Fast forward to the present: I have a master’s degree in public health and my weight is under control. I’m the director of programs at Clinicas de Salud del Pueblo, a non-profit community clinic that provides health, dental, behavioral health, and education services to people in Imperial County.

Unfortunately, obesity is much more common here than when I was a kid. Today, 4 in 10 children in Imperial County are considered obese or at a weight that puts them at high risk for serious health problems like Type 2 diabetes, high blood pressure, and complications from asthma. Couple this with the county’s high poverty rate of 22 percent, and you have a recipe for an unhealthy community.

To determine if a child’s weight is a problem, a key measure is body mass index—measuring the child’s weight against a national standard of what’s considered healthy for their height, age, and gender. A child in the 85th percentile or more is considered overweight; at the 95th percentile and above, a child is obese.

One major problem in dealing with childhood obesity is that many parents see it as something their children will outgrow—not a major health concern that requires treatment. The clinic used to take this approach, too. We told parents and children to eat healthy and exercise, and to come back next year for a physical exam. This method didn’t work. Most kids don’t grow out of being overweight or obese and many parents don’t know how to help them make healthy choices around food and exercise.

In 2011, my community clinic saw an opportunity to expand our work and join forces with other agencies in the region to come up with a new strategy for controlling obesity. One focus of our work is to try to identify obesity problems much earlier in children’s lives, and monitor the problem more closely over time.

We desperately wanted an approach that would work. So our coalition included San Diego State University’s Institute for Behavioral and Community Health as the lead agency so that we’d have top researchers. My clinic and the Imperial County Public Health Department provided on-the-ground knowledge. And in order to get real money, we applied for a 4-year research grant from the Childhood Obesity Research Demonstration (or CORD) study of the Centers for Disease Control and Prevention.

The grant program is part of the Affordable Care Act and aims to tackle childhood obesity in impoverished communities. We were fortunate to be one of just three sites funded in the United States—the others are in Massachusetts and Texas. We aren’t scheduled to present the results of our project, which is called Our Choice/Nuestra Opción, until 2016 as CDC is working on a report to Congress first. We have already learned a few things we can share.

The study is focused on three Imperial County communities (Brawley, El Centro, and Calexico). When we launched Our Choice/Nuestra Opción last year, we invited about 600 children who had been diagnosed at our clinic as overweight or obese to participate—and we allow any family that comes through our doors to access the services.

The family wellness program engages the entire family in learning to make healthy choices. Three to four times a year, the overweight or obese child visits the clinic to see a clinician for a weight management and wellness exam. A patient care coordinator also works with the family to connect them with community resources—everything from recreation programs to food stamps.

Finally, community health workers (or promotoras) lead a series of 17 wellness and physical activity workshops over six weeks for both parents and kids. There are workshops just for adults focused on parenting skills like communication, setting rules, and the importance of being a good role model when it comes to healthy living. There are also workshops for the entire family where they set realistic goals and come up with a wellness plan. Finally, families learn to incorporate fun games into physical activities. For example, everyone pretends to be on a ship where a “captain” calls out commands like “drop the anchor” or “swab the deck,” which are different stretching exercises.

When we launched Our Choice/Nuestra Opción, we were not prepared for how challenging this was going to be. For example, only half of the families invited are taking advantage of the new family wellness program. For many families, it’s hard to find the time to participate in the workshops twice a week—or to make the follow-up visits so the child’s weight and wellness plan can be monitored.

One of the first families to participate in Clinicas’ new family wellness program was the Padillas. Their 11-year-old daughter had been struggling with her weight for a few years and her mother knew the family needed help. She was overweight herself.

Nevertheless, it was difficult for the Padillas to be a part of the program. The family doesn’t have a car and needed to find a ride or take the bus, which can be tricky after 8 p.m. when most workshops end. The mother said that she felt guilty when she didn’t follow the healthy life plan she worked on at the clinic. Like many families, she felt reluctant to visit the clinic if the family had lapsed. We stress that the important thing is to stay on track as much as possible.

