Are We Truly Clueless About Weight Control?

The prevalence of obesity has skyrocketed during the past two decades, and overweight and obesity have arguably become the gravest public health threat in the United States because of the chronic diseases affiliated with these conditions. Today, more than 65 percent of adults in the United States are considered either overweight or obese (defined as a BMI >25).

The trends of obesity (defined as a BMI >30) in adults by State, derived from the Behavioral Risk Factor Surveillance System (BRFSS) data from 1985 to 2001, have dramatically increased. In 1985, few States reported 10-14 percent of their adult population as obese. By 2001, most States reported adult obesity levels of 20-24 percent, with one State reporting levels of more than 25 percent.

Using the BRFSS data to consider diabetes trends among adults, including gestational diabetes, it appears that diabetes trends follow the same pattern of increased BMI. In 2001, many more States reported an increase in the number of adults with diabetes than in 1990. The diabetes projections suggest that matters will continue to worsen for both adults and children. In addition, other health conditions that are associated with obesity are likely to rise, including cancer, osteoporosis, hypertension, cerebrovascular disease, renal function disorders, gastrointestinal disorders, and mental health disorders.

Using the BRFSS data to consider diabetes trends among adults, including gestational diabetes, it appears that diabetes trends follow the same pattern of increased BMI. In 2001, many more States reported an increase in the number of adults with diabetes than in 1990. The diabetes projections suggest that matters will continue to worsen for both adults and children. In addition, other health conditions that are associated with obesity are likely to rise, including cancer, osteoporosis, hypertension, cerebrovascular disease, renal function disorders, gastrointestinal disorders, and mental health disorders.

For children, the future looks ominous. In a period of 20 years, adult-onset (type 2) diabetes, which previously affected only the middle-age population, has become a pediatric scourge. Given the strong association between diabetes and heart disease, this generation is destined to have adolescent heart disease. CVD may soon become a routine pediatric problem. Children are more harmed by the adverse effects of poor diet and lack of physical activity than by alcohol, tobacco, and illicit drug use combined. Today's children may experience a shorter life expectancy than their parents in addition to serious psychological sequelae.

Americans are obese because of a food-centered culture and an environment that makes it possible. Physiologically, the body is designed to absorb and retain calories. Our Stone Age physiology makes it extremely difficult not to gain weight in the modern world, where a sea of available calories makes weight gain easy. However, individuals vary markedly in their susceptibility to weight gain. Genetic factors and the different types of obesity may play a role. Yet the formula for weight control is the same for everyone: balance calories consumed and calories burned.

The concept of a healthier weight needs to be communicated and promoted not only to those individuals who are obese, but also to children and youth before they become obese. There are far too many inaccurate weight-loss messages that the public must muddle through. Current fads include the numerous diets advocating a reduction in carbohydrates as well as foods with a low glycemic index. Many people are fixated on the quick fix regardless of the consequences.

The public health community must take what its members already know about healthful eating and physical activity and make the information accessible to all individuals through environmental change in schools, at the worksite, and in the community. A recent review of the scientific evidence due to be published in 2004 in the Community Guide for Preventive Services shows the following strategies as having merit.

In schools:

• Provide education in healthful nutrition.
• Implement routine physical activity during the school day using creative approaches, such as 5 to 7 minutes of fun physical activity at the start of every class session.
• Focus on reduced television viewing.
• Ban vending machine sodas and caloriedense snacks.
• Offer in-season fruits and vegetables.
• Cultivate a culture of healthful eating.
• Capture height and weight measures on a routine basis.

At worksites:

• Offer structured physical activity, either via onsite facilities or through incentives for employees.
• Promote use of stairs instead of elevators.
• Offer healthful nutrition choices.
• Provide practical nutrition education/self-help materials.
• Establish and promote a culture of commitment to healthful practices.

In communities:

• Involve families in health promotion.
• Include sidewalks and parks in urban plans.
• Provide nutrition information in restaurants, particularly in fast food establishments.
• Promote and subsidize farmers markets.
• Offer on-site education in supermarkets.
• Offer routine clinical counseling about weight control.

While working for these environmental changes, it is imperative that individuals also be empowered to safeguard their weight and that of their family members. Combating the epidemic of obesity can begin one family at a time. Because there is abundant evidence as to what constitutes a healthful dietary pattern, less time and fewer resources should be devoted to debates about different diets, and more should be devoted to how to adopt and sustain the basic dietary pattern-- rich in vegetables, fruits, and whole grains-- known to promote both health and weight control. Educating the public about unknown challenges, such as sensory-specific satiety and how to contend with it, can make portion control far more feasible. Empowered with the right kinds of knowledge, families can create safe nutritional environments in their own homes at the same time our nation engages in a society-wide effort to create a safer nutritional environment for us all.