On Curbing Obesity

COMMENTARY
On Curbing Obesity
Amitai Etzioni
Published online: 20 February 2014
# Springer Science+Business Media New York 2014
Abstract Public policies to combat obesity (with the notable exception of Let’s Move, initiated by Michelle Obama) tend to focus on reducing caloric intake (dieting). These efforts often fail and have some negative side effects and multiple economic and human costs. To the extent that we are dealing with individuals
(rather than with societal factors) a more effective policy would give more weight to exercise as compared to dieting and, above all, focus on parents (and thus on young children) rather than on adults. This is the case because as children become adults, their BMI is set to a very considerable extent.
Keywords Obesity . Health . Diet . Parenting
Many programs that aim to curb what has been called the
“obesity epidemic” in America are misfocused. They put too much weight on reduction of caloric intake via dieting and too little on expending calories via exercise; they pay insufficient attention to the ill effects of dieting; they target the general population instead of focusing on the parents of young children; and they focus on individual behavior much more than on societal factors. This article takes it for granted that large numbers of Americans have an unhealthy high and rising
Body Mass Index (BMI), although this assumption is not shared by everyone.1
Calorie Intake vs. Output
In seeking to curb obesity, individuals, the health care profession, and public authorities recommend changes in behaviors that encompass both reducing the intake of calories (mainly via dieting) and increasing the expenditure of calories through exercise. However, often much more attention is dedicated to reduction in caloric intake versus increase in caloric output. To document this observation, it would be necessary to analyze the advice given by health care professionals to their patients, mass media messages, popular books, commercial programs
(such as Weight Watchers), various laws (e.g. those that require restaurants to post the caloric content of their food), and pronouncements by elected officials and public health authorities.
This cannot be done here. Instead I merely illustrate this point. Numerous books, articles, and programs that promote dieting as the way to reduce one’s BMI do not mention exercise at all. (This article discusses dieting only as a way to reduce caloric intake and not as a way to change the mix of the kinds of calories one ingests). Others mention it as a supplement that helps people lose weight and keep it off.
Granted, quite a few others do recommend both, but even these grant dieting more prominent attention. See, for instance, highly popular books such as Dr. Atkins’ New Diet
Revolution, The South Beach Diet, The Zone Diet, and The
Flat Belly Diet. The same holds for popular weight loss programs such as Jenny Craig, NutriSystem, and Weight
Watchers.
A minor incident illustrates the thesis at hand.
Michelle Obama unveiled in 2010 an obesity-curbing program that comes close to the balance here favored.
Her program, which is called Let’s Move, by its very title evokes the image of exercise (although it can also be understood to mean, let’s get started). The program evenly balances dieting and exercise. Of its four elements, one (physical activity) concerns exercise, one concerns diet (access to affordable healthy food), and the remaining two split the focus. “Healthy choices” encourages parents to set examples for their children by purchasing nutritious food and incorporating physical activity, and “healthier schools” aims to ensure that schools provide healthier lunches and opportunities for
1“An Epidemic of Obesity Myths,” The Center for Consumer Freedom,
June 2, 2004, http://consumerfreedom.com/news_detail.cfm/h/2535-anepidemic- of-obesity-myths. A. Etzioni (*)
The George Washington University, 1922 F St. NW, Room 413,
Washington, DC 20052, USA e-mail: [e-mail]
Soc (2014) 51:115–119
DOI 10.1007/s12115-014-9749-2 students to exercise. Nevertheless media reports on the
Obama initiative focused on dieting. For example, the headline in the New York Times ran, “Obama
Administration Aims to Push Candy and Sugary
Drinks Out of Schools.”2 Other articles about the initiative had headlines such as “Can Michelle Obama Put
America’s Children on a Diet?” and “Ridding Schools of Junk Food.”3
Reversing the Priorities
The reason the focus on dieting should be downgraded and exercise upgraded are three: dieting very often fails; it exacts considerable medical, psychological, and social costs; and it has some negative side effects. In contrast, exercise can lead to lasting results all by itself, is essential for the success of dieting for most people, poses lower costs, and has mainly positive side effects.
