Childhood Obesity and Women's Health

We're pleased to be able to offer you two thought-provoking articles on childhood obesity. Why would a women's health newsletter address this issue? The Network believes that the current focus on childhood obesity has implications for the health of women, and that it is a double-edged sword. On the one hand, it can be a good thing for programs to spotlight the role of the food industry in creating a heavier and less healthy population, including children, especially if those programs advocate for policies that create change in the environment. On the other hand, we believe that these programs may exacerbate size discrimination, which is not only common but is a threat to the good health of large people.

In the articles below, we offer Sarah Samuels' description of an excellent program striving to change the environment of children in California in ways that will reduce childhood obesity. Pat Lyons' article critiques the focus on obesity and argues that children's health can be better served by programs that focus instead on good health and positive body esteem at every size. We encourage you to read, think and get involved.

- Cindy Pearson, Executive Director

Shift the Spotlight to Government Policies, Industry Practices

by Sarah E. Samuels

Childhood overweight and physical inactivity have reached epidemic levels in the United States, and they are taking a terrible toll on health. More than one in seven youth ages six to 17 are overweight, ^1,2 with the result that children are experiencing rising rates of diseases traditionally considered "adult conditions," such as type 2 diabetes. Many factors contribute to children's weight gain, but there is consensus among scientists and medical professionals that it is chiefly a symptom of poor diet and inadequate physical activity.^{3, 4} Unhealthy habits increase the risk of these conditions even among children of normal weight.

Preventing childhood obesity requires addressing the social and environmental factors that undermine children's health. Efforts to treat overweight children through dieting, drugs or surgery only place the children at higher risk of ongoing health problems and serve to further stigmatize these children. An alternative approach is that of the Strategic Alliance, a California-based coalition working to promote healthy eating and activity for everyone. We hope to do this by reframing the debate away from individual choice and lifestyle, and toward industry practices and government policies and their impact on nutrition, physical activity and the environment.

Individual, Social and Environmental Factors

The scientific literature suggests that the growing prevalence of overweight and physically inactive children is caused by many individual, social and environmental factors, including increasing portion sizes, increasing consumption of fast food and soft drinks, insufficient funding for nutrition and physical activity programs, availability of soda and junk food on school campuses, poor physical activity facilities in schools and communities, limited compliance with physical education requirements in many schools, limited access to healthy foods in low-income neighborhoods, and advertising of junk food to children and their families.

Most children in the United States do not get enough physical activity; fully a third are considered physically inactive, according to CDC's Youth Risk Behavior Survey.⁵ That same survey found that only half of U.S. students were enrolled in a physical education class, and only a third attended such a class each day.

Although poor nutrition, physical inactivity and diabetes are more prevalent among all children, those who are ethnic minorities and/or socioeconomically disadvantaged are impacted disproportionately. Among young women ages 10 to 19, declines in physical activity are steeper for African-Americans than whites, and in general, lower social class status is associated with less physical activity.⁶

Marketing and advertising play a particularly significant role in shaping norms and practices, especially for children. Children view between 20,000 and 40,000 commercials per year, more than half of them for food. Over 75 percent of food advertising budgets and 95 percent of fast food chains' advertising budgets are for television, resulting in children viewing a food ad every five minutes of television-viewing time, on average. ^7-8

Promoting Healthy Food and Activity Environments

The enormity of corporate influence spotlights the need for new policies impacting the food and physical activity environment. In California and elsewhere, for example, statewide and local policies have been adopted to eliminate the sale of sodas and junk food on school campuses. The Strategic Alliance supports changes in five key sectors that influence the food and physical activity environment. The following summarizes some of these recommended changes:

Children's Environments

• Eliminate fast food, junk food and soft drinks—and the marketing of these products—from these settings.
• Establish break times for safe, unstructured outdoor play.
• Equip every facility with working water fountains or other sources of free drinking water.
• Provide children with safe walking and hiking routes to schools and other key destinations.

Government

• Direct public funds to improve the availability of affordable nutritious foods, pedestrian and bicycle access, and parks and other facilities for active recreation. 
• Discourage the use of public funds for subsidizing the production or marketing of products contributing to poor health.
• Encourage government workplaces to provide healthy foods in cafeterias and vending machines, and to facilitate exercise through bike racks, well-lit stairwells and showers.

Industry Practices

• Encourage industry to adopt guidelines for responsible marketing of food, entertainment and sports-related products to children to eliminate the promotion of unhealthy behaviors.
• Discontinue corporate sponsorships/partnerships that link popular children's media icons with soft drinks, fast foods and other unhealthy products.

