Why do more and more kids in the U.S. have pudgy paunches bulging over the tops of their low-rider jeans? When it comes to the much-publicized childhood obesity epidemic, everyone has a pet theory.
With today's super-sized fast food portions, kids pack it in by the fistful of fries and 20-ounce Coke. More meals at home consist of takeout or precooked ready-made fare, loaded with fat and calories. TV and video games have vanquished running around outside. Kids in the city have too few safe places to play. And kids in the suburbs have no sidewalks to walk on, much less places to walk to. Fewer kids walk or ride their bikes to school, either because there's no safe route, or it's simply too far. At school, phys ed and recess have been shortened or eliminated, through the double whammy of budget cuts and renewed emphasis on academic testing. And many schools sell junk food to kids in the cafeteria in an attempt to subsidize shrinking budgets through soft drink and candy bar revenue.
Even "Sesame Street's" Cookie Monster, that shameless calorie-hound, is drawing suspicion. This season, the beloved blue glutton will learn to scarf fewer cookies so he can be a role model for healthier eating habits.
No one really knows which of these concurrent factors has had the single biggest impact on kids' widening waistlines, but it all adds up to a country where about 20 percent of children are overweight. Epidemiologists at the Centers for Disease Control and Prevention estimate that if the obesity epidemic continues, 30 percent of boys and 40 percent of girls born in the U.S. in 2000 will have diabetes at some point in their lives. And this generation of American kids will be the first in 200 years to have a shorter life expectancy than their parents, according to a controversial new study published last month in the New England Journal of Medicine. The study found that today's kids may shed as many as five years off their life.
In "Fed Up! Winning the War Against Childhood Obesity," Dr. Susan Okie, a family physician and medical journalist, argues that even as doctors continue to research the myriad causes of the super-sizing of American kids there's a lot that parents and society can do to fight back. A contributing editor for the New England Journal of Medicine, Okie, who worked for many years at the Washington Post, spoke with Salon about what can be done to help today's fat kids -- and why even an obese child should never be put on a diet.
Do you think that a misplaced fear of giving a kids an eating disorder or a lifelong complex about food keeps parents from trying to change their children's weight or bad eating habits?
For a long time the pediatric community really worried about focusing on how much food children ate because they were afraid that kids who had the potential to become obsessive about food might end up with an eating disorder.
But have parents internalized that message as well?
I think that parents of girls may have. There's been a lot in the press over the years about eating disorders and girls, but it's a fairly rare thing. It's almost unheard of in black girls, and it's fairly rare in white girls. But it gets a lot of press and parents worry about it.
But obesity is common. It's not that you want children to learn to count calories or become obsessive. But society has become unable to figure out what an adequate portion size is because there has been so much super-sizing in restaurants and in the grocery stores. And even at home people tend to serve larger portions than they need. Just learning reasonable quantities is an important thing to do in order to try to reverse the obesity epidemic.
How should a parent talk to a fat kid about the child's weight?
It may be easiest for the parents to bring the child to the pediatrician, and have that conversation with the pediatrician there.
The point is to impress on the child that it is a health issue. It's not that there is something wrong with the child's body, or that the child is doing something wrong. If the parents have a similar issue, or did when they were children, they should say something like: "I've struggled with this myself. The reason that I'm concerned about your weight, and your doctor is concerned, is that we want you to be healthy, and we want you to have a long life. There's a problem with weighing too much. Having too much fat can put you at risk of developing some health problems. And we want you to grow up healthy and strong, and able to do all the things that you want to do."
Focus on the fact that it's a health issue. It's not a beauty issue, or a glamour issue, or anything like that. And emphasize that this is a problem that you're going to help the child with.
But what if your child is not overweight, and you're trying to prevent him or her from becoming fat?
You would take a somewhat similar tack, and say: "In our family, we're all going to try to eat healthy and do the things that are good for our bodies. And the reason that we buy certain foods and not others is because we all want to stay as healthy as we can. We want to try to make good food choices so our bodies can do the things that we want them to do. So you can play and be strong."
So, that's why you can't have the Cocoa Puffs?
"That's why we don't buy the Cocoa Puffs. We're trying to make you stronger and healthier."
