy investment in hunting or gathering—very different from today’s world where more people earn their living in sedentary occupations. From household chores, to workplace productivity, to daily transportation, getting things done requires fewer calories than it did in past generations.

Our jobs have become more and more sedentary, with fewer opportunities for non-exercise thermogenesis (NEAT) throughout the day. There’s less time in the school day for recess and physical activity, and fears about neighborhood safety limit kids’ ability to get out and play after the school day is over. Our towns and cities are built more for cars than for walking or biking. We can’t turn back the clock on human progress, and finding a way to stay healthy in obesogenic environments is a significant challenge.

Our environments can also impact our food choices. We’re surrounded by vending machines, fast food restaurants, coffeeshops, and convenience stores that offer quick and inexpensive access to calories. These foods are also heavily advertised, and especially when people are stretched thin by working long hours or multiple jobs, they can be a welcome convenience. However, they tend to be calorie-dense (and less nutrient-dense) and more heavily processed, with amounts of sugar, fat, and salt optimized to make us want to eat more, compared with home-cooked food. In addition, portion sizes at restaurants, especially fast food chains, have increased over the decades, and people are eating at restaurants more and cooking at home less.

Poverty and Food Insecurity

Living in poverty usually means living in a more obesogenic environment. Consider the fact that some of the poorest neighborhoods in the United States—with some of the highest rates of obesity—are often not safe or pleasant places to walk, play, or exercise. They may have busy traffic and polluted air, and they may lack sidewalks, green spaces, and playgrounds. A person living in this type of neighborhood will find it much more challenging to get adequate physical activity compared with someone living in a neighborhood where it’s safe to walk to school or work, play at a park, ride a bike, or go for a run.

In addition, poor neighborhoods often lack a grocery store where people can purchase fresh fruits and vegetables and basic ingredients necessary for cooking at home. Such areas are called “ food deserts ”—where healthy foods simply aren’t available or easily accessible.

Another concept useful in discussions of obesity risk is “food insecurity.”  Food security  means “access by all people at all times to enough food for an active, healthy life.” 8  Food insecurity  means an inability to consistently obtain adequate food. It may seem counter-intuitive, but in the United States, food insecurity is linked to obesity. That is, people who have difficulty obtaining enough food are more likely to become obese and to suffer from diabetes and hypertension. This is likely related to the fact that inexpensive foods tend to be high in calories but low in nutrients, and when these foods form the foundation of a person’s diet, they can cause both obesity and nutrient deficiencies. It’s estimated that 12 percent of U.S. households are food insecure, and food insecurity is higher among Black (22 percent) and Latino (18 percent) households. 3

What about genetics? While it’s true that our genes can influence our susceptibility to becoming obese, researchers say they can’t be a cause of the obesity epidemic. Genes take many generations to evolve, and the obesity epidemic has occurred over just the last 40 to 50 years—only a few generations. When our grandparents were children, they were much less likely to become obese than our own children. That’s not because their genes were different, but rather because they grew up in a different environment. However, it is true that a person’s genes can influence their susceptibility to becoming obese in this obesogenic environment, and obesity is more prevalent in some families. A person’s genetic make-up can make it more difficult to maintain energy balance in an obesogenic environment, because certain genes may make you feel more hungry or slow your energy expenditure. 2

Solutions to the Obesity Epidemic

Given the multiple causes of obesity, solving this problem will also require many solutions at different levels. Because obesity affects people over the lifespan and is difficult to reverse, the focus of many of these efforts is prevention, starting as early as the first years of life. We’ll discuss individual weight management strategies later in this chapter. Here, we’ll review some strategies happening in schools, communities, and at the state and federal levels.

Support Healthy Dietary Patterns

Interventions that support healthy dietary patterns, especially among people more vulnerable because of food insecurity or poverty, may reduce obesity. In some cases, studies have shown that they have an impact, and in other cases, it’s too soon to know. Here are some examples:

• Implement and support better nutrition standards for childcare, schools, hospitals, and worksites. 9
• Limit marketing of processed foods, especially ads targeted towards children.
• Provide incentives for supermarkets or farmers markets to establish businesses in underserved areas. 9

Figure 9.21. Farmers markets can expand healthy food options for neighborhoods and build connections between consumers and local farmers.

• Place nutrition and calorie content on restaurant and fast food menus to raise awareness of food choices. 9 Beginning in 2018, as part of the Affordable Care Act, chain restaurants with more than 20 locations were required to add calorie information to their menus, and some had already done so voluntarily. There isn’t yet enough research to say whether having this information improves customers’ choices; some studies show an effect and others don’t. 10 Many factors influence people’s decisions, and the type of restaurant, customer needs, and menu presentation all likely matter. For example, some studies show that health-conscious consumers choose lower calorie menu items when presented with nutrition information, but people with food insecurity may understandably choose higher calorie items to get more “bang for their buck”. 11 Research has also shown that adding interpretative images—like a stoplight image labeling menu choices as green or red as shorthand for high or low nutrient density—can help. And a 2018 study found that when calorie counts are on the left side of English-language menus, people order lower-calorie menu items. Putting calorie counts on the right side of the menu (as is more common) doesn’t have this effect, likely because the English language is read from left to right. 12 Some studies have also found that restaurants that implement menu labeling offer lower-calorie and more nutrient-dense options, indicating that menu labeling may push restaurants to look more closely at the food they serve. 10,13

• Increase access to food assistance programs and align them with nutrition recommendations. For example, in 2009, the U.S. Department of Agriculture revised the food packages for the Women, Infants, and Children (WIC) program to better align with the Dietary Guidelines for Americans. The new packages emphasized more fruits, vegetables, whole grains, and low-fat dairy and decreased the availability of juice. After this change, there was a decrease in the obesity rate of children in the WIC program. Similar progress may be made by increasing access to the Supplemental Nutrition Assistance Program (SNAP) in order to reduce food insecurity. Many farmers’ markets now accept SNAP benefits for the purchase of fresh fruit and vegetables. 3
• Tax sugary drinks, such as soda and sports drinks, which contribute significant empty calories to the U.S. diet and are associated with childhood obesity. Local taxes on soda and other sugary drinks are often controversial, and soda companies lobby to prevent them from passing. However, early research in U.S. cities with soda taxes show that they do work to decrease soda consumption. 3 In the U.S., soda has only been taxed at the local level, and the tax has been paid by consumers. The United Kingdom has taken a different approach: They started taxing soft drink manufacturers for the sugar content of the products they sell. Between 2015 and 2018, the average sugar content of soda sold in the U.K. dropped by 29 percent. 14

Support Greater Physical Activity

Increasing physical activity increases the energy expended during the day. This can help maintain energy balance, thus preventing weight gain. It may also help to shift a person into negative energy balance and facilitate weight loss if needed. But simply adding an exercise session—a run or a trip to the gym, say—often doesn’t shift energy balance (though it’s certainly good for health). Why? Exercise can increase hunger, and there’s only so many calories a person can burn in 30 or 60 minutes. That’s why it’s also important to look for opportunities for non-exercise activity thermogenesis (NEAT); that is, find ways to increase movement throughout the day.

• P rioritize physical education and recess time in schools. In addition to helping kids stay healthy, movement also helps them learn.  
• Make neighborhoods safer and more accessible for walking, cycling, and playing.
• When safe, encourage kids to walk or bike to school.
• Build family and community activities around physical activity, such as trips to the park, walks together, and community walking and exercise groups.
• Facilitate more movement in the workday by encouraging walking meetings, movement breaks, and treadmill desks.
• Find ways to move that are enjoyable to you and fit your life. Yard work, walking your dog, playing tag with your kids, and going out dancing all count!

VIDEO: “ James Levine: ‘I Came Alive as a Person’ “ by NOVA’s Secret Life of Scientists and Engineers, YouTube (April 24, 2014), 3:04 minutes. This short video explains some of the research on NEAT and efforts to increase it in our lives

VIDEO: “ The Weight of the Nation: Poverty and Obesity” by HBO Docs, YouTube (May 14, 2012), 24:05 minutes.

VIDEO: “ The Weight of the Nation: Healthy Foods and Obesity Prevention” by HBO Docs, YouTube (May 14, 2012), 31:11 minutes. These segments from the HBO documentary series, “The Weight of the Nation,” explore some of the causes and potential solutions for obesity.

