As one who loves to eat, it is with some trepidation that I approach this subject of obesity. I’m probably considered overweight by those who determine these things, though I’m fairly confident I’m not obese. When I look down, I have an unobstructed view of my feet, and even though my inseam has not kept up with my waist size, I don’t weigh all that much more than I did when I graduated from high school 40 years ago. Maybe 20 pounds. Give or take 10 or 15. You know how it is.
At least I wasn’t fat as a kid. And neither were most of my generation. But that’s changed, and pretty dramatically.
The Centers for Disease Control and Prevention (CDC) has been conducting an extensive study, called the National Health and Nutrition Examination Survey, of American health since the 1950s. As a result, we have a clear picture of how we’ve changed, in both size and health. In the 1960s, 24.3 percent of American adults were overweight. “Overweight” is defined as having a body-mass index of more than 27. (Body mass = kilograms/meters2.)
According to this calculation, a six-foot-tall man is overweight if he weighs more than 204 pounds (uh-oh). A five-foot-tall woman is overweight if she weighs more than 140 pounds. Even though body-mass index is falling out of fashion as a measurement, it still serves well for comparison. Using that measurement, today over 60 percent of Americans are overweight. One might argue that the definitions are overly inclusive (some would say harsh). But the fact of the matter is, American men on average are 17 pounds heavier than in the late 1970s. American women on average are 19 pounds heavier.
More disturbing than us corpulent adults, however, are our kids—who are ballooning. The proportion of overweight children, age 6-11, has more than tripled since the CDC study began. According to Ruth Bindler, WSU College of Nursing, slightly more than 17 percent of youths aged 2-19 are above the 95th percentile in weight.
If being overweight were simply a matter of buying bigger clothes, no big deal. It’s the resulting health problems that concern Bindler and her research partner Kenn Daratha.
Bindler is a pediatric nurse and head of the College of Nursing’s doctoral program. Daratha is an assistant professor in the Informatics Program at WSU Spokane.
“We know that a huge percentage of obese children will become obese adults,” says Daratha.
Bindler and Daratha direct a multi-year USDA-funded project, called TEAMS (Teen Eating and Activity Mentoring in Schools), in an attempt to address what many consider an epidemic of overweight and obesity in this country. TEAMS engages 244 Spokane children in after-school exercise programs and as research subjects. The goal of the project is to improve the health of middle school students and prevent the development of obesity during adolescence.
Bindler and Daratha organize lacrosse games and snowshoe expeditions and take the children rock climbing at REI, in an attempt to reverse a distressing prevalence of ill-health indicators among increasingly younger children. An extension nutrition educator, Summer Goetz, provides nutritious snacks.
TEAMS is composed primarily of middle-school kids who have no other after-school opportunities.
“Two-thirds of our children are not meeting the daily recommendation of 60 minutes of moderate to vigorous physical activity,” says Daratha. “Two-thirds of the kids also spend in excess of two hours of entertainment screen time.” Daratha says encouraging physical activity is the most effective approach to countering overweight and related health problems. Changing dietary habits is considerably more difficult.
In spite of the program’s goals, “We were told initially that we weren’t going to get kids who are obese; they weren’t going to sign up,” says Bindler, obviously pleased that those kids proved the skeptics wrong. Half of the participants are overweight or obese, indicating a willingness to change behavior if provided the opportunity.
Many of the physical activities included in the study are ones that children haven’t had much exposure to, such as lacrosse. The reasoning is they’re provided a level playing field, with no initial skill advantage within the group.
One of the problems leading to decreased physical activity among the general school population is an increasing exclusivity. If a child decides at age 13 that he wants to start playing basketball, says Daratha, he is faced with peers who have been playing in organized leagues since they were five or six.
Add to that the decreasing opportunities in general. Responding to the need to cram in more instructional time in reading and math, schools have been dropping not only organized physical education classes, but recess. That trend is highest in lower income schools.
The current sport system is set up to benefit the kids who need it least, says Daratha. “We’re trying to involve as many kids as possible in physical activity.”
Bindler, Daratha, and others are particularly concerned about the prevalence of metabolic syndrome in adolescents. Metabolic syndrome is a diagnostic construct, a combination of indicators of diabetic risk. Increasingly, children are showing such signs as high blood pressure, hypertension, and insulin resistance.
