The Growth of Obesity in the United States: A Review for General Public A tsunami of colossal magnitude has been

and is assaulting the welfare of the majority of the nations on the earth. The welfare of these nations is dependent on the health and health care costs of their populations and the health of these populations is closely linked to their nutrition. For millennia, food scarcity or food mal-distribution with resultant starvation and malnutrition have plagued nations and their populations, linking the welfare of the nation with the health of the people and the supply of food. However, in the past several decades a time span of only one generation a tidal wave of over-indulgence in poor nutritional choices with resultant obesity has breached many of the old food distribution barriers, thrusting obesity into the forefront as the top nutrition-related contributor to ill health in the world. This is particularly prevalent in the developed nations and characteristically, is most evident in the United States. In the United States, this malaise has not quietly infected fragments of society but it has visibly permeated through all segments of society. However, the component of American society that has most been noticeably affected is that component which is most defenseless against such a surge of poor nutrition children. Compounding the problem is that the group of children that has been the most affected by poor nutrition and obesity is that segment that is already saddled with socioeconomic stresses. Despite the magnitude of this problem, it is possible to not only stem this surge towards obesity but also to reverse the trend. This prospect can be achieved by initially confirming the full extent of the problem of obesity in the nation, then establishing the most significant relationships between ill health and obesity, then identifying the closest associations of obesity with poor nutrition, next focusing on the

most direct connections between poor nutrition and socioeconomic status, and finally, targeting the most promising solutions to these connections. Confirm, establish, identify, focus, and target this paper will use these methods to review the connections of obesity with poor nutrition and with socioeconomic status in the United States. The extent of the global problem of obesity has been acknowledged in multiple articles. It has been estimated that over 1 billion people throughout the globe are overweight (1, p.243). In the United States, approximately 65% of all adults are considered overweight and 30% are considered obese (1 p. 23). This represents a doubling of the percentage of the obese population in the United States since 1990 (2). The percentages of children in the United States who are classified as overweight or as obese is approximately half of the percentages in adults yet these percentages still denote approximately 12 million obese children in the United States (2, p.1). Although obese children do not share all of the heightened health risks that obese adults have, obese children do have a high tendency to become obese adults, adding to the total number of people who are at risk for obesityrelated illnesses. The cost of these obesity-related diseases has been estimated by the American Heart Association at $147 billion a year or 17% of the medical spending in the United States (2, p.1). This staggering cost reflects the effects of ill health due to poor nutrition on the health and welfare of the nation and its population. To further follow this impact of poor nutrition, it is necessary to establish the relationships between ill health and obesity. Overweight and obesity are terms used to describe the health conditions of a person whose weight is significantly higher than his or her ideal healthy weight. To better objectively quantify these conditions, the National Center for Health Statistics and the

National Center for Chronic Disease Prevention and Health Promotion developed weightheight tables that were derived from a weight-height formula. This formula yields a number that is a reliable indicator of body fatness for most people. This indicator is the Body Mass Index or BMI. The formula is as follows: BMI = weight in kg / (height in m) squared. A healthy weight of a given height for an adult would yield a BMI of 18.5 24.9. An overweight adult would have a BMI over 25. An obese adult would have a BMI over 30(3). The BMI is the clinical measurement that most closely mirrors the body fat content as demonstrated by comparisons to the more direct measurements of body fat content such as underwater weighing, skin fold thickness measurements, and dual energy x-ray absortiometry (4). Despite its usefulness, BMI remains a screening tool and is not a diagnostic tool for the population. Its inherent inaccuracy can be demonstrated in those people, such as many athletes, who possess high contents of muscle mass which would result in elevated BMI levels. In contrast, some overfat individuals have an abundance of fat but may have a misleadingly normal BMI. The same formula for BMI is used for adults and children; however, the interpretation of the number is different. In adults, the categorization by BMI is not dependent on either the sex or the age of the individual. However, in children, the categories are sex and age specific. This is due to the changes in body fat content as children age and to the intrinsic differences in body fat content between boys and girls

(3). For children, percentiles are given that indicate the relative position of the childs BMI in reference to children of the same sex and age. An overweight child would be in the 85 94.9 percentile. An obese child would be in the 95 or greater percentile (5).