Why is it bad to put even a fat child on a diet? What's wrong with a diet?
The psychology of a diet is that it is something that you do temporarily in order to drop a certain number of pounds. You eat in some weird way, and you deny yourself things that you would normally want to eat for a proscribed period of time until you lose the weight that you think you need to lose. And then you go back to your normal ways.
But with kids, especially, what you want to do is long-term behavior change. You want to teach them to eat healthy, and to internalize new habits, so they will make healthier eating choices and those choices will stick.
It's much more realistic -- and more successful in the long term -- to come up with a new eating plan, and to work slowly to change behavior. Going on a drastic diet just makes people feel deprived. They can deprive themselves for a short period of time, but then they start to become angry about feeling deprived, and then they tend to boomerang back to where they were.
So, what do you think are the one or two most important steps parents can take to keep their children from becoming dangerously overweight without putting them on a diet?
They can go through their pantry and their refrigerator and make sure the foods and drinks there are healthy. Adults also need to model behavior. If the adults adopt healthy-eating choices, then kids will be more likely to pick up those habits.
Try as a family to build activity into the daily routine. Families should find ways to walk or bike to more places, and to make a point of going outside and playing in the yard.
Monitoring how much TV kids are watching, and trying to reduce their screen time is another proven thing parents can do. There are these electronic monitors that were used in a study where researchers were doing an intervention to reduce kids' TV time. Basically, you dial in your child's weekly TV allowance, and the TV cuts off when the allowance is up.
One researcher you quote says that you don't have to try to get your kids to exercise more, you just have to try to get them to watch less TV, and then they'll naturally get more exercise.
Right, they'll find other things to do. And almost anything else they do will be more active.
One study you wrote about even suggested that having your kid stare at a wall -- if you could get the child to do that -- would actually be better for him than watching TV. Why is that?
In this study, they had kids doing various sedentary things, and the kids who watched TV burned fewer calories than they did doing any other sedentary activity. Maybe it has a sedating effect on your metabolism.
There are multiple ways in which TV may contribute to obesity. There's the fact that you're not burning calories. There's the fact that children and adults tend to eat unconsciously while they're watching TV, if they have food or drink in front of them. And there's the fact that there's a lot of advertising on TV so you're constantly getting cues to go get a snack or go get a soda.
And I even read one study that said when people eat lying down they tend to feel less full, and they tend to go on eating longer. A lot of kids snack lying down while they're watching TV.
It seems clear from your book that if a child is overweight the whole family has to change.
I heard this from so many experts. And then when I spent time with families that were actually dealing with the problem, it was clear that when the obese kids were singled out, when they felt like they were the only one having to change, and everyone else got to do their normal thing, they got really angry and resentful.
And I remember that myself. I was overweight when I was 10, and I got put on a diet by the pediatrician, and I had to eat rye crisp crackers with a slice of cheese instead of a sandwich for lunch. I got so sick of being on this diet, while no one else in my family was doing anything different. It was just horrible. I felt really singled out.
But given the time bind that working parents are under, it seems like so many of these suggestions require more time: eat less fast food and takeout by cooking more meals at home, spend more time exercising with your child. How realistic do you think that these suggestions are?
It's going to be hard for parents to do it all alone. I think that society has to change, too. Places that run after-school programs are going to have to become sensitized to this problem. If they provide snacks they should provide healthy ones, and instead of keeping the kids inside doing homework they should take them outside to play.
A lot of families with working parents figure out ways to cook ahead. You can cook a large quantity of something. Or, you can find things that are fairly quick to make such as chicken breasts instead of fried chicken.
It's important for people to have the kind of control over what they're eating that comes with preparing it yourself. And if you're going to buy takeout, there are healthier things to buy and less healthy things to buy. You don't have to get pizza all the time.
It seems like we've really engineered a society that's designed to make people fat. We take elevators instead of stairs. We drive instead of walk. Some of the suggestions in this book seem to go against America's culture of convenience, like getting off the bus earlier and walking the last few blocks to work, or parking farther from the grocery store. We've made our lives super-convenient, and now we have to purposely inconvenience ourselves to become healthy again. Won't that require a kind of reverse engineering of the whole American lifestyle?