In a recent paper, Bindler and Daratha note that girls are showing an alarming increase in waist circumference. “Waist circumference, a measure of abdominal adiposity,” they write, “has been associated with incidence of cardiovascular disease in adults. In children and adolescents, waist circumference has been identified as a predictor of insulin resistance.”
“The prediction now,” says Bindler, is that of babies born today, one in four boys, and one in three girls, will develop diabetes in their lifetime.”
The cumulative result of these obesity related health problems is even more startling.
“This is predicted to be the first generation where the kids are going to live shorter life spans than their parents,” says Bindler, referring to conclusions of a 2005 study published in the New England Journal of Medicine. According to the study, obesity has become so prevalent that the health problems associated with it are likely to affect people much earlier in life than is now the norm.
“Adults in their 40s are already having revascularization procedures,” says Daratha. Revascularization is a surgical procedure to restore proper oxygen and nutrients to the heart.
Daratha wonders whether 12-year-olds who already have hypertension and insulin resistance will even make it into their 40s.
“When will they need revasc? Twenties, thirties? Those are driving questions.”
Every time Bindler and Daratha’s team assesses a child, it captures over 100 pieces of information about his or her dietary habits.
“B vitamins, dairy consumption, blood pressure—there’s a tremendous depth of topics because of the commitment made early on,” Daratha continues. “So we’re really in an exciting phase,” with data ready for analysis.
Others working on the project include Sue Butkus, an extension nutritionist in Puyallup; Tom Power, head of WSU’s human development department; Mike Steele, a clinical psychologist who recently went to Auburn University; and Sarah Ullrich-French, an educational psychologist.
They also had a “host of students working for us this summer,” says Daratha, through a program they call Advancing the Science of Early Adolescent Health. In fact, Daratha introduces me to his two sons, both WSU students, who are working with the program. Kelvin is a junior in civil engineering. Kristopher is a freshman in pre-med.
Student employees learn to conduct literature searches and reviews, write literature reviews, formulate search hypotheses, and analyze data, says Daratha. “They report that to us, which forms the basis for papers we write during the academic year.”
How do pediatricians handle the epidemic? Do they understand what they’re dealing with?
“One thing we’re aiming to show,” says Bindler, “one doesn’t even need to do a blood test for lipids and insulin and glucose” to determine diabetic risk in the child. Blood pressure and weight status mirror what’s happening in the body.
It’s only recently, however, that pediatricians have shed their reluctance to label kids overweight or obese, she says. In the past, worrries that the family might be offended, or the child might suffer from resulting lack of self-confidence, overrode health concerns.
“Many times families think their child is normal because no one ever said anything to them.”
On the other hand, even pediatricians’ increasing willingness to address the problem offers only a partial solution, as only 38 percent of children are seen on an annual basis by a doctor.
With or without a doctor’s attention, a lot of overweight children are headed for the same problems suffered by those much older.
“We don’t know what long-term effect hypertension will have, when kids start out with it,” says Daratha.
It’s the same with diabetes, says Bindler. Consider the effects of diabetes—neurological changes, retinal problems, blindness, amputations. If a person starts to suffer the effects in 40s or 50s, that’s one thing.
“It is very different if you start at 19. The cost to our economy and our health care system is pretty astounding.”
According to a recent study released by the Centers for Disease Control and the nonprofit research group RTI International, overall obesity-related health spending has reached as much as $147 billion a year. Obesity is now responsible for 9.1 percent of medical expenditures, compared to 6.5 percent in 1998.
Americans may still be the portliest in the world, but other countries are catching up, including their children. Our obesity rate currently stands at 32 percent. But Great Britain is close behind at 27 percent. Even China is suffering from its newly discovered Western diet and its accompanying diseases. How is it that the World Health Organization is claiming that just in the last few years we’ve gone from under-nutrition to obesity being our biggest collective nutritional problem?
One of the more recent interesting books on our diet and health is Michael Pollan’s In Defense of Food, which follows closely on his popular Omnivore’s Dilemma. The latter is the object of WSU freshmen’s attention this fall in the Common Reading Program. Pollan will be visiting campus in January.
