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Although every day we read news reports linking health problems to diet and lifestyle, there remains a dearth of books on the topic that consider obesity from a variety of standpoints that include medical, personal, financial, and related considerations. The Obesity Reality discusses these viewpoints to explain how and why the problem exists both in the United States and around the world, and in men, women, children. More than a billion people are overweight and that number is expected to increase substantially over the next decade.

How can we live past 90 while being obese? How can we remain healthy until our last breath? During the last decade, doctors have been successfully applying medical principles to the search for an obesity cure. But there is no magic medication, no vaccine that can head off the obesity epidemic as sweeps across the planet.

Ali discusses the realities of obesity and its repercussions, which include poor health, high medical costs, restrictions on lifestyle and activities, and more. He shows how we can address obesity, starting in childhood, to prevent it from getting worse, both on a personal and on a societal level, and how we can reverse its effects through proper diet, exercise, and lifestyle choices as well as medical procedures and medications.

Naheed Ali , M. Find out more at http: Disclaimer Prologue Part I: Theory and empirical data from the field of behavioral economics suggest that the majority of physical activity and eating behaviors are routine rather than choices made after deliberation about a set of options Just and Payne, ; Just et al. An evolutionary argument is related to the observation that human physiological responses to foods containing fat and sugar still are geared primarily to avoiding hunger and conserving energy, with no innate mechanisms to ensure maintenance of energy balance when such foods are available in high quantities and the demand or opportunity for caloric expenditure is low WHO, In this scenario, even conscious efforts to prevent excess weight gain are likely to be ineffective.

Ethical principles, as well as numerous precedents, can be cited to support the concept that government has a responsibility to protect the health of the public and therefore the authority to intervene in relevant societal sectors and processes Economos et al. Precedents include laws that require the use of seat belts in cars or helmets while cycling, restrict the use of certain drugs, make it illegal to drive a vehicle while under the influence of alcohol, or restrict tobacco smoking in public venues, as well as laws supporting water fluoridation or fortification of foods with folic acid.

In these cases, governments have determined either that it is essential to ensure that the interventions in question reach the general public without requiring an active choice on the part of each individual e. Public schools, in particular, have an obligation to question and refute policies that do not benefit their students and their communities and a corresponding responsibility to protect students, for whom school attendance is mandated, from harm Crawford et al. Children and adolescents spend up to half their waking hours in school, where they may consume as much as one-third to one-half of their daily calories.

Therefore, the school food environment is a logical focus for efforts to encourage healthy dietary behaviors. Today, school food service includes two competing arms—the federally regulated reimbursable National School Lunch and School Breakfast programs and the competitive food and beverage marketplace, which has expanded substantially during recent decades.

Competitive foods and beverages are those sold throughout schools in vending machines, school stores, and snack bars and at fundraisers. They are typically of low nutritional quality, such as sweetened beverages, chips and other salty snacks, and sweets such as cookies and pastries Crawford et al.

A Comprehensive Approach to a Growing Problem

Efforts to encourage children to eat nutritionally sound school meals are undermined by the provision of snacks and beverages that compete with healthier options Crawford et al. Students at schools providing nutritious food offerings still have access to a variety of food choices, along with the option of bringing foods from home. Their freedom of choice is not unjustly breached by limiting the availability of obesogenic foods on campus Crawford et al.


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Aggressive marketing of high-calorie foods to children and adolescents has been identified as one of the major contributors to childhood obesity IOM, Marketing of non-nutritious foods and beverages on public school grounds e. Frequent exposure to this marketing in schools in low-income areas where children and adolescents are at greater nutritional risk is at odds with fairness and social justice Crawford et al. How to protect children and adolescents from potential adverse effects of such marketing is a major public health policy issue, argued primarily on ethical grounds and, in schools, on economic grounds.