References:

• 1 CDC. (2019, September 12). New Adult Obesity Maps. Retrieved October 30, 2019, from Centers for Disease Control and Prevention website: https://www.cdc.gov/obesity/data/prevalence-maps.html
• 2 CDC. (2019, January 31). Adult Obesity Facts | Overweight & Obesity | CDC. Retrieved October 30, 2019, from https://www.cdc.gov/obesity/data/adult.html
• 3 Trust for America’s Health. (2019). The State of Obesity: Better Policies for a Healthier America . Retrieved from https://www.tfah.org/report-details/stateofobesity2019/
• 4 Swinburn, B. A., Kraak, V. I., Allender, S., Atkins, V. J., Baker, P. I., Bogard, J. R., … Dietz, W. H. (2019). The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. The Lancet , 393 (10173), 791–846. https://doi.org/10.1016/S0140-6736(18)32822-8
• 5 UNICEF. (2019). The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world . New York.
• 6 Jaacks, L. M., Vandevijvere, S., Pan, A., McGowan, C. J., Wallace, C., Imamura, F., … Ezzati, M. (2019). The obesity transition: Stages of the global epidemic. The Lancet Diabetes & Endocrinology , 7 (3), 231–240. https://doi.org/10.1016/S2213-8587(19)30026-9
• 7 Townshend, T., & Lake, A. (2017). Obesogenic environments: Current evidence of the built and food environments. Perspectives in Public Health , 137 (1), 38–44. https://doi.org/10.1177/1757913916679860
• 8 Pan, L., Sherry, B., Njai, R., & Blanck, H. M. (2012). Food Insecurity Is Associated with Obesity among US Adults in 12 States. Journal of the Academy of Nutrition and Dietetics , 112 (9), 1403–1409. https://doi.org/10.1016/j.jand.2012.06.011
• 9 CDC. (2019, June 18). Community Efforts | Overweight & Obesity | CDC. Retrieved October 30, 2019, from https://www.cdc.gov/obesity/strategies/community.html
• 10 Bleich, S. N., Economos, C. D., Spiker, M. L., Vercammen, K. A., VanEpps, E. M., Block, J. P., … Roberto, C. A. (2017). A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior. Obesity (Silver Spring, Md.) , 25 (12), 2018–2044. https://doi.org/10.1002/oby.21940
• 11 Berry, C., Burton, S., Howlett, E., & Newman, C. L. (2019). Understanding the Calorie Labeling Paradox in Chain Restaurants: Why Menu Calorie Labeling Alone May Not Affect Average Calories Ordered. Journal of Public Policy & Marketing , 38 (2), 192–213. https://doi.org/10.1177/0743915619827013
• 12 Dallas, S. K., Liu, P. J., & Ubel, P. A. (2019). Don’t Count Calorie Labeling Out: Calorie Counts on the Left Side of Menu Items Lead to Lower Calorie Food Choices. Journal of Consumer Psychology, 29(1), 60–69. https://doi.org/10.1002/jcpy.1053
• 13 Theis, D. R. Z., & Adams, J. (2019). Differences in energy and nutritional content of menu items served by popular UK chain restaurants with versus without voluntary menu labelling: A cross-sectional study. PLOS ONE , 14 (10), e0222773. https://doi.org/10.1371/journal.pone.0222773
• 14 Public Health England. (2019). Sugar reduction: Report on progress between 2015 and 2018 . Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832182/Sugar_reduction__Yr2_progress_report.pdf

Image Credits

• Figure 9.17. “Obesity Trends Among U.S. Adults, BRFSS, 1990-2010” by Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention is in the Public Domain
• Figure 9.18. “Prevalence of self-reported obesity among U.S. adults in 2011 and 2018” by Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion , Centers for Disease Control and Prevention is in the Public Domain
• Figure 9.19. “Trends in obesity prevalence” by National Center for Health Statistics is in the Public Domain
• Figure 9.20. Elements of obesogenic environment: “wocintech” by WOCinTech Cha is licensed under CC BY 2.0 ; “Perfect timing” by Tamara Menzi , Unsplash is in the Public Domain, CC0 ; “Vending machines” by Purchase College Library is licensed under CC BY-NC 2.0
• Figure 9.21. Farmers markets. “group of people standing near vegetables” by Megan Markham is in the Public Domain, CC0 ; “Veggies at Corvallis Farmers Market” by Friends of Family Farmers is licensed under CC BY-ND 2.0
• Figure 9.22. Menu labeling. “Ballpark Calorie Counting” by Kevin Harber is licensed under CC BY-NC-ND 2.0
• Figure 9.23. Increasing physical activity. “Early bird” by Jorge Vasconez is in the Public Domain, CC0 ; “boy running to the future” by Rafaela Biazi is in the Public Domain, CC0 ; “people riding bicycles inside bicycle lane beside skyscraper” by Steinar Engeland is in the Public Domain, CC0

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Childhood and Adolescent Obesity in the United States: A Public Health Concern

Adekunle sanyaolu.

1 Federal Ministry of Health, Abuja, Nigeria

Chuku Okorie

2 Essex County College, Newark, NJ, USA

3 Saint James School of Medicine, Anguilla, British West Indies

Jennifer Locke

Saif rehman.

Childhood and adolescent obesity have reached epidemic levels in the United States. Currently, about 17% of US children are presenting with obesity. Obesity can affect all aspects of the children including their psychological as well as cardiovascular health; also, their overall physical health is affected. The association between obesity and other conditions makes it a public health concern for children and adolescents. Due to the increase in the prevalence of obesity among children, a variety of research studies have been conducted to discover what associations and risk factors increase the probability that a child will present with obesity. While a complete picture of all the risk factors associated with obesity remains elusive, the combination of diet, exercise, physiological factors, and psychological factors is important in the control and prevention of childhood obesity; thus, all researchers agree that prevention is the key strategy for controlling the current problem. Primary prevention methods are aimed at educating the child and family, as well as encouraging appropriate diet and exercise from a young age through adulthood, while secondary prevention is targeted at lessening the effect of childhood obesity to prevent the child from continuing the unhealthy habits and obesity into adulthood. A combination of both primary and secondary prevention is necessary to achieve the best results. This review article highlights the health implications including physiological and psychological factors comorbidities, as well as the epidemiology, risk factors, prevention, and control of childhood and adolescent obesity in the United States.

Introduction

Childhood and adolescent obesity have reached epidemic levels in the United States, affecting the lives of millions of people. In the past 3 decades, the prevalence of childhood obesity has more than doubled in children and tripled in adolescents. 1 The latest data from the National Health and Nutrition Examination Survey show that the prevalence of obesity among US children and adolescents was 18.5% in 2015-2016. Overall, the prevalence of obesity among adolescents (12-19 years; 20.6%) and school-aged children (6-11 years; 18.4%) was higher than among preschool-aged children (2-5 years; 13.9%). School-aged boys (20.4%) had a higher prevalence of obesity than preschool-aged boys (14.3%). Adolescent girls (20.9%) had a higher prevalence of obesity than preschool-aged girls (13.5%; Figure 1 ). 1 Moreover, the rates of obesity have been steadily rising from 1999-2000 through 2015-2016 ( Figure 2 ). 1 According to Ahmad et al, 80% of adolescents aged 10 to 14 years, 25% of children younger than the age of 5 years, and 50% of children aged 6 to 9 years with obesity are at risk of remaining adults with obesity. 2

Prevalence of obesity among children and adolescents aged 2 to 19 years, by sex and age: the United States, 2015-2016.

Trends in obesity prevalence among children and adolescents aged 2 to 19 years: the United States, 1999-2000 through 2015-2016.

