Fat land : how Americans became the fattest people in the world (22 page)

It is hardly surprising that the two most important behavioral changes involve food and exercise — less of one and more of the other. It is surprising, however, just how much of a difference such changes can make. Numerous recent studies — across large numbers of diverse Americans, as well as studies from other countries — show not only that the effects of type 2 diabetes can be substantially reduced through better eating and vigorous exercise, but that diseases like type 2 can actually be prevented by adopting such behaviors. In one study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases released in 2001, researchers from Massachusetts General Hospital recruited 3300 people with a condition known as impaired glucose tolerance — a kind of precursor to type 2 in which the body's ability to process sugar is slowed, but without any outward symptoms of disease. The subjects were then split up into three groups. One received a daily dose of metformin, a common pharmaceutical treatment for diabetes, along with basic dietary and exercise advice. A second group received a placebo along with the same advice. The third group got no drug, but instead received regular coaching on how to incorporate exercise into their daily schedules and how to best modify their diets. Three years

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later, the results were published. Among participants receiving the placebo, 11 percent developed diabetes. Among those receiving metformin, 7.8 percent developed the disease — a reduction of about one third. The big surprise was what happened among those who got no drug but who received in-depth coaching on diet and exercise. Among that group, only 4.8 percent developed diabetes — about half the rate of the control group. Among those in the coached group who were aged sixty or older, the drop in the disease rate was even more precipitous — nearly three quarters. In fact, in one third of the group, blood glucose levels returned to normal. The message was clear: Simple, consistent changes in diet and activity levels can dramatically alter an individual's metabolic destiny.

The key qualifier is the term "consistent." Getting that consistency comes with a price. In the case of the study that price was an investment in time and resources — weekly classes, coaches who followed a participant's progress, continuing medical and dietary monitoring by committed professionals. The question from a broader, policy-oriented point of view seems clear: How can we encourage such investments by large numbers of individuals, so that they become habit? The answer can be found in a number of programs that are dealing successfully with children who are either obese or at risk of becoming so. In other words, with the potentially obese adults of the future.

For twenty years, the trailblazer in the arena of childhood obesity treatment has been Stanford University's Leonard Epstein. A pediatrician and the head of the Stanford Pediatric Weight Control Program, Epstein pioneered the use of basic behavioral modification techniques, combined with a special diet and exercise program, to treat obesity in young children. The cornerstone of his approach is what he has dubbed the Stoplight Diet, which defines all foods by their calorie content and then divides them up into the three colors of the traffic light: red (for stop), yellow (for proceed with caution), and green (eat as one pleases). Children then

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count up the number of servings of each "color" so as to monitor their daily calorie count. This kind of clear, unambiguous division has been crucial, says Epstein. "It is our experience that some patients find looking for loopholes to be challenging and rewarding. As a result, it is better to leave little room for interpretation in defining dietary changes." He also notes that low-fat or diet versions of a normally high-calorie food should be avoided, so as to prevent continued exposure to such tastes.

As one might expect, Epstein is also concerned with increasing a child's physical activity, but his approach swerves from the predictable paths in two important ways. First, though Epstein believes that both structured exercise — sports and fitness programs — and lifestyle exercise — the "building in of a daily activity like walking to increase one's total expenditure" — can be critical to a child's success in maintaining a healthy weight, he also stresses the importance of activity choice. Children who are allowed to choose their own form of activity seem more likely to meet their daily calorie expenditure goals. Second, Epstein believes that reducing sedentary behavior may be more important than promoting physical activity itself. In a series of studies, Epstein and his colleagues at Stanford found that fat children who were either punished for sedentary activities or positively reinforced for decreasing TV viewing, playing computer and board games, or talking on the phone lost significantly more weight than peers who were simply reinforced for increasing physical activity. Epstein speculates about the reason, noting that the children in the decreased sedentary behavior group may have felt more personal control over being more active than those in the other group, who may have felt resentful toward parents who were pushing them into activity.