Statutory regulation of food marketing to children and adolescents has been proposed, on the grounds that children and adolescents are a vulnerable population in this respect because of their inability to understand the commercial intent of advertising Hawkes, ; Pomeranz, ; Swinburn et al.

Attempts to pass laws to this effect have not been successful, however, based on a ruling in that to restrict advertising would violate the First Amendment of the U. Constitution, which guarantees the right to free speech and extends this protection to commercial entities. A prior IOM report on this issue recommends that the food industry voluntarily restrict advertising of unhealthy foods and beverages to children and adolescents IOM, A recent evaluation concludes that food and beverage companies have made moderate progress in this respect, with only limited progress being seen in other subsectors of the food industry Kraak et al.

Public health experts continue to conclude that statutory regulation will be needed to address the problem. They base this conclusion on comparisons of what has been accomplished through voluntary measures and what is perceived as being needed, as well as on increasing changes in advertising practices designed to circumvent the ability of children and adolescents to understand or defend against them Goren et al. Current public- and private-sector efforts to standardize and strengthen ways of classifying foods as appropriate or inappropriate to advertise to children and adolescents could facilitate progress in regulating food marketing to children and adolescents through either voluntary or statutory means.

An important aspect of this challenge is the nature of the food industry—that is, the desirability of having a positive, cooperative relationship with the system that provides our food. Here the difference between the food and tobacco industries is paramount: In the framework of Kersh and Morone regarding the type of climate that is sometimes necessary to generate public action on personal behavior, the tobacco industry can readily be demonized, but doing so is more difficult and less desirable with respect to the food industry.

Efforts to address the obesity epidemic must consider the potential impact of actions taken on those children, adolescents, and adults who are already obese. Environmental and policy changes that will make it easier to achieve and maintain energy balance should have positive effects across the continuum of body weight. However, the process needed to achieve these changes may inadvertently worsen the day-to-day lives of obese children, adolescents, and adults. The pervasive negative societal attitudes about obese people have been well documented, held by the general public; by employers; by schoolteachers and other professionals, including health professionals; and by children, adolescents, and adults who are obese Andreyeva et al.

Greater awareness of obesity may increase these negative perceptions and the bias and discrimination experienced by obese people. Emphasizing the costs of treating obesity may cause a backlash in which obese people are blamed for rising health care costs, including public expenditures for Medicaid and Medicare.

Similarly, emphasizing effects of having a heavier population on infrastructure and other aspects of the economy may increase negative attitudes about obese people. Another potential adverse consequence, of particular importance for children and adolescents, is the inadvertent generation or aggravation of poor body image, low self-esteem, preoccupation with dieting, or inappropriate weight concern, which can impair healthy growth and physical and psychosocial development Griffiths et al.

Kersh and Morone point out the troubling reality that movements toward government action on personal behaviors sometimes take an oversimplified view that begins with public disapproval or demonization of the affected population—e.

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Given the prevailing attitudes about obesity and the fact that it is more prevalent in low-income and minority communities, the same effect could occur in the case of the obesity epidemic. Policies and practices to address obesity must take this potential for harm into account and incorporate appropriate safeguards, including the institution of measures to track such outcomes.

The case for addressing the obesity epidemic cannot be made at the expense of obese people. Ethical arguments can be and have been made against measures that penalize obese people. For example, when airlines began requiring passengers who were unable to fit safely into one seat to pay full price for a second seat, many major airlines were sued for discrimination. The Canadian Supreme Court formally prohibited airlines from charging obese passengers for additional seats. Despite the opposition, however, some airlines have kept such policies in place. Careful consideration of the terminology used when discussing the topic and images used to illustrate obesity is warranted to avoid reinforcing negative stereotypes.

Preventing Suicide: A Comprehensive Public Health Approach

In addition, making an effective case for universal interventions—that is, environmental and policy-level changes that do not rely on screening and identification of children, adolescents, or adults who are at high risk of obesity or are already obese IOM, —will help mitigate potential adverse effects on individuals. The potential for negative stereotyping and social disapproval also applies at the group level.