Curbing Intake Fails Most Times Robust data leaves little doubt that most people are unable to lose significant amounts of weight and maintain the loss.4 Most people who lose weight regain it, many in rather short order.
For instance, a study of one well-known commercial weight loss program found that 58 % of participants had dropped out after 3 months; by a year, only 6.6 % of dieters remained in the program.5 Furthermore, although there is no scientific consensus on the exact percentage of dieters who regain their weight, studies show that the majority (sometimes as high as 83 %) of people who have lost weight regain most or all of it within
5 years.6 For instance, one study shows that 5 years after the end of a behavioral weight control program, the average subject had not only gained back the lost weight, but weighed
1.49 lb more than before treatment.7 In another, the majority of women who had undergone one of three different obesity treatments and lost weight had regained this weight within
5 years.8 An overview of the studies involved, with the subtitle
“Diets Are Not the Answer,” concludes, “there is little support for the notion that diets lead to lasting weight loss or health benefits.”9
It should be noted that the success rate of losing weight through dieting and keeping it off—as low as it is—is likely to be even lower because the measurements used unwittingly make the findings look better than they actually are. For instance, many studies stop observing those studied after relatively short periods of time—some after only 3 months.
The fact that people regain weight as more time passes after their diet ends indicates that dieting is even less effective than is often reported.10
Dieting has Medical, Psychological and Social Costs and
Negative Side Effects Obesity reduction policies that focus on reducing caloric intake are particularly problematic because, as a side effect, they often generate behaviors that have ill effects on a significant number of the people involved.
There is relatively little data on the subject, arguably because
American society, preoccupied with urging people to lose weight, is uncomfortable with the suggestion that dieting causes harm. Available data do show that many people, especially women and girls, engage in various unhealthy behaviors in order to lose weight, including following unhealthy fad diets and abusing laxatives.11 Moreover, some people resort to weight-loss medications that are associated with dangerous health risks—for example, phen-fen.12 Eating disorders like
2 Gardiner Harris, “Obama Administration Aims to Push Candy and
Sugary Drinks Out of Schools,” The New York Times, February 8, 2010.
3 Margaret Talev, “Can Michelle Obama Put America’s Children on a
Diet?” McClatchy-Trinbune News Service, February 27, 2010; Lynn
Sweet, “Ridding Schools of Junk Food,” Chicago Sun-Times, February
10, 2010.
4 D.W. Swanson and F.A. Dinello, “Follow-up of patients starved for obesity,” Psychosomatic Medicine, 32 (1970), 209–214; F.M. Kramer, et al. “Long-Term Follow-Up of Behavioral Treatment for Obesity:
Patterns of Weight Regain Among Men and Women,” International
Journal of Obesity, 13 (1989), 123–163; D.D. Hensrud, et al., “A
Prospective Study of Weight Maintenance in Obese Participants
Reduced to Normal Body Weight Without Weight-Loss Training,”
American Journal for Clinical Nutrition, 60 (1994), 688–694; R.W.
Jeffrey and R.R. Wing, “Long-Term Effects of Interventions for Weight
Loss Using Food Provision and Monetary Incentives,” Journal of
Consulting and Clinical Psychology, 63 (1995) 793–796; R.W. Jeffrey and S.A. French, “Preventing Weight Gain in Adults: The Pound of
Prevention Study,” American Journal of Public Health, 89 (1999),
747–751; Simone A. French, et al., “Weight Loss Maintenance in
Young Adulthood: Prevalence and Correlations with Health Behavior and Disease in a Population-Based Sample of Women Aged 55–69
Years,” International Journal of Obesity, 20:4 (1996):203–310.
5 C.E. Finley, et al., “Retention Rates and Weight Loss in a Commercial
Weight Loss Program,” International Journal ofObesity, 31 (2007): 292–
298.
