An Essay on Obesity

OBESITY:
As It Is Experienced in the United States, Massachusetts, and Boston, and Effective Strategies to Confront the Epidemic
- By Robert Ferguson-

Personal Interest and Thesis:

I chose to write an essay on the obesity epidemic because of my interest in using exercise science as a preventative treatment in medicine and because I wanted to find out how various strategies could be used to prevent what seems to be an individual choice. I want to get beyond the standard discussion involving body mass index (BMI) measurements and the food guide pyramid as an educational tool.

Many Americans are hesitant to discuss effective interventions to combat the obesity epidemic because of the nagging, persistent thought that individuals are to blame and the strong influence of libertarianism in the United States. In writing this essay I hope to reduce these frustrating notions by characterizing the epidemiology of obesity as it is experienced in the United States, Massachusetts, and Boston. I will then describe current strategies that are being implemented; paying particular attention to a report entitled Community Action to Change School Food Policy: An Organizing Kit. I will conclude by addressing which strategies I think the public will favorably respond to.

Epidemiology and Socioeconomic Status:

Obesity is defined as a BMI of 30 or greater. Health risk factors begin to increase at a BMI of 25 (Schneider, 2006, p. 272). Obesity is thought to cause hypertension, hyperinsulinemia, and type 2 diabetes. These three diseases are classified as metabolic syndrome, which can induce osteoarthritis and cancer. Diabetes itself results in life long medication and can cause eye, kidney, nerve, and heart damage. (Brown, 2001, p. 225-228). All of these diseases can be prevented with social intervention, exercise, and healthy diets.

In 2000 “Poor diet and physical inactivity” caused 365,000 deaths, making it the second leading “actual cause” of death in the United States. In comparison tobacco came in first causing 435,000 deaths in 2000 (Schneider, 2006, p. 219). It is now widely accepted that 30% of adult Americans are obese and prevalence in adolescent Americans has tripled since 1980 (Peters, 2006, p. 4), while obesity prevalence is 0% in Amish men and 9% in Amish women. It is facts like these that cause many health officials to say “we have literally engineered physical activity out of our lives” (Peters, 2006, p. 6).

Obesity prevalence differs between socioeconomic status (SES) at the national level. Females with less than 12 years of education are 2.5 times more likely to become obese compared to college graduates. Black men are less likely to become overweight than White men (Schneider, 2006, p. 273); however, the Black adult population has a greater prevalence rate of obesity than the White population (Health, 2006).

Taking a look at state level epidemiology and health disparities brings the epidemic closer to our doorstep. Massachusetts is ranked 49th among the heaviest nations in the United States (1st being the heaviest) (TFAH, 2006) with 18.4% of the adult population being obese and 10% of adolescents being obese (The State, 2006). Even though Massachusetts is ranked 49th in the nation it still failed to meet the Healthy People 2010 goal, which is set at 15% (TFAH, 2006).

According to data collected in 2003 16.2% of Whites, 27.6% of Blacks, and 22.0% of Hispanics were obese in Massachusetts. The Black population had the highest mortality rate due to heart diseases at 312.9 per 100,000 and the Hispanic population had the highest prevalence rate of diabetes at 8.7% (Health, 2006). These rates reflect the devastating effects of obesity and how they correlate with race/ethnicity at the state level.

Looking at obesity prevalence at the local level brings the epidemic knocking at your doorstep. 48% of Boston residents are overweight or obese while 66% of United State citizens are overweight or obese (BPHC, 2006). The Boston Public Health Commission (BPHC) held a neighborhood meeting in 2006 and presented statistics according to race/ethnicity and according to neighborhoods in the Boston area. When the neighborhoods were analyzed, North Dorchester and Mattapan, both at 63% prevalence, experienced the highest percentages of overweight or obesity while the Back Bay and Fenway, both at 31% prevalence, experienced the lowest percentages of overweight or obesity (Obesity, 2006, p. 10-13).

The effect of obesity in Boston can be analyzed by looking at obesity associated mortality rates. Mattapan, North Dorchester, Fenway, and Back Bay experienced a diabetes age-adjusted mortality rate per 100,000 of 54, 30, 46, and 19, respectively. Heart disease age-adjusted mortality rates per 100,000 did not differ greatly between Mattapan, North Dorchester, and Fenway; however, the Back Bay experienced a significantly lower age-adjusted mortality rate of 90 compared to the 228 heart disease mortality rate that North Dorchester experienced (Obesity, 2006, p. 10-13). Once, again a low prevalence of obesity is usually associated with low mortality rates for obesity related diseases.

