Childhood obesity is very much in the news these days, as well as it should be. Reflecting back over several decades of work in the community food field, it feels incomprehensible to me that one in five American children now (compared to one in twenty in 1980) fall into the body mass index (BMI) obesity danger zone. BMI is the most accepted measurement of healthy/unhealthy weight, though by itself it is not an indication of any specific medical condition. In 2013, however, the American Medical Association officially recognized obesity as a chronic disease. Over 220 health conditions have been linked to obesity, not the least of which is that obese children run a high probability of becoming obese adults with greater risk of even more health complications. According to a New England Journal of Medicine projection, 57% of today’s two-year-olds will be obese by the time they reach 35 Simulation of Growth Trajectories of Childhood Obesity into Adulthood | NEJM
I find so much of this data frightening, perhaps, because my awareness of body size as an issue has surfaced gradually over the course of my lifetime. My first recollection was an incident that occurred when I was 11-years old. As I was leaving my New Jersey elementary school one sunny spring afternoon, I noticed a circle of classmates staring at the ground in front of them. Elbowing my way into the silent crowd, I saw two of my classmates, Davey and Richie, locked in a brutal playground brawl. Davey had pinned Richie to the ground with his knees while his hands were locked in a death grip around his throat. “What’s going on?” I asked to no one in particular. “Richie called Davey ‘fat-so’” was the reply. I knew that Davey, certainly on the chubby side, was the only kid in the school who’d likely pass for barely overweight today, and that Richie, always a wise guy, loved picking on him.
At that moment, much to our impotent horror, Richie was paying the price. His eyes were bulging, his face was beet-red, and except for a few gasps of breath, he was nearly motionless. Fortunately, two male teachers jumped into the fray and pulled Davey off, hauling him away to God knows where while the school nurse administered first-aid to Richie. The rest of us, in a state of shock, were disbursed, replete with enough grist for weeks’ worth of boyish gossip.
The fight today, the one that has escalated well beyond a playground tussle, is over our individual and national approach to obesity, weight, diet-related disease, body size, and a host of other terms that increasingly carry fraught associations. What has exacerbated the fight, at least partially, is the lack of consensus among experts as to obesity’s cause. At one recent international gathering of researchers in the United Kingdom (Opinion | Scientists Don’t Agree on What Causes Obesity, but They Know What Doesn’t – The New York Times (nytimes.com) John Speakman, a biologist offered this assessment of the days-long debate: “There’s no consensus whatsoever about what the cause of it is.” In other words, obesity is a far more complex issue than most of us have thought.
Take the study of genetics, for instance. There is a genetic component to human obesity that accounts for 40% to 50% of the variability in body weight status, and that is substantially higher in individuals with obesity and severe obesity (about 60%-80%). After controlling for BMI, science has learned that the genetic contribution to the accumulation of harmful forms of fat ranges from 30% to 55%. Genetics of Obesity: What We Have Learned Over Decades of Research – PubMed (nih.gov). In fact, we now know that, “227 genetic variants involved in different biological pathways … have been associated with polygenic [involvement of multiple genes] obesity.” Recent progress in genetics, epigenetics and metagenomics unveils the pathophysiology of human obesity – PubMed (nih.gov). In addition to polygenic contributions, there are some known single-gene causes of obesity. For example, genes that regulate hunger, (e.g., in the MC4R pathway) underly the cause of a portion of the approximately 5 million individuals in the US who experience early-onset, severe obesity. Genetic Testing For Obesity | Uncovering Rare Obesity® Program.
Such advances are bringing us ever closer to the new age of personalized medicine where we will be able to see how genetic factors affect the outcome and choice of obesity treatments. With more studies being conducted, the introduction of precision obesity treatment is brought nearer. According to one paper, “We can predict that, in the future, when receiving a new patient in our obesity department, we will be able to determine the patient’s personal responses to the different treatments through genetic testing, so that we can choose the most appropriate method.” gox033 (2).pdf.
I highlight the role of genetics in some detail to illustrate just one of many complicated sets of contributors to the obesity crisis. As I was doing my community work in Hartford, Connecticut, a city with a high poverty rate, I literally witnessed the transformation of body sizes take place before my eyes. In the 1970s and 1980s, hunger and food insecurity, associated with rising food prices and poverty, were the dominant food threats. By the 1990s, overweight, obesity, and the increase in diet-related illnesses such as diabetes had eclipsed hunger. That made sense as we saw the city morph into a food desert and food swamp as the supermarkets exited and fast-food joints proliferated. Our response then was a multi-faceted strategy to effectively flood lower income neighborhoods with healthy, affordable food, accompanied by nutrition education. I can say in retrospect that our impact was limited because it was too narrow. Certainly, something more comprehensive was called for.