Obesity can affect all aspects of children and adolescents including but not limited to their psychological health and cardiovascular health and also their overall physical health. 3 The association between obesity and morbid outcomes makes it a public health concern for children and adolescents. 4 Obesity has an enormous impact on both physical and psychological health. Consequently, it is associated with several comorbidity conditions such as hypertension, hyperlipidemia, diabetes, sleep apnea, poor self-esteem, and even serious forms of depression. 5 In addition, children with obesity who were followed-up to adulthood were much more likely to suffer from cardiovascular and digestive diseases. 3 The increase in body fat also exposes the children to increase in the risk of numerous forms of cancers, such as breast, colon, esophageal, kidney, and pancreatic cancers. 6

Due to its public health significance, the increasing trend in childhood obesity needs to be closely monitored. 7 However, these trends have proved to be challenging to quantify and compare. While there are many factors and areas to consider when discussing obesity in children and adolescents, there are a few trends that are evident in recent studies. For example, the prevalence of obesity varies among ethnic groups, age, sex, education levels, and socioeconomic status. A report published by the National Center for Health Statistics using data from the National Health and Nutrition Examination Survey provides the most recent national estimates from 2015 to 2016 on obesity prevalence by sex, age, race, and overall estimates from 1999-2000 through 2015-2016. 1 Prevalence of obesity among non-Hispanic black (22.0%) and Hispanic (25.8%) children and adolescents aged 2 to 19 years was higher than among both non-Hispanic white (14.1%) and non-Hispanic Asian (11.0%) children and adolescents. There were no significant differences in the prevalence of obesity between non-Hispanic white and non-Hispanic Asian children and adolescents or between non-Hispanic black and Hispanic children and adolescents. The pattern among girls was similar to the pattern in all children and adolescents. The prevalence of obesity was 25.1% in non-Hispanic black, 23.6% in Hispanic, 13.5% in non-Hispanic white, and 10.1% in non-Hispanic Asian girls. The pattern among boys was similar to the pattern in all children and adolescents except that Hispanic boys (28.0%) had a higher prevalence of obesity than non-Hispanic black boys (19.0%; Figure 3 ). 1 This review article is aimed at studying the health implications including physical and psychological factors and comorbidities, as well as the epidemiology, risk factors, prevention, and control of childhood and adolescent obesity in the United States.

Prevalence of obesity among children and adolescents aged 2 to 19 years, by sex and race and Hispanic origin: the United States, 2015-2016.

Methodology

We performed a literature search using online electronic databases (PubMed, MedlinePlus, Mendeley, Google Scholar, Research Gate, Global Health, and Scopus) using the keywords “childhood,” “adolescents,” “obesity,” “BMI,” and “overweight.” Articles were retrieved and selected based on relevance to the research question.

Ethical Approval and Informed Consent

Ethics approval and informed consent were not required for this narrative review.

Definition of Childhood Obesity

Defining obesity requires a suitable measurement of body fat and an appropriate cutoff range. 8 Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared, rounded to 1 decimal place. Obesity in children and adolescents was defined as a BMI of greater than or equal to the age- and sex-specific 95th percentile and overweight with a BMI between the 85th and 95th percentiles of the 2000 Centers for Disease Control and Prevention (CDC) growth charts. 9

However, the use of the BMI percentile according to the age/sex of the CDC growth charts for very high BMIs can result in estimates that differ substantially from those that are observed, 10 , 11 and this constrains the maximum BMI that is attainable at given sex and age. 12 , 13 These limitations have resulted in the classification of severe obesity as a BMI ≥120% of the 95th percentile rather than a percentile greater than the 95th percentile. 11 , 14 A BMI of 120% of the 95th percentile corresponds to a BMI of ~35 among 16 to 18 year olds.

Physiology of Energy Regulation and Obesity

Obesity is a chronic multifactorial disease, characterized by an excessive accumulation of adipose tissue, commonly as a result of excessive food intake and/or low energy expenditure. Obesity can be triggered by genetic, psychological, lifestyle, nutritional, environmental, and hormonal factors. 15

Obesity is found in individuals that are susceptible genetically and involves the biological defense of an elevated body fat mass, the mechanism of which could be explained in part by interactions between brain reward and homeostatic circuits, inflammatory signaling, accumulation of lipid metabolites, or other mechanisms that impair hypothalamic neurons. 16

Normal energy regulation physiology is under tight neurohormonal control. The neurohormonal control is performed in the central nervous system through neuroendocrine connections, in which circulating peripheral hormones, such as leptin and insulin, provide signals to specialized neurons of the hypothalamus reflecting body fat stores and induces appropriate responses to maintain the stability of these stores. The hypothalamic region is where the center of the regulation of hunger and satiety is located. Some of them target the activity of endogenous peptides, such as ghrelin, pancreatic polypeptide, 17 peptide YY, and neuropeptide Y, 18 as well as their receptors.

The physiology of energy regulation may result in obesity in susceptible people when it goes awry from genetic and environmental modulators. There is strong evidence of the majority of obesity cases that are associated with central resistance to both leptin and insulin actions. 19 , 20 The environmental modulators equally play critical roles in obesity. Changes in the circadian clock are associated with temporal alterations in feeding behavior and increased weight gain. 21 Stress interferes with cognitive processes such as executive function and self-regulation. Second, stress can affect behavior by inducing overeating and consumption of foods that are high in calories, fat, or sugar; by decreasing physical activity; and by shortening sleep. Third, stress triggers physiological changes in the hypothalamic-pituitary-adrenal axis, reward processing in the brain, and possibly the gut microbiome. Finally, stress can stimulate the production of biochemical hormones and peptides such as leptin, ghrelin, and neuropeptide Y. 17

The lateral hypothalamus (LH) plays a fundamental role in regulating feeding and reward-related behaviors; however, the contributions of neuronal subpopulations in the LH are yet to be identified thoroughly. 22 The LH has also been associated with other aspects of body weight regulation, such as physical activity and thermogenesis. 23 The LH contains a heterogeneous assembly of neuronal cell populations, in which γ-aminobutyric acid (GABA) neurons predominate. 23 LH GABA neurons are known to mediate multiple behaviors important for body weight regulation, thus altering energy expenditure. 23

Etiology and Risk Factors

Excess body fat is a major health concern in childhood and adolescent populations. The dramatic increase in childhood obesity foreshadows the serious health consequences of their adult life. As obesity begins from childhood and spans through adult life, it becomes increasingly more difficult to treat successfully. Being able to identify the risk factors and potential causes of childhood obesity is one of the best strategies for preventing the epidemic. 24

According to the Morbidity and Mortality Weekly Report released in 2011, there is an acceptance that there is no single cause of childhood obesity and that energy imbalance is just a part of the numerous factors. 25 Many children have a discrepancy between what is taken in and what is expended. 26 For example, children with obesity consume approximately 1000 calories more than what is necessary for their body to function healthily and to be able to participate in regular physical activities. Over 10 years, there will be an excess of 57 pounds of unnecessary weight. With excessive caloric intake, as well as sedentary lifestyles, childhood obesity will continue to rise if no changes are implemented. Adding daily physical activity, better sleep patterns, as well as dietary changes can help decrease the number of excess calories and help with obesity-related problems in the future.

Also, during childhood, excess fat accumulates when the increase in caloric intake exceeds the total energy expenditure. 26 Furthermore, children living in the United States today compared with children living in the 1900s are participating in more than 6 hours per day activities on social media. This includes but is not limited to traditional television, video gaming, and blogging/Facebook activities. An additional economic rationalization for the increase in childhood obesity is technology. In other words, Americans can now eat more in less time.

In a study, Cutler et al found that an increase in consumption of food tends to be related to technology innovation in food production and transportation. Technology has thus made it increasingly possible for firms to mass prepare food and ship to consumers for ready consumption, thereby taking advantage of scale economies in food preparation. The result of this change has been a significant reduction in the time costs for food production. These lower time costs have led to increased food consumption and, ultimately, increased weights. 27 Eliminating the time cost of food preparation disproportionately increases consumption for hyperbolic discounters because time delay is a particularly important mechanism for discouraging those individuals from consuming. 27 Society today prefers immediate satisfaction with regard to food and convenience over the long-term goals of living a long, healthy life. The availability of high-caloric, less-expensive food coupled with the extensive advertisement and easy accessibility of these foods has contributed immensely to the rising trend of obesity. 28 For example, there have been reductions in the price of McDonalds and Coca-Cola (5.44% and 34.89%, respectively) between 1990 and 2007, while there was about a 17% increase in the price of fruits and vegetables between 1997 and 2003. 29

Likewise, only 16% of children walk or bike to school today as compared with 42% in the late 1960s. However, the distance, convenience, weather, scanty sidewalks, and anxiety about crimes against children could all contribute to this difference. Furthermore, with elementary, middle, and high school combined, only 13.8% of these schools provide adequate daily physical education classes for at least 4 hours a week. 30

Some other potential risk factors have been reported through research studies that involve issues that affect the child in utero and childhood. Table 1 represents potential risk factors and confounders of childhood obesity. 31

Potential Risk Factors of Childhood Obesity.

Abbreviations: BMI, body mass index; SES, socioeconomic status.

