Obesity wars hit PDX
Experts say junk food in bull's-eye of next big health campaign
As far as Dr. Daniel Marks is concerned, he had no choice. State law requires physicians treating underage patients to report suspected abuse or neglect to authorities.
Marks, an endocrinologist and child obesity researcher at Oregon Health and Science University, had before him a boy with multiple complications due to his lack of fitness. The boy suffered from adult onset diabetes, sleep apnea, a knee deformity brought on by his excessive weight and partial heart failure.
The boy weighed 400 pounds. He was 11 years old.
Marks says he and others tried to get the family to change the boy's diet and lifestyle. Social workers talked with the boy's parents. A psychologist worked with the boy. Without the changes, Marks says, the boy would almost certainly die young, possibly before his 20th birthday.
Nothing worked. The boy's father was bedridden and said providing the fast-food burger meals they were eating three times a day was one of the few ways he could make his child happy.
The diet continued. So Marks began proceedings that resulted in the boy being placed in foster care.
'It was an intractable social situation,' Marks says.
It is also a situation at the center of a heated national controversy. The public health world was rocked two weeks ago when a commentary in the Journal of the American Medical Association raised the possibility of placing more children like Marks' patient in state custody for their health. There has been a considerable outcry, but physicians such as Marks say for the absolutely worst cases, 'this is something we talk about all the time.'
What worries Marks is that he's seeing more morbidly obese children, children who he says won't live far into adulthood. He's even consulting on obesity issues with parents of infants.
'They're coming to me younger and younger,' he says.
But Marks says he also sees one sign of hope: more parents and children are listening to his advice and changing their habits than when he started practicing 16 years ago.
Courtesy of NYC Health Department • Decades of anti-smoking messages such as the signature ad below worked to change public attitudes toward smoking. The New York City Health Department is pioneering ads (above) that point out the amount of sugar people consume each day through sweetened beverages.
© 1999 World Health Organization
The JAMA commentary has engendered a new round of discussion in what many believe will eventually be seen as 'the obesity wars,' comparable to the battle public health officials have been waging against tobacco during the past 50 years.
Tobacco smoking and obesity have a great deal in common, say public health experts. Both, to some extent, stem from lifestyle choices that can shorten lives and result in huge public health care expenditures.
Cigarette smoking is considered the No. 1 cause of preventable deaths in the United States. Obesity is No. 2, but, according to a 2004 U.S. Centers for Disease Control and Prevention study, obesity is about to take over the No. 1 spot.
Americans spend about $147 billion each year in direct medical costs due to obesity. A 2004 Rand Corp. study estimated that within 10 years, 20 percent of all U.S. health care spending would be on obesity-related diseases.
There are differences, too. Nobody has to smoke, and the decision is black and white: either you smoke or you don't. Everybody has to eat. Eating produces societally acceptable pleasure. Even physical activity - the other half of the obesity equation - is something we all do to a greater or lesser extent.
So, experts say, public policies that limit food choices or dictate food costs through subsidies and taxes will likely be more difficult to sell to the public than measures that have restricted smoking.
It's one thing to demonize a McDonald's cheeseburger or make it difficult for a child to acquire fast food, but what about a cheeseburger from an upscale restaurant or a burger grilled at home?
Seattle pediatrician Robert Pretlow says that 10 years from now, there will be public health policies restricting children's access to at least some of those burgers, and more.
The focus of the obesity wars, Pretlow says, has so far been public education, and it hasn't worked. Obesity rates have soared during the past decade. One third of U.S. and Oregon adults are obese; two-thirds of U.S. adults (61 percent of Oregon adults) are overweight.
Pretlow is one of the more strident voices for dramatic public health policies that he thinks are inevitable. 'I think junk food will start to be restricted. Taxed. Or the obesity problem is going to bankrupt our country,' he says.
Looking into the future Pretlow envisions a day when those under 18, who cannot legally purchase tobacco products, won't be able to purchase certain nutrition-empty, highly caloric foods. He sees zoning laws keeping fast-food outlets and convenience stores from locating near schools. He's convinced that cigarettes and certain foods have more in common than people realize.
In June, Pretlow published a paper in the journal Eating Disorders, titled, 'Addiction to highly pleasurable foods as a cause of the childhood obesity epidemic.' He says that science will eventually make moot the question of whether the obese are responsible for their conditions as similarities between drug addiction and food addiction become more established.
Pretlow bases much of his prediction on recent breakthroughs showing that the same brain mechanisms that regulate drug addiction appear to be involved with compulsive overeating in obese people. In his research, Pretlow works with obese children who, he says, cannot resist a small number of fast foods and junk foods that have been engineered with additives and flavor enhancers to be irresistible to kids.