6 Swanson and Dinello, “Follow-Up”; PM Stalonas, et. al., “Do behavioral treatments of obesity last? A five-year follow-up investigation,”
Addictive Behaviors, 9:2 (1984): 175–83; TA Wadden, et. al.,
“Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective.” International Journal of
Obesity, 13 Suppl 2 (1989):39–46; R.W. Jeffrey and R.R. Wing, “Long-
Term Effects of Interventions forWeight Loss Using Food Provision and
Monetary Incentives.”
7 Stalonas, et. al., “Do behavioral treatments of obesity last?”
8 TAWadden, et. al., “Treatment of obesity.”
9 Traci Mann, et al., “Medicare’s Search for Effective Obesity
Treatments,” American Psychologist, 62:3 (April 2007): 220.
10 Mann, et al., “Medicare’s Search,” 223.
11 U.S. Department of Health and Human Services Office on Women’s
Health, “Eating Disorders and Obesity: How Are They Related?” http:// www.womenshealth.gov/BodyImage/bodyworks/CompanionPiece.pdf. 12 Food and Drug Administration, “FDA Announces Withdrawal
Fenfluramine and Dexfenfluramine (Fen-Phen),” September 15, 1997, http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformation forPatientsandProviders/ucm179871.htm.
116 Soc (2014) 51:115–119 anorexia, bulimia, and binge eating disorder may not be directly caused by cultural pressures to lower one’s
BMI, but they are reported much more frequently in societies and periods in which lower body mass is strongly promoted.13 In addition, psychological costs should be considered. These include lower self esteem, guilt, and a higher risk for clinical depression which are unwittingly propelled by the obesity reduction campaigns.14 People who weight cycle (sometimes referred to as
“yo-yo dieting”), a behavior in which they lose weight and regain it several times over, as millions do, are reported to be subject to increased risks for high blood pressure, high cholesterol, gallbladder disease, and other health problems.15
Moreover, obesity reduction campaigns engender social costs. They feed into discrimination against people with a high body mass. Forty-three percent of overweight and obese people report that they experienced weight bias from their employers or supervisors.16 More than two-thirds of obese and overweight people (69 %) report that they had experienced bias by doctors.17 A significant number of obese people report that physicians blame many of their symptoms on their weight, and are reluctant to treat them because of their weight.18 Thirty-one percent of nurses stated that they would prefer not to care for obese patients, and 24 % agreed that obese patients “repulsed them.”19 Forty-three percent of teachers agreed with the statement that “most people feel uncomfortable when they associate with obese people.”20
Teachers have lower expectations for their overweight students.
21 The use of the term “fat” as distinct from “obese,” reflects the critical tone ofmany of the new public policies that urge lifestyle changes.
In addition, obesity reduction policies tend to reinforce and exacerbate the stigmatization of people with a high BMI.
Obese people are viewed as “lazy, less competent, and lacking in self-discipline” by their co-workers.22 Overweight people earn up to 6 % less than their non-overweight colleagues and receive fewer promotions.23 There is “consistent evidence of weight discrimination at virtually every state of the employment cycle, including career counseling, selection, placement, compensation, promotion, discipline, and discharge.”24
American culture is strongly biased against obese people.
The American ideal of beauty is associated with being slender.
There are very few obese (or even overweight) movie stars, television news anchors, models, or people featured in advertisements. Exercise
The data on effects of exercise on BMI do not all point in the same direction. A meta-analysis of numerous studies finds very limited differences between groups that engaged only in dieting, those that combined diet with exercise, and those that only exercised, although it found the first two groups did somewhat better.25 One should note, though, that the exerciseonly groups included people with significantly lowerBMI and of much younger age than the others, and that many of the studies were greatly limited in time, which tends to favor dieting, because it washes out over time. Indeed one study covered people only for 3 months. Other studies find that while exercise is not a main way to reduce BMI, it plays a key role in keeping it low, once weight has been lost.26 Finally, a study comparing dieting only and exercise only, which followed participants for two years, found that while the diet-alone group regained on average 2 lb above where they started, the exercise-only group had maintained an average weight loss of 6 lb.27
13 Ethan Watters, “The Americanization of Mental Illness,” New York
Times, January 8, 2010, http://www.nytimes.com/2010/01/10/magazine/
10psyche-t.html.
