Combating Obesity: Challenges and Choices - Wiley Online Library

Introduction

Combating Obesity: Challenges and Choices John C. Peters

Perhaps at no time in recent history has a threat to the public health been so great. The prevalence of overweight and obesity now affects two-thirds of the adult population and more than one in seven of our youth, and it is getting worse. Projected adverse health effects and reduced quality of life associated with overweight and obesity are staggering and threaten to bankrupt our health care system in the coming years. An early vision of what is to come is seen in the 10-fold rise in the past decade in the incidence of type 2 diabetes among children and adolescents in association with the dramatic increase in the prevalence of obesity. Beyond the direct healthcare-cost implications, this worsening situation among our youth raises the specter of dramatic increases in disease-related morbidity and mortality and dramatic losses in human capital and quality of life, as a consequence of the decades of treatment that individuals must undergo. In response to these trends, public health officials and medical experts alike have declared the obesity problem to be an epidemic. Unfortunately, although obesity has been recognized as a serious problem for years, we seem little closer today to a clear solution for prevention and treatment than we were a decade ago. More and more people are beginning to ask, what has gone wrong and what can we do? There is a growing consensus among experts that the secular trend in obesity sweeping the nation is not caused by defective biology but rather is environmentally driven. In fact, obesity may be viewed as a normal biological adaptation to the prevailing environment rather than a physiological system gone awry. For many people, weight gain is the only means to achieve energy balance in an environment that encourages excess energy intake and very low levels of physical activity. Because levels of physical activity are so low, energy consumption frequently exceeds energy expenditure, and the only way to restore energy balance is to increase body mass, which elevates the resting metabolic rate. Energy balance is thus, restored, but at the expense of a greater fat mass.

Nutrition Science Institute, The Procter and Gamble Company, Cincinnati, Ohio. Address correspondence to John C. Peters, The Procter and Gamble Company, 11810 Miami River Road, Room 1D32A, Box 742, Cincinnati, OH 45252. E-mail: [email protected] Copyright © 2003 NAASO

The series of articles published in this volume examine three key aspects of this alarming public health issue. First, Jeffery and Utter (1) provide a comprehensive review of the current scientific literature concerning environmental contributions to obesity, emphasizing current understanding of environmental factors that affect eating and physical activity behaviors. Next, Lowe (2) examines whether it is feasible, given the prevailing environment, for individuals to self-regulate energy intake to maintain weight. Finally, Baranowski et al. (3) describe current knowledge about the effectiveness of behavioral change models and their potential application to obesity prevention. Each of these groups of investigators has done a thorough job of reviewing the literature in these key areas. Rather than discussing their particular findings and conclusions, in this brief introduction I comment on some of the overarching challenges that we face in dealing with obesity in the United States and the implications for making meaningful progress in stopping the advancing epidemic.

Environmental Pressures So, what is wrong with the environment? What specific environmental factors are responsible for the dramatic increase in the prevalence of obesity? Numerous features of the food and physical activity environments can easily be pointed to as possible causal factors by applying old-fashioned common sense or what might be called “kitchen logic.” On the surface, it just makes sense that people are heavier in a world where food is nearly everywhere in giant portions, and it is possible to lead a gainful life without having to do any appreciable physical activity. Unfortunately, however, little hard scientific evidence can apportion a role for any specific factor to the alarming rise in the prevalence of obesity that has occurred within just the past two decades. Many of the data are observational, and, therefore, causal inferences cannot be drawn. Likewise, different data sets do not always agree, making interpretation difficult. For example, as Jeffery and Utter (1) point out, nationwide food consumption surveys between the 1960s and the present indicate that total energy intake has not increased appreciably, despite the increase in the prevalence of obesity. Other data sources, however, indicate that per capita food availability has increased by ⬃15% since 1970. The latter data are difficult to interpret, given that OBESITY RESEARCH Vol. 11 Supplement October 2003

