Off the Scale

If there is one thing Kathryne Haywood has learned in her 45 years, it’s how to lose weight. “I think I’ve been dieting since I was 15,” says Haywood. She has tried Weight Watchers, the Atkins diet, the Zone diet, an all-liquid diet, a fruit diet. Many worked, but the red line on her bathroom scale always crept back up again.

Now, Haywood is trying again. She recently enrolled at the Johns Hopkins Weight Management Center, aiming to shed at least 100 pounds from her current 283. But the odds are against her, as even Lawrence Cheskin, the Center’s director, acknowledges. Only about one-third of the patients who lose weight through the Center manage to keep off at least half of it for more than one year—a relatively high success rate in the weight management field. 

“The environment we live in and the culture make it easier to gain weight than to burn it up,” says Cheskin, MD, an associate professor with the School’s Center for Human Nutrition. “We’ve become very food-centric.” Americans are surrounded by a virtual orgy of food images, smells, and messages: Commercials urge us to “super size,” snack on cookies, celebrate with pizza, and show our loved ones how much we care by baking them a chocolate cake. At the same time, our lifestyle is moving farther away from the physical activities that would burn up some of those calories. The result: an obesity epidemic that refuses to ebb.

Diets can work. People can lose weight on the Atkins diet or the banana diet or other new-fangled diets, says Benjamin Caballero, the director of the School’s Center for Human Nutrition. Everyone is familiar with the testimonials and photos—a beaming, trim woman standing in the tub-size pants she wore before losing 100 pounds. But tinkering with the diet formula will not solve the obesity epidemic—the extra pounds carried by millions of Americans. Attempting to curb obesity without addressing the larger factors fueling the epidemic is like trying to cure childhood diarrhea when the water is contaminated, says Caballero, MD, PhD. 

The solution, then, must include nothing less than changing the environment, say public health leaders. They are seeking solutions that will reduce obesity among populations, not just individuals.

By now, the statistics are familiar. In the past two decades, the percentage of American adults who are obese has doubled. Almost one out of three American adults is now obese, and 64 percent are overweight or obese. Compared to adults of healthy weight, overweight or obese adults face an elevated risk for a host of health problems. According to a recent study, severely obese people are seven times more likely to have diabetes, six times more likely to have high blood pressure, twice as likely to have asthma, and four times as likely to have arthritis. And some of these same diseases are now for the first time appearing in children, as childhood obesity keeps climbing at ever steeper rates. In two decades, obesity doubled among children and tripled among teens.

In recent months, the discourse on obesity has taken a new turn, as critics intimated that some of the blame for Americans’ bulging bellies lies with the very institutions that define nutritional standards.

Most provocative was a story by science journalist Gary Taubes in the July 2002 New York Times Magazine. On its cover, the magazine featured a photo of a big, fatty steak garnished with a large pat of butter. Taubes argued that the promotion of a low-fat diet, by the National Institutes of Health, the Surgeon General, and other authorities, and the marketing of reduced-fat foods drove Americans to consume more starches and sugar—resulting in increased obesity. “The percentage of fat in the American diet has been decreasing for two decades,” yet obesity has risen, Taubes reported in the story, which ran under the headline “What if it’s all been a big fat lie?” 

Taubes proposed that people try the Atkins diet, a high-fat, high-protein, low-carbohydrate regime that has been denounced by the American Medical Association. 

As for alternative explanations for the obesity epidemic, Taubes largely dismissed those. He mocked the notion that a “toxic food environment” (of high-fat foods and gigantic portions and ubiquitous food advertisements) could be driving the epidemic. Might declining physical activity play a part? No. Americans, he pronounced, are caught up in “a culture of physical exercise [that] began in the United States in the 1970s—the ‘leisure exercise mania.’ ”

Taubes’ story rankled many nutrition scientists, including Caballero, a member of the Institute of Medicine's Food and Nutrition Board. The scientific panel defines the nutritional requirements of a healthy diet (which have included the Recommended Dietary Allowances, and the expanded version of the RDAs known as the Dietary Reference Intakes, or DRIs). Many health and agricultural institutions, from the Food and Drug Administration to the American Heart Association, rely upon the Board’s scientific reports to formulate their policies. 

Caballero calls Taubes’ piece a “huge oversimplification.” True, the percentage of fat in the American diet has gradually fallen for several decades, and obesity has risen. But coincidence does not prove causation; no hard evidence shows that one contributed to the other. Says Caballero, “A greater number of low-fat products in the grocery stores can’t be extrapolated to mean a decrease in consumption of fat in the population.”