14 John B. Dixon, Maureen E. Dixon, and Paul E. O’Brien, “Depression in Association with Severe Obesity,” Archives of Internal Medicine, 163
(2003): 2058–2065.
15 “Weight Cycling,” National Institute of Diabetes and Digestive and
Kidney Disease, http://win.niddk.nih.gov/publications/cycling.htm.
16 Rebecca M. Puhl and Kelly D. Brownell, “Confronting and Coping withWeight Stigma” An Investigation of Overweight and Obese Adults,”
Obesity, 14 (2006): 1802–1815.
17 Ibid.
18 Kolata, 68–69.
19 Rudd Center for Food Policy and Obesity, “Weight Bias: The Need for
Public Policy,” 2008, http://www.yaleruddcenter.org/resources/upload/ docs/what/bias/WeightBiasPolicyRuddReport.pdf, 5.
20 Ibid., 6.
21 K.S. O’Brien, J.A. Hunter, and M. Banks, “Implicit Anti-Fat Bias in
Physical Educators,” International Journal of Obesity, 31:2 (2007): 308–
314.
22 Mark V. Roehling, “Weight-Based Discrimination in Employment:
Psychological and Legal Aspects,” Personnel Psychology, 52:4 (1999):
984.
23 Charles L. Baum and William F. Ford, “The Wage Effects of Obesity:
A Longitudinal Study,” Health Economics, 13:9 (2004) 885–899; Eng S.
Loh, “The Economic Effects of Physical Appearance,” Social Science
Quarterly, 74:2 (1993); 4420–437.
24 Roehling, “Weight Discrimination and the Workplace,” 177.
25 W.C.Miller, D.M.Koceja, and E.J. Hamilton, “AMeta-Analysis of the
Past 25 Years ofWeight Loss Research Using Diet, Exercise or Diet Plus
Exercise Intervention,” International Journal of Obesity, 21:10 (1997),
941–947.
26 James W. Anderson, Elizabeth C. Konz, Robert C. Fredrich, and
Constance L. Wood, “Long-Term Weight Loss Maintenance: A Meta-
Analysis of U.S. Studies,” American Journal of Clinical Nutrition, 74:5
(November 2001): 571–584; Gretchen Reynolds, “Weighing the
Evidence on Exercise,” New York Times, April 18, 2010.
27 Martha L. Skender, et al., “Comparison of 2-YearWeight Loss Trends in Behavioral Treatments of Obesity: Diet, Exercise, and Combination
Interventions,” Journal of the American Dietetic Association, 96:4 (April
1996): 342–346.
Soc (2014) 51:115–119 117
Also, while exercise can inspire cult-like devotion and has ill side effects and costs, they seem to be significantly lower— per pound lost and kept off—than dieting. This point should be treated as a working hypothesis that remains to be documented. Finally, while dieting has little, if any, benefits if no reduction in BMI is gained and maintained, exercise does. Many of these are obvious and well known. Exercise improves heart function and decreases the risk of heart disease, lowers blood pressure, regulates insulin sensitivity, helps to prevent and alleviate osteoporosis, improves metabolism, increases and reportedly improves psychological and cognitive functioning.
28 One should add that while exercise is a stress reliever and a mood elevator, diet can have the opposite effect.
If one adds to these considerations the differences in costs, which are widely understated, the importance of upgrading exercises to the status of at least equal partner with dieting stands out. Given that dieting (in the form of reduction of caloric intake rather than change in themix of calories ingested) fails most times for most people—and has little if any positive side effects but some negative ones—for every 100 people who diet, there are at least 80 who both pay the costs of dieting and experience all the ill effects of a high BMI. In contrast, people who exercise are not only likely to sustain their lower BMI but also to benefit from the largely positive side effects of exercise.
