Description
OBESITY: ORIGINS AND SOLUTIONS HOW DID AMERICANS GET SO FAT?
If you have been to your local shopping mall recently and are older than 20 years of age, you have witnessed the growing girth of many Americans. The United States is now the fattest country in the world! The U.S. government regularly surveys the American public to put numbers on the face of fatness. These surveys are called the National Health and Nutrition Examination Surveys (NHANES). Between 1960 and 1976, there was a slow rise in the number of Americans who were overweight. This rise was similar to the slow increase in overweight that occurred from the time of the Civil War (in 1860) through 1976 (Bray 1976a). Between 1976 and today, however, there has been a big jump in the number of overweight and obese Americans. The number has more than doubled between 1980 to 2002 (from 14.5% to 33.5% obese) (Ogden et al. 2007). The increased rate at which people are becoming fat has led some to label this an “epidemic” (the World Health Organization [WHO], the National Heart, Lung, and Blood Institute [NHLBI]).
Figure 1 shows this pattern of increase for three levels of body weight. The upper limit of normal is 25 body mass index (BMI) units, a number we will describe in more detail in Chapter 2. People above a normal BMI of 25 have increased from 45% of the population to over 60% today—a rise of more than one-third. A BMI of 30 in Figure 1 is the dividing line for obesity. The number of adults above a BMI of 30 has grown from 14% in 1960 to over 30% today—a 100% increase. The final line at a BMI of 40 defined the dividing line for the very obese. Very obese people were uncommon in 1960 but are now more than 5%—a more than 400% increase.
Nearly 40 years ago, even before the “obesity epidemic” began in earnest, the plight of fat Americans became my life’s work. Much of my office practice of medicine dealt with obese ado-lescents and young adults. Back in the 1960s, I was saddened and dismayed by the young people weighing more than 300 pounds who came to my office for help. The problem is much worse now. In the 1960s, the group with a body weight greater than 300 lbs was less than 0.1% of the American population. Now it is over 5% and growing rapidly. Thirty years ago, I published my first book on obesity, (Bray 1976a) followed by an update in 2007 (Bray 2007b). Twenty-five years ago, I pub-lished my first treatment program to help people manage their weight problem (Bray 1982). Many things have changed in the intervening years. Preparation of this book has been strongly influenced by my experiences at the Pennington Biomedical Research Center in Baton Rouge, Louisiana. When I became director of this center in 1989, the current obesity epidemic was in full swing. As director of this magnificent nutrition research facility, I had additional resources to tackle the problem that has been my life’s work. This book incorporates many new ideas about weight management that I have learned through the help of many patients and professional colleagues.
Let me put my strategy of weight management forward for you and then fill in the details about how this approach came about. First, we know that in famines, and when food is in short supply, people don’t gain weight—indeed, they lose weight (Ravelli et al. 1999; Franco et al. 2007). No food—no fatness. This means that food plays a key part in the problem (Swinburn et al. 2009).
Focusing on food and how its intake is regulated is the first step toward understanding the epi-demic of obesity. Reasoning that some foods are playing a bigger role than others, we examined the data from the U.S. Department of Agriculture about changes in food supply during the twentieth century. One of the striking findings was that the epidemic of overweight occurred in parallel with the introduction of high fructose corn syrup (HFCS) into the American food supply (Bray 2004). The association between the rapid rise in obesity and the introduction of HFCS doesn’t prove that HFCS is the cause of obesity—obesity clearly has a number of causes, many of which are related to eating more food than we need. But the evidence is growing that the fructose that comes from HFCS or sucrose (table sugar) may be one contributor to the rise in obesity rates (Vartanian et al. 2007; Malik et al. 2010).
Along with a major shift in the supply of caloric sweeteners in the American diet, a number of other changes have occurred over recent decades that impact the epidemic of obesity. These trends can be summed up under the five “Bs”: Beverages, Burgers, Behavior, Being Active, Buyer Beware.
Beverages: I have already introduced you to beverages sweetened with fructose from either HFCS or sugar. There are a number of potentially harmful effects of fructose on body weight (Malik et al. 2010; Bray 2009). Thus, reducing fructose intake makes sense to me and soft drinks and sweetened fruit drinks that contain this sugar are easy targets. Several studies reviewing scien-tific publication (meta-analyses) have shown that soft drink consumption predicts energy intake and often weight gain and obesity (Vartanian et al. 2007; Olsen and Heitmann, 2009; Malik et al. 2009). Get as much of your fluid and beverage needs as you can from water, tea, or coffee—at least six to eight 8-ounce glasses a day and avoid beverages that have fructose in them.
Burgers: Everyone, or nearly everyone, has eaten at one of the fast food restaurants. They are ubiquitous in the United States and around the world. Burgers tend to be loaded with fat —but they are “tasty.” Over the past 50 years, the size of most burgers has ballooned. A single large burger meal can provide 1000 calories or more, which is 50% or more of the calories needed by many Americans each day. These are problem foods for some people who want to lose weight and keep it off, as well as for people who do not want to gain weight. This threat to a healthy weight was shown dramatically in the documentary movie, Supersize Me. The director, Morgan Spurlock, gained over 25 pounds in 1 month while supersizing his meal every time it was offered. Grilling burgers at home without the “special” sauce is good advice.
Behavior: Eating and drinking are behaviors. One view has it that we become overweight because we have “faulty” behaviors. Whether true or not, this idea has been helping people plan what they eat, and with whom and where they eat, to get better control over their own personal eating. The Internet is one of the most striking developments of the past decade (Winett et al. 2005). The power of the Internet is being harnessed to use in behavioral weight management, and offers promise for the future. One of the most important concepts has been the control of portion size using “portion-controlled” foods. I will explore behavioral techniques in Chapter 6 and focus on the types of foods and beverages to include in a diet plan.
Be as active as you can to counteract the tendency to be inactive. Society no longer requires much strenuous activity, unless we choose to do so. Television, video games, and comfortable automo-biles all make the United States one of the most inactive societies on earth. Inactivity is the norm. We know that overweight people sit an average of 2 hours more per day than do thinner people. Standing up while talking on your cell phone uses more energy. The beauty of the cell phone is that you can talk anywhere and walk while doing so, all of which burns more energy. A step counter to count the steps you take, described in Chapter 6 is one way to set a goal of becoming more active.
Buyer Beware: We are all influenced by the prices of the things we buy, including food. Price reductions and sale items get our attention. Food pricing works the same way. Special deals, such as “two-for-the-price-of-one” and “supersizing” are ways of selling more for a “better deal”—a better deal for the seller maybe, but not necessarily a better deal for you. Buy healthy foods, not necessarily the cheap ones. Remember, you don’t have to clean your plate. Put the waste in the garbage bin rather than on your own waist. Avoid combinations of fructose from HFCS or sugar and fat.