To understand how SES influences the prevalence of obesity and obesity associated mortality rates at the local level we must look at the median household income and education levels in North Dorchester and Back Bay. Back Bay has a median household income level of $63,587 compared to North Dorchester’s median household income of $34,132. Four percent of Back Bay residents did not graduate high school compared to 31% of North Dorchester residents (Mulligan & Auerbach, 2003, p. 9).

In recent years there has been a push to determine what social environmental factors may prevent the low SES population from living a healthy lifestyle. Dr. Powell et al. studied neighborhood demographics and the availability of “physical-activity related facilities.” They found that “physical-activity related facilities” were less likely to be found in areas where the median income level was lower, where higher proportions of racial minorities were located, and in urban areas compared to suburban areas (Powell, 2006). A second study conducted by Dr. Moore et al. examined the association between neighborhood demographics and the availability of food stores. They found that low-income and black neighborhoods had more grocery stores than the wealthier neighborhoods, but fewer supermarkets. Fruit and vegetable markets were less common in low-income and black neighborhoods as well. Dr. Moore et al. concluded “To the extent that supermarkets offer a broader choice of affordable healthy foods, these patterns could have consequences for the diets of residents” (Moore, 2006, p. 9). Both investigators identified two obstacles that low SES residents must overcome to improve their health.

Economic Impact:

The economic cost of obesity places a tremendous burden on the public sector. Most Americans accept the fact that tobacco is responsible for a tremendous percentage of healthcare expenditures. More precisely, for 1997-2001, tobacco was responsible for $75 billion in direct medical costs annually (Economic, 2005). However, many are unaware that overweight and obesity contributed to $78.5 billion ($92.6 billion in 2002 dollars) in direct medical expenditures in 1998 and obesity alone contributed to $47.5 billion according to the National Health Accounts (NHA) study (Overweight and Obesity: Economic, 2006). As a result, health insurance premiums and social security taxes have increased, and health care is rationed.

The state is not immune to the economic burden of obesity as well. In 2000 Massachusetts attributed $1.822 billion in direct medical expenditures to obesity. Of that amount Medicare covered $446 million and Medicaid covered $618 million (Overweight and Obesity: Economic, 2006). Acknowledging that the government pays $1.064 billion while private health insurance pays $0.758 billion demonstrates that the public sector—and not the private sector—carries the weight of the economic cost. These costs are unnecessary because the epidemic can be prevented.

Interventions at the National, State, and Local Level:

The epidemiology creates awareness and addresses the need to understand why the epidemic exists. By describing the obesity epidemic as “knocking at your door step,” I have utilized the health belief model. The model stresses that the individual is vulnerable, that the disease is severe, and that taking action is beneficial (Schneider, 2006, p. 238). An ecological model “looks at how the social environment, including interpersonal, organizational, community, and public policy factors, supports and maintains unhealthy behaviors” (Schneider, 2006, p. 239-240). Public health officials use these models to understand what causes the epidemic and to determine how to effectively eradicate the epidemic (Schneider, 2006, p. 240-241). Each strategy that I will present falls under one of the categories associated with the ecological model.

Understanding the social environment, as the ecological model suggests, is the first step to combat the epidemic. Dr. John C. Peters in “Obesity Prevention and Social Change: What Will It Take?” comments on the “American sense of ‘the deal’: ‘Buy one, get one free’.” Why order a number five when you can order a number five supersized for 0.35 cents extra? He goes on to state “The behaviors that promote obesity (eating too much and moving too little) provide an immediate reward” (Peters, 2006, p. 8). He terms this phenomenon the biological incentive. Dr. Peters suggests that companies should require employees to participate in a wellness program in order to receive health care coverage (Peters, 2006, p. 8). Employers would be happy because the cost of health insurance would decrease and employees would have a biological incentive to exercise.