Hence for every 100 people who increase their exercise, all will benefit, whether or not they reduce their BMI.
Focus on Young Children, That Is, on Parents
Data suggest that set weight ranges—the level of body mass into which most adults seem to be locked—are set early in life
(aside from effects of genetic predisposition). According to one study, obesity in infants is only a 20%predictor of obesity in adulthood; by the time children reach the age of 6, it is
50 %, and by the time they are adolescents, it is 90 %.29
Another study provides lower correlations but reaches the same general conclusion. It shows that the earlier the intervention, the greater the likelihood of success. An obese child at 3 has only a 23 % likelihood of being overweight or obese as an adult. At 8, the probability is 24 %; at 13, 44 %. By
18 years old, the child has a 66 % likelihood of being overweight or obese as an adult.30 Furthermore, obese males and females at age one are respectively only 1.3 and 1.4 times as likely as normal weight infants to be overweight or obese as an adult, but obese males and females at age 18 were 6.1 and 4.9 times as likely as those of normal weight to be overweight or obese as an adult.31 It seems that pathways become difficult to modify once they are set.
If additional evidence were to reinforce the finding that patterns of behavior leading to obesity are ingrained early in life, obesity reduction policies and campaigns should focus on early childhood;32 that is on educating parents; the staff at child-care centers, pre-school programs, and primary schools; and pediatricians. This policy strongly contradicts the suggestions of the authors of the meta-review of on the subject that urge focusing on the elderly.33 Societal Factors vs. Lifestyle Changes
The campaigns to reduce obesity largely focus on changing lifestyles by individuals. The clear implication is that it is up to the obese people to lead a healthier life. “People are told they only have themselves to blame if they are fat,” writes Gina
Kolata.34 This approach draws on and feeds into the precept that people have personal responsibility for the etiology of their illnesses and thus for their health. It is based on a strong
American cultural precept that we each have free will and are autonomous individuals in control of our lives. Failures are due to us, not “The System.”
Actually, as far as obesity is concerned, unlike some other behaviors—say, drinking and driving—individuals’ degree of freedom is relatively limited. Reference was already made to pathways set in infancy largely by one’s parents, over which adults have little control. Moreover, obesity is promoted by societal factors. A sound public policy would focus on modifying these factors rather than on personal efforts. The argument is not that people have no responsibility in this matter, but that societal factors are more important in this particular area. To illustrate the kind of societal factors involved, a few examples follow. Until recently, soft drink lobbies successfully prevented schools from banning the sale of sodas and blocked drives to remove vending machines from schools, even paying schools to keep their vending
28 Gerald F. Fletcher, et al., “Statement on Exercise: Benefits and
Recommendations for Physical Activity Programs for All Americans,”
Circulation, 94 (1996): 857–862.
29 Gail Nunlee-Bland, “Doctor on Childhood Obesity,” NPR All Things
Considered, February 9, 2010, http://www.npr.org/templates/story/story. php?storyId=123537465. 30 Shumei S. Guo and William Cameron Chumlea, “Tracking of Body
Mass Index in Children in Relation to Overweight in Adulthood,” The
American Journal of Clinical Nutrition, 70S (1999): 145S-148S.
31 Shumei S. Guo and William Cameron Chumlea, “Tracking of Body
Mass Index in Children.”
32 Solveig A. Cunningham, et al., “ Incidence of ChildhoodObesity in the
United States, ” The New England Journal of Medicine, 370.5 (2014):
403–411.
33 Miller, Koceja, and Hamilton, 946.
34 Kolata, 188.
118 Soc (2014) 51:115–119 machines.35 Recently, many school districts responded to tight budgets by eliminating physical education requirements.
36 Thus children, including those of the age at which the best long-term results can be achieved, are presented an unhealthy diet and removed from the most promising treatment: exercise.
