Generation Extra Large: Rescuing Our Children from the Epidemic of Obesity by Lisa Tartamella, Elaine Herscher, and Chris Woolston (Basic Books, 272 pages, $25.00)
Our Overweight Children: What Parents, Schools, and Communities Can Do to Control the Fatness Epidemic
by Sharron Dalton (University of California Press, 292 pages, $24.95)
Consuming Kids: The Hostile Takeover of Childhood
by Susan Linn (New Press, 256 pages, $24.95)
Food Politics: How the Food Industry Inﬂuences Nutrition
and Health by Marion Nestle (University of California Press, 469 pages, $29.95)
The Weight Of It: A Story of Two Sisters
by Amy Wilensky (Henry Holt, 203 pages, $23.00)
A human disaster is unfolding in front of our eyes: American kids and adults are relentlessly growing fatter and, consequently, sicker. But the disaster is not just the product of individual appetites; powerful institutions, private and public, have been complicit in creating and exacerbating the problem. That, in a nutshell, is the message of these books, which together tell a story of abject national failure.
I come at this subject both professionally and personally. As a biological anthropologist and (nonpracticing) physician, I have taught and written about the biological basis of hunger and satiety and devoted years to developing a model of healthy diet and lifestyle. I also have direct experience with the problem: As a boy, I spent many not-so-happy hours in the “husky” boys' section at downscale department stores, and though I outgrew that chubbiness, I became overweight again in middle age, during my wife's long, unsuccessful battle with cancer. Since then I've lost the extra weight and worked hard to keep it down. So I've not only studied this problem; I've also been there.
Two of these books focus on obesity in children. Generation Extra Large is an easy overview, Our Overweight Children more substantive and thorough. Consuming Kids is broader, detailing corporations' increasingly aggressive marketing to children -- not just bad food but toys, media, clothing, sex, violence, beer, and (yes, still) cigarettes. The author did some dedicated spying at marketing conferences, and what she learned will turn your stomach whether or not you are dieting.
Food Politics is a solid, important treatise. Taking the health effects as given, it details how food companies undermine public health and inﬁltrate institutions that are sworn to protect it. If, after Marxism's demise, you need evidence of the pervasive complicity of government in the amassing of wealth by a few to the detriment of the many, look no further. In a different vein, The Weight of It is a touching memoir of sisterhood, woven around the lifelong obesity of the author's much-loved sister and its eventual cure (I use the word advisedly) by gastric bypass surgery.
Concern about the growing public-health threat of obesity, called “epidemic” in two of the subtitles, is not misplaced. One imperfect but useful medical measure is the Body Mass Index (BMI): weight in kilograms (pounds over 2.2) divided by the square of height in meters (inches times 0.0254). Physicians often use a BMI of 25 as the cutoff for normal weight and 30 to separate overweight from obesity. By this deﬁnition, about a third of American adults are in each category. The 5 percent with BMIs over 40 are called morbidly obese. In its recommendations for children and adolescents, the federal government's Centers for Disease Control (CDC) avoids the term “obese,” using instead “at risk for overweight” and “overweight” for children with BMIs, respectively, between the 85th and 95th and above the 95th percentile.
The death rate from all causes among the morbidly obese is double that of the non-overweight. A study in the December 23 New England Journal of Medicine followed more than 100,000 women for 24 years; death rates from heart disease and cancer, the leading and second-leading causes of mortality in the United States, were well predicted by BMI. “Even modest weight gain during adulthood,” the authors concluded, “was associated with a higher risk of death.” This study also challenged the “fat and ﬁt” notion; inactive lean women had lower risks than active obese ones.
This is just one study in one week in one leading journal, among thousands. Other research shows that weight loss, including by gastric bypass surgery, reduces the risk of diabetes and hypertension, and that dietary and lifestyle changes can reverse the clogging of arteries. The CDC assigns about 300,000 of the premature adult deaths in the United States each year to overweight, a number that rivals smoking deaths. The evidence for major health risks of obesity is, to put it modestly, decisive.
So much for adults. The CDC recommendations for children sound a ringing alarm. In addition to the risks already mentioned, the agency warns that gallstones, fatty degeneration of the liver, early maturation, sleep apnea, inadequate breathing, and orthopedic complications of the legs and feet are all more likely in obese children.
Confused about the varied deﬁnitions? Skeptical of the risks of overweight in the moderate range? It doesn't matter. Draw the line where you like, the trend is the same: Adults and children are a lot fatter than they were 30 years ago, by any measure. The CDC's vintage percentile charts appear to be old, but the agency should continue using the same ones, or over the coming years the “normal” category will expand upward to include those at risk. By the ofﬁcial deﬁnition, the proportion of overweight (obese) children has tripled to 9 million, or 16 percent, since the mid-'70s. The change is readily seen even before age 2.
