Epidemic's causes are complex and difficult to pinpoint
By JULIE MINDA
Part 1 in a series on the ministry's response to the U.S. obesity epidemic
Obesity rates have been rising rapidly in the U.S. and have reached epidemic levels. But health experts, including those in the ministry, are finding it difficult to get at the heart of the issue and to find an effective solution to it.
The problem is complex, said Dr. Azhar Qureshi, because weight gain and loss involve a constellation of factors. Qureshi is senior vice president for community health at St. Joseph Health System of Orange, Calif. Those factors can be personal, since a person's age, gender, body type, metabolism and genetics can affect their body size; behavioral, since choices around eating, exercising and lifestyle impact weight; social, since family norms influence choices; societal, since messages in the culture shape decisions; and environmental, since surroundings can dictate what healthy options are available.
With so many contributing causes, health experts are tackling the obesity challenge from many directions. Many, including those in the ministry, offer personal health programs: nutrition counseling, exercise regimens, behavioral counseling, pharmaceutical programs and bariatric surgery. Many care providers twin individualized care with a public health approach, developing broad-based programs for building awareness of obesity-prevention behaviors, disseminating information on ways to combat unhealthy weight gain and offering incentives and programming for people to improve their health.
Julie Trocchio, CHA senior director of community benefit and continuing care, said that "preventing or reversing obesity and the problems associated with obesity is central to promoting the health of individuals and of communities.
"It's one of the biggest needs of our time," Trocchio said.
Widening nation
Speaking at a summit on obesity at Washington, D.C.'s Providence Hospital in the spring, Dr. Scott Kahan described the nation's expanding waistlines as a societal problem affecting everyone. Kahan, who is a weight management expert on the faculty of George Washington University School of Public Health and Health Studies and Johns Hopkins University, said that obesity was not a significant problem until the mid- to late-1980s when the rates began rising quickly. Currently more than one in three Americans are obese and an additional one in three are overweight, according to the Centers for Disease Control and Prevention. The CDC categorizes people as "overweight" or "obese" based on their height and weight.
"This has been an entire population shift," Kahan said. "Overweight and obesity are now the norm. This is one of the biggest preventable causes of death, and it's a big problem for the U.S."
The CDC estimates that obesity costs the nation more than $147 billion annually in health care spending. With federal health care reform efforts aimed at reducing health care spending through prevention, obesity is a focus area for many federal agencies.
States and communities have concerns about the health cost overhang of obesity-related disease. The National Governors Association has highlighted a dozen-plus states that have developed policy, organized task forces and/or implemented programming to fight obesity — with many of them focusing on childhood obesity in particular.
Some jurisdictions have gone so far as to outlaw the use of trans fats in restaurants, or passed regulations requiring the posting of restaurant foods' calorie counts. But others have decried the rise of the "nanny state" and moved to ban obesity-related lawsuits against food manufacturers.
The health experts, politicians and the six in 10 overweight U.S. adults can agree on this though: the issues and behaviors behind the nation's weight problem resist an easy solution.
Temptation aplenty
Kahan explained that obesity is rising in part because the environment is full of "default" conditions that promote unhealthy eating. Heavily processed, unhealthy foods like soda, chips and candy, which earlier generations of Americans considered treats, are now a part of many people's daily diets. Processed foods may provide cheaper calories than healthy alternatives like fruits and vegetables, so people fill up on them.
Plus, cookies and high-fat salty snacks taste good. Kahan said scientists have spent years engineering processed foods to be nearly irresistible to the brain, making them far more desirable than non-manufactured whole foods. And Dr. David Kessler, a former commissioner of the U.S. Food and Drug Administration, has written that people's minds and bodies change when they consume foods containing sugar, fat and salt. He has said food manufacturers manipulate these ingredients to stimulate people's appetites as they eat.