The Padillas eventually started to figure out how to manage the plan and make changes to their lifestyle. They went out on walks (even when it was 105 degrees), watched less TV, gave up drinking sweet tea, and ate less of their favorite (fattening) Mexican foods.

This year, the 11-year-old girl’s body mass index went down from the 98th percentile to the 95th, a small step in the right direction. Major weight loss takes time, and the Padillas have made real progress by changing their behavior. The family now eats more fruits and vegetables, drinks more water, goes to sleep earlier, and includes more physical activities in their daily routine. The child’s weight is still monitored by a clinician and the family is welcome to attend any physical activity and wellness workshops.

But it’s not just families that need to commit to change. In many cases, social service agencies, including those of us working in the project, also need to model better behavior, like serving healthy food in public meetings. As part of Our Choice/Nuestra Opción, experts conducted training with the staff of clinics, childcare facilities, schools, recreation agencies, and restaurants. We also launched a public outreach campaign focused on healthy behaviors, like drinking water instead of sugary drinks, getting enough sleep and physical activity, and eating more fruits and vegetables. There are Our Choice/Nuestra Opción posters all over Imperial County with these messages.

The magical solution to childhood obesity that I wished for when I was a kid doesn’t exist. Tackling this problem means making a long-term commitment—and understanding that change won’t happen overnight. This is as true for families as it is for all of us.

The post I Can’t Cure Your Child’s Obesity appeared first on Zócalo Public Square.

We foolishly thought that our experiment to improve on Mother Nature’s options for fatty food and replace saturated fat with “healthier” trans fats was a win-win. But trans fats have turned out to carry some of the same health risks as saturated fats, and it has taken an unfortunate amount of time for that to become clear.

Trans fats don’t have to be artificial—some are also found in nature. Bacteria in cows and sheep are known to create trans fats that appear in the milk we drink and the mutton we eat. But for 94 percent of human existence, we consumed small amounts of trans fats. Even after the domestication of cattle, our consumption of natural trans fatty acids did not typically exceed half of 1 percent of daily calorie intake until modern times.

Creating the trans fats we typically think of involves chemically processing an oil with acceptable health characteristics (such as cottonseed oil) to make it mimic saturated fat. In 1901, a German chemist discovered that exposing polyunsaturated oil to a metal catalyst made it denser. This property caught the eye of Crisco, and the company introduced a special kind of shortening in 1911—the first American food product to include industrial trans fats. Crisco’s shortening is semi-solid at room temperature, and the oil remains stable when used for deep frying, which made it appealing to cooks and food manufacturers. It gave food a longer shelf life and cost less than butter, lard, or tallow. Not only that, a pie made with Crisco lacked the animal flavors you might find in one made with lard or tallow.

Trans fats began to appear in baked goods in the 1920s but really took off during World War II, when lard was scarce and expensive. Margarine replaced butter—and manufacturers embraced trans fat as a cheaper and more desirable alternative to saturated fat.

Trans fats then got a boost from the medical community. In the 1980s, health authorities responded to the results of studies such as the Seven Countries study of heart disease by urging Americans to reduce their intake of saturated fat to minimize the risk of heart disease. In one of history’s greater ironies, the Center for Science in the Public Interest lauded fast food companies in the early 1980s for replacing heart disease-risky saturated fat with trans fats made from what they described as “heart-healthy” polyunsaturated fats.

By 1989 more than 10,000 food products sold in the U.S. contained trans fats. In the early 1990s, 95 percent of prepared cookies and 100 percent of crackers manufactured in the U.S. contained trans fats, according to FDA estimates.

Then scientists discovered alarming health effects of trans fats. In one clinical trial, the people who consumed trans fats had significantly higher levels of LDL-cholesterol (the “bad cholesterol) in their blood and lower levels of HDL-cholesterol (the “good” cholesterol), both reliable predictors of cardiovascular disease. Trans fats consumers showed even worse cholesterol levels than those who consumed similar amounts of saturated fat. Other studies revealed additional negative health effects. When trans fats were substituted for saturated fats, inflammation increased lesions in artery walls; trans fats also increased stiffening of the arteries.