In his In Defense of Food, Pollan synthesizes a broad range of literature that addresses the subject of nutritional quality, from Marion Nestle’s provocative Food Politics to Harvey Levenstein’s insightful Paradox of Plenty. Pollan is hardly alone in arguing that as food has become increasingly refined, it has had a negative effect on our health. What he has accomplished is synthesizing an enormous amount of information on the effect of our current diet and placed it on the plate in front of us.
The most basic refinement of our food, of grain, has increased its storage life and makes it easier to digest. However, as grains are refined, by definition they lose their essential nutrients, including the germ and bran, leaving primarily carbohydrates. Refined carbohydrates have been implicated in chronic diseases, heart, disease, diabetes, and some cancers. But a more significant observation is what Pollan calls one of the simplest relationships among foods, the zero-sum: “If you eat a lot of one thing, you’re probably not eating a lot of something else.”
Bindler and Daratha are well aware of this relationship. About a third of the children in their study get the recommended amount of fruit each day. Only a tenth get the recommended amount of vegetables.
“And if you take away ketchup and French fries…” says Bindler.
Interest of the Consumer
“Economists tend to roll their eyes at Michael Pollan,” says economist Trenton Smith. “He ignores the benefits of processed foods,” such as storage life and the comparative ease of distribution.
“On the other hand, he seems to have the science right.”
Right enough at least for Smith, along with fellow economists Hayley Chouinard and Philip Wandschneider, to examine Pollan’s premise, that a diet composed largely of processed food can be hazardous to your health, from a market perspective.
In a recent paper, “Waiting for the Invisible Hand: Market Power and Endogenous Information in the Modern Market for Food,” the economists ask, “Should the nutritional quality of the modern American diet be viewed as the natural outcome of an efficient market?”
The authors approach this question a little differently than might be expected. They point out that they do not emphasize the usual culprits of market failure, namely the moral hazard associated with health insurance and agricultural subsidies. Among other things, agricultural subsidies, particularly for corn, have been blamed for the ubiquitous increase in the use of high fructose corn syrup and its resulting health effects.
Taking a different tack, the economists argue that “the market outcome we observe is the product of a costly information problem, which has been exacerbated historically by a number of key policy decisions.”
That costly information problem refers to our understanding of the food we eat. Citing classic economics papers, they lay out various relationships between consumer and consumed. “Search goods” are those that the consumer knows the quality of. The consumer thus will search for that good at the lowest price. Consumers do not know in advance the quality of “experience goods,” but only after the goods have been consumed.
And then there are “credence goods.”
“A credence good is a step beyond,” says Smith. “Even after you’ve consumed it, you don’t know the quality.” Credence goods represent much of our current processed food—which in turn represents much of the interior of the modern supermarket (to the exclusion only of the fresh food on its periphery) and just about everything you buy at a fast food restaurant.
Smith likens a credence good to car repair or modern medicine. The mechanic knows everything about your car. You know nothing. All you want is for your car to run. “With processed food, it’s much the same thing,” says Smith.
Who knows how that list of 39 mysterious ingredients is going to affect your future health? And what exactly is disodium guanylate? It can’t be bad for you if it’s listed as an ingredient, can it? So you eat whatever it is that contains the disodium guanylate, and the additive satisfies with miraculous effect some basic salt, fat, and sugar cravings. And all you can do is just hope that the “Good For You!” label is serious.
Smith and his colleagues point to a number of changes in our diet that have led to what they consider the dietary market breakdown. But what it boils down to is “costly search.” Time and literacy (and not just a casual version of either one) are required for a consumer to understand links between diet and health. Which fat is good, and which bad, for you this week? Was it unsaturated or… Can you remember?
Not only do experts disagree, but information on food labels is hardly forthcoming. There may be plenty of information on a package. But it offers little insight as to what effect the food might have on your health.
At this point, the authors suggest in a footnote a simpler term for the avoidance of “costly search,” and that is “habit.” In other words, it’s just too hard to figure out the link between processed food and its health merits, so consumers settle for the status quo.