Epstein has since delineated a number of other elements critical to childhood weight loss programs. They are, in toto, clear, concise, and demanding. Parents must play an active role in treatment, but not necessarily as "co-patients." Rather, they are best used as monitors and enlightened authority figures. They are best

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left out of specific counseling and exercise sessions, leaving children in a less inhibited arena in which to learn and play. For the first eight to twelve weeks of the program, children should receive weekly follow-up sessions with a counselor; monthly follow-up sessions should continue for the next six to twelve months. In essence, parents are charged with changing the environment that encourages obesity. High-calorie foods should be removed from the home. The number of meals eaten outside the home should be drastically reduced. The soup pot or the casserole dish should be left in the kitchen, not set on the table family style, so as to increase the effort required for additional portions. TVs should be removed from bedrooms. Children should be taught to monitor their body weight, to set reasonable weight loss goals not to exceed one pound a week, and, when required, to enter into a written contract with their parents, with each side carefully delineating their responsibilities in the weight loss effort.

All of which may sound somewhat draconian to the ears of a generation raised to believe that, when it comes to food, personal choice and individual autonomy should trump traditional parental authority. Yet Epstein, unlike a generation of diet gurus who tried to separate control and children's eating habits, can show consistent and healthy results from his approach. Ten years after onset of treatment, some 30 percent of his patients were no longer obese, with 33.5 percent maintaining at least a 20 percent weight loss. His message is unequivocal: Parents must take back control of the table.

Dr. Francine Kaufman, head of the pediatric endocrinology department at Los Angeles's bustling Children's Hospital, has for the last few years successfully woven together some of Epstein's concepts with some of her own to deal with the city's growing problem of childhood type 2 diabetes. Once a week for eight weeks, a group of fifteen or so children, usually accompanied by one parent, file into her department for a two-hour "Kids and Fitness" program. Many come referred by pediatricians, others by

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school nurses and social services. After a weekly weigh-in, the children and their parents part, the latter to a waiting room, the former to a large conference room. For the next hour, the children are led through a variety of physical activities, ranging from calisthenics to running games to a smaller version of volleyball. "What's amazing is how uninhibited the kids are when the adults are gone and they are just around a bunch of other overweight kids," says Marsha MacKenzie, who runs the program for Kaufman. "The other day we had to laugh, because we asked them what game they would like to play, and a group of them yelled out 'Dodgeball!' Which, of course, they would never do at school, because they are the ones who usually get singled out to be bashed by the ball because they are a natural target for bullies."

For the second hour of Kaufman's program, parents are reunited with their child for a session of nutrition education. It is, to be frank, a troublesome undertaking. During the three sessions I attended, it was not unusual to witness a parent walk into the class eating french fries from McDonald's or sipping a thirty-two-ounce Big Gulp Coke from the local convenience mart. "We have to start from ground zero," says MacKenzie. "It's easy to pass judgment and say, people should know this and people should act this way, but the fact of the matter is that few doctors — let alone parents — know the basics of good nutrition."

MacKenzie and her staff focus each week's discussion on one element of a typical food label — on its fat content, added sugars, calories, portion sizes. Children must then choose from a lineup of typical popular foods, from Cheetos to Cap'n Crunch, and calculate out loud whether it is a good food or a bad food, based on the nutrition information they are studying that week. In a lesson about portions, for example, children were asked first to pour out what they considered one portion. They were then asked to read out loud what the label indicated was one portion, and then to pour out that amount on a small weighing scale. In most cases, the estimated serving size was at least three times the label

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serving size. "That drives the point home, both for the kids and the parents," says MacKenzie. But it also drives home how much educating needs to be done all over the city.

