Fat land : how Americans became the fattest people in the world (21 page)

To find out if that were the case, Hebebrand and his fellows at the University of Marburg, Germany, examined the parents of 471 extremely obese children and adolescents. The researchers took down three key pieces of data: the parents' current measured height, the parents' current self-measured height, and the parents ' recalled weights and heights at ages twenty and thirty, the

WHAT THE EXTRA CALORIES DO TO YOU

period when most couples meet and marry. They then referenced these measures against BMI averages for the general population. When they charted the cross-references, they found a high degree of assortative mating; obese children tended to have parents who mated when they themselves were obese. Although the results are only suggestive — Hebebrand was unable to show that the rate of assortative mating itself has increased over time — his finding falls in line with what is already known about obese children and obese parents. It is this: Obese parents influence their children's fatness both through genetics and through environment. "It is not exactly a straight line," Hebebrand says. "There are all kinds of other factors going on here. Take the case of the thinner person marrying the fatter person, who soon drags the thinner person down into his or her habits. He watches ten hours of TV and she begins to do the same, and over time she becomes obese too. In this case it was not the genetic expression of obesity from assortative mating that makes for fat kids. It's the environment that both the parents produce."

In all of this — fat attracting fat, stigma causing assortative mating, fat producing fat — there glimmers just a touch of the old eugenicist impulse. Yet in this case, recognizing such a dynamic might help prevent a eugenic reality, for however parents become obese, one thing is indisputable: Fat parents are more likely — much more likely — to raise fat children, who are in turn more likely to be fat adults, who are then more likely to continue the daisy chain until, as James Hill fears, all Americans are overweight or obese. And that day is not far away . . .

Let us now spend an imaginary day with a typical American, circa 2050, when overweight and obesity are the norm, and when the social divisions are not between the slim and the fat but between the obese and the not so obese. In other words, a lot like today, only intensified by a factor of one hundred.

Our average guy arises late in the morning, later than he had planned. He has slept poorly. The night before, the CPAP (for

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continuously pressurized air pathway) machine that provides an extra forceful flow of air to aid with his sleep apnea had been louder than usual. Looking in the mirror, he takes in his visage: Across the bridge of his nose and under his eyes rises a freshet of new acne, the nightly legacy of the sticky plastic face mask he must wear in order to remain hooked up to the CPAP machine. "Shit," he mutters.

He takes a shower, shaves, dresses. He curses at his ever too small pants and shirt — hadn't he just purchased a larger size a few months ago? — and then turns to the mirror again. He examines the dark circles under his eyes and the Acanthosis nigricans on his neck, then decides to cover up the latter with his wife's face powder. From his desk he picks up his blood sugar meter and, in the first of a half-dozen tests he will administer throughout the day, pricks his finger, draws blood, and measures his glucose level. He then injects his thigh with the first of several doses of insulin. Running late, he decides that, despite the worsening pain in his arthritic knee, he will forgo his pain medication, and walks out to the kitchen.

He cannot have his favorite breakfast, pancakes, because his blood sugar will soar if he eats more than one. (And what is the use of that? he reasons.) He drinks a cup of black coffee, has some oatmeal with nonfat milk and artificial sweetener, kisses his wife, and leaves for work.

In traffic, his blood pressure soars. Did he take the medication for that today? He cannot remember. The cell phone beeps; it is his wife reminding him that he has to take his son Jonny to the endocrinologist today. Only nine, the boy is already forty pounds overweight, and just last week he had another fainting spell at recess. It may have been from hypoglycemia. Whatever the cause, the school nurse sent home an embarrassing ultimatum: Get Jonny checked or she would have to notify social services.

Finally our average guy arrives at work. The office is humming; business is good. But, again, the new sales charts under-

WHAT THE EXTRA CALORIES DO TO YOU

score that, as a salesman, our man is not what he used to be. Getting in and out of the car to make sales calls, always arduous even when he was not obese, is now something to be avoided altogether. The two-hour drop in his afternoon energy level doesn't exactly help either. Nor does his aching knee. He checks his blood sugar and begins the afternoon round of phone calls. He is glad that he ordered the large-type phone pad, since his eyesight too is not what it once was.