Catalano et al argues that maternal BMI before conception, independent of maternal glucose status or birth weight, is a strong predictor of childhood obesity. 32 Infants at the highest quarter for weight at 8 and 18 months are more likely to become children with obesity at age 7, than children in the lower quarters. Certain behaviors have been linked to childhood obesity and overweight; these are a lack of physical activity and unhealthy eating patterns (eating more food away from home, drinking more sugar-sweetened drinks, and snacking more frequently), resulting in excess energy intake. 22 , 31 In addition, when one parent presents with obesity, there is an increased potential for the child to become obese over the years. Naturally, the risk is higher for the children when both parents present with obesity. Furthermore, a study that followed children over time observed that children who got less sleep <10.5 hours at age 3 were 45% more likely to be children with obesity at the age of 7, than children who got greater than 12 hours of sleep during their first 3 years of life. 33 , 34

While all the above-mentioned factors are informative, there is still the need for further research concerning childhood and adolescent obesity and obesity in general. Risk factors for obesity in childhood are still somewhat uncertain, and evidence-based research for preventative strategies is lacking. Moreover, effective action to prevent the childhood obesity epidemic requires evidence-based on early life risk factors, and this evidence, unfortunately, is still incomplete. Furthermore, a research study has attempted to capture the complete picture of childhood obesity early life course risk factors. In the study, they identified that parental BMI and gestational weight gain among other factors should be considered in prevention programs. 35

Health Effects of Childhood Obesity

Childhood obesity is known to have a significant impact on both physical and psychological health. Sahoo et al stated that “childhood obesity can profoundly affect children’s physical health, social and emotional well-being, as well as self-esteem.” They associated poor academic performance and a lower quality of life experienced by the child with childhood obesity. They also stated that “metabolic, cardiovascular, orthopedic, neurological, hepatic, pulmonary, and menstrual disorders among others are consequences of childhood obesity.” 36 There are many health consequences of childhood obesity, and three of the more common ones are sleep apnea, diabetes, and cardiovascular diseases. 36

Psychological Consequences of Obesity

Several studies related to childhood and adolescent obesity have focused primarily on physiological consequences. Other studies have been conducted regarding the association between psychiatric disorders and obesity; these have resulted in conflict due to obesity being found to be an insignificant factor for psychopathology. However, a comparative study by Britz et al found that high rates of mood, anxiety, somatoform, and eating disorders were detected among children with obesity. The study also observed that most psychiatric disorders began after the onset of obesity. In this large population-based study, it was found that a staggering 60% of females and 35% of males reported that they have engaged in binge eating and expressed a lack of control over their diet. 37

Goldfield et al conducted a study among 1400 adolescents with obesity, overweight, and normal weight in grades 7 to 12. Their BMIs, as determined by the International Obesity Task Force, were the criteria used to define each group. Each participant completed a questionnaire on body images, eating behaviors, and moods. Adolescents with obesity reported significantly higher body dissatisfaction, social isolation, depression symptoms, anhedonia, and negative self-esteem than those of normal weight. 38 There is widespread stigmatization of people with obesity that causes harm rather than the intention to motivate people to lose weight. Stigma contributes to behaviors such as binge eating, social isolation, avoidance of health care services, decreased physical activity, and increased weight gain, which worsens obesity and creates additional barriers to healthy behavior change. 39 Weight-based bullying in youth is considered a common, serious problem in many countries. 40 In a study conducted by O’Brien et al, to test whether the association between weight stigma experiences and disordered eating behaviors, that is, emotional eating, uncontrolled eating, and loss-of-control eating, are mediated by weight bias internalization and psychological distress among 634 undergraduate university students, and results of statistical analyses showed that weight stigma was significantly associated with all measures of disordered eating, and with weight bias internalization and psychological distress. 41

Asthma and Obesity

There is mounting evidence that childhood obesity is a risk factor for the development of asthma. 42 A research study was conducted by Belamarich et al to investigate 1322 children aged 4 to 9 years with asthma. Obesity, as defined by the CDC, is the BMI, with weight and height being greater than the 95th percentile. This was the criteria used to identify the 249 children with obesity, while the BMI between the 5th and 95th percentile identified the children who were not obese. After a baseline assessment was done, the 9-month study found that the children with obesity had a higher number of days of wheezing over 2 weeks (4.0 vs 3.4) and as well had more unscheduled emergency hospital visits (39% vs 31%). 42

Obesity directly correlates with the severity of asthma, as well as poor response to corticosteroids. 43 In fact, children with obesity who also have a history of asthma are more challenging to control and linked to worse quality of life. 44 A prospective trial found that weight loss in patients with obesity and a history of asthma can significantly aid them to control the asthma attacks. 43

Chronic Inflammation and Childhood Obesity

Lumeng and Saltiel reported that obesity in children affects multiple organ systems and predisposes them to diseases. The effect of obesity on the tissue can manifest in the development of insulin-resistant type 2 diabetes, the risk of cancer, and pulmonary diseases. 45

The inflammatory response to obesity triggers pathogens, systematic increases in circulatory inflammatory cytokines, and acute-phase reactants (eg, C-reactive proteins), which inflames the tissues. This is often caused by the activation of tissue leukocytes. Chronic inflammation in children with obesity can induce meta-inflammation that is unique when compared with other inflammatory paradigms (eg, infection, autoimmune diseases). 45 Researchers have reported that children with obesity are at risk of lifelong meta-inflammation. In these children, the inflammatory markers are elevated as early as in the third year of life. 45 , 46 This has been linked to heart disease later in life. 19 The long-term consequences of such findings can cause cumulative vascular damage that correlates with the increased weight status. 47

The short-term and long-term effects of obesity on the health of children is a significant concern because of the negative psychological and health consequences. 46 The potential negative psychological outcomes are depressive symptoms, poor body image, low self-esteem, a risk for eating disorders, and behavior and learning problems. Additional negative health consequences include insulin resistance, type 2 diabetes, asthma, hypertension, high total, and low-density lipoprotein cholesterol and triglyceride levels in the blood, low high-density lipoprotein cholesterol levels in the blood, sleep apnea, early puberty, orthopedic problems, and nonalcoholic steatohepatitis 46 , 47 ( Figure 4 ). Children with obesity are more likely to become adults with obesity, thus increasing their risk for several diseases before they even reach their teen years. 48

Comorbidities and potential health consequences of childhood obesity. 47

Prevention and Control

There are two primary components to the prevention and control of childhood obesity.

The first is to educate parents on proper nutritional requirements for their children and the second is to implement the learned information. Educating parents on proper nutrition and dietary caloric intake requirements for their children is at the forefront for the prevention of obesity; however, the way the information is disseminated may affect the usefulness of the information. For example, one of the main limitations to the education of parents about childhood obesity is that typically written information is used as the conduit to health information and disease prevention. 49 The Growing Right Onto Wellness (GROW) trial used a systematic assessment of patient education material that was used for the prevention of childhood obesity in the low health literate population. 49 Results suggest that the average readability is of grade 6 level (SMOG [Simple Measure of Gobbledygook] Index 5.63 ± 0.76 and Fry graph 6.0 ± 0.85) and that adjustment of education material must be done for low health literate populations to adequately comprehend educational material and maintain motivation on the prevention of childhood obesity. 49 A similar study was conducted to further support this improvement when using color-coordinated diagrams to help parents visualize instead of trying to comprehend with numbers and words. It proved to be successful as parents were able to see where they were going wrong and make the necessary changes in their children’s diet. 49

Similarly, the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development conducted a study on 744 adolescents and parents, and analyzed data to determine if parental (maternal and paternal, individually) reactions to children’s behavior was related to childhood obesity. 50 The study concluded that informing parents that their attitude toward their children’s behaviors will play a prominent role in preventing childhood obesity. 50 Parental education on nutrition, health, and the involvement of politicians, physicians, and school personnel are key for the prevention of childhood obesity. However, community and educational institutions have begun legislating and incorporating programs such as providing healthy foods at schools and also health information sessions directed toward young individuals, aimed at preventing childhood obesity in the United States and Canada. 51

Another effective prevention measure against childhood obesity is the awareness of parents on the meal and snack portion sizes. In a systematic review conducted on the effects of portion size manipulation with children and portion education/training interventions on dietary intake with parents, it was determined that the ability of adults to accurately estimate portion size improved following education/training. 52 Education of parents and children on diet requirements has its limitations in that the information must be easy to understand and be easily accessible in order to be practical. Making the available education materials easier to understand from just tables and numbers to more relatable aspects such as colors or figures, parents were able to visualize the changes they need to make whether it is with regard to portion sizes or even seeing how much childhood obesity is present in their family. Although much of the literature provided to parents is targeted to help those with lower numeracy skills, many parents benefited from the information being comparative from right/wrong and good/bad with regard to dieting. 49