The Department of Agriculture and Congress determine the composition of food served by the National School Lunch
Program to millions of low-income children. To a considerable extent the composition reflects the kinds of foods agribusiness is keen to unload rather than that which is best for the children’s health.37
The former FDA Commissioner David Kessler, details in his book The End of Overeating the ways food scientists working for major corporations engineer foods that motivate people to increase their consumption.38 They also play a role in cereal advertising aimed at children. In 2008 alone, four major cereal companies (General Mills, Kellogg, Post, and
Quaker) spent more than $156 million combined on marketing to children.39 The average preschooler sees
642 cereal ads per year on television.40 Children’s cereals have 85 % more sugar and 65 % less fiber than cereal marketed to adults, and eight of the top ten least healthy cereals are in the top ten of those most frequently marketed to children.41
True, in recent years, there has been some improvement in the role played by societal factors from the viewpoint of curbing obesity. A fair number of schools now provide healthier food, some have removed the vending machines, and cereal companies have scaled back some of their advertising.
Bruce Silvergrade, of the Center for Science in the Public
Interest, puts it rather mildly when he states, “Obesity is not merely a matter of individual responsibility.”42 David
Leonhardt of The New York Times puts it too strongly when he claims, “The solution to these problems [the obesity epidemic] are beyond the control of any individual. They involve a different sort of responsibility: civic—even political—responsibility.”
43 Both factors are involved, but more attention should be paid to societal factors, especially those that affect young children. The ways these changes can be made concerns the way the societal and political system is structured and may be modified, a subject that is beyond the range of this article.
Obesity is a serious health problem, but a rather intractable one. It requires costly interventions . These, however, are unlikely to generate significant gain as long as the focus is on reducing caloric intake through encouraging individuals to change their eating habits. Much more focus should be given to (a) caloric expenditure (exercise); (b) parenting, as opposed to adult behavior; and (c) societal rather than personal factors.
In addition, muchmore attention should be paid to the adverse side effects of dieting.
Amitai Etzioni is a University Professor and Professor of International
Affairs at The George Washington University. He previously served as a Senior Advisor at the Carter White House; taught at
Columbia University, Harvard, and the University of California at
Berkeley; and served as the President of the American Sociological
Association.
A study by Richard Posner ranked him among the top 100
American intellectuals. He is the author of numerous books, including
The Moral Dimension and My Brother’s Keeper.
35 National Soft Drink Association v. Block (1983) http://law.gsu.edu/ library/index/bibliographies/view?id=170; Janet Adamy, “First Lady
Arms to Fight Fat,” Wall Street Journal, February 9, 2010; Topher
Sanders, “Junk Food Ban Vs. First Coast Schools’ Soda Deals,”
Florida Times-Union, March 3, 2010.
36 Brian Dakss, “Obesity Up, Phys Ed Down,” CBS News, January 27,
2005, http://www.cbsnews.com/stories/2005/01/27/earlyshow/ contributors/debbyeturner/main669760.shtml. 37 Amy Joy Lanou and Patrick Sullivan, “Hungry for Change,”
Tompaine.com, http://www.organicconsumers.org/sostudents/ hungry101903.cfm 38 David A. Kessler, The End of Overeating: Taking Control of the
Insatiable American Appetite, (New York: Rodale, 2009).
39 Jennifer Harris, Marlene Schwartz, Kelly Brownell, “Nutrition and
Market Ratings of Children’s Cereals,” Cereal FACTS, http://www. cerealfacts.org/media/Cereal_FACTS_Report_Summary.pdf, 3.
40 Ibid.
41 Ibid.
42 Bruce Silverglade, “Generation Excess—A Conference on Obesity,
Diet, and Public Policy: Closing Remarks,” February 3, 2004, www.tacd. org/events/meeting6/b_silverglade.doc. 43 David Leonhardt, “Fat Tax,” The New York Times, August 12, 2009, http://www.nytimes.com/2009/08/16/magazine/16FOB-wwln-t.html. Soc (2014) 51:115–119 119
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