In the period between 1987/88 and 1994/96, the percentage of fat in the American diet did fall—from 36 percent to 33 percent, according to USDA surveys—“hardly earth-shattering,” says Caballero. And percentages tell only part of the story because Americans also increased their total consumption of calories. So while the percentage of fat in the diet declined relative to carbohydrates, people appear to be consuming more total fat than they did before.

So what is making people fat?

Caballero believes that degradation of the American diet is  partly to blame. The trend toward the super size—in which a typical fast-food meal has grown from a one-ounce burger and eight-ounce soft drink to a six-ounce burger and a 64-ounce soda in the past 40 years—has not helped. Americans’ love affair with soft drinks also troubles Caballero. Daily soda consumption increased 74 percent in teenage boys and 65 percent in teenage girls between 1977/79 and 1994. Americans now consume more soda than milk. Research suggests  that children who drink a lot of soda are more likely to be obese than children who drink little or none.

All told, Americans ate 148 calories more per day by the mid-1990s than they did in the mid-1970s. 

That might seem like a lot, but Caballero believes another trend is more pernicious: the sharp decline in physical activity. “We’ve become a passive, automatic society,” he says.

“Now, 74 percent of the population doesn’t have the minimum physical activity recommended by the CDC: 30 minutes per day,” Caballero exclaims. “And of those 74 percent, 30 percent don’t do anything!”

Many factors indicate that Americans are becoming more sedentary. High school students who participated in daily physical education classes dropped from 42 percent in 1991 to 29 percent in 1999, according to the CDC. Nielsen data show American families watched 36 more minutes of TV per day in 1999 than they did in 1982. And studies by Johns Hopkins School of Medicine researcher Ross Andersen suggest children’s programming—in which 60 percent of the ads are for food—has another insidious effect: prompting children to eat and eat. 

After analyzing the results of a CDC survey called NHANES III, Andersen and his colleagues found that the more TV children watch, the more they eat. Girls who watched TV for five hours or more per day consumed about 200 calories more than girls who watched one hour or less. And researchers have only begun to analyze how the Internet, Playstation, Gameboy, and other electronic pastimes are contributing to the hours children spend sitting. 

The answer then, is simple, at least according to some observers. Overweight people simply need to eat less and exercise more. They should have the fortitude to resist that Whopper, and take personal responsibility for losing weight and keeping it off. In advertising parlance, they should just do it!

But the cases of weight management patients like Kathryne Haywood suggest the limitations of expecting personal responsibility to cure the nation’s obesity problem.

Haywood has many motivations for losing weight. She was diagnosed with diabetes six years ago, and would reduce her risk of complications from the disease if she lost weight. Her mother, too, has diabetes, and had both legs amputated as a result. “I don’t want to go through that,” Haywood vows. 

She is also receiving the best weight-loss care that science has to offer. A dietitian at Hopkins’ Weight Management Center helped her develop a balanced, low-calorie diet. An exercise physiologist assessed her metabolic rate and body fat composition, and gave her an exercise plan. Other specialists help her work through behavioral and psychological hurdles to losing weight.

But Haywood also faces strong traditions and habits that permit, if not encourage, her to remain obese. She comes from an African-American family that continues the Southern cooking traditions where the biscuits are rich and the greens are stewed in pork fat. “In my family it’s normal to be overweight,” says Haywood. “All the women are a little overweight. We use food as a celebration, as a reward.” 

Over the years, says Haywood, food became her compensation for stress, and she’s had her share as she’s helped care for an ailing father and mother. After her mother had her legs amputated, Haywood put on 70 pounds in eight months. 

Compounding matters, many of her co-workers are overweight or obese, yet show no interest in losing weight to improve their health. While Haywood does not feel stigmatized for being obese, she is isolated at work in her efforts to shed pounds.

Losing weight and keeping it off are an enormous struggle, Haywood says. “Just do it” does not cut it.

Cheskin says his philosophy of weight management emphasizes developing lifelong habits that enable patients to maintain a healthy weight after they leave the Center’s care.

He has some thoughts on what an overweight society could do to improve the odds. Just as a dieter should remove the junk food from his pantry shelves, a society should reduce the availability of junky food. “Promote, advance what’s helpful. Diminish, tax, restrict what’s bad for weight control. Advertise and promote healthy foods as much as we have unhealthy foods,” says Cheskin.

“Some people need constraints,” says Caballero. “Some people would never take the stairs unless we blocked the elevators. It will be very difficult to change the will of the people. So we need to create an environment where being more active is easier.” 