The study recommended that proper educational materials, including useful and understandable literature, be used to control meal portion sizes and to help parents identify when children are at risk of obesity. Similarly, healthy eating practices should be taught by schools as a mandatory and essential method in the prevention of childhood obesity. 52

The implementation of healthy eating practices and adequate exercise regimes are essential in the prevention and control of childhood obesity. For example, information from systematic reviews, randomized controlled trials, and well-designed observational studies indicate that evidence-based prevention and control of childhood obesity can be accomplished with the collaboration of community/school, primary health care, and home-based/family-based interventions that involve both physical activity and dietary component. 53 In particular, the control of children with obesity is of significant value, as is the prevention of obesity. Two randomized control trials of 182 families were conducted from November 2005 to September 2007, and they studied the efficacy of US pediatric obesity treatment guidelines in children aged 4 to 9 years with a standardized BMI (ZBMI) greater than the 85 percentile. 54 Briefly, Trial 1 studied the impact on ZBMI by reducing snack foods and sugar-sweetened beverages and increasing fruits, vegetables, and low-fat dairy. 54 Trial 2 studied the impact on ZBMI by decreasing sugar-sweetened beverages and increasing physical activity and increasing low-fat milk consumption and reducing television watching. In Trial 1, the resulting ZBMI reduced within 6 months, and this was maintained through to the 12th month (ΔZBMI 0-12 months = −0.12 ± 0.22). 53 In Trial 2, the resulting ZBMI reduced within 6 months and continued to improve till the 12 months (ΔZBMI 0-12 months = −0.16 ± 0.31). 50

A similar cluster-randomized trial in England studied the effects of the reduction of carbonated beverages on the number of children with obesity in 29 classes (644 children). 51 Results indicate that a decrease of 0.6 glasses of carbonated drinks (250 mL) over three days per week decreased the number of children with obesity by 0.2%, while the control group increased by 7.5% (mean difference = 7.7%, 2.2% to 13.1%) at 12 months. However, diet control is only one component of the control and prevention of childhood obesity, while adequate exercise is another. 55

A systematic review and meta-analyses of the impact of diet and exercise programs (single or combined) was done on their effects on metabolic risk reduction in the pediatric population. 56 Analyses indicated that the addition of exercise to dietary intervention led to greater improvements in the levels of high-density lipoprotein cholesterol (3.86 mg/dL; 95% confidence interval [CI] = 2.70 to 4.63), fasting glucose (−2.16 mg/dL; 95% CI = −3.78 to −0.72), and fasting insulin (−2.75 µIU/mL; 95% CI = −4.50 to −1.00) over 6 months. 56 Diet and exercise are both important factors in the control and prevention of childhood obesity. It is our recommendation that parents and community (teachers and doctors) should be involved in identifying children at risk based on their BMI and participate in implementing practices such as good diet control through the reduction of sugary drinks, fatty foods, and also encouraging safe exercise programs to prevent and control childhood obesity in the society. 56

While all of the previous data express the more obvious prevention methods with regard to childhood obesity, it is imperative to note that ensuring that the whole family is involved in the intervention will yield the greatest results. 2 All current studies indicate that families must be included in childhood treatment of obesity. However, for the success of the child’s weight loss program, it is vital that the parents understand that the causes of obesity are often a mixture of four factors: genetic causes, parental habits, overeating, and poor exercise habits. Thus, instilling some responsibility on the parents and informing them that controlled food preparation, diet control, and family participation in physical activities will all assist in the treatment and control of obesity in their children. 2

Childhood obesity has increased significantly in recent decades and has quickly become a public health crisis in the United States and all over the world. Its increase in prevalence has provoked widespread research efforts to identify the factors that contributed to these changes. 57 Obesity starts with an imbalance between caloric intake and caloric expenditure. 58 Children with obesity are at greater risk of adult obesity; therefore, if we can educate and improve the health habits of families even before they start having children, this can help reduce the increasing rate of childhood obesity in the United States. Parents and caregivers with proper education on the causes and consequences of childhood obesity can help prevent childhood obesity by providing healthy meals and snacks, daily physical activity, and nutrition education to their family members. 59 Families need to take the approach of not adapting to their family being on a diet but more of a healthy lifestyle. A family’s home environment can influence children at a young age; therefore, making changes starting in the household early can educate and influence them to grow up healthy. Although prevention programs may be more expensive in the short term, the long-term benefits acquired through prevention are much more likely to save an even greater amount of health care costs. Not only will the children have a better childhood and self-esteem, but prevention programs can also decrease the incidence of cardiovascular diseases, diabetes, stroke, and possibly cancers in adulthood. 60 The overall need to decrease the obesity rate will help children and their families in the generations to come by building a healthy lifestyle and environment. In order to tackle the climbing obesity rate, overall health and lifestyle needs to be a priority as they balance one with the other. 49 While effective interventions to thwart childhood obesity still remain elusive, the sustainability of the interventions already in place will enable children and their families to adopt these important health behaviors as lifelong practices and improve their health. 58

Treatment of Obesity and the Physiology of Energy Regulation

As discussed previously, a variety of mechanisms participate in weight regulation and the development of obesity in children, including genetics, developmental influences (“metabolic programming” or epigenetics), individual and family health behaviors, and environmental factors. Among these potential mechanisms, only environmental factors are potentially modifiable during childhood and adolescence.

Unfortunately, despite intensive lifestyle modifications and support for healthy practices within the children’s environment, some children will continue to struggle with extreme excess weight and associated comorbidities. 61 , 62 Therefore, a combination of pharmacotherapy and lifestyle modification can be considered. 61 Overweight children should not be treated with medications unless significant, severe comorbidities persist despite lifestyle modification. The use of pharmacotherapy should also be considered in overweight children with a strong family history of type 2 diabetes or cardiovascular risk factors. Constant bidirectional communication between the brain and the gastrointestinal tract, as well as the brain and other relevant tissues (ie, adipose tissue, pancreas, and liver), ensures that the brain constantly perceives and responds accordingly to the energy status/needs of the body. This elegant biological system is subject to disruption by a toxic obesogenic environment, leading to syndromes such as leptin and insulin resistance, and ultimately further exposing individuals who are obese to further weight gain and type 2 diabetes mellitus. Currently, the only Food and Drug Administration–approved prescription drug indicated for the treatment of pediatric obesity is orlistat (Xenical; Genentech USA, Inc, South San Francisco, CA). 63 Orlistat works by inhibiting gastric and pancreatic lipases, the enzymes that break down triglycerides in the intestine. Moreover, imaging studies in humans are beginning to examine the influence that higher- order/hedonic brain regions have on homeostatic areas, as well as their responsiveness to homeostatic peripheral signals. With a greater understanding of these mechanisms, the field moves closer to understanding and eventually treating the casualties of obesity.

The number of children with obesity in the United States has increased substantially over the years; due to its public health significance, the increasing trends need to be closely monitored. While a complete picture of all the risk factors associated with obesity remains elusive, many of the studies agreed that prevention is the key strategy for controlling the current problem. Since the combination of diet, exercise, and physiological and psychological factors are all important factors in the control and prevention of childhood obesity, primary prevention methods should be aimed at educating the child and family and encouraging appropriate diet and exercise from a young age through adulthood while secondary prevention should be targeted at lessening the effect of childhood obesity by preventing the child from continuing unhealthy habits and obesity into adulthood. A combination of primary and secondary prevention is necessary to achieve the best results. Thus, a combined implementation of both types of preventions can significantly help lower the current prevalence of childhood and adolescent obesity in the United States. Failure to take appropriate actions could lead to serious public health consequences.

Author Contributions: AS: Contributed to conception and design; drafted manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

XQ: Contributed to the acquisition, analysis, and interpretation.

JL: Contributed to the acquisition, analysis, and interpretation.

SR: Contributed to the acquisition, analysis, and interpretation.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Who Is Responsible for the Obesity Epidemic in the USA? Thesis

Introduction, the summary of “don’t blame the eater” by david zinczenko, the summary of “what you eat is your business” by radley balko.