Into the evolving path of our growing understanding has stepped a variety of interesting and competing ideas about how to address the problem, including the possibility that obesity is not really a problem at all. In fact, terms like obese or overweight are being replaced by such descriptors as “large-bodied people,” and the belief that people of any size can be healthy, regardless of what their BMI levels suggest. Even the use of BMI as an indicator of anything has been called into question. One proponent of the concept of healthy at any size goes as far as to distribute cards to parents before their children’s doctor exams that say, “Don’t Weigh Me!” as a rejection of weight as a health indicator, and to protect children from stigmatization. One dietitian told me that she removed the word “Weight” from the title of a book she authored because she knew the word’s use had become too controversial.
Underlying much of the debate is the belief that by diagnosing someone as “obese” or “overweight” and prescribing a weight reduction plan and other interventions under the supervision, for instance, of a registered dietitian, brands the child with a Scarlet “F” (for “Fat”). Even more, any discussion or suggestion that someone or a group of people have weight issues can create, in the minds of some advocates, a “body toxic environment” where “weight-shaming” is one of the chief pollutants.
Health at Every Size (HAES) is one group that associates “weight-centered bias” and “policies discriminating against fat people” with racism and oppression of Black people. One of their principles is to “reject the idealizing or pathologizing of specific weights” and, rather than dieting, recommends “eating for well-being,” and rather than physical activity, promotes “life-enhancing movement to the degree that they choose.” In other words, the celebration of one’s body is placed above any medical or cultural pressure to alter its size.
Returning for a moment to Davey, I don’t think I could find a better case study for the harm that stigmatization can cause. Having remained in contact with numerous schoolmates over the years, one hears—allowing for the hyperbole that old men are prone to—how Davey’s legend continues. There is agreement that he was expelled from junior high school for throwing a desk at a teacher. Similarly verified is how his childhood weight shaming and resulting rage were channeled into arguably acceptable uses including stints in the Marine Corps, CIA, and Drug Enforcement Agency.
Looking at the 600-plus beautiful teenage faces in my high school graduation yearbook, I couldn’t find more than a handful that had retained even a moderate amount of baby fat. A glance at randomly selected American high school yearbooks today would find 19 percent of the students obese and another 16 percent overweight, numbers that carry predictable population-wide health consequences. Along with gun violence, school lockdowns, anxiety, and mental health issues, including suicide, today’s young people face an ever-steeper climb to a healthy and productive adulthood. For the high school graduating class of 1968, the only “public health crisis” we faced, other than perhaps the Vietnam War, was teenage acne, a condition we referred to as our “zit-geist.”
While fat-shaming and body stigmatization cause harm, and even more to the point, may make the recipient of such messages unreceptive to any intervention (or worse, susceptible to eating disorders like bulimia), we cannot ignore the looming health crisis apparent in the nation’s soaring obesity figures. According to the Center for Disease Control and Prevention, the US obesity prevalence was 41.9 percent in 2020. (NHANES, 2021) Compared to 30.5 percent in 2000. During the same time, the prevalence of severe obesity increased from 4.7% to 9.2%. (NHANES, 2021). Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer. These are among the leading causes of preventable, premature death. The estimated annual medical cost of obesity in the United States was nearly $173 billion in 2019 dollars. Medical costs for obese adults were $1,861 higher than for people with healthy weight. The cost to the economy is estimated at $90 billion annually due to lost worker productivity. And since a public health crisis is a terrible thing to waste, opportunistic entrepreneurs have nourished a weight loss and diet management market reached now valued at over $84 billion in revenues for 2021 (projected to reach $130 billion in 2027). The demand is driven by increasing obesity and diabetic populations, fitness/diet companies’ promotional strategies, rise in disposable income, and affordable cost of bariatric surgeries.
As we’ve come to expect in a racially inequitable America, people of color get less of the good stuff and more of the bad stuff, particularly health problems. Non-Hispanic Black adults had the highest age-adjusted prevalence of obesity (49.9%), followed by Hispanic adults (45.6%), non-Hispanic White adults (41.4%) and non-Hispanic Asian adults (16.1%).
Those are the numbers, and as best as we know at this time, those are the facts. So why does it seem as if the lifeboat that should be rescuing our children can’t find a course? When I read and listen to child health advocates stress stigma avoidance over even the most modest of dietary and physical activity interventions, I often find myself incredulous, especially after reading the summation of the Academy of Nutrition and Dietetics’ statement on the problem of childhood obesity, which I quote here at length:
Childhood obesity adversely affects the endocrine, cardiovascular, orthopedic, gastrointestinal, and pulmonary systems. It’s associated with greater risk of CVD [cardiovascular disease] later in life. Two risk factors of CVD more common in obese children than in healthy-weight children are hypertension and elevated cholesterol. In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more. Other studies have shown increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes. Childhood obesity also is associated with breathing problems, such as sleep apnea and asthma. Moreover, obese children are likely to develop joint problems and musculoskeletal discomfort. They’re at greater risk of having fatty liver disease, gallstones, and gastroesophageal reflux (i.e., heartburn). Many of these comorbidities that used to be considered “adult diseases” are now regularly seen in obese children.