Also, since consumers respond favorably to large portion sizes, retailers and restaurants have offered increasingly large — and unhealthful — servings. According to the National Heart Lung and Blood Institute, average portion sizes have grown dramatically over the past 20 years, and these changes distort what Americans think of as a "normal" portion size.
Kahan noted that marketers have developed sophisticated and extremely effective selling techniques for processed foods. According to a study in The International Journal of Behavioral Nutrition and Physical Activity, U.S. children may view upwards of 20,000 commercials annually, and more than 50 percent of these are food ads.
It can be difficult for communities to counteract the barrage of food advertising aimed at children, said Rhonda Brown, regional director of community health development for Hospital Sisters Health System's Western Wisconsin division and director of a coalition called the Chippewa Health Improvement Partnership. That coalition has built awareness — including through messages on local movie theater screens — on the unhealthiness of sugary beverages.
Busy, yet sedentary lifestyles
Brown said the pace of life and social norms in the U.S. also are contributing to obesity.
When people are busily "running errands, working long hours, et cetera, and not taking the time to cook healthy meals and (when they) are grabbing fast food or not-so-healthy convenience store
foods on the run, then they are more likely to gain weight or maintain an unhealthy weight," explained Brown. According to the U.S. Department of Agriculture, about 50 percent of food expenditures in 2004 were made away from home, up from 34 percent in 1974.
When people are not buzzing from activity to activity in their cars, they may like to decompress from their day with a sedentary activity.
Julie Edwards of Provena Saint Joseph Medical Center in Joliet, Ill., said there has been a big increase in people staying in to watch TV and play video games. "There's less physical activity," said Edwards, director of mission services for the facility.
The Nielsen media research company bears this out. Nielsen tracking of TV viewership shows that Americans have been increasing their television consumption since Nielsen began tracking in the 1950s. In the 1950-51 tracking period, the average household spent an average of four hours and 43 minutes daily watching TV. For the 2010-11 period, the daily viewership was nearly twice that — more than eight hours and 30 minutes.
A 2010 report by the Kaiser Family Foundation found that on average American children aged 8 to 18 log 7.5 hours daily in front of television and computer screens. Black and Hispanic youth consume nearly 4.5 hours more media daily than do white youth, according to the report.
To get kids moving, Provena Saint Joseph runs a series of after-school programs for elementary school students, incorporating exercise and nutrition education. Edwards said with 70 percent of children at or below the poverty level in the targeted school district, the programs are a way of preventing or reducing obesity among a vulnerable population. According to the Food Research and Action Center of Washington, D.C., studies have found that low-income children are more at risk of obesity than their higher-income counterparts.
Other research highlighted by the Action Center shows that the same generally holds true for adult low-income populations as well. With vulnerable people more at risk than others, this is an issue that should be of concern to Catholic health care, said Edwards.
Given the scale of the epidemic and the lack of consensus among experts about how to address it, the ministry is finding itself among the pioneers in developing obesity programming. Ministry experts know it will be a protracted effort, but they hope to make headway person by person, pound by pound.
Catholic health facilities are offering programs that help employees stay at or return to a healthy weight, and they are working in their communities, offering public health approaches to curb obesity. Those efforts will be examined in upcoming issues ofCatholic Health World.
Undignified treatment
While obesity rates are high, society generally does not accept heavy people, said Dr. Scott Kahan, a weight management expert on the faculty of George Washington University School of Public Health and Health Studies and Johns Hopkins University.
"It's really quite striking how horrible people can be toward fat people," he said. He noted that U.S. society "generally terribly looks down on, stigmatizes, teases and is disrespectful toward people who have excess weight."
Even clinicians have been documented discriminating against overweight people, Kahan added.
He said that many people incorrectly believe obese people don't care how they look or feel or that they are not trying to lose weight. To the contrary, Kahan said, research that he and colleagues have conducted shows that the vast majority of obese people have tried to lose weight and that over half in his study were actively trying to lose weight at the time of the research.
Defining obesity
The Centers for Disease Control and Prevention determine healthy weight ranges using body mass index calculations.