For example: Developers should be required to include sidewalks when they build communities. Companies should be prohibited from filling school vending machines with soft drinks and fat-filled snacks. Schools should be mandated to offer physical education. Unions should demand exercise breaks in the workplace (much the way they lobbied for ergonomically designed work areas). The Nutrition Labeling and Education Act, adds Caballero, which requires that nutrition information appear on packaged food sold in supermarkets, should be expanded to include restaurants. “So people can read, ‘This hamburger contains two portions.’ ”

Basically, the healthy eating and exercise message needs to be repeated over and over. While these messages may seem like old news, says Cheskin, “they’re not getting through. Compare it to the hundreds of thousands of times you’ve been told to eat a Big Mac or, in effect, to be a couch potato.”

To override the blare of TV food commercials, the seduction of the super size, and the perfume of Cinnabon, messages about eating right and exercising need to blast through the airwaves, smile out from billboards, and saturate the culture. Marketers need to pitch healthy eating and exercise as something that is as “cool” as the competition.

Some answers may come from a project developed by Joel Gittelsohn, an associate professor with the School’s Center for Human Nutrition. The Healthy Stores Project involves promoting healthy foods and recipes in communities that have been plagued by high rates of obesity and obesity-related diseases. After completing a pilot study in the Marshall Islands, Gittelsohn’s team is beginning to introduce the interventions in grocery stores on the San Carlos and White Mountain Apache Reservations in Arizona, through funding from the U.S. Department of Agriculture.

When a customer enters an Apache “healthy store,” she might see a poster on the front window promoting the “healthy foods” label. As she strolls down the aisles, she finds such labels on shelves holding nutritious, low-fat foods, such as pretzels and baked chips in the snack food aisle. In the dairy section, the shopper might receive a free sample of low-fat milk, and information on the health advantages of low-fat rather than whole milk. In the deli section, she might find red skin potato salad and rotisserie chicken alongside the usual selections of fried chicken and chimichangas. Or she might watch a cooking demonstration of a healthier way to prepare a common recipe.

In Gittelsohn’s intervention, healthy eating messages will soon go beyond store boundaries. A cartoon about nutrition and exercise featuring an Apache family will run in local newspapers. And Gittelsohn is lining up a local musician who will write and perform songs for the radio that blend messages about nutrition with cultural themes. “All of this needs to be reinforced repeatedly,” says Gittelsohn. “It’s not enough to be using just one pamphlet or just one poster.”

To gauge whether the interventions are succeeding, the researchers are keeping a log of sales data for each store and conducting home interviews. They are also monitoring the weight of a subgroup of  women to determine whether the project reduces obesity levels. 

Gittelsohn is currently developing Healthy Stores programs for Baltimore and Hawaii. If these first projects prove successful, the model could be applied on a larger, even national, scale.  But changing people’s behavior is not easy, as Gittelsohn learned in an earlier attempt to reduce childhood obesity called the Pathways Project .

Pathways met with both successes and disappointments. The School’s program, which involved seven American Indian reservations starting in 1993, aimed to reduce childhood obesity by at least 5 percent. But by the end of the intervention, though the children knew significantly more about good nutrition and exercise, their obesity rates had not declined. Caballero now concludes that focusing on schools is not enough. After school, children can all too easily plop down in front of the TV and stuff themselves with potato chips. Effective programs must involve the family, workplace, and community—strategies the Healthy Stores researchers are now trying to implement.

Public health authorities have an ambitious goal: to reduce the prevalence of obesity among U.S. adults from 31 percent to less than 15 percent by the year 2010.

But how to get there?

Nutrition scientists use the term “nutrition transition” to refer to dietary changes that occur as societies develop. Barry Popkin, a professor of nutrition at the University of North Carolina, has outlined these progressive stages in The Nutrition Transition: Diet and Disease in the Developing World, which he and Caballero co-edited. 

People begin as hunter-gatherers, relying on a low-fat animal and plant-based diet. (Meat from free-roaming animals is low in fat.) They battle high rates of infectious disease but rarely suffer chronic diseases (stage 1). They then developed a less varied diet that spawns nutritional deficiencies such as kwashiorkor, scurvy, pellagra, and beriberi (stages 2 and 3). Later, technology reduces physical labor and make possible a diet rich in fat, sugar, and processed foods. Society then suffers high rates of heart disease, cancer, diabetes, and other degenerative diseases (stage 4). Americans and other industrialized societies are in this stage. 

 Finally, in the next stage, people become more aware of how a healthy diet prevents degenerative disease. They exercise more and live longer, healthier lives, with less heart disease, cancer, and diabetes.

No society has yet advanced to stage 5. And finding the way there is an experiment. But it is an experiment we must attempt, says Caballero. “With  64 percent of the population overweight, we face a serious social danger. We need to do what we have to to reduce that threat.”