Exercise Scientists point to what they refer to as the “energy gap.” Scientists determined that if Americans burn 100 extra calories each day, 90% of the population could prevent weight gain. America on the Move is a program that promotes small individual initiatives such as these (Peters, 2006, p. 8). Hagan et al. reported that changes in diet increased weight loss by 5.5-8.4% and diet plus exercise increased weight loss by 7.5-11.4% (Jakicic & Gallagher, 2003, p. 91). As this study confirms, it is imperative that healthy exercising habits are promoted along with healthy eating habits.

The Federal Trade Commission (FTC) has the authority to regulate commercial activities that are deceptive. Studies have shown that children younger than eight are unable to critique advertisements aimed directly at them. These children are exposed to 40,000 food advertisements per year, half of which are misleading or inaccurate (Mello, Studdert, & Brennan, 2006, p. 2601). The current strategy is to provide “equal time for messages that promote good nutrition and physical activity” (Mello, Studdert, & Brennan, 2006, p. 2604) without limiting free speech necessarily.

Legal action is a public policy intervention at the state level that could confront the obesity epidemic. The constitution provides states with police power, which involves taxation and “altering the costs of certain choices” (Mello, Studdert, & Brennan, 2006, p. 2601) thus promoting healthy behavior. Seventeen states as well as the District of Columbia currently tax soda and junk food (Supplement, 2006, p. 1).

Consumer-protection laws can be used in suits when a company engages in “deceptive business practices.” However, it is difficult to show direct harm and to prove that the dangers are not “open and obvious” (Mello, Studdert, & Brennan, 2006, p. 2603). Libertarians are quick to point out that junk food harms the consumer but it does not harm innocent bystanders. In response to the backlash, 24 states have passed laws that actually limit the number of obesity-related lawsuits ( Massachusetts is not among them) (Supplement, 2006, p. 1).

A report called F as in Fat: How Obesity Policies Are Failing in America, 2006 evaluated state policies that combat obesity. It notes that Massachusetts has enacted physical education requirements, health education requirements, and has a “CDC State-Based Nutrition & Physical Activity Program” (Supplement, 2006, p. 3-4). However, in 1996 the Massachusetts Board of Education repealed regulations that specified duration and frequency requirements in physical education (PE) class (Community, 2006, p. 67). The report concludes by suggesting that the government should prolong their funding, improve community sidewalks, and subsidize health club memberships (TFAH, 2006).

School-based interventions are considered the foundation of obesity interventions because staying physically active and consuming nutritious food is critical during growth spurts, and it can establish healthy behaviors at a young age (Veugelers & Fitzgerald, 2006). Dr. Veugelers et al. studied the effectiveness of school obesity-related programs. The study showed that students who attend schools that follow the CDC recommendations experienced lower rates in obesity and overweight compared to schools that simply offered healthy alternatives (Veugelers & Fitzgerald, 2006). Data from other studies show that 60% of schools sell soft drinks and only 28% of high school students participate in PE class (Mello, Studdert, & Brennan, 2006, p. 2604). The study and statistical figures presented suggest that school interventions are gold mines for public health officials.

Massachusetts attempted to set school nutrition requirements for unregulated foods and beverages under a bill entitled An Act to Promote Proper School Nutrition. Despite the effort by the Massachusetts Public Health Association (MPHA), the bill was never voted on in the House (Childhood, 2006). MPHA continues to push the intervention by providing a free 67-page report entitled Community Action to Change School Food Policy: An Organizing Kit, which can be downloaded from their website. The purpose of the kit is to provide concerned parents with a seven-step process on how to regulate school foods and beverages sold in their school district. The steps are as follows: (1) Learn about the issue, (2) Form a Committee, (3) Research, (4) Raise Awareness and Get Input, (5) Adapt the Sample Policy, (6) Present to School Committee and (7) Publicize the Policy (Community, 2006, p. 2). The kit also provides information on the legislative bill entitled, An Act to Improve Quality Physical Education. The bill would require 150 minutes of PE per week in the elementary schools and 225 minutes per week in the middle schools and high schools (Community, 2006, p. 66).

Community Action to Change School Food Policy: An Organizing Kit is an excellent strategy. Instead of giving up when the legislative bill they advocated was not even voted on, the MPHA designed a kit that gives the public sector a chance to implement the bill’s core principles. I find the kit to be an effective strategy because it was produced at a time when the government required that each school design a Wellness Policy if they accepted funding for the National School Breakfast and Lunch Programs under an act entitled Child Nutrition and WIC Reauthorization Act of 2004 (Community, 2006, p. 3). This gave the parents a chance to design the Wellness Policy instead of leaving it up to the school boards, who are often influenced by political factors. This kit is a model example for what other organizations can do when their interventions fail.