I think that it would make it easier if there were more reverse engineering. I talked to people trying to think about how to do this, who said that companies should make stairways more inviting. They should put signs near the elevator that say take the stairs up three flights or whatever. They should have the stairwells nicely painted and have pictures hanging on the wall. Where I work, the stairwell is pretty grim. Buildings should be reengineered to make stairs both more accessible and more attractive, more brightly lighted.
But it's hard. I find it hard. I feel like I should be parking father from work, and so far I haven't found a parking garage located in the direction that I would have to walk to head home. It takes a lot of conscious planning.
The people at the National Institutes of Health who give grants on obesity prevention have become so sensitized that they do things like throw away the remote control on their TV, and put the washing machine a flight down, so they have to go up and down stairs with loads of laundry. They really have tried to engineer their homes to make everybody move around more.
A new report published in the New England Journal of Medicine argued that for the first time in two centuries American children will have shorter lives than their parents, because of obesity. What do you think are the odds of reversing this trend?
If we're going to reverse it it's going to take decades, because there are millions of children who are affected, and so much of this is so engrained in American society. But I think that with tobacco, we've seen a huge change in the social norms. You've seen a real reduction in the acceptability of smoking. I think that can happen with unhealthy foods. But it's going to take years until doughnuts are no longer an accepted way to raise money in schools.
If obesity is really an epidemic, especially among kids, why isn't it being treated like one? Does the public fail to understand that it's dangerous?
Most people have still not realized just how dangerous it is. But when they read stories that say that the life expectancy is going to go down they'll start to.
If the child doesn't have any obvious medical health problems yet, then the parents are less inclined to take it seriously. In some cultures, when babies or young children are really hefty, hearty eaters, it's considered a sign of good parenting. So, it just hasn't been considered a health problem. And doctors and healthcare providers have to do a lot of education to convince parents that it is.
Is part of it that some obesity-related diseases don't show up for some time?
Yes. You have lots of kids who are developing what used to be called "adult onset diabetes" because we have so many more children who are severely overweight, who are severely obese compared with 20 or 30 years ago. Those children are developing complications such as diabetes, high cholesterol, bone problems, joint problems.
But many of the kids who are really overweight now don't have diabetes yet. They might have abnormal handling of glucose in their bodies, but that could only be diagnosed by a blood test. And they may not be getting the blood test. Or, they might have high cholesterol that hasn't been picked up, or they might have high blood pressure. But to the eye, they don't look like they have any health problems, except that they're overweight. So, a parent might not realize that the child's long-term health is being affected.
Do you see this really as a parenting problem, or as a societal problem?
It's a societal problem, because it's an epidemic that happened because of some combination of changes in the modern environment. And parents aren't any less equipped now than they were 20 or 30 years ago. Parents today know as much as parents did then, but it's just not enough anymore, because they're dealing with a different environment. Parents today have to be more equipped than they were in the past. They just have to be more conscious and more educated about nutrition.
And what about at the civic level? What are one or two things that should happen that will actually make a dent in this epidemic?
There are a lot of school systems around the country that have begun to try to do things about vending machines and the a la carte food choices in schools, and a lot of that has been impelled by parents.
It's hard for schools because they often depend on vending machine revenues. But if schools can make a commitment to having healthy food and drink choices in school, and getting the unhealthy ones out of there, I think that would make a difference.
At the schools that I visited in Boston, they're putting in place curricula that have been tested and found to be pretty effective -- Planet Health and Eat Well & Keep Moving. What I saw was that in the course of teaching all these lessons about nutrition and physical activity, the teachers and administrators themselves were becoming a lot more sensitized to the problem.
And they were changing their behavior. Some of the teachers weren't ordering Chinese lunches anymore, they were bringing their own lunches. And they were drinking water, and going for walks. At PTA meetings they were no longer serving soda. They were serving water. So, the schools can have a huge social impact. They're sort of little nodes of change, and if you can get the people in the school to do something about this problem, then they can impact a lot of people.
You report that there's a lot of action in individual schools or districts on childhood obesity. But there's not a lot happening from the top down. Do you think anything will happen at the federal level?