'These kids are stunningly open and honest and they say they are addicted to this stuff,' Pretlow says.
The response, Pretlow says, will be making those addictive foods unavailable to children.
'The way it's defined now is nutritional versus not nutritional,' he says. 'That's not going to work. It's going to have to be addictive foods versus non-addictive foods.'
Tribune Photo: Christopher Onstott • Dr. Bob O'Rourke consults with Sharon Rollins about her upcoming gastric bypass surgery at OHSU. O'Rourke says most of his patients cannot address their obesity through diet and exercise - no matter how hard they try.
Bigger than will power
OHSU's Marks doesn't want to see taxes and restrictions on unhealthy foods such as sugar-sweetened beverages. He'd rather attack those foods closer to their source by eliminating federal farm subsidies that have allowed nutrient-deficient foods such as sugary drinks and fried snacks to sell cheaper than healthier foods such as fresh fruits and vegetables.
But Pretlow and Marks agree that science is going to make even more difficult the judgments that will guide public health policy.
So does Robert O'Rourke, an OHSU bariatric surgeon, who says that 99 percent of obese patients who use diet and exercise to lose weight eventually fail. Increasingly, O'Rourke says, research is finding that some people have metabolisms that nearly ensure they will become obese.
'When we ask obese people to go out and lose weight it's equivalent to asking drug addicts to quit drugs while everyone around them is using them,' O'Rourke says. 'People are starting to understand that this is a problem that's much bigger than will power.'
Public policy experts say that media campaigns eventually convinced the public that smoking around others and not wearing seat belts were morally wrong. But stigmatizing the obese won't work, says Rebecca Puhl, director of research and weight stigma initiatives at the Yale University Rudd Center for Food Policy and Obesity.
Puhl says obese people are already more stigmatized than smokers. And studies have shown that when the obese feel the spotlight of public judgment, they react by eating more and gaining weight.
The Rudd Center has led the fight for taxes on sugar-sweetened beverages, which Puhl says is a natural first battleground. The average American consumes 22.5 teaspoons of manufacturer-added sugar per day, and almost half of that comes from sodas and fruit drinks, according to a U.S. Department of Agriculture study.
That 2010 study reported that a soda tax raising the price of sweetened drinks 20 percent would cause the average adult to lose 3.8 pounds in a year. The average child would lose 4.5 pounds.
'Taxing soda is a great example of a public health measure to improve health,' Puhl says. 'It's a nice parallel to tobacco. We're taxing a product that is harmful to health. Soda is not healthy for anybody, regardless of what they weigh.'
Courtesy of CHOA • This Children's Healthcare of Atlanta ad is part of a campaign that some say goes too far in stigmatizing the obese. Experts say public health campaigns are going to have to tread more delicately with anti-obesity ads than they have with anti-smoking campaigns over the years.
Singling out sweetened drinks such as soda is unfair and counterproductive, says Chris Gindlesperger, spokesman for the American Beverage Association, which represents the country's non-alcoholic beverage manufacturers.
'It's wrong to single out one product when we're talking about an overarching problem like obesity. Taxes don't make people healthier,' he says.
Gindlesperger says his association supports posting calorie counts on drinks and eliminating high-calorie drinks in schools. But, he says, tax increases on unhealthy foods are divisive and won't work.
'People can decide what to drink and eat for themselves,' Gindlesperger says. 'They certainly don't need government help to do that.'
So far, the soda wars have been won by the beverage industry. Public health proponents have managed to get soda taxes instituted by the state legislatures of Maine and Washington. In both places, the beverage industry funded public referendums to repeal the taxes, and won.
Gindlesperger says the message was clear.
'People see that when government starts to reach its hand into their grocery carts there's no telling where it will stop,' he says.
Puhl and others say the message was that widespread public education and softer measures may have to substitute for the more drastic tactics such as soda taxes and an end to government subsidies. Required fast-food calorie counts on menus began in the last year in Oregon, but there are no studies yet to determine if that is changing eating habits.
Puhl and others say the government should finance projects to turn some towns and neighborhoods into laboratories. Sodas and snack foods can be eliminated in one town's schools, and children studied to learn whether that measure affects obesity rates.
Fitness initiatives for children could be pushed, or a local tax could change the price of sweetened drinks.
'A lot of people say there's no evidence this works. We're not going to know what works until we try,' says Puhl.