Schools have long offered tremendous promise as possible battlegrounds against childhood obesity. After all, more than 95 percent of American youth between the ages of five and eighteen are enrolled in school. Though school authority has been whittled down substantially over the years, the institution, by sheer dint of its daily presence, still exerts enormous influence on the lives of its subjects. In the early 1980s the Yale obesity expert Kelly Brownell undertook a small-scale intervention at public schools in Fort Myers, Florida, using nutrition education, physical activity training, changes in food service, and behavior modification techniques with a group of overweight children. The students were able to achieve and sustain a notable weight loss of 15 percent. At the time, many hailed the Brownell approach as a possible new standard in the treatment of childhood obesity.

But the Brownell approach fell victim to the cultural politics of the 1980s, namely, the fear that fat children undergoing such treatment would be stigmatized by their peers. Although it is true that some stigmatizing occurs when any group is singled out for special treatment, this objection — and it was voiced widely and vehemently throughout the decade — ignored the most basic truism about fat and stigmatization: The best way to prevent it is to avoid becoming obese in the first place. As the influential — and, it should be noted, very politically sensitive — International Journal of Obesity worried in a review of school programs in 1999, "It is interesting that few studies on school-based treatment of obesity were identified after 1985 ... Greater awareness of the stigma attached to participating in school-based treatments may have decreased enthusiasm for the programs, even though they appear to be effective [emphasis mine]."

Yet the "decreased enthusiasm" seems to be limited to the adults. A more recent survey, based on in-depth interviews with

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sixty-one overweight adolescents from large inner-city schools, indicated not only that children want such programs, but that they are willing to put up with their possible social ramifications if such a program "was undertaken in a supportive and respectful manner, offered fun activities, was informative, was sensitive to the needs of overweight youth and did not conflict with other activities."

Such interest by children has helped launch a new generation of school-based interventions. One of the most promising involves preventive screening. In a study by the University of Houston and Baylor College, scholars looked at how a child's weight in, say, kindergarten would predict that child's chances of becoming obese at a later age. Researchers collated the weights and BMIs of 1013 Mexican American children in a Texas school district. They then tracked the children as they progressed through the system. They found that a kindergarten BMI was highly predictive of obesity at later dates. A child with a low kindergarten BMI of 16.5, for example, would have only a 21 percent chance of becoming obese by fifth grade. A kindergartner with a BMI of 20.9, however, would have a 70 percent chance of becoming an obese fifth grader, while a kindergartner with a BMI of 23.7 would have a 91 percent probability of becoming obese.

While the Houston-Baylor study provides schools with one way to assess a child's relative risks, a program in San Jose, California, has carved a potential path toward reducing both current and future obesity rates. The impetus for it flowed from both theoretical and practical concerns. Researchers from Stanford's Departments of Pediatrics and Medicine had long theorized that if sedentary behaviors like TV-viewing and video game-playing were linked to increased obesity, then programs that taught children to reduce such activities might lead to reductions in adiposity. Meanwhile, teachers and parents in the San Jose School District, aware of increasing obesity rates, were looking for ways to deal with the issue. They decided to give the Stanford researchers access.

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To find out if their hypothesis held, the researchers recruited 192 third- and fourth-grade students from two socioeconomically matched schools. One school was assigned to implement a program to reduce TV and video game use, the other was not. The means of the intervention was simple: Limit access to TV sets and game machines, teach children to budget their use, then teach them how to become more selective viewers and players. This the researchers sought to inaugurate and support through traditional classroom instruction. Teachers in the intervention school were trained to administer eighteen specialized lessons, each thirty to fifty minutes in length, taught during regular school hours during the first two months of the school year. The first few lessons taught the students how to monitor and report their own TV and game use, followed by a "TV Turnoff." The TV Turnoff challenged children to watch no TV and play no video games for ten days. After the turnoff, students were told to budget their viewing to seven hours per week. The last lessons sought to increase students' ability to be selective, "intelligent viewers," and to become advocates for reducing the use of such media among their peers. At home, each student TV was equipped with an electronic TV time manager, which logged and measured TV time through the use of a personal code, without which the set would not operate.