< p>Perhaps an even stronger barrier to market change is the consumer’s acceptance of marketing and branding. “More Fiber!” sounds good when you just caught a soundbite about needing more fiber in your diet. And if your favorite brand of cereal adds “More Fiber” on its box, well, then, Grrrrreat!
Also, the nutritional information that consumers receive comes overwhelmingly from the producers themselves, through advertising. According to the USDA Economic Research Service, all USDA expenditures on nutrition education, evaluation, and demonstrations in 1997 added up to less than 5 percent of the amount spent by the industry on food advertising. Ask your children how much USDA nutritional information they picked up watching cartoons last weekend.
Smith points out that in the 1930s, in response to concerns over inconsistent quality in canned goods, Congress considered updating the 1906 Food and Drug Act to include a grading system. They proposed standards for canned foods signified by grades that could be placed on can labels by manufacturers.
Although manufacturers had supported an earlier watered-down version, they adamantly opposed more specific grading. The legislation was also opposed by mass circulation magazines such as Good Housekeeping, as food companies were their biggest advertisers.
“Placed in historical context,” the authors conclude, “it becomes apparent that the modern American epidemic of diet-related chronic illness is at least in part the product of a fundamental failure of the market to deliver high quality foods to the consumer.”
Still, they are optimistic about the possibility for change, citing recent policies requiring labeling of trans fatty acids, which are produced commercially through partial hydrogenation. Although we were formerly encouraged to eat trans fats, it was later discovered that they had no nutritional value and in fact were even worse than the feared saturated fats they were meant to replace.
It turns out that scientific truth on food labels can indeed lead to behavior change. Once the National Academy of Sciences determined that there is no safe level of commercially produced trans fat in the diet, that it leads to heart disease, nearly every trans-fat product on the market has been reformulated.
“That this transformation took place nearly a century after the widespread adoption of partially hydrogenated vegetable oils is a lesson that should not be lost in future efforts to remedy the credence problem with processed food products.”
Promoted as lower cost and healthier than butter and lard, partially hydrogenated vegetable oils were used to make margarine and Crisco. Butter and lard are once again perceived by many as superior not only in taste, but nutrition.
Smith, Chouinard, and Wandschneider propose two principles toward lessening the credence problem and improving the value of our food supply.
For their first principle, they cite their progenitor Adam Smith: “Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to only so far as it may be necessary for promoting that of the consumer.” Pretty radical stuff when applied to the mid-section of a typical supermarket.
Not only does this open the way to a natural preference for healthy food, if consumers can understand what they’re getting, they argue, it also implies “that the interests of large producers should not be given first—nor even, perhaps, last—priority when implementing new regulations.”
They also insist that food policy should be conservative, that it should err on the side of the natural, reflecting the conservative precautionary principle more generally observed in European health policy.
“There is no reason,” they argue, “food standards could not be developed that inform the consumer, in effect, of the extent of processing—how far removed this product is, if you will, from the foods your great grandmother ate.”
Gallery :: Vintage food advertisements
Sleep it off
by Cherie Winner :: Forget working off those extra pounds. If you really want to lose weight, put on some comfy sweats, set aside a block of time, ban all interruptions—and take a nap.
Better yet, get at least eight hours of sleep every night.
That’s the advice of Washington State University neuroscientist James Krueger, an expert on what goes wrong when we don’t get enough sleep. Besides dimming our ability to concentrate and making us more vulnerable to infections, sleep deprivation also stokes our appetite and ratchets down our metabolism—a perfect recipe for weight gain.
“We have an epidemic of obesity in this country because, in part, people aren’t sleeping,” says Krueger. Experiments done with human subjects have repeatedly shown a link between sleep loss and hunger. “If you restrict your sleep, you eat more and gain weight,” even though you’re active for more time each day. “If you get your proper amount of sleep, you actually eat less.”
With Eva Szentirmai and Levente Kapas of WSU Spokane, Krueger has investigated some of the small hormones that maintain the body’s three-way balance among sleep, the craving for calories (hunger), and how fast we burn calories (metabolic rate).
One hormone, ghrelin (GRAY-lin), makes us feel hungry and also inhibits sleep. Krueger’s research team recently discovered that a related hormone, obestatin (oh-be-STAT-in), does just the opposite: it inhibits food cravings and promotes sleep.