Among other things, Massachusetts implemented Healthy Choices in 70 Middle Schools, and developed an after-school program with the YMCA and University of Massachusetts Boston. The state is currently planning to develop a searchable web page that will provide information on physical activity opportunities and information on resources to promote healthy habits (Overweight and Obesity: State-Based, 2006).

At the local level Mayor Thomas M. Menino and the BPHC developed a program called Boston Steps, which involves eight communities in the Boston area that are most affected by chronic diseases associated with overweight or obesity. The plan includes NeighborWalk and healthy eating programs like WeCan and BestBites. WeCan intends to educate the public on nutritious foods by providing parents with “tools” to keep their children healthy ( Boston Steps, 2006) while BestBites encourages restaurants to voluntarily add healthy alternatives (BPHC, 2006). Fifteen restaurants are participating as of December 2006 (Participating, 2006). Other states such as New York are taking steps to regulate the amount of trans-fatty acids to 0.5 grams per serving (Lueck, 2006).

The above discussion pertains to public health intervention; however, the field of medicine is working to eradicate the epidemic as well. Medical strategies are unable to fix the root of the epidemic, which is why 10% of preventable, premature deaths are associated with lack of medical care (Illingworth & Parmet, 2006, p. 584). However, the “medical system is called on to deal with the…failures in public health” (Schneider, 2006, p. 434) and when the two fields work together prevalence and incidence rates will simultaneously decrease.

The number of gastrointestinal surgeries for severe obesity began at 16,000 in the 1990s and increased to 103,000 in 2003. The fear with the surgeries is that the field is progressing too quickly for patient safety. As a result, the MPHA has offered recommendations (Steinbrook, 2004). A few medications are now approved by the Federal Drug Administration (FDA). The two most promising medications are mixed noradrenergic-serotonergic agents such as sibutramine and reduced nutrient absorption agents such as orlistat. The idea is that patients will take these drugs just as high blood pressure patients take drugs (Yanovski, 2002). Some scientists are now studying a gene in rodents called the ob gene that secretes the hormone leptin; however, obese rats have a decreased level of leptin while obese humans have too much leptin (Brown, 2001, p. 232). Clearly further investigation is needed before genomics can be used to identify the cause of obesity.

Conclusion:

Public health officials are faced with a new problem that requires new interventions that differ from anti-tobacco campaigns. Libertarians see second-hand smoke as a threat to their health, whereas an individual’s decision to eat at McDonald’s does not pose a threat to anyone else. Dr. Mello notes, “whereas settlement funds from tobacco lawsuits were available to pay for [antismoking] advertisements, counteradvertising campaigns to encourage better nutrition would require public funding” (Mello, Studdert, & Brennan, 2006, p. 2607). As a result, changing the social environment should be the number one priority. The public will respond favorably to balancing the number of junk food commercials with the number of healthy food commercials because it does not limit free speech, necessarily. A great way to influence eating habits is through public school interventions as demonstrated by Veugelers et al. Subsidizing fitness memberships should be seriously considered on the state level, because diet alone will provide limited results as demonstrated by Gallagher et al. Medicalizing the problem may seem counterproductive to public health officials; however, it forces Americans to realize the complexity of the epidemic and appreciate that it is not solely based on individual behavior. Pointing to SES provides a similar effect.

The United States is seen as a fat, lazy, and sloppy country and is loosing respect and credibility throughout the world. The United States can combat obesity effectively when the public acknowledges that societal factors exist and when public health and medicine work as a coherent body dedicated to health.

References

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Trust for America's Health (TFAH). (2006). Massachusetts Ranks 49th Heaviest in the Country, According to a New Report That Finds America's Obesity Epidemic Is Getting Worse. Trust for America's Health Press Release. Retrieved November 19, 2006, from http://healthyamericans.org/reports/obesity2006/release.php?StateID=MA

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Yanovski, S. Z., & Yanovski, J. A. (2002). Drug Therapy. New England Journal of Medicine, 346, 591-602. Retrieved November 16, 2006, from www.nejm.org

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