A person's BMI is his weight in pounds divided by his height in inches, squared and multiplied by a conversion factor of 703. So, for a person whose weight is 150 pounds and whose height is 65 inches, the calculation would be: [150 ÷ (65)2] x 703 = 24.96. According to the CDC, while the calculation is the same for children, teens and adults, result interpretation differs for people under age 20. For them, age and gender factor into the interpretation of results, whereas that is not true for adults.
Adults with a BMI between 25 and 29.9 are considered overweight, and someone with a BMI of 30 or more is considered obese. For example, a person who is 69 inches tall and weighs 203 pounds or more will have a BMI of 30 or higher and will be classified as obese.
According to the National Heart Lung and Blood Institute, people should interpret BMI scores with caution, since the calculation can overestimate body fat in people with a muscular build and could underestimate body fat in people with low muscle mass.
The math of weight gain, loss
It's a common lament: It's easy to put on weight and hard to lose it.
The National Heart Lung and Blood Institute says that moderately active females should eat between 1,800 and 2,200 calories per day, and moderately active adult men, between 2,200 and 2,800 calories per day. When a person eats just 100 calories per day above his or her daily caloric needs, that can produce a weight gain of about 10 pounds in a year, according to the Mayo Clinic.
But, to lose one pound per week, a person must cut his or her intake by 500 calories per day, according to Mayo. That can be a challenge, given that the average energy intake is about 2,500 calories per day for men and about 1,770 for women, according to 2007-08 numbers from the Centers for Disease Control and Prevention.
To burn an extra 500 calories, a 160-pound person would need to walk briskly for nearly two hours.
The medical approach to obesity treatment
Clinicians recommend different treatments for obesity based on the severity of a person's weight concerns, health status, physical capabilities and motivation to succeed. According to the online site WebMD, approaches may include:
- Nutrition counseling to help patients change their eating habits and cut back on their intake of unhealthy calories.
- Exercise training to help people increase their physical activity level and burn more calories.
- Emotional or behavioral counseling to help them address concerns that may trigger unhealthy habits.
- A medicine regimen. Some medications make people feel full sooner, some limit the body's ability to absorb fat, some control binge eating.
- Surgery to reduce the size of the stomach and limit how many calories are absorbed by the intestines.
- Alternative medications, including the human chorionic gonadotropin, or hCG, hormone, which some claim suppresses hunger and triggers the body to use fat for fuel. Experts at WebMD say evidence is lacking that hCG is an effective weight loss tool.
Clinicians usually combine a few of these approaches at once. For instance, since nonsurgical weight loss requires that a person burn more calories than he or she ingests, clinicians instruct patients to cut their calories and increase their physical activity level.
Which is more costly: Healthy or unhealthy foods?
Research published in the journal Food Policy indicates that healthy, nutrient-dense foods tend to cost more per calorie than do refined grains, sweets and fats, and that the price disparity appears to be growing.
A recent opinion piece by The New York Times' Mark Bittman takes issue with this premise. Bittman, author of the paper's "Minimalist" food column and himself an avid cook, writes that healthy, home-cooked food is less expensive than fast food restaurant fare. He calculates that a home-cooked meal of roasted chicken, vegetables, salad and milk would cost about $14 for four to six people, whereas a typical meal for a family of four at McDonald's including burgers, chicken nuggets, fries and soft drinks costs from $23 to $28.
Dr. Scott Kahan said Bittman did not factor in a scarce commodity in today's society — the time it takes to find frugal, yet healthy recipes, shop, cook and clean up afterwards. Kahan is a weight management expert on the faculty of George Washington University School of Public Health and Johns Hopkins University.
"In our busy society, few people have the luxury (to make healthy family meals at home) — even if they have experience with shopping and cooking, which most don't." And, he said, those unhealthy eating habits will be hard to break since many children aren't learning at home or at school how to shop for, and cook, healthy meals.
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