Health Care System 

• Encourage medical providers to adopt standards of practice that focus on education and minimize the use of surgical or pharmaceutical treatments for childhood obesity.
• Encourage health professionals and institutions to use their influence to advocate for healthy food and physical activity environments as essential elements of good health.
• Encourage health care facilities to support healthy behaviors including breastfeeding, healthy food options and physical activity, and not to permit fast food chains on site.

Media

• Ensure that media stories related to obesity, nutrition and physical activity include an environmental and policy perspective as well as discussion of individual responsibility.
• Reduce ads targeting children on television and radio.
• Shift the focus of obesity-related stories toward healthier eating and activity and away from weight loss.

The Strategic Alliance is engaged in building a broad and diverse membership. For more information, visit www.eatbettermouemore.org or StrategicAlliance@preventioninstitute org.

Sarah E. Samuels, DrPH, is president of Samuels & Associates (www.samuelsandassociates.com), which specializes in public health research, evaluation and policy. She is a founding member of the Strategic Alliance, ccxhair of the California Project LEAN steering committee, an advisor to the Women's Health Collaborative, an evaluation advisor to the CDC Youth Media Campaign and a former Pew Health Policy Fellow at the Institute for Health Policy Studies, University of California, San Francisco.

REFERENCES

1 Flegal K, Carroll MD et al. "Prevalence and Trends in Obesity Among U.S. Adults, 1999-2000." Journal of the American Medical Association 288: 1723-1727.

2 Ogden CL, Flegal KM, Carroll MC, Johnson CL. "Prevalence and Trends in Overweight Among U.S. Children and Adolescents, 1999-2000." Journal of the American Medical Association 2002; 288: 1728-1732.

3 Berkey CS, Rockett HR, Field AE, Gillman MW, Frazier AL, Camargo CA Jr., Colditz GA. "Activity, Dietary Intake and Weight Changes in a Longitudinal Study of Preadolescent and Adolescent Boys and Girls. Pediatrics 2000; 105(4):E56.

4 Rowlands AV, Eston RG, and Ingledew DK. "Relationship Between Activity Levels, Aerobic Fitness, and Body Fat in 8- to 10-Year-Old Children." Journal of Applied Physiology 1999; 86(4): 1428-1435.

5 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System: United States Summary Results 2001. National Center for Chronic Disease Prevention and Health Promotion. Atlanta, GA2001.

6 Lee RE, Cubbin C. "Neighborhood Context and Youth Cardiovascular Health Behaviors." American Journal of Public Health 2002; 92(3): 428-436.

7 Laura PW. "Coaxing the Smile That Sells: Baby Wranglers in Demand in Marketing for Children." New York Times, November 1, 1999.

8 Pollack J. "Foods Targeting Children Aren't Just Child's Play: Shape-Shifting Foods, 'Interactive' Products Chase Young Consumers." Advertising Age, March 1, 1999.

Just Say No to the "War on Obesity"

by Pat Lyons

As Americans have gained weight, community-based coalitions have emerged to wage "war on obesity," with a special emphasis on the weight gain of children. With this article, I hope to urge those engaged in such efforts to take a different course. Rather than focusing on reducing childhood obesity, which holds potential for harm, I believe it is more effective to promote environmental changes that will improve nutrition and physical activity for all children. I urge people to stop using the terms "obesity," "epidemic," "childhood" and "war" in the same breath, especially in the name of health; to stop promoting a "thin is best" medical and cultural ideal; and to turn their attention instead toward condemning—rather than condoning—weight prejudice.

Sticks and Stones and Words That Can Hurt You ...

I cringe every time I hear the word "obesity." In 20 years of talking with large women, I have never met someone who does not associate the word with some measure of shame and distress. Just this morning I talked to a 40-year-old African-American woman whose doctor told her she was "obese" at 12. "I just never “got over it," she said. For me at age 58, the word is a constant reminder that from childhood on, no matter how healthy I have always been, a single number on a weight chart can label me with a disease and determine how I should be treated. As a practical matter, if we want to inspire community coalitions to work together we must first stop using insulting and shaming language.

But this phenomenon is about more than just words. The federal "war on obesity" is a real war with casualties. Labeling more than 60 percent of Americans as overweight or obese and promoting weight-loss solutions that have failed for 40 years exposes the most vulnerable communities—poor people and communities of color with the highest rates of weight gain—to added health disparities due to weight discrimination. But weight discrimination is not even on the radar of most discussions—let alone funding—to address health disparities.