Obesity has become a widespread problem in the United States, causing a considerable amount of concern in the public health sector. The current public health report on the prevalence of this lifestyle condition shows that 32.2 percent of men and 35.5 percent of women suffer from obesity (DeBono, Ross and Berrang-Ford 747). This prevalence raises a lot of concern because obesity underlies other serious health conditions, including non-alcoholic fatty liver disease, sleep apnea, stroke, hypertension, cardiovascular disease, and diabetes mellitus.

Furthermore, obesity compromises the quality of the sufferers’ lives such as the reduced socialization and segregation from socioeconomic opportunities. Similarly, the trend of obesity in childhood as a source of public health concern cannot be overlooked. According to Singh et al. (682), the rates of childhood obesity in the United States have increased threefolds over the past three decades. This is an issue of public health concern that needs to be addressed before it explodes.

This paper evaluates the position of two articles authored by Zinczenko and Balko respectively. In his article “Don’t Blame the Eater”, Zinczenko exonerates the public from the blame for the high prevalence rate of obesity in the United States. He argues that the public should not be restricted on their right to choice of food. The second author, Balko, wrote an article titled: “What you eat is your business”. He places the responsibility for the increased rate of obesity on the public’s irresponsible eating behaviors. While the increasing rate of obesity and the risks it poses to the public continues to dominate the media, it is not known precisely who takes the major blame for this trend. However, the USDA’s Food Stamp Program appears to be responsible for this crisis as it fails to develop and implement policies that limit access to fast foods as they are the primary cause of obesity.

This article written by David Zinczenko appeared in the New York Times magazine on November 3, 2002. The author has blamed the government’s slackness in implementing policies to regulate the fast food industry as the main cause of the high rates of obesity. Zinczenko has also pointed at a declined social system as the other cause of the rise in obesity. With regard to the latter cause, he reflects how he had a poor health choice while growing up in the mid-1980s: ”Lunch and dinner, for me, was a daily choice between McDonald’s, Taco Bell, Kentucky Fried Chicken or Pizza Hut” (391).

The article has also outlined that the lack of harsh policies has encouraged eating junk food, as the ads on fast foods do not warn of the health consequences thereof. The ads do not also display the contents and caloric value of the products. As such, the article has blamed the government and public health stakeholders for the rising rate of obesity.

The article, authored by Radley Balko, has opposed the existing measures to put obesity on hold, which are ineffective as argued in this article. This author describes these measures and indicates the reasons for their ineffectiveness as taking away a sense of responsibility for their health from the public. He stipulates that people should take responsibility for their own food choices. The politics-driven strategies focus on the vendors of food rather than the fact that a lot of taxpayers’ money has been channeled towards these initiatives, which Balko (396) views as misplaced. According to Balko, this approach to fighting obesity is wrong. Such a political strategy should be aimed at intervening in various food choices that American consumers have access to. In this case, the government should endeavor to ensure that consumers own and take responsibility for their individual health. However, as Balko has noted: “we’re doing just the opposite” (396).

This article highlights the need for citizens to take responsibility for their food choices as a way of reducing the rates of obesity in the US. It blames the high rates of obesity on the approach to defining it as a public issue, as opposed to an individual issue. This, according to Balko, “transforms the US into a nation where citizens are… becoming less responsible for [their] own health and more responsible for everyone else’s” (396). In the conclusion of the article, Balko notes that the most effective strategy to deal with the issue of obesity is to ensure that this public health crisis has been removed from “the realm of public health” (397).

In my opinion, individuals should be responsible for the increasing rates of obesity. Health is a right for every person and in this regard, I am inclined to agree with Balko that we need to take responsibility for our own health. Nevertheless, the government should ensure a level playing ground for both fast-food chains and healthy food vendors. This can be achieved by regulating advertisements for both fast foods and healthy foods. In addition, the nutritional information on fast foods should be vetted accurately and conform to the set laws.

The strategy to address obesity in the United States should be two-sided. On one hand, the government needs to increase tax on fast foods and soda so that these establishments can embrace healthy food choices. On the other hand, insurance rates for obese people should be raised so that they can take responsibility for their health.

Balko, Radley. “What You Eat is Your Business.” Reason 2004: 395-397. Print.

DeBono, Nathaniel L, Nancy A Ross and Lea Berrang-Ford. “Does the Food Stamp Program Cause Obesity? A Realist Review and a Call for Place-based Research.” Health & Place 18.3 (2012): 747-756. Print.

Singh, Gopal K, et al. “Racial/Ethnic, Socioeconomic, and Behavioral Determinants of Childhoodand Adolescent Obesity in the United States: Analyzing Independentand Joint Associations.” AEP 18.9 (2008): 682-695. Print.

Zinczenko, David. “Don’t Blame the Eater.” New York Times 2002: 391-393. Print.

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Bibliography

IvyPanda . "Who Is Responsible for the Obesity Epidemic in the USA?" May 29, 2022. https://ivypanda.com/essays/who-is-responsible-for-the-obesity-epidemic-in-the-usa/.

• Writing Methods in by Zinczenko’s Article “Don’t Blame the Eater”
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Let Them Eat … Everything

In the age of Ozempic, the “fat activist” Virginia Sole-Smith is inspiring and infuriating her followers.

Virginia Sole-Smith at her home in Cold Spring, N.Y. Credit... Marisa Langley for The New York Times

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By Lisa Miller

• April 21, 2024

The sheet-pan chicken and roasted broccoli are out of the oven, and white rice is steaming on the stove. Virginia Sole-Smith, who has spent a decade writing about how women think and feel about their bodies — and how they pass along those feelings to their children through food — is about to serve dinner to her daughters, Violet, 10, and Beatrix, 6.

Sole-Smith tries not to be a short-order cook. “Respect the labor,” is how she puts it, reminding her children that if they don’t like what she has prepared, there’s other stuff to eat in the house. A pullout shelf in the pantry holds Tate’s chocolate chip cookies, Goldfish crackers, pea snaps, and chocolate kisses. There are raspberries and grape tomatoes in the fridge.

What Sole-Smith hopes to model, she said in a five-hour interview at her home in Cold Spring, N.Y., is “that you can be a mom who doesn’t live solely in service of other people.” That “you deserve time to yourself and that you’re a person with needs, that those needs matter.”

She ferries the girls’ plastic plates to the front-porch table, evading the miniature Bernedoodle, Penelope. A year ago, Sole-Smith published “Fat Talk: Parenting in the Age of Diet Culture,” a guide to helping parents grapple with their discomfort and anxiety about weight and food. At the moment when Ozempic-like drugs are enabling people to become thin, Sole-Smith has become one of the country’s most visible fat activists, calling out the bias and discrimination faced by people in bigger bodies, especially from doctors and research scientists.

She asserts her own right to be “fat,” the preferred adjective in her corner of the internet. In Sole-Smith’s house there are neither “good” or “bad” foods nor “healthy” or “unhealthy” ones; doughnuts and kale hold equivalent moral value and no one polices portion size. By relieving herself and her family of rules about eating, Sole-Smith believes she will have a better chance of raising children who are proud of their bodies, trust themselves to enjoy their food and leave the table when they’re full. She serves dessert and snacks, like Cheez-Its, along with the dinner entree; her kids can eat their meal in any order.

“Fat Talk” is, in a way, Sole-Smith’s manifesto of liberation from what nutritionists call “diet culture”: the enormous pressure American women, in particular, feel to be thin and to raise thin children. For many years, she covered health (including for The New York Times), and her reporting on the pursuit of thinness prompted her rejection of it.

For Sole-Smith, “diet culture” has come to symbolize all the crushing expectations under which American women live. In her Substack newsletter and podcast, Burnt Toast, she muses on whether hewing to a household budget , gardening only with native plants , or limiting kids’ screen time can be regarded as diets.

Sole-Smith separated from her husband Dan Upham last June, and in that upheaval has had to reconsider many family rituals, including dinner. Sole-Smith and Upham attempted a regular dinner hour — Upham said he considered it “sacrosanct” — but when they split, neither child wanted to come to the table at all. And then Sole-Smith hit on a fix: She released her kids from the pressure to politely converse by allowing them to read at the table.

At dinner on this cool night, each girl grabs a brownie and then, after a few bites of broccoli or chicken, wanders off to play on the large rocks that line the front lawn. As she eats, Sole-Smith wonders aloud whether heterosexual marriage itself might be a diet.