7S

Introduction, Peters

food wastage has also increased over the same time frame (4), making it hard to estimate how much actual food consumption may have increased. Clearly, other trends related to food intake correspond temporally with the rise in the prevalence of obesity, and Jeffery and Utter (1) also enumerate these trends. Overall, there seems to be a unidirectional trend toward increasing convenience in food availability, both in the home and away from home. The rise in the proportion of meals consumed away from home, including the increased numbers of fast food offerings, and the relatively high energy densities of many of the most popular foods, may increase the probability of excess energy consumption. Portion sizes have also increased dramatically over the last two decades, and human feeding studies have indicated that total energy intake tends to increase with increased portion size, at least in the short term (5). In addition, the composition of the U.S. food supply has shifted in the past few decades, providing relatively less red meat, less refined sugar, and less whole milk and butter, whereas increases in the amounts of chicken, fruits and vegetables, cooking oil, cheese, corn sweetener, and both regular and diet soft drinks in the common diet have been seen (1). At the same time, the cost of food continues to fall as a portion of disposable income (6). In consumer terms, this means that the cost of eating has gone down and food is a better “deal” now than ever before. Even less information on temporal trends in physical activity behaviors in the U.S. is available. Recent surveys indicate that the amount of physical activity performed during leisure time has not changed in recent decades (1). However, less information is available on how patterns of non-leisure time physical activity have been affected by the changing environment. Certainly, the increased reliance on personal automobiles, automation in the workplace, and the shift from a manufacturing-based economy to an automation-, service-, and information-based economy have likely contributed to a reduction in the amount of daily physical activity required on the job. The requirement of physical activity in schools has been systematically eliminated in favor of more classroom time, and even the provision of opportunities to engage in physical activity at recess seems to be a thing of the past. Likewise, in nearly every other aspect of daily life, we have developed technologies and products that save time, increase convenience, and reduce the need for physical effort. In many cases, we spend the “saved” time engaging in attractive sedentary pursuits like watching television or surfing the Internet. Taking all these trends together, one might conclude that we have systematically engineered physical activity out of our lives. Despite the circumstantial evidence that numerous environmental factors may promote a positive energy balance and obesity, it is essentially impossible, retrospectively, to assign proportional causality to any of these factors. Too many things have changed simultaneously over the past 8S

OBESITY RESEARCH Vol. 11 Supplement October 2003

three decades to disentangle what is cause, what is effect, and what is simple association. Even if we knew which factors were responsible for fractions of the variance associated with a given weight outcome, would this ensure a solution to the obesity problem?

Social Forces I hypothesize that the factors examined thus far are not the core drivers of the obesity problem. The environmental characteristics discussed above may merely be surface signs and symptoms of deeper causal forces. In effect, what some have described as a “toxic environment” (7) can be viewed as an unintended consequence of economic and social choices made for reasons not related to concerns about health. In searching for an environmental solution to the obesity epidemic, the first question that we should ask is why is the environment the way it is? If the environment is being driven by a larger set of economic forces and social values, it seems reasonable to ask whether it is feasible to expect meaningful individual or population behavioral change by targeting only certain environmental features associated with eating and physical activity behaviors, without changing the larger system within which these behaviors operate and are encouraged, penalized, and rewarded. It can be argued that obesity is a social problem (8), driven in many dimensions by our deeply held values and beliefs and the systems that we as a society have constructed to develop, reward, and perpetuate this value system. Our forefathers founded this country on strongly held beliefs about the value of personal liberty and being able to pursue one’s own dream. At the core of these values is the seemingly inherent drive to secure a better future for ourselves and our children. This may mean different things to different people, and the way social systems evolve to sustain this drive may change over time, but in today’s more uncertain world, being able to secure a better future seems to translate to earning more money and to raising your standard of living, and to do so as quickly as possible. This equation seems to operate at the societal level as well. As a nation, year after year, we pursue the goal of increasing the total output of goods and services, of growing the economy. To increase output, however, productivity must increase, and this, in turn, demands that more technology be invented and that more effort be spent in the pursuit of making and selling more goods and services. It is noteworthy that at no time in history have more individuals been invested in the stock market (9). This in itself creates even greater pressure for industry to make and sell more, because a much larger proportion of the population is directly invested in the productivity-prosperity equation. Aside from these direct investors, large segments of the population have a sizeable piece of their retirement nest eggs tied to the fortunes of the stock market. What individ-