But in fact we don't even need obesity measures because we have a more ominous indicator: Type 2 diabetes, which not long ago was called “adult-onset” to distinguish it from Type 1, which usually strikes children. Both involve high levels of blood glucose, potentially leading to loss of sensation in the limbs, infection and amputation, kidney disease, and blindness.
But the two diseases are different: Type 1 is due to insulin deﬁciency, Type 2 to insulin resistance. And in some 90 percent of cases this resistance is caused by chronic obesity. Type 2, once rare in childhood, now beats Type 1 by 5 to 1 in pediatric clinics. One in 100 children have it, more than 200,000 nationally. Their problems are labor-intensive for pediatricians, whose clinics will be swamped—and that's before considering such consequences as high blood pressure, heart disease, and asthma.
Why have American children grown fatter and more vulnerable to serious illness? Bad food, no exercise. But behind these two causes lie many political tales.
First, the poor are fatter throughout life. They are ignorant of nutrition, and the food industry and its government allies keep them that way. The urban poor have no access to fresh fruits and vegetables because grocery stores that stock them do not exist in their neighborhoods. And they are rightly afraid to let their children go out and play on dangerous streets; the kids sit at home in front of television sets through which the bad-food purveyors -- not to mention those hawking toys, clothes, entertainment, sex, and violence -- wield their enormous media power. Add to this a cultural bias among the poor, stronger in some ethnic groups, in favor of overweight as a cushion against starving. One result is that New York's poorest neighborhoods have rates of diabetes approaching 15 percent.
But the overall epidemic cannot be laid at the door of the poor. In 1998, 26 percent of adults below the poverty line were obese, but so were 15 percent of those in the highest-income bracket, with average Americans in between. Trends are similar in all economic and ethnic groups, and, as Sharon Dalton puts it, “the obesity epidemic has ‘gone global'” across many cultural boundaries. We have a commanding lead -- French researchers are alarmed that their 7- to 9-year-olds are as plump as ours were in the late '80s -- but neither poverty nor anything uniquely American can explain more than a part of this dismal phenomenon.
Soft drinks, fast food, and a couch-potato lifestyle go a long way toward explaining the rest. These affect all levels of society, ethnic groups, and countries within the reach of Coca-Cola and McDonald's. These and other relatively new and increasingly pervasive aspects of our culture amount to a toxic environment. Seventy percent of the food industry's $11 billion a year in advertising goes to convenience foods, candy, snacks, alcohol, soft drinks, and desserts; about 2 percent goes to fruits, vegetables, grains, and beans.
This cultural toxicity is deepening. Imagine, if you will, that minute traces of lead were found in fast food, or that HIV, at some very low risk level, could occasionally be transmitted in a soft drink. Imagine that ﬁve hours a day in front of a television or computer screen gradually caused some children to go blind, but one hour a day did not. What kind of response do you think such discoveries might get -- from the media, from parents, from the government? Well, these things do gradually cause diabetes, and diabetes causes blindness, kidney disease, and heart disease. Three-hundred-thousand excess deaths a year, 800 a day, a September 11 equivalent every four days. Where is the outcry?
Instead, we have a toxic pact between industry and public institutions. For her very responsible book, Marion Nestle interviewed scores of knowledgeable people in the food industry, government, and academia. They told her many things, but not one would speak for attribution. How beholden they must be to, or how frightened of, those who control the trillion-dollar annual cash ﬂow that agribusiness generates. The American Heart Association counts more than 50 food companies among its sponsors. The Food and Nutrition Board of the Institute of Medicine takes money from M&M Mars. Among the direct supporters of journals reporting nutrition research are Coca-Cola, Gerber, Nestlé/Carnation, Slim-Fast, and the Sugar Association.
Children are tragically vulnerable. Their schools literally push high-calorie, low-quality food through vending machines. Recess has been all but abolished in many schools, and physical education is pathetically inadequate. One of the conferences Susan Linn spied on issued a brief on marketing to “‘Kids 6-11 with a bull's-eye of kids ages 7-9. These kids are at a crossroads, with one foot in the kid world and one in the adult world.'” A foot in the adult world at 7 to 9?
It's science now. Research shows that “up to 46 percent of sales in key businesses that target children” are due to nagging. Parents are typed by vulnerability to children's whining and targeted accordingly. A senior manager for one food company said, “All our advertising is targeted to kids. You want that nag factor so that seven-year-old Sarah is nagging Mom in the grocery store … .” Lucy Hughes, an advertising executive, said, “If we could develop a creative commercial … that encourages the child to whine … then we're successful.” To resist, marketers know, a parent would have to fend off hundreds of nags a month. Most cave.