I'm discouraged about the federal level because even things that work have been cut out of the budget. There was a pilot program that the U.S. Department of Agriculture had for providing free fruits and vegetables to kids in schools in certain states. And it really improved kids' fruit and vegetable consumption. But that program got cut. I think on the federal level if they could do something to subsidize the price of fruits and vegetables that would make a big difference. But I don't know if the money is there.
How much does this problem with children correlate to class? Are wealthy kids skinny and poor kids fat, or is obesity creeping into the middle and upper classes as well?
The rise in obesity rates has affected all socioeconomic groups, and it has affected all racial and ethnic groups in all regions of the country. But the highest rates are in the poorest states, and in the poorest counties. So, it is related to income. It's also related to ethnic group. There are very high rates in Mexican-Americans, Native Americans, and higher rates in African-Americans than in whites.
Andrew Drewnowski at the University of Washington has done a lot of work on the economic side. Based on all these economic analyses, he believes that it's because it's so much cheaper to eat a high-fat, high-calorie diet than it is to eat a diet with lots of fresh fruits and vegetables in it. Because they're fresh and they spoil, fruits and vegetables are more expensive. Fats and sugars are very cheap, so foods that are made with fats and sugars are cheaper. And processed food doesn't spoil. It's just more economical for people who are on a fixed income or a low income to eat very calorie-dense foods. And that's the kind of diet that people tend to become overweight on.
Right now, the food and advertising industry are self-regulating when it comes to advertising to kids. But last month, Sen. Tom Harkin, D-Iowa, said that he's going to introduce a bill that would give the Federal Trade Commission the authority to regulate advertising to kids. Do you think that will help, and do you think it's likely to happen?
In the '70s, there was an effort by the FTC to ban advertising to kids under the age of 7 or 8. And there was a huge backlash on the part of the food industry and all the advertisers and there was a big lobbying effort against it. Congress ended up not only reversing this ban but cutting the FTC's funding. So, it really didn't fly the last time.
It would be a good thing [if advertising was curtailed]. There's a fair amount of data that shows that kids under 7 can't tell the difference between an ad and regular programming.
Do you think that the threat of obesity lawsuits is going to make the food industry change what it markets and sells? Kraft made a big announcement that it's not going to advertise some of its worst foods, such as Kool-Aid and Chips Ahoy, to very young children.
I see the industry going in two different directions at once. For instance, Pepsi said that they were going to make Diet Pepsi their flagship beverage, not regular Pepsi anymore. And they were going to spend much more advertising money on Diet Pepsi. Brock Leach, a senior vice president at PepsiCo said recently that in the last 15 years convenience was the value-added thing that people were willing to pay for. They think that in the next 15 years it's going to be health. So they're moving to market their products as healthy now. They're trying to reduce saturated fats and various sugars so that they can put stickers on their products and market them as better for you.
At the same time, you see Hardee's just introduced the Monster Thickburger, and, apparently, it's really popular. So, you see the industry going in two directions at once. Because the public is going in two directions at once.
But you don't see the healthier direction you describe as some kind of reaction to the fear that they're going to be regulated or sued?
No, I think it's more of a reaction to all the media attention that obesity is getting, and the fact that people are talking about it, and people are concerned. They see that there is a market for healthier products.
Paul Campos, author of "The Obesity Myth," has argued that American's anxiety about fat is really a form of anxiety about our bigness as a culture. He said in an interview with Salon: "Overconsumption in America is closely equated with class: The higher up you go the more you consume. The only area in which consumption is inversely related to class is caloric overconsumption. So the American elite project anxiety about the fact that they're massively overconsuming economically and materially through a disgust for fat, lower-class people." What do make think of that argument?
It's a tortured argument compared with the actual statistics that we have on the numbers of medical problems that are cropping up in obese kids and adults. I don't disagree that America is an overconsuming society. I do think that we consume far more than we should in terms of energy and consumer goods.
But that doesn't get away from the fact that obesity is making people sick. It's making adults sick. It's making children sick. It may be reducing future life expectancy of the kids who are alive today. You don't have to make philosophical arguments to make that point. It's pretty much hard fact.