Freedom and choice
In Oregon, few of those experiments are occurring, says Raquel Bournhonesque, co-director of Portland nonprofit Upstream Public Health. Bournhonesque says outside of a bill that makes it easier to get Oregon farm products into school cafeterias, not one obesity prevention measure received so much as a hearing in the 2011 Legislature.
Bournhonesque would like to see a soda tax. She'd like to see the state impose nutritional standards on the meals served to kids in child care facilities. She'd like to see physical education five days a week in public schools. Only 55 percent of Oregon eight graders and 12 percent of 11th graders attend gym class every day. She'd like to see funding for safe routes to school programs that encourage kids to walk or bike to school rather than take a bus.
Other policy experts have suggested that government assistance money, such as food stamp benefits, be restricted so recipients could not use it to buy soda or unhealthy snacks. Or, that governmental approval of new developments include a health impact statement in addition to environmental impact statements.
Bournhonesque preaches patience, pointing out that for decades the tobacco industry defeated smoke-free workplace laws, until the public's acceptance of the danger of secondhand smoke led to smoking restrictions.
'I think our winning on tobacco has less to do with stigmatizing and shaming smokers and much more to do with just making it more difficult to smoke around folks who aren't smoking,' Bournhonesque says. 'People already know eating junk food and smoking are bad for you. It's more about making healthier food more accessible and making unhealthy food less accessible.'
This shift is going to happen, says Lawrence Wallack, dean of the Portland State University college of urban and public affairs. And it won't take as long as it did with tobacco.
'It won't take 30 years,' Wallack says. 'Historically, the big industry argument is about freedom and choice. Secondhand smoke broke that down. Now it was no longer about an individual choosing to smoke or not. It became, 'That person's behavior affected my health.' The key to this whole thing is cracking the freedom-and- choice argument.'
Wallack says that the health consequences of obesity will become increasingly visible in the years to come. Public support for dramatic policy changes will follow.
'The costs will become so high that everybody realizes this interconnection that we all have, that it's about community health and not just about individual health,' Wallack says.
Advocates for obesity laws have one advantage that anti-smokers didn't, he adds.
'People walking around with lung cancer didn't necessarily look any different,' Wallack says. 'The problem is going to be much more visible and we're going to be hearing about the impact of (obesity) much more.'
Pawns in a game
The key to bringing the public around to accepting dramatic anti-obesity measures will be soft stigmatism, says Kevin Mercuri, president of New York City's Propheta Communications, a public relations firm that works in consumer and government affairs.
Mercuri says that soft stigmatism convinces the public that people who litter or drive while drunk or smoke near others were selfishly endangering everybody.
'You're still going to have to be very careful and selective,' Mercuri says. 'You can't show a terribly obese person because then you're stigmatizing those people. The images will have to be of certain body parts that are affected by obesity.'
For instance, Mercuri says, ads could show people who lost limbs as a result of diabetes, similar to anti-smoking ads that have shown smokers with tracheotomy tubes in their throats.
Soft stigmatism can mean focusing on children and how their adult lives are affected by the eating habits they pick up when young, Mercuri says. Eventually, if school cafeterias eliminate unhealthy foods, parents will follow suit at home, he adds.
What Mercuri calls 'the first dent in the armor' would be measures outlawing direct marketing of unhealthy foods to children. The public would support that, he says, because it plays on parents' universal desire to protect their children.
'Coming out and saying 'You can no longer market to our children in this manner' would actually work,' Mercuri says.
Roberta Friedman, director of public policy at the Yale Rudd Center, agrees.
'Somehow we have to make people understand that they are pawns in a game,' she says.
Changing diets is only part of the obesity fight solution
Unhealthy eating is one thing, lack of exercise another. Both contribute to obesity, but they aren't necessarily equal.
Oregon Health and Science University obesity researcher Dr. Daniel Marks says that when it comes to fighting the health effects of obesity, 'I would take exercise every time.'
Diabetes and heart disease are among the most serious health consequences of obesity in children, and Marks says both respond better to physical activity than to dietary change.
'You can be heavy and be incredibly healthy,' Marks says.
It may be easier for anti-obesity advocates to focus on food with measures such as soda taxes, but Marks says that would be ignoring more than half the obesity problem.
A bigger issue with obese children, Marks says, is the amount of screen time they get in front of televisions, computers and video games. Marks says research shows that even children reading books and sleeping burn more calories than those passively watching a screen.
Getting all those kids moving their bodies is just as important as changing their diets, he says.
'We need to get away from worrying about whether someone is overweight or not,' Marks says. 'The issue is, do they have a healthy and sustainable lifestyle or not?'