At around four, a marked silence falls outside his office door. His officemates burst in with a birthday cake and a song. His assistant gets out a knife and begins serving slices of the cake with ice cream. She offers him a plate, and he demurs. She insists. He refuses again, but feels ashamed to reveal why he cannot eat such a sugary treat, and so eventually relents. An hour later he is flushed, sweaty, and dizzy. He vows never to do such a stupid thing again.

Outside, the cool air dries his sweat-beaded brow. He gets in his car and drives over to day care to pick up Jonny. When he gets there his son is crying. "They ... they used me as a dodgeball target again!" he explains. "They . . . they call me earthquake boy because I'm so . . ." Jonny doesn't need to finish the sentence.

"Aren't there other . . . heavy kids in your class? What do they do when ..."

His son cuts him off. "It's just that I'm the biggest," he blurts out.

It is a long, uncomfortable drive.

At the doctor's, the boy fares better than he thought he would. "I'm thinking that the fainting may be more from stress — from all the teasing and harassment — than from his blood sugar," the doctor says. "But you better get that hip checked out . . . When did he start walking like that?" He writes out a referral to a specialist in pediatric bone disease. "Just in case," he says, not very convincingly.

At home, waiting for dinner, he opens the mail. There is a notice from his HMO — again — telling him that his rates have

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gone up. Again. Also, the co-pay for medications has jumped; given the fact that he pays upward of $200 in co-payments a month already, it makes him worry: What would he do if he ever lost his job, or even if the company scaled back its health coverage? He shudders to recall a nightmare he had earlier in the week, one in which he was being told by his physician that "amputating today is not what it used to be — amputees can live full, long lives . . ." He decides to pay more attention to the chronic numbness in his left foot.

Dinner, since it is diabetically correct, is not worth eating, but he does so anyway, if just to spend some time with his wife. She, too, has weight-related woes; though not yet a full-blown diabetic, she nonetheless feels the limitations of being obese. Her energy level is low. She seems to sweat endlessly. Her gynecologist has called her back for more x-rays and a discussion of whether she should have surgery to remove the large but (so far) benign ovarian cyst she has had for the past two years.

Later, while the family is watching TV, he sneaks into the kitchen and eats handful after handful of the cookies he stashed behind the coffee tin the evening before. The momentary pleasure is followed by a rush of guilt, then nausea, then clammy sweating. He relaxes for a while longer, resolves never to do that again, and decides to turn in early.

In bed, he sets the CPAP machine on low, puts in his earplugs so he doesn't have to listen to the thing chug and puff all night, and gets ready to put on the mask. Shit, he thinks. Perhaps if he swabs it with alcohol first he will not wake up with another crop of unsightly red zits.

They are, after all, more than a little embarrassing, particularly at age thirty-five.

WHAT CAN BE DONE

About five years ago, the schools of San Antonio, Texas, some of the most rapidly growing in the nation, confronted a troubling revelation: A new study by a local nonprofit health agency showed that, unless administrators acted to make substantial changes, there would soon be as many as 3000 type 2 diabetic children in the district's fifty elementary schools. The principal cause, the study had concluded, was excess body weight. Almost all of the children at risk had BMIs of greater than 27 — they were already substantially overweight — and many had BMIs far in excess of 30, the cutoff for clinical obesity. Nearly as awful — at least to the men and women who ran the schools — was the implication that the San Antonio schools were themselves at least partly to blame for the trend. The study authors — all from the local Social and Health Research Center, headed by Dr. Robert Trevino — had found, among other things, that the school cafeterias were serving a menu laced with excess fats and sugars, that the food service staff had no idea about how to make fresh fruits and produce palatable to kids, that after-school care was bereft of any meaningful physical activity, and that teachers in the districts had few if any classroom materials for teaching sound nutrition and exercise practices. "We scared the hell out of them," says Trevino of the school

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district's reaction to his study. "They realized it was both the right thing to do and that it was in their self-interest to deal with it."