Likewise, food availability and promotion are less favorable to healthy eating patterns in such communities e. Black and Latino children and adolescents are particularly targeted by marketers of sugar-sweetened beverages and fast food, and their vulnerability to such advertising may be increased by their developmental characteristics, limitations on their ability to recognize when advertising is targeting them, and certain techniques used in multicultural marketing Grier, ; Grier and Kumanyika, ; Powell et al.

However, evidence indicates that the lowest-cost foods may be the least healthy Drewnowski, Thus, households with limited resources may buy less healthy foods to stretch their dollars. It is worth noting that among immigrant populations, the prevalence of obesity tends to increase with duration of residence in the United States Oza-Frank and Cunningham, , a fact that also strongly implicates environmental factors in excess weight gain. Sociocultural influences are part of the environment affecting physical activity and eating habits, and interact with other aspects of the environment Swinburn et al.

Characteristics of physical activity or food marketing environments and the high prevalence of obesity itself may influence social norms about physical activity and healthy eating, making higher weight, consumption of high-calorie foods and beverages, and sedentary behavior seem normal and appropriate. Body image norms that associate thinness with ill health and larger body sizes with good health and robustness may decrease recognition of clinically significant obesity and undercut motivation for weight control, particularly if large body size is normative in the community Brown and Konner, ; Diaz et al.

Ethnically targeted marketing, which incorporates cultural preferences, imagery, and traditions and relationship building with the targeted communities Tharp, , may reinforce cultural attitudes and preferences that favor the consumption of high-fat or high-sugar foods if these are the types of foods marketed. With respect to low-income or food-insecure populations, retail food promotions such as two-for-one deals, 99 cent menus, or large portion sizes, which are for relatively less healthful foods, may hold appeal Power, Also, foods that are promoted as normative and desirable for the general population may be attractive to consumers in low-income populations as symbols of belonging or participating in mainstream lifestyles Power, Examples of outcomes of interest for tracking progress in the process of change include 1 the quality, scope, reach, and intensity of effects of obesity prevention policies and programs, to answer the questions of what is being done and whether enough of the appropriate types of interventions are occurring to expect success and 2 improvements in intermediate measures of progress toward goals, such as the indicators listed in Boxes and Assessments should include measures relevant to reaching high-risk populations.

Ideally, assessments of progress through interim measures would be traceable to particular intervention approaches and also to obesity outcomes. The committee that produced Progress in Preventing Childhood Obesity: IOM, concluded that the infrastructure for assessing progress was severely underdeveloped and inadequately conceptualized. That report includes specific guidance on needed approaches and provides an evaluation framework to facilitate adoption of these approaches.

GOALS OF OBESITY PREVENTION

Several advances have since been made in the development of concepts and tools for assessing the success of obesity prevention efforts. These include the aforementioned IOM report on a framework to inform decision making on obesity prevention IOM, , several ongoing efforts to compile evidence on promising programs Appendix B in IOM, , recommendations for improving the likelihood that ongoing policies and programs can be well evaluated Leviton et al. Although the obesity epidemic in the United States has been instrumental in bringing worldwide attention to the problem—as noted in Chapter 1 and illustrated by Figures and in Chapter 2 , showing the increases in global as well as U.

Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.

Extensive analyses and strategizing on how to approach the epidemic have taken and continue to take place in many countries, particularly in light of the implications of obesity for rising rates of cardiovascular diseases, diabetes, and other noncommunicable diseases globally OECD, ; Swinburn et al. Among the most comprehensive efforts to understand the obesity epidemic, identify effective interventions, and formulate a national action plan was carried out by the Foresight Group in the United Kingdom Foresight, , which identified a broad range of factors that influence obesity and relationships among key factors in an effort to develop the most effective future responses to obesity for that country.