ual or institutional shareholder does not want his or her investment to grow? This broader participation in the global economy by increasing segments of the population undoubtedly helps perpetuate the more frenzied pace of commerce that seemingly has but one objective: to make and sell more products and services. It is interesting that many of the Fortune 500 companies that dominate retirement funds and institutional investment portfolios are industries involved in producing and selling food, inventing and selling technologies that save labor and reduce physical activity, and offer ever more attractive forms of sedentary entertainment. So, the very industries that we rely on to build our own economic future are integral to the environment that we now recognize as helping to promote obesity. As if these forces were not enough to drive us toward creating an environment that promotes obesity, the challenge of preventing obesity is made even more daunting by our own biology: a blueprint that seems to reinforce our predisposition to find even better, cheaper ways to deliver high-energy food and to find even more ways to provide incentives for sedentariness. Humans are essentially “hardwired” to prefer foods high in sugar and fat and, hence, rich in energy, and we are not predisposed to engaging in physical activity for the purpose of being physically active per se (8). Thus, it is not surprising that after reviewing the evidence about factors affecting human food intake, Lowe (2) concludes that it is essentially infeasible for humans to self-regulate food intake under current environmental circumstances, at least not without applying substantial cognitive control. So, what is the point? The point is that at an overarching level, the environment is the way it is because that is the way we want it to be. It best serves the needs we currently value most as a society. In addition, economists would likely argue that the current configuration approximates the most efficient way to meet those needs within the prevailing set of social and economic priorities. As former U.S. Department of Labor Secretary and social economist Robert Reich wrote recently, “If people wanted to live according to different priorities and were willing to accept the sacrifices that those different priorities entailed, presumably they’d do so” (Ref. 9, p. 218). We have more fast food restaurants and packaged foods because people want more convenience. Convenience foods are generally high in fat, sugar, and calories because they make foods taste good and those ingredients are inexpensive, made so by years of agricultural advances designed expressly to provide more of these ingredients at lower cost. In addition, “supersizing,” which amounts, of course, to paying relatively less to get more, is part of our American culture and has become the definition of the “deal.” However, environmental factors affecting body weight control go beyond the food environment. We engineer the need for

physical activity out of workplaces because it takes time away from being more productive. We design communities and businesses alike to be “drive-through” to save time, so that we can devote more time to being productive or spend more time with our families, because we have spent too much time being productive. “Our incentive and reward system is also set up to perpetuate this situation. In the U.S., we reward hard work in a manner that encourages people to work harder” (Ref. 9, p. 273). The role of economics in driving environmental trends and perpetuating our social system cannot be overstated. Our drive to earn more and to be more productive as a society affects not only decisions made by individuals, but also pervades institutional decisions, many of which affect the shape of our environment and the attendant consequences for promoting obesity. In reference to how economic forces affect social choices, Reich writes, “Judges, legislators, editorial writers, and average citizens alike typically form their opinions on the basis of what alternative best promotes economic growth or best advances the wellbeing of consumers by lowering prices and generating better products” (Ref. 9, p. 235).

Social Choices Even if one accepts that the current shape of our “obesigenic” environment is driven by deeper social and economic forces and that we are all a party to its current form, does this mean that we really want the world to be this way? Does this mean that we are powerless to do anything about it? Certainly not. As a society, we are empowered to choose the direction in which we go. So, why have we not acted? Perhaps it is because we have never before been faced with such a crisis driven by myriad factors affecting multiple behaviors. In addition, we have only limited experience (e.g., creating smoke-free environments) in figuring out how to make socially relevant decisions that change the environment in ways that reinforce positive individual health behaviors. What changes will be necessary to have a meaningful impact on obesity in the next several decades? How do we make healthy lifestyle choices more socially normative, increasing demand for goods and services and policies that perpetuate a new healthier future state? How do we change the current value equation to make this happen? In this issue of Obesity Research, Baranowski et al. (3) point out that current behavioral change models have not been very successful at changing long-term eating and physical activity patterns and may be inadequate to support successful interventions that would reverse the obesity epidemic. Why have we been largely unsuccessful? One might argue that we have attempted to change eating and physical activity patterns, behaviors that are motivated by multiple drivers not necessarily related to health, through mediators that are not of primary importance to the individual at the OBESITY RESEARCH Vol. 11 Supplement October 2003