“There’s a thing with marriage where you’re like, ‘But he’s a good guy. But it’s pretty good. Like, this is fine. Like, I shouldn’t blow up our lives,’” she said. At the same time, she continued, “Shouldn’t I want more freedom than this?” Just as Sole-Smith progressed from trying to wrestle her body into thinness in her 20s to accepting herself at 42, she is also trying to relinquish the notion that marriage — “especially to this thin, attractive man who finds me sexy” — is a marker of success.

“We would all do a lot better to be less afraid of divorce, just as we would do a lot better to be less afraid of being fat,” she said. “What if you just let go?”

No Pro-Weight-Loss Comments Allowed

Sole-Smith has emerged as an inspirational, infuriating voice on the subject of bodies at a moment when there is no neutral zone. Since “Fat Talk” became a New York Times best seller last May, Burnt Toast has grown to nearly 50,000 subscribers — mostly white, straight, millennial mothers who have struggled with eating, body image, and weight. In Sole-Smith’s reader survey, about half of her audience identified as “fat.” On Burnt Toast no pro-weight-loss comments are allowed.

The most fervent 10 percent of Burnt Toast adherents pay $50 or more per year for extra content, which provides Sole-Smith an annual salary of about $200,000, twice as much as she ever made as a freelance writer. Her fans love her for giving them permission to stay off the scale at the doctor’s office and for teaching them how to talk to their kids about bodies and food. Amy Nemirow, a subscriber from suburban Philadelphia, said the community at Burnt Toast helps her “look in the mirror and appreciate how I look and what my body is capable of.”

Sole-Smith relies on scientific research to bolster her message. Data shows that being shamed about weight is linked to depression, anxiety and social isolation , as well as poor physical health . Significant weight loss through dieting is extremely hard to sustain . Bias from doctors can lead to avoidance of medical care and worse health outcomes. Eating disorders — including bingeing and anorexia — are common in people in larger bodies .

“The consequences are clearly demonstrated,” said Kelly Brownell, a professor emeritus of public policy at Duke University who has spent five decades studying obesity and its prevention. “They’re social in nature, psychological, and medical, too. When you add all that up, it clearly means that weight stigma is having an impact on health.”

The relationship between weight and health is extremely complex, and longitudinal studies can’t predict any individual’s vulnerability to disease. Still, decades of research demonstrates a strong association between excess fat and increased risk of five of the top 10 leading causes of death in the United States: cardiovascular disease , cancer , stroke , diabetes and liver disease . Doctors who focus on obesity are alarmed by the growing percentages of Americans who have it — 42 percent by the latest count .

“I think it’s possible to simultaneously hold in your mind that the condition of obesity is concerning, while at the same time protecting the rights of the people who have it,” Brownell said. “You can think of many other parallels, like depression or alcoholism, where you don’t want the people who have these things to be stigmatized — there are clearly negative effects of that — but it doesn’t mean you discount the ravages of those diseases.”

Like most internet personalities, Sole-Smith deploys her persona — a self-confident suburban mother with enviable hair and an obsession with gardening — in service of her battle cry: a body is not anyone else’s problem to solve. Sole-Smith does not dispute that in some cases, excess fat may contribute to disease, but she believes that weight stigma is “the foundation of everything about weight and health that nobody has been looking at for so long.” She is part of a fractious, vocal band of activists and advocates who argue that the real epidemic is bias, not obesity. Some reject even the word “obesity,” which is a medical diagnosis, as derogatory, too tangled with a long history of sexism and racism from doctors, advertisers, and health editors to be neutral.

What most riles readers who encounter Sole-Smith is the calm assurance with which she lays down arguments that seem to defy common sense. This is especially true when she talks about Oreos, as she has done many times, and did again when I asked her about them in Cold Spring. Her position is, in a way, the wedge that divides her fans from her haters and draws attention online. Sole-Smith says that parents need not be concerned about how many Oreos their children eat (the same goes for Halloween candy and ice cream), and when I asked her whether a boundary — say, three Oreos at a time — might be sensible, she pushed back.

“What happens when your kid goes on a play date to my house? I can tell you. Your kid eats nine Oreos,” she said. If parents put restrictions on foods, then children will never figure out how to eat according to their bodies’ own needs, she explained.

When she said such things publicizing her book, readers went mad. A short, positive review in the Washington Post garnered more than 1,700 comments, with an overwhelming number calling Sole-Smith silly, immoderate, and anti-science. “Just letting kids be fat is a form of abuse,” one reader wrote. In The Cut , one commenter, of more than 340, wrote, “It’s like saying kids will intuitively choose math lessons over cartoons and video games.”

But Sole-Smith is committed to her stance. At her last checkup, her blood work showed high cholesterol for the first time, and her doctor suggested she limit saturated fats and start baking cookies with margarine. She’s waiting to see her results “in a year when I’m not launching a book and getting divorced,” she said, with a small laugh. If her cholesterol warrants medication at her next visit, “then great. Medication,” she said. “But no. I will not pursue intentional weight loss to manage a cholesterol level.” As she sees it, the risks to her mental health by restricting her diet outweigh whatever other benefit she might gain.

‘What Your Body Is Meant to Be’

Sole-Smith was raised by divorced parents in Guilford, Connecticut, an affluent suburb of New Haven. Her mother, who is English, was an insurance executive. Her father was a political science professor at Yale, and later at the University of Pennsylvania. Marian Sole preferred a restaurant meal after a long day at work. Rogers Smith, an avid exerciser, would pat his belly when offered dessert and say, “TFA,” which meant, “too fat already.”

Through her father, Sole-Smith belongs to the family that founded H.D. Smith, a national pharmaceutical wholesaler acquired in 2018 by AmerisourceBergen. “It was the back story of my life, and it does shape my life,” Sole-Smith said. “It provides a lot of financial security for my family,” she added. “It is not a privilege I earned, and it is an enormous privilege.”

Sole-Smith started out in women’s magazines in the early 2000s, when “thin” equaled “healthy” and master cleanses were de rigueur. She didn’t consider herself a dieter, but she scheduled her workday around her trips to the gym, which in turn were timed around reruns of “The West Wing,” because, she said, “I could only stand to be on the treadmill if I was watching ‘The West Wing.’” She ran half marathons. “They were the ‘can you have it all’ years,” she said. “You’re going for the big job. You’re going for the perfect body. You’re going for the great marriage. You’re going for motherhood. You’re going for the perfect home.”

She did not begin to reconsider her relationship to food and fat until 2013, when Violet, then four weeks old, was diagnosed with a severe congenital heart defect. Violet required a dozen surgeries, and for most of the first two years of her life was fed through tubes. One consequence was that when she was physically strong enough, she did not know how to eat . Having been passively nourished for so much of her life, her brain did not recognize her appetite.

“The Eating Instinct: Food Culture, Body Image, and Guilt in America,” Sole-Smith’s first book, published in 2018, described how she learned to relinquish her fantasies about motherhood and nourishing her child so that Violet might survive. “The Eating Instinct” offered up “ intuitive eating ,” a feeding method established in the 1990s that was gaining traction among millennial parents. It suggested that all the old rules — “clean your plate” and “no dessert until after dinner” — might not apply. When Violet was 2, Sole-Smith and Upham had to overcome their acculturated anxieties about the sugar and fat in chocolate milk. Violet started drinking half a gallon each week.

In Cold Spring, Sole-Smith said she would write the book very differently today. For one thing, she was still using the words “obese” and “obesity” without qualification. And some part of her was blaming people in bigger bodies for a lack of discipline. “I was still thinking at that point that a fat body was a problem to solve,” she said, “versus this is what your body is meant to be.” “The Eating Instinct,” a quiet book, sold about 2,000 copies in print. “I do think being more clear on a provocative argument, versus asking careful questions about it, is just more marketable,” she said, in retrospect.

A Job Becomes a Calling

Sole-Smith didn’t have a moment of radicalization. It was more like a gradual shift in perspective. After “The Eating Instinct,” she began to encounter ideas she hadn’t previously grappled with, she said. She was already familiar with the work of the nutritionist Lindo Bacon , whose 2010 book, “Health at Every Size: The Surprising Truth About Your Weight,” challenged doctors to treat patients without recommending weight loss. Sole-Smith also knew Lisa DuBreuil, a clinical social worker in Boston who sees people with eating disorders. When introducing someone to fat activism, DuBreuil often starts by saying that “it’s normal for there to be a wide range of body sizes. That fat people have always existed,” she said in an interview. The relief and recognition can be very strong. Educating Sole-Smith was like watching a person “stepping out of the matrix,” she added.