In 1994, epidemiologists estimated that 30,000 cardiovascular deaths per year in the U.S. could be attributed to the consumption of trans fats. That same year, the Center for Science in the Public Interest did a complete about-face. They petitioned the FDA to require that food products containing trans fats include information about the amount per serving on the label and urged the public to limit its intake.

In 1999, the FDA announced that food product manufacturers had seven years to reformulate their products and list the trans fat content on labels—or at least the labels on any product with 0.5 grams or more. By 2006—when those labels first began appearing on products—the damning evidence against trans fats now included 12 clinical trials, one of which suggested that eliminating industrial trans fats from the food supply could prevent at least 72,000 heart attacks and strokes every year.

U.S. food manufacturers initially opposed FDA regulation of trans fats on the grounds that trans fats had been used for decades and were generally regarded as safe. But they began reformulating products anyway because of the bad press. Since then, manufacturers have reduced or replaced the trans fats in thousands of products—mostly energy-dense and nutrient-poor foods such as cakes, cookies, pies, pastries, and savory snacks. The McDonald’s baked apple pie, for instance, no longer uses trans fats and instead uses palm oil, a tropical plant oil with levels of saturated fat that are unusually high for a plant-based oil.

But we are mistaken if we think eliminating trans fats from American food products will result in a significant reduction in obesity-related diseases like heart disease and diabetes. We won’t see the results we’re hoping for until we change how and what we eat.

As any parent of a vegetable-rejecting child knows, it can take time to learn to like fruits and vegetables. My diet in college was heavy on cheeseburgers, French fries, ice cream, and pizza, with maybe a piece of fruit and a few vegetable servings. Over time, I’ve trained my body to prefer a healthy lifestyle. I eat six servings of fruit and six or more servings of vegetables every day. Now, even a single potato chip makes me feel queasy. Eating this way takes time—about 30 minutes to prepare dinner each night, plus three trips a week to the grocery store for fresh produce. Based on a sophisticated measure of my heart functioning, my current biological age is 27. (My real age is 62.) At this point, I’m addicted to the DASH diet, which calls for eight or more servings of fruits and vegetables combined a day. It may be the one addiction that is unequivocally good for you. And it contains negligible trans fats.

The post Remember When Trans Fats Were Supposed to Be Good For You? appeared first on Zócalo Public Square.

Last week in the same newspaper, food columnist and author Mark Bittman called the toddler obesity plunge a “tribute to the improved Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which encourages the consumption of fruits and vegetables; to improved nutrition guidelines; to a slight reduction in the marketing of junk to children; and probably to the encouragement of breast-feeding.”

But in fact, this spectacular drop is likely an artifact of the data sample, for which 2- to 5-year-olds are a small portion. Indeed, as Paul Campos has pointed out in The New Republic, rates of obesity among this group have gone up and down several times within the past decade. The real story is less spectacular but clearer: Rates of obesity for Americans of all ages—which increased during the 1980s and 1990s—have plateaued since 2000.

The question is why, and the answer is that we have no idea. We know no more about why rates of obesity stabilized in the 2000s than we do about why they increased in the 1980s and 1990s.

There is no shortage of hypotheses, as I discovered when doing research for my book on scientific and political debates over body weight. Some point to fluctuating levels of caloric intake, but this has been difficult to demonstrate. Indeed, one study found that that children and adolescents in 1988 to 1994 were consuming the same amount of calories as their counterparts had in the 1970s, despite increases in the numbers of overweight children and adolescents during this time. Others point to increased consumption of sugared drinks, meat, or carbohydrates, but hard evidence of any of this is hard to come by.