If 70 percent of obese children have at least one CVD risk factor, how can we countenance such a low-key, almost passive approach to “large-bodied children” that in all likelihood will consign millions to a lifetime of ill-health and possibly premature death? I certainly loved my “look” in college, a filter-less Pall Mall cigarette dangling from my pouty lips that, with my long hair gave me the rebellious image that my classmates and I strove so hard to cultivate. But when it finally dawned on me that my pack-a-day image enhancers would put me in an early grave, I tossed them in the trash.
Fortunately, there are strategies that, when applied in a systems-like fashion, hold promise of stemming the tide of obesity and overweight. They can be found in a summary version in Today’s Dietitian CPE Monthly: Childhood Obesity Prevention and Treatment – Today’s Dietitian Magazine (todaysdietitian.com). In addition to what can be done at the individual or family level, the options for action include the need to eliminate food deserts, an increase in the availability of affordable, healthy foods like fresh fruits and vegetables, and a vigorous push-back against the food industry which pumps ultra-processed foods into our nation’s veins. And what’s key in all of these approaches is the need for better collaboration between all of the stakeholders.
I’m also happy to see the Biden-Harris administration step up to the challenge with both the National Strategy on Hunger, Nutrition, and Health and a proposed federal budget that puts our money where their mouths are. Food insecurity, a poor diet, physical inactivity, and ill-health often walk down the same road. It’s heartening to see the federal government making strong recommendations to attack these problems in a more or less joined-up fashion.
As I looked over the evidence of what works and the general attitudes and positions of the different camps, one theme appeared to loosely unite everyone’s perspective on child obesity—the role of parents/adults. The first interesting fact that struck me is that the prevalence of obesity is lowest among college graduates (26.3%) compared to those holding no more than a high school diploma (35.5%). While this does not imply that less educated people will be less healthy role models, it does underscore the need for parents to pay attention to their children’s health and even take an assertive position when necessary. Today’s Dietitian reinforces this notion by placing parents at center stage for developing healthy eating behaviors. They state that the “Prevention of childhood obesity should begin early in life, during the fetal period and the first two years of life. In addition to learned behaviors, long-term taste preferences are developed in utero and during breast-feeding. Children are likely to prefer the foods their mothers exposed them to at these stages.”
When we look at the way the Women, Infant, and Children (WIC) program operates, we see the emphasis for nutrition counseling placed on the mother. If mom has dietary issues, working with her to correct problems will hopefully spill over into their children’s eating behavior and physical activity patterns. A modest reduction in obesity among 2-to-4-year-olds in the WIC program (from 15.9% to 13.9% since 2010) gives this emphasis some credence. And with the focus of the Biden-Harris Administration on WIC bringing the number of eligible participants up from 50% to 60%, the positive health impacts of the program are likely to spread further.
A consistent emphasis on working primarily with parents seems to also be supported by the anti-stigma advocates. Registered Dietitian Jill Castle, director of the popular website and podcast “The Nourished Child,” is a strong proponent of a “whole child approach” to weight and health matters. While she strenuously opposes any messages or actions that might make a child feel “unworthy,” Castle stresses the need to help parents set up healthy lifestyles which will also influence their children. Like many nutritionists and dietitians who are focused on stigma avoidance, she’s not a big fan of doctors who don’t seem to use the correct language when discussing children’s weight and/or health issues. She says the doctor should talk only with the parent(s) about these matters and “keep the children out of the room!”
As I cast my eyes over what increasingly looks like a battlefield, but one on which everyone wants the same thing—the health and well-being of our children—one poignant memory comes to mind. Some 25 years ago, the organization I ran, the Hartford Food System hosted a job slot for a high school student doing community service work. In this case, the student was a young Black woman who happened to be very overweight. On her third day with us, she brought a liter-size bottle of Coke to work and put it in the office refrigerator. I passed her at a moment when she was taking a break and pouring herself a large glass of Coke. With little or no thought in advance, I said something to the effect that she might want to try water once and a while to quench her thirst. She looked at me funny, proceeded to finish her Coke, and when she left for the day, she never came back. I knew I had blown it, and I regret to this day saying what I said.
We cannot deny the long-term toll that childhood obesity will take on today’s young people any more than we can shame others for the size and shape of their bodies. At the very least, we know the latter doesn’t work, and for the sake of those who are obviously at risk for a lifetime of health complications, we as parents, health providers, and community activists are irresponsible if we tiptoe around our nation’s looming public health crisis. A culture of acceptance and avoidance is no substitute for a sensitive society committed to the health and preservation of their children. To that end, those with the most experience and the most evidence must collaborate on a plan to reduce childhood obesity and promote the healthiest children possible.
Several people provided assistance in writing this article. In particular, I would like to thank Theresa Yosuico Stahl, RDN (www.remindfuleating.com) and Fern Gale Estrow, RDN for their timely advice.