The most chilling new trend is described in Consuming Kids: Schools have gone into business with junk-food merchants. Ninety-eight percent of high schools and 43 percent of elementary schools have vending machines, and many get kickbacks from sales. Given our shameful underfunding of schools, educators are desperate. Some school districts are paid by commission. From Generation Extra Large: “In 1998, John Bushey, the executive director of school leadership for Colorado Springs School District 11, wrote a letter to the district pointing out that it was lagging far behind its goal to sell 70,000 cases of Coke products.” Without such sales, “it wouldn't get the full beneﬁts from Coke.”
Tommy Thompson, until recently the health and human services secretary, has been in a public state of denial about the causes of obesity, much like South African President Thabo Mbeki's long refusal to acknowledge the link between HIV and AIDS. The same rejection of science, the same self-serving pomposity, the same dire public-health results. Touting his “Small Steps” campaign designed to cajole people into little lifestyle changes, Thompson sermonized, “First, we have to work hard to spread the gospel of personal responsibility.” New guidelines published in January are an improvement, but they are still only guidelines -- personal responsibility again -- and they do not end the complicity.
Former Surgeon General David Satcher has commented -- despite “a lot of respect for Secretary Thompson” -- that “we need some big steps to deal with this … . A lot of people are going to die because of this epidemic. … I don't think any epidemic can be stopped without major public commitment.” The man who appointed Thompson did not count on the personal responsibility of voters to ensure his re-election, nor did he allow his opponent to outspend him on marketing the way snacks outspend vegetables. He ﬁgured people needed encouragement, and spent hundreds of millions of dollars to get his countervailing message across to them.
Does personal responsibility count? Of course it does. People ask me how I lost 50 pounds in four years. I always say, “I took in fewer calories than I put out. If you do that, you will lose weight. If you take in more calories than you put out, you will gain weight. That's it. It's not even a law of medicine. It's a law of physics.” But the diet industry can't make $6 billion a year saying that, so the companies -- including the well-regarded Weight Watchers -- say all kinds of things that have never been scientiﬁcally tested. Are there tricks? Sure, and I know most of them. But they do not change the law, nor do they change its major corollary, which the same industry spends much of those billions to obscure: Losing weight hurts.
You are, in effect, in the initial stage of starvation. Every cell in your body is screaming to your brain, “Find food!” There are so many fail-safe signal systems to generate hunger that I have lost count of them. You won't be hungry every minute, and you do get used to it, but it remains unpleasant. You may have headaches, stomachaches, sleep disturbances, difﬁculty concentrating, anxiety, or depression.
But I have worse news: Maintaining a desired weight is unpleasant for most of us, too. It still entails frequent hunger. Why? Because at that weight, most of us don't shut down the hunger signals. Our animal and human ancestors spent millions of years in conditions of ﬂuctuating scarcity. We evolved to build fat in times of abundance, a buffer against the inevitable lean season. Now it never comes, and the great majority of successful dieters rebound. They eat until they are satisﬁed, and that puts on weight.
As for your children, you can supply the willpower during the decade or so that you control them. Just say no -- to harmful food, to hours a day in front of TVs or computer screens, and to aggressively marketed toys and clothes they don't need. Eventually the whining will stop and they will form habits. That is called cultural transmission. Try it. It works.
But ultimately, “just say no” is not enough, any more than it is in the realm of sex. Our children need social support, and so do we, but we get the opposite. Linn says, “Let's ban marketing to children,” and cites a number of countries that have. Certainly vending machines should be banned from schools and the literally sickening complicity between marketers and school administrators summarily ended. A wall is needed between the food business and governments local and national, but especially between corporations and regulators at the Food and Drug Administration and the Department of Agriculture. These agencies should become very aggressive in labeling, exposing, and teaching about bad food and about the sleazy marketing tactics that make children crave it. Schools should be centers of health education, not vectors of food-borne illness.
As tough as this effort will be, we have to try, and the four books here that deal with the politics of food and consumption are full of good ideas. On an individual level, most of us know what to do but don't do it. Wilensky's account of her sister's happy transformation should help silence those who think that getting obese people to accept their bodies is an adequate solution. But most of us don't need drastic measures, just a lot of willpower and a little help from our culture. Stopping the culture -- the corporations and their government allies -- from working against us and our children is a vital step.
Will we one day see a food-industry mogul follow the lead of a high executive from the tobacco industry and break down in tears on the witness stand as he contemplates the vast human damage he has done? I hope so. In the meantime, we should, literally and ﬁguratively, cultivate our gardens, stay active, and, as always, guard our children from those who would harm them, however cleverly the harm is disguised.
Melvin Konner is the author of The Tangled Wing: Biological Constraints on the Human Spirit, Becoming a Doctor, and seven other books. He teaches at Emory University.