It's important to question some basic assumptions as well. The real question, according to Jeffrey Friedman, MD, PhD, a genetics expert at Rockefeller University, is: why are only 15 percent of kids fat? Virtually the entire population can easily access food and be inactive, so why not all kids? His answer is that the variance in weight of the population is genetics at work. The other issue to consider is the aging population. Modest weight gains of 10 to 20 pounds have nudged 80 percent of people ages 50 to 59 into a higher weight category that labels them overweight or obese. Paradoxically, this is happening as the average American lifespan continues to increase. These questions require further digging into the numbers and demand not accepting at face value the use of the term "epidemic."

One key reason that coalitions focus on obesity is to attract funding for much-needed nutrition and exercise promotion programs. But critical thinking is crucial, and we must stop just going along with the use of violent metaphors and a war mentality on complex social issues. This mentality has never worked! Witness the wasted billions on the "just say no" war on drugs. And remember, this is America, where people are spectacularly successful at taking things way too far, especially in the name of health.

What's Wrong With This Picture ...

Reading the news gives one grave pause:

• Last year, school districts in Pennsylvania, Florida and California sent letters home to parents telling them their children were too fat. This year, an Arkansas, school district proposed putting BMI (body mass index) on student report cards.
• In separate cases over the past two years, social workers in Michigan and New Mexico removed three-year-old children from parents who "let them get too fat." In the Michigan case, the mother's second child was also removed from her—at birth.
• The August 29 New York Times reported that hospitals cannot keep up with the demand for weight-loss surgery. Other developments: the American Academy of Pediatrics published guidelines for weight-loss surgery, and stories and ads in my local newspapers present the surgery as a simple procedure, even for teens.
• In September, a study on anti-fat bias among health professionals found that even those who work in weight research and clinical interventions hold "strong weight bias, indicating pervasive and powerful stigma" against the very people they say they want to help. ¹

Examples like these demonstrate the critical need for coalitions to use caution when addressing weight and health issues, to include anti-weight discrimination advocates in their work and to consistently aim to reduce anti-fat bias. Shame cannot cure obesity. Instead, shame and stigma fuel desperate and often harmful behaviors. Even more caution is needed with children. In 1994, several years before the recent hysteria about weight, a Report on Discrimination Due to Physical Size by the National Education Association stated that "for fat students the school experience is one of on-going prejudice, unnoticed discrimination and almost constant harassment... [F]rom nursery school through college, fat students experience ostracism, discouragement and sometimes violence."² A study published in 2003 found that bias against fat children has increased 40 percent since the 1960s.³

Rather than challenging weight prejudice, however, some health professionals use these findings as supposed motivation for weight loss. But telling kids that losing weight is the answer to escape prejudice not only won't work, it sets them up for a lifetime of failure and pain. Instead, we should focus on creating a world that fosters the best health possible and helps kids learn to stand up for themselves, love their bodies and treat themselves well regardless of their weight.

Focusing on Health at Every Size

Rather than focusing on weight per se, I believe it is what we try to do about weight that can help or harm us, both as individuals and as a society. By focusing on weight, weight loss becomes the marker of success or failure. Setting up an outcome of reducing childhood obesity plays right into the hands of weight-loss surgeons and drug companies when interventions fail. They say: "See, better exercise and nutrition are not enough. We need the big weapons: drugs and surgery." A weight focus also lets fast food companies off the hook; their spin doctors already insist the main culprit is inactivity, not food. Focusing on nutrition and health for all kids pulls that rug from underneath them. Interventions to improve school lunches and access to healthy foods, foster enjoyable physical education and after-school activities, and promote positive body esteem and strong social support can succeed independent of weight.

The bottom line is that healthy kids and adults come in all shapes and sizes. After all the rotten weight publicity lately, people really deserve a break. Let's give it to them.

Pat Lyons, RN MA, is a longtime Network member, co-author of Great Shape: The First Fitness Guide for Large Women [iUniverse, 2000] and a member of the Steering Committee for the Center for Weight and Health at the University of California, Berkeley, www.cnr.berkeley.edu/cwh. She can be reached at plyons@earthlink.net.

REFERENCES

1 Schwartz M et al. "Weight Bias Among Health Professionals Specializing in Obesity." Obesity Research 2003; 11(9): 1033-1039.

2 Puhl R, Brownell K. "Bias, Discrimination and Obesity." Obesity Research 2001:9:788-805.

3 Latner J, Stunkard A. "Getting Worse: the Stigmatization of Obese Children." Obesity Research 2003: 11: 452-456.