The hormonal mix in our systems regulates our behavior, but that regulation is a two-way street. Our behavior affects what hormones we produce. If you don’t get enough sleep, the hormonal mix changes to enhance your appetite and increase food-seeking behavior (in other words, you get the munchies). When you’re well-rested, the mix shifts toward more obestatin, which tamps down those hunger pangs.
To Krueger, it’s no coincidence that the nation has both a high rate of obesity and a high rate of sleep deprivation. It’s also no surprise that we’re seeing both problems starting early in life, he says. “Children are staying up and playing with their computers, so they’re voluntarily depriving themselves of sleep. As a consequence, they eat more and they’re getting heavy.”
It’s possible that sleep-deprived people eat more because they feel stressed, but Krueger says stress doesn’t fully account for the link between lack of sleep and increased hunger. In lab tests, rats stayed awake for days as they tapped a bar that sent current to an electrode implanted in a pleasure center in their brains. Like kids staying up late playing computer games, the rats voluntarily chose to skip sleep. They probably weren’t stressed about it as they would have been had the researchers prodded them to stay awake—and still they gained weight.
Krueger, who for years has been urging people to get more sleep, thinks the hunger connection might be what finally gets us to take our sleep needs more seriously. In our society, it’s common and even fashionable to shrug off sleep deprivation; but almost everyone is concerned about their weight.
A very curious thing happens when a person undergoes bariatric surgery, a procedure performed on the obese through which the stomach is reduced in size. Not only does the patient lose weight, he develops an appetite for fruits and vegetables and loses his fondness for sweets and fat. In fact, says neuro-endocrinologist Robert Ritter, evidence shows that weight loss following bariatric surgery is not due to smaller stomach size or mal-absorption. Rather, it’s an endocrine change, though why is not yet understood.
“If we can mimic endocrine change, we don’t need the knife anymore,” says Ritter.
That “if,” though, is a big one.
Communication between the brain and the gastrointestinal tract can be very complicated. That’s the one clear message Ritter derives from his research on satiation signals to the brain.
Ingested energy—food—passes through three distinct body compartments, says Ritter: the gastrointestinal tract, storage, and catabolic. Each provides signals that control food intake. Some of these signals may provide a pharmaceutical antidote to overeating someday. But so far, there is no silver bullet.
“Pharmacological approaches are transient,” says Ritter.
For one thing, isolating and synthesizing those factors present a challenge. But another is that those signals can be overridden.
Take leptin, for example. Leptin is a recently discovered hormone released by fat itself, providing a satiating signal to the brain. Leptin reduces food intake by reducing meal size and may work by enhancing other peptide signals from the GI tract. However, people who need intervention have already developed a resistance to its satiating message.
Ritter’s research is funded by two National Institutes of Health grants. One covers his work with satiation inducing peptides CCK, GLP-1, and Peptide 1, and their interactions. The other grant focuses on glutamate, probably the most common excitatory neurotransmitter.
Neurotransmitters are chemicals that relay and modulate signals between neurons and other cells. It’s interesting, says Ritter, that the neurons themselves on the vagus nerve, the nerve that connect the GI tract and the brain, produce receptors to the same transmitter they receive, which is glutamate.
Ritter is interested in why these receptors are on the neurons and how they’re used. He believes they fine-tune the strength of the sensory signal. A peptide released from the gut activates the vagus nerve. The signal is then made stronger or weaker by changing the amount of glutomate interacting with the receptors on the nerve. Blocking the receptors causes animals to increase meal size.
“So you can have all kinds of signals coming in, and if you turn the volume way down, you can still eat a bigger meal.”
“There are so many things that influence intake,” says Ritter. “The size of the plate, who you’re with when eating, all these things can dramatically change the way you eat. But that doesn’t mean that physiological feedback signals, from a clinical standpoint, may not be our first line to intervene.”
On the web
Time Magazine‘s list of top-ten highest caloric fast foods
A visual coronary of disgusting foods from “This Is Why You’re Fat” by Jessica Amason and Richard Blakeley, HarperStudio, 2009
America’s Top 10 Healthiest Fast Food Restaurants courtesy Health.com