According to another line of research, reviewed in Julie Guthman’s 2011 book Weighing In, the weight gain of the 1980s and 1990s may be largely an adaptive response to toxins in our water, air, clothing, and elsewhere. According to this argument, the body creates fat deposits as part of an effort to store these toxins away from vital organs. In this scenario, weight gain may not be—in itself—a bad thing, although it may be indicative of other problems. Some research suggests that a small but significant part of the weight gain of the 1980s and 1990s can be attributed to smoking cessation, clearly a positive development that we do not wish to reverse.

The more interesting theories underscore the importance of broad societal trends. Some researchers argue that increases in obesity rates in the 1980s and 1990s were due to growing levels of inequality. They point to evidence that obesity rates rose highest in those nations with the greatest levels of inequality and with the stingiest welfare states, as well as among the poorest members of all societies. They reason that economic inequality and insecurity produce high levels of stress, raising levels of cortisol, which, in turn, leads to weight gain. Generous welfare states buffer people somewhat from the effects of economic insecurity and the related impact on their waistlines.

It’s clear that the poor and socially disadvantaged are more likely to be categorized as overweight or obese, though why that is isn’t so clear. The answer may lie in unequal access to information, fruits and vegetables, safe opportunities to exercise, greater exposure to toxins, or elevated stress and cortisol levels. There is also evidence that weight-based discrimination leads to downward mobility among those biologically predisposed to corpulence. According to this view, being fat makes you poor, rather than the other way around.

What’s frustrating about not being able to isolate precisely why our population’s weight skyrocketed at the end of the 20th century and has since stabilized is that it then becomes difficult to rely on the right public policy measures to further the trend.  Many of the policy interventions that are being credited for creating our current obesity plateau were developed a decade or more after the start of this trend. More to the point, even public health interventions designed to help people—children in particular—lose weight have been shown to produce no weight loss, even when they were successful in changing diet and exercise behaviors.

This is not to say that policy efforts—such as improving access to fruits and vegetables in low-income neighborhoods, improving the nutritional value of school lunches, or building more bike paths and parks—are not laudable. Having access to delicious and healthy foods and safe opportunities for movement are likely to improve our overall quality of life and perhaps even health outcomes. Working to alleviate poverty and economic insecurity is also likely to have all sorts of social benefits, even if these efforts do not lead us to lose weight.

And maybe that is OK. There is growing evidence that people benefit from physical activity and improved diet even in the absence of weight loss. For instance, several studies have shown that physically fit “obese” individuals have a lower incidence of heart disease and mortality from all causes than do sedentary people of “normal” weight. Similarly, a clinical trial published in the New England Journal of Medicine showed that adopting a Mediterranean diet reduced cardiovascular risk without inducing weight loss. And economic security has consistently been shown to positively affect health and longevity, which is—after all—what all this is about.

Or isn’t it?

The post Your Toddler May Soon Be Fat Again appeared first on Zócalo Public Square.

The show’s premise is that anyone can be thin if they work hard at it. If some people are fat, it is because they don’t care enough to try to better themselves. Not only are they slothful and gluttonous, but—because obesity is a deadly and costly disease—they are risking their own health and the economic health of the nation for their self-indulgent ways. In one episode of an earlier season, a doctor tells a 20-year-old male contestant, “You have so much to live for. What are you doing?” to which the shamed contestant responds, “Throwing it away.” After being told that his death is imminent due to his weight, another contestant confesses to his doctor, “I realize how selfish I’ve been.” Later in the season, a physical trainer explains to viewers, “To get in shape and to change your life doesn’t come free; you’ve got to earn it. And if they want it bad enough, if they can change themselves mentally and emotionally right here, the rest will follow.” Over and over again, the show portrays being heavy as both a death sentence and a personal choice.

In fact, body weight is determined by a host of biological, genetic, and social factors, often beyond one’s personal control. According to one estimate, 70 percent of the variation in people’s weight can be accounted for by genetic inheritance. This helps explain why the weight loss produced by diets tends to be temporary. As geneticist Jeffrey Friedman has explained, “In trying to lose weight, the obese are fighting a difficult battle. It is a battle against biology, a battle that only the intrepid take on and one in which only a few prevail.” So it’s not surprising that The Biggest Loser does not follow up with contestants years after the show to see whether they have been able to keep the weight off or not.