The annals of public health are chock-full of such momentary bureaucratic realizations — realizations that soon dim and fade as new and seemingly more urgent concerns wrinkle the public brow. The course that usually follows is as predictable as a Hollywood B movie: Posters inveighing against the evil get tacked up around the school. Memos go out to teachers, principals, and sometimes even parents. There follows a special "awareness" program, designed to change attitudes toward the problem and invite candid discussion. More pamphlets will be passed out. The PTA might receive a special report on the subject. An already overburdened principal will be assigned to head a committee to look into possible solutions. The issue will take its place alongside the others waiting in line, collecting administrative dust.

History, however, will in this case take due note: This is exactly what San Antonio did not do. Instead, the school district tried an aggressive and unconventional strategy that broke the mold of the traditional public health response to chronic disease. The first part of the strategy was to recognize that obesity and type 2 diabetes among its students was, first and foremost, a class issue. It wasn't something that, as most public health campaigns (often artificially) insist, affects everybody. "It's not a gene thing, it's a poverty thing," as Trevino says. That observation guided the district's allocation of resources — time, money, and expertise — and, as a result, made for a more targeted, efficient solution.

The second part of San Antonio's approach was even more controversial. Instead of focusing the main part of its efforts on the children themselves, the administration turned its attention to changing itself. "We didn't believe it was enough to put a few more dollars into a nutrition class and so to change some kids' attitudes and beliefs about food and health," says Trevino, who was put in charge of the effort. "We believed that you had to change their environment — their total school environment."

WHAT CAN BE DONE

This Trevino and his staff did by devising an extensive series of lesson plans designed to change the health environments of targeted elementary schools. In the cafeteria, food service workers were tutored in state-of-the-art food preparation and food presentation schemes — all designed to increase the amounts of fruits and vegetables consumed and to lessen the amounts of added fats and sugars. Older students were drafted to monitor the eating habits of their younger schoolmates at lunchtime. In classrooms, students had new lesson plans designed to educate them about what choices they should make in the cafeteria setting — in essence, creating demand for the new cafeteria fare. Trevino also dedicated thirty-two new lesson plans to after-school care, where TV and video games had come to supplant physical activity as the recreational mainstay. The result was to transform the traditional after-school program into a highly popular "health club" — a place where child care met both traditional and non-traditional exercise and sports programs. There were even lesson plans for parents, principals, and school medical personnel.

A year later, the district assessed Trevino's intervention. In the cafeteria, there had been two dramatic improvements. Compared with a control group of schools that had not adopted the changes, the percentage of calories from fat dropped from an average of 34 percent to 30 percent — well in line with USDA guidelines — and the number of fruits and vegetables consumed per meal had more than doubled, from 1.2 to 2.5. The control group's fat content and fruit and vegetable consumption remained the same. Fitness scores, mainly aerobic capacity, also improved dramatically in the experimental schools, rising by 4.6 percent against the control group's rise of .8 percent. Most important, the average blood sugar measurement among the schools' type 2 diabetics had registered remarkable decreases — from 123 to 99; the kids in the experimental schools now had near-normal blood glucose counts.

San Antonio's success points up one of the few bright patches in Fatland America: By and large, we already know what kind of

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basic health strategies work, at least when it comes to children, and, in many cases, what works for adults, when it comes to reducing both the incidence of obesity and its consequences. It was not always so. In a review published in 1978, researchers gloomily concluded that "clinically significant changes for obese children are rare. Follow-up data . . . show consistently that subjects fail to continue losing weight or even maintain weight losses experienced during treatment." By 1994 the general wisdom on the subject had completely reversed itself, with one reviewer noting that "overall, treatments for childhood and adolescent obesity were found to produce medium sized treatment effects at post-test" with follow-ups showing that they "continue to maintain moderate results." Basic behavioral modification was the treatment of choice.