In 2019, Sole-Smith read “Fearing the Black Body: The Racial Origins of Fat Phobia” by Sabrina Strings, a sociologist at the University of California, Santa Barbara, which reframes the cultural and medical concern about obesity as “a way to craft and legitimate race, sex, and class hierarchies.” Sole-Smith started to absorb the larger capitalist critique: Even fat activism had been co-opted by women’s magazines, advertisers, and fitness companies and turned into “body positivity,” a defanged version that “really centers, you know, ‘small fat’ white women like me,” Sole-Smith said, using the identifier she learned around then. Sole-Smith started to spell the word “ob*sity” wherever she could.

Sole-Smith began to feel that her freelance specialty, analyzing obesity research studies for editors at mainstream publications , was “just exhausting and not moving the needle.” She increasingly felt that discrimination was the problem, not proving or disproving that excess fat made people sick. “It doesn’t matter what people’s health status is. Right? Drug addicts are worthy of dignity and respect in medical care. Like, it doesn’t matter whether you caused it, doctors are supposed to meet you where you are,” Sole-Smith said in Cold Spring. Upham saw a change come over her. “When she was in magazines, that was a job. This felt more like a calling,” he said.

In September 2020, Sole-Smith wrote “ What If Doctors Stopped Prescribing Weight Loss ?” an article that evoked the analogy between weight stigma and racism. By then, she had given up trying to dress to de-emphasize her shape. She had moved, definitively, into plus sizes, and found freedom in finally accepting herself. She embraced horizontal stripes, conventionally proscribed for women in bigger bodies. It felt “a little subversive,” she said.

An Argument About Butter

Life in the Cold Spring house grew stressful as the pandemic wore on. The dog wouldn’t stop barking. Violet was attending second grade at her private school in a mask and mostly outdoors. Beatrix was 3. Sole-Smith was working on “Fat Talk” and building Burnt Toast. The extroverted Upham, who worked in communications, was going stir crazy in isolation. He had always been outdoorsy, hiking in the White Mountains or trail running in the Shawangunks. But now, cut off from his friends and two years into sobriety, he began running with urgency on the trails by their house. “I ran hundreds of miles,” he said. Child care was on the list of topics they argued about, Upham said.

For her part, Sole-Smith was newly aware of “the value of comfort eating,” she said. “We demonize it so much.” She began to think about all the ways that she and her friends had punished themselves by abstaining from food. “I deserve softness. I deserve a little tenderness,” she said. “Everything is chaos. It’s nice I can make brownies.”

In almost every respect, Upham had “an easy time” with Sole-Smith’s radicalization, he said. But he did find the notion of “de-prioritizing exercise” to be “challenging” — and not because he regards physical activity as a virtue. Hardcore exercise is his way of life. “It’s hard for me to see past that sometimes,” he said.

In the spring of 2021, with Americans exhausted and edgy and many only recently vaccinated, Sole-Smith emerged as a voice of reassurance. In April, she published a piece in Good Housekeeping saying she had no intention of getting her prepandemic body back. “When it’s safe to re-enter the world, my sweatpants are coming with me,” she wrote. When new studies reported trends of pandemic weight gain , Sole-Smith went on Brian Lehrer, the WNYC call-in show. “Anything you had to do for your mental health in the last year, whether that was more comfort eating, more sleep, more anything, that was a good choice for your health,” she told a listener who felt terrible about regaining the 50 pounds he lost before the pandemic.

It was around this time that she and Upham had an argument about butter. Beatrix had eaten a whole stick, “jammed it in her mouth,” Sole-Smith said in Cold Spring, because she thought it was cheese. Upham — whom Sole-Smith describes as more of a “rules guy” — wanted to intervene, but Sole-Smith disagreed. “If I put butter on the table and a kid wants to eat the butter, that’s fine with me,” Sole-Smith said. (Upham said he now regrets his response. He probably thought eating a whole stick of butter was “just disgusting,” he said, “but I really am on team calories.”)

Answering Critics By Eating Brownies

Ozempic became a national obsession in the winter of 2023, just as Sole-Smith was heading out to promote “Fat Talk,” giving her a foothold in the news cycle that she could not have anticipated. The more she became known for dismantling anti-fatness, the more editors and bookers invited her to give her opinion.

That January, Sole-Smith wrote an opinion piece for The New York Times responding to new guidelines issued by the American Academy of Pediatrics that recommended Ozempic-like drugs for a subset of obese children as young as 12. The first chapter of “Fat Talk” is titled “The Myth of the Childhood Obesity Epidemic,” and in her article, she wrote, “We cannot solve anti-fat bias by making fat kids thin.”

This view prompted an outcry. Dr. Barry Reiner, a pediatric endocrinologist in Baltimore, was “personally infuriated,” he said, and stayed up past midnight one night writing a letter to the editor . Historically, Type 2 diabetes has been an adult-onset disease, but “for the past several years, I’ve been seeing a lot more of it,” Dr. Reiner said. “These children are not going to have a healthy life, or a normal life span.” While it’s theoretically possible for a person to carry a lot of excess weight into maturity and remain healthy, “I think that’s a vast minority, maybe approaching a myth,” Dr. Reiner added.

In his newsletter ConscienHealth, Ted Kyle, who formerly worked in obesity policy for GlaxoSmithKline, called out Sole-Smith for ignoring facts, “which don’t melt away because our feelings are strong.” He linked to a study from Yale University that showed a rising prevalence of fatty liver disease during the pandemic among children with obesity — a condition that can lead to “liver cancer, cirrhosis, and death,” Kyle wrote.

Then, in April, Sole-Smith went on “Fresh Air” and offered a political analysis. “Celebrating a thin white body as the ideal body is a way to other and demonize Black and brown bodies, bigger bodies, anyone who doesn’t fit into that norm,” she said. Social media predictably exploded at this. On Fox, Greg Gutfeld mocked Sole-Smith’s “horrible, stupid” remarks. On the Reddit channel “ fatlogic ,” one person queried whether it wasn’t racist for “middle class white women to be casting themselves as the victims of racist violence and chattel slavery,” while another wondered, “Has she not seen black people that already are skinny/slim/fit? We’re not all ‘thick’ or obese.”

In May, after “Fat Talk” hit the best-seller list, Sole-Smith took a victory lap on Instagram . Wearing a bright pink dress, she posted some of the hate messages she had received. “I can see why you’re single. No one wants to spend time with a fat slob shoving pizza in her fat mouth,” read one. As these notes flashed across the screen, she ostentatiously ate a brownie.

Earlier in our conversation in Cold Spring, Sole-Smith talked about all the ways in which every person undermines their own health, by drinking alcohol, say, or opting out of the gym; even people who refuse to wear motorcycle helmets are freer from judgment than fat people, she said. During dinner, with the girls playing in the yard, this question of autonomy came up again, in a more philosophical way. I asked Sole-Smith what it meant to make less-than-optimal choices about personal health in the name of autonomy when others — children, family members, friends, a community — are dependent on you.

“Health is a resource and a privilege so many people don’t have access to,” Sole-Smith began. There are mothers who are substance users, older mothers, and mothers with congenital health conditions. No parent has an obligation to pursue good health, and to believe so “is fundamentally a very ableist perspective,” she said.

She continued, “Is health that I eat this broccoli for dinner? Or is health that I managed to have a few minutes of connection with my daughter today?”

Sole-Smith announced her separation in September in the most viral issue of Burnt Toast to date, but neither she nor Upham will say why they split. They had been together since high school, and Upham has been a character in Sole-Smith’s work at least since Violet was born. What Sole-Smith does say is that she’s become “deeply critical of the institution of marriage and what it asks from straight women.” In her writing and talking about marriage (and divorce) on Burnt Toast, she denounces the unequal division of emotional labor that so many women in her cohort complain of: the hours spent planning meals and communicating with teachers and arranging play dates in addition to their full-time jobs.

“Deciding to get divorced is terrible. Being divorced is amazing,” she said.

As Sole-Smith considers all the ways she is enjoying her release from what she calls “the hyper-competent oldest daughter in me,” she notices that Beatrix is beginning to shiver in her thin T-shirt. Another rule to which Sole-Smith fails to adhere is appropriate outerwear, she said, with a laugh. Her girls are always either overdressed or underdressed. She yells toward Beatrix. “Are you done with your chicken?” But Beatrix, wearing headphones, doesn’t hear. Sole-Smith leans down and gives Beatrix’s dinner to the dog.

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