The extent of shaming that takes place on The Biggest Loser is extreme, but the general attitude that anyone can—and should be able to—lose weight by applying themselves is pervasive. In researching my book What’s Wrong with Fat?, I analyzed hundreds of news reports on “obesity” published between 1995 and 2005, and discovered that the issue is treated as much a moral scourge upon the land as it is a health issue. News reports overwhelmingly emphasize individual blame and responsibility. A typical 2003 news article says, “The two prime culprits for this expanding obesity are inactivity and overeating, and TV watching is linked to both of them.” Making the moral implications clear, the article speaks of children spending “lazy hours in front of the TV.” Indeed, television is the preferred example of a sedentary activity, since it is widely regarded as morally suspect. Among the hundreds of articles I read, not one spoke about children becoming obese because they are spending too much time reading, playing board games, or engaging in other sedentary—but virtuous—activities, as this would have muddied the simple narrative of obesity as the product of bad individual choices or behavior.

There are health risks associated with higher body mass, the clearest being Type 2 diabetes, which becomes more likely with increased weight. Yet even here, it is unknown whether being heavy causes diabetes, whether diabetes causes weight gain, or whether both conditions are caused by a third factor, such as poor nutrition, stress, or genetic factors. Moreover, the association between weight and Type 2 diabetes is not perfect. Some thin people develop the disease, and many fat people never will.

A 2008 study showed that a person’s weight is not a perfect predictor of metabolic abnormalities in blood pressure, triglycerides, cholesterol, glucose, insulin resistance, and inflammation. Almost a quarter of normal-weight people had abnormal profiles, while more than half of overweight people and almost a third of obese people had normal profiles. In other words, treating weight as a proxy for health could result in the under-diagnosis of more than 16 million normal-weight Americans and the over-diagnosis of almost 56 million overweight and obese Americans.

While there is a lot of uncertainty about the health risks of weighing more than average, there is growing evidence that our widespread societal anti-fat bias takes a toll on public health in many ways. Afraid of public ridicule or abuse, some heavy women avoid exercising in public or even leaving their homes, depriving themselves of social interaction. Women categorized as obese are more likely than thinner women to report that they experience the doctor’s office as a hostile environment. Such women are also, on average, less likely to get Pap smears, contributing to higher rates of cervical cancer among women categorized as obese. And the fear of becoming fat can lead women of all sizes to develop eating disorders and body-image problems that diminish their lives and can be extremely dangerous to their health.

Yale researchers have shown that weight discrimination in the United States has increased dramatically in the past decade and is now comparable in prevalence to rates of reported racial discrimination, especially among women. Multiple studies have documented weight bias in employment, healthcare, education, and public spaces—unequal treatment based on stereotyping fat people as lazy, unmotivated, sloppy, and lacking in self-discipline and competence. Heavier women are not only less likely to be hired and less likely to earn a higher salary compared to their similarly qualified thinner peers, but they are also less likely to marry or to marry a high-earning spouse. Unlike thinner women, who can more easily climb the social and economic ladder, heavy women face the prospect of downward social mobility.

My colleagues and I have conducted research that suggests that exposure to moralizing messages promoted on shows like The Biggest Loser worsen anti-fat prejudice. We found that people who read a news report discussing an alleged obesity health crisis were more likely to agree—compared to those who read an article on a topic not related to weight—with stereotypes of fat people as unlikable, untrustworthy, and less intelligent than thinner people. Other studies have shown that individuals who think people can control their weight are more likely to believe that weight-based discrimination is justified. By aligning herself with The Biggest Loser, Michelle Obama further legitimizes anti-fat attitudes, and the ills they spread.