The needed societal changes must be achieved through a public health approach that focuses on policy change and interventions in the environments in which people live, learn, work, and play. Complex realities associated with the obesity epidemic include practical and policy considerations, some of which may impede progress or lead to unintended adverse consequences that must be addressed during the design, implementation, and evaluation of measures to accelerate obesity prevention.

These considerations include the nature of modern lifestyles, uncertainty or ambivalence about whether or how governments or other decision makers should use policy strategies to shift population physical activity and eating behaviors, the tensions associated with attempts to regulate food marketing to children and adolescents, and the potential adverse effects of obesity prevention efforts on individuals and population subgroups that are most affected by obesity.

The relevant causal pathways, settings, and sectors for intervention in other high-income countries e. Analyses and experiences from these countries—for example, with respect to taxation; regulation of food advertising; and school, health care, or whole-community interventions—or modeling of cost-effectiveness may offer rich opportunities to inform U. The committee recognized the potential value of learning from this broader experience. However, experiences in other countries underscore the importance of tailoring and adapting strategies to policy mechanisms, environmental characteristics, health care systems and other institutional infrastructures, and sociocultural norms and values that apply nationally, regionally, and locally.

Healthy Eating Active Communities. Healthy Eating Active Living. National Programme on Diet and Physical Activity. Turn recording back on. National Center for Biotechnology Information , U. Key Messages Now that obesity prevention efforts have some momentum, clarification of goals and targets for change going forward is essential. Goals for children, adolescents, and adults focus on prevention, with identification of specific behavioral targets and key outcomes for individuals and populations. An ecological model can be used to identify behavioral settings and sectors of influence in which and by which actions can be taken to improve environments for physical activity and healthful eating.

Strategies for taking action are multifaceted and interrelated and include policy and legislative approaches, approaches that change organizational policies and practices and environments in communities and neighborhoods, health communication and social marketing approaches, and interventions in health care settings. Although there is not yet agreement on the set of specific strategies that will be effective, existing frameworks and successful models of social change can offer guidance on how to tackle the obesity epidemic utilizing a systems approach. Measures with which to track progress are critical.

Progress in achieving obesity prevention can be assessed in the short term by indicators of change in the environments that influence physical activity and eating. Goals for Adults As noted in Chapter 2 , the major human and societal consequences of obesity culminate during the adult years, and these consequences can be mitigated by stabilization of weight in the adult population. Realities of the Way Americans Live Perhaps the most prominent and overarching of the practical realities associated with preventing obesity is that Americans are now accustomed to the very societal influences that predispose the average person to gain excess weight.

Environmental and Policy-Level Intervention Versus Freedom of Choice Concern that intervening to change environments will inappropriately and unfairly constrain individual freedom of choice is a continuing part of the debate about how to address the obesity epidemic Kersh, The Context for the Exercise of Free Choice Must Be Improved Evidence suggests that the current range of choices related to physical activity and food intake is limited and biased toward the unhealthy end of the continuum such that policies are needed to improve the environment for free choice.


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  • Many Apparent Choices Reflect Habitual or Natural Responses to Environmental Cues Theory and empirical data from the field of behavioral economics suggest that the majority of physical activity and eating behaviors are routine rather than choices made after deliberation about a set of options Just and Payne, ; Just et al. Government Has a Responsibility to Protect Health Ethical principles, as well as numerous precedents, can be cited to support the concept that government has a responsibility to protect the health of the public and therefore the authority to intervene in relevant societal sectors and processes Economos et al.

    Regulation of Food Marketing to Children and Adolescents Aggressive marketing of high-calorie foods to children and adolescents has been identified as one of the major contributors to childhood obesity IOM, Effects on Children, Adolescents, and Adults Who Are Obese Efforts to address the obesity epidemic must consider the potential impact of actions taken on those children, adolescents, and adults who are already obese.

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    The Obesity Reality

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    The Obesity Reality: A Comprehensive Approach to a Growing Problem

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