9S


point of decision, given the totality of immediate personal priorities and rewards facing the individual. Why would someone want to make a healthier food or physical activity lifestyle choice in today’s world? Our natural biological drive is to eat more and move less, behaviors that are inherently rewarding. Why would we do otherwise, unless there is a greater incentive to behave differently? In the context of obesity and healthy lifestyles, we are rarely provided incentives or rewarded for making healthful lifestyle choices, whether the choices concern food or physical activity. The rewards currently must come from within the individual, and these rewards alone have not been successful in motivating large segments of the population to change their health behaviors. It is time that we seriously examined what external incentives and rewards would be required to change the behavior of a significant fraction of the population. It seems unlikely in the short term that we can rely on more people reaching a high enough state of self-actualization that health behaviors ascend to a priority level of importance in their lives. Rather, we must begin examining what conditions would be required to make more people see that making healthy lifestyle choices is in their immediate self-interest. As a society we have made certain choices that served us well in the past, and these unintentionally led to the current obesity-promoting environment. Given the obesity-related health crisis that is looming, we clearly need to make some new choices: about what we want the future to look like, about what consequences and tradeoffs we are willing to accept, and about what we will adopt as new social norms. So, what will we choose, and how should we engage in moving ahead? At one end of the social change spectrum there are voices calling for policies that would limit or restrict choice and that would penalize people for making certain choices. At the other end of the spectrum there are those who would have us do nothing, keep going “full speed ahead.” For these stakeholders, the status quo looks better in immediate economic terms. For many, I would venture to guess that a better future state lies somewhere in between: a state that balances our American ideals of personal liberty (e.g., choice) and opportunity (e.g., commercial freedom) with social policies that ensure that as we continue to modify our environment, we examine publicly the consequences of our actions for the health of the population, and we make informed choices. In the end, we will have to find the right balance of tradeoffs and consequences that the majority of Americans will be able to live with. As for how to proceed, we also have choices. Some would argue that positive change will happen faster if we eliminate commercial interests from engaging in the dialog, 10S


as they are blinded by self-interest and would only work to delay moving ahead from the status quo. Others would embrace all sectors and interests to get to the endgame sooner, that is, to identify what is needed from each sector to support and perpetuate the new state and to get on with creating the future, unleashing the power and innovation of the market that will certainly drive rapid change once the target is identified. There are no experimental data that can answer the question of which approach will be better and take us to a solution faster. One thing is clear, however, at least for the food environment. There will always be a need for an industry to produce and sell food. When that industry has been called on in the past to respond to consensus public health needs, it has responded quickly and efficiently. For example, in the Healthy People 2000 report (10), the food industry was challenged to introduce 5000 new reduced-fat food products by the year 2000. The industry met the goal by 1995, five years ahead of schedule. This example highlights, in essence, a form of public–private partnership that can be used as a model of how involving private interests in addressing public health issues can be effective. Because the obesity issue is tied so strongly to economics, and economics is tied to social change, I conclude with a final quote by Reich (Ref. 9, p. 250), in which he writes about the impact of the new global economy on social evolution. I believe that this applies directly to the obesity situation in the U.S. today. “This cannot be—it must not be—solely an economic conversation. It is more fundamentally a moral one. We are not mere instruments of the new economy. We are not slaves to its technological trends. And we should not misdirect the blame for its less desirable, more worrisome consequences. As citizens, we have the power to arrange the new economy to suit our needs and, in so doing, to determine the shape of our emerging civilization. Every society has the capacity— indeed, the obligation—to make these choices. Markets are structured by them. Families and communities function according to them. Individuals balance their lives within them. It is through such decisions that a society defines itself. The choices will be made, somehow. They cannot be avoided. The question is whether we make the most important of these choices together, in the open, or grapple with them alone in the dark.”

Perhaps the single most important thing we can do to combat obesity is to engage in an honest, open, and inclusive dialog, and soon. References 1. Jeffery W, Utter J. The changing environment and population of obesity. Obes Res. 2003;11. 2. Lowe MR. Self-regulation of energy intake in the preven-


3.

4.

5.

6.

tion and treatment of obesity: is it feasible? Obes Res. 2003;11. Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change models helpful in guiding efforts directed at prevention of weight gain? Obes Res. 2003;11. Kantor LS, Lipton K, Manchester A, Oliveira V. Estimating and addressing America’s food losses. http://www.ers. usda.gov/publications/foodreview/jan1997/jan97a.pdf (Accessed November 2002). Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr. 2002;76:1207–13. Putnam JJ, Allshouse JE. Food consumption, prices and expenditures, 1970 –1997. USDA Statistical Bulletin 965.

7.

8.

9. 10.

Washington, DC: Food and Rural Economic Division, Economic Research Service, U.S. Department of Agriculture; 1999. Horgen KB, Choate M, Brownell KD. Food advertising: targeting children in a toxic environment. In: Singer DG, Singer JL, eds. Handbook of Children and the Media. Thousand Oaks, CA: Sage; 2001, pp. 447– 62. Peters JC, Wyatt HR, Donahoo WT, Hill JO. From instinct to intellect: the challenge of maintaining healthy weight in the modern world. Obes Res. 2002;3:69 –74. Reich RB. The Future of Success. New York: Alfred A. Knopf; 2001. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Public Health Service; 1991.


11S