Moreover, discussing physical activity and nutrition solely as weight matters, instead of contributors to one’s broader health, is counterproductive. Plenty of people make positive changes to their diet and increase their physical activity as part of an effort to lose weight. If they don’t lose weight or their weight plateaus, they become frustrated and revert to their old ways, even though the behavioral changes bring with them other positive health dividends. Given how difficult it is to lose weight, the First Lady should consider using her platform to promote a more constructive message: that people of all sizes can make positive nutritional and exercise changes.

The post Humiliating Fat People Is Hazardous to Our Health appeared first on Zócalo Public Square.

Moderator David H. Freedman, a contributing editor at The Atlantic, asked the panelists if they could name the single most important, effective action we can take to get the word out when it comes to public health.

UCLA health economist Frederick J. Zimmerman said that when we talk about incentives and laws that affect our dietary behavior, we often talk about the government interfering with our freedom and about personal responsibility. We need to rethink the terms, he said, and ask some fundamental questions: “What does freedom mean, what does power mean, what does personal responsibility mean?”

University of Minnesota social psychologist Traci Mann said we need to attack public health issues on multiple levels: those of individuals, couples, families, schools, and communities.

“Policy is not a dirty word,” said Los Angeles County Director of Public Health Jonathan Fielding. For 20 years, we tried to convince people to wear seatbelts through public service announcements; nothing worked. Once seatbelt wearing became part of the law, however, behaviors changed and lives were saved. “Public health works by successive redefinition of the unacceptable,” he said.

So what would a really smart, government-sponsored health propaganda campaign look like today?

Zimmerman said that the best campaigns, like California’s anti-smoking ads, tie into people’s sense of autonomy: “Send a clear signal that you are being manipulated when you see a food ad.”

We have to talk about the food industry, added Fielding—about how it’s trying to maximize consumers’ value, not health or community benefit. And we have to work with industry leaders, too, to persuade them to help change our palates—by cutting salt in their products, for example. Media, he said, only works in synergy with policies and incentives.

Mann has studied how people make decisions and exercise self-control, and her single overarching finding is that most people don’t have much self-control. To the extent that they do have self-control, it varies in response to their environment. If we want to change behavior, she said, we must change the environment.

When, asked Freedman, does something like a soda tax work?

Zimmerman said you can’t simply consider the economic impact of a tax; a small increase on soda price doesn’t affect demand. But if you tell consumers they’re paying a “sin tax” on their soda, the tax will have a much greater impact on their behavior. “No one,” he said, “wants to pay for something twice.”

There are a lot of different ways to affect people’s decision-making, said Fielding. You can cross-subsidize as well—decrease the price of a salad while increasing the price of everything else on a cafeteria menu. Or, a store can put healthier food at the front, closer to eye level.

“I’m a huge fan of nudges,” said Mann—very tiny efforts that yield huge results. She’s seen something as simple as a larger spoon in the vegetables at a school cafeteria increase kids’ vegetable consumption.

Big box stores, said Fielding, can be much more helpful in prompting people to make healthy choices: “We need to get them on our side—on the side of the consumers’ health.”

In the question-and-answer session, audience members asked about the New York City move to outlaw supersized sodas and about getting people to take a longer-term view of their health when it comes to decision-making.

Fielding called the soda ban “small but useful”; people can still drink as much soda as they want, but they have to fill up three or four times to get to a liter as opposed to once.

Even tiny obstacles like this, said Mann, can be enough to stop people—and they don’t get in the way of our cherished freedom. Making behaviors a tiny bit harder can be surprisingly effective.

How do we get people to consider the long-term effects of their behavior on their health?

The panelists agreed that this is impossible; if people were thinking about the future they’d make different choices.  “You have to start with where people are,” said Fielding. “You can’t start with where we would like them to be.”

Zimmerman called the economists’ idea that people carefully weigh the pros and cons of every decision they make “a bunch of BS.” He added, “That’s not how people make decisions, even really big decisions.”

In sum, we’re tremendously influenced by our peers, our families, our histories—and by our environment. We’re not as rational as we think, and the best health propaganda recognizes and works with that.

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