Not only does the BMI fail to discriminate between fat mass and lean mass in an individual important in Type 2 diabetes but it is also incapable of distinguishing the distribution of fat in an individual important in the metabolic syndrome. However, as a rough indicator of national obesity, an abnormally high BMI has been demonstrated to exhibit a direct relationship with many chronic health problems. The most significant of these health problems are cardiovascular diseases, Type 2 diabetes, and cancers. The cardiovascular diseases related with obesity include hypertension, myocardial ischemia, and strokes. All three of these diseases have increased in incidence in the United States in the past several decades. This increase has been linked with the concurrent rise in obesity. Obesity has also been linked with diabetes. Of the two main categories of diabetes immune-mediated Type 1 and insulin resistant Type 2 the latter is much more common. The latter is also much more closely linked with obesity (1, p.109). Not only has the incidence of Type 2 diabetes in adults in the United States increased with the rise in obesity but it has also permeated into the younger age groups so that it now outnumbers Type 1 diabetes in children and adolescents. Furthermore, as the U.S. population also becomes increasingly overweight, the percentage of children with Type 1 diabetes who are obese is also increasing, accentuating the morbidity and mortality of that disease in the younger age groups (6). Several cancers have also demonstrated a relationship with obesity a relationship exemplified by the recent increase in the incidence of these cancers in the U.S. with the rise in obesity. Obese individuals demonstrate an increased incidence in the development of endometrial, prostate, and colon cancers (1, p.255). Obese individuals are also at a higher

risk of developing other debilitating chronic illnesses such as arthritis, cholelithiasis, and non-alcoholic steatohepatitis. Non-alcoholic steatohepatitis, in particular, has become under much investigation recently due to its close linkage with obesity and its potential progression to hepatic failure. Despite the severity of the relationship of obesity with health problems in the United States, the etiology of obesity is relatively simple the existence of an energy imbalance. The energy input exceeds the energy output. The input consists of calories from ingested food; the output is due to metabolism and physical activity. However, the factors that cause this imbalance are more complex. To help identify the associations between obesity and poor nutrition, these factors can be collated into two main categories biological factors and environmental factors. The biological factors include genetic links and physiological causes. The genetic predisposition to obesity has been demonstrated in studies of pairs of identical twins. Such studies have shown that even when identical twins are raised apart in different environments, the twins show similar weight gain patterns. Studies have also shown that a child with no obese parent has a 10% chance of becoming obese, a child with one obese parent has a 40% chance of becoming obese, and a child with two obese parents has an 80% chance of becoming obese. (1, p 258). Such studies reveal the genetic linkage between biology and obesity. Other biological origins for obesity have also been investigated, linking obesity with the physiological mechanisms of fat storage and fat metabolism. These researchers have studied the number, size, and metabolic activity of the fat cells in different groups of the population. The association of certain ethnic groups with obesity is most likely a combination of genetic links and physiologic causes (1, p. 109). A

study of adults in the United States completed by the Center for Disease Control in 2008 revealed that African-Americans had a 51% higher prevalence of obesity and HispanicAmericans had a 21% higher prevalence of obesity than Caucasians had (7). Similar

ties between ethnicity and obesity have also been demonstrated in less geographically dispersed groups such as Eskimos and Native Americans. These links between ethnicity and obesity become entangled with environmental factors. The environmental factors are often interconnected and difficult to isolate; however, they can also be divided into psychosocial factors and socio-economic factors. The psychosocial causes that have been connected to obesity include excessive food intake to cope with stress or boredom as well as hectic lifestyles that discourage healthy, balanced meals. The socioeconomic factors have received more attention from national investigators, linking obesity to low socioeconomic status or SES. In particular the segments of population with the highest poverty rates and the lowest education levels have not only been linked with high obesity rates but also exhibit the most rapid rises in those rates over the past several decades (8,9). These investigations have pointed to poor nutrition as the chief contributor to obesity in those segments of the population as well as in the other segments of the population in the United States. These studies have focused on the low cost of energy-dense foods relative to the cost of more healthy foods. Energydense foods are defined as food high in their energy density as measured in MJ / kg (10). Such foods are typically composed of refined grains, added sugars, and fats. Because of their lower cost, such foods are more attractive to low income consumers. Compounding the problem is that the added sweets and fats in these foods increase their palatability further augmenting their desirability. Although low cost, energy-dense, and palatable

foods are desired by all segments of the population, people of low SES are particularly prone to this diet due to the scarcity of healthier dietary options. These options are often limited not only by disposable income but also due to the paucity of full-scale groceries with their wider dietary choices in the low SES neighborhoods. Studies have also shown a higher density of convenience stores and fast food stores in these neighborhoods other sources of energy-dense foods (10). The food assistance programs and the school lunch programs have also added to the problem. Many of these programs offer energy-dense foods; school lunches have been demonstrated to be notoriously energy-dense (11,12). The connections of obesity with poor nutrition and with low socioeconomic status were clearly summarized by authors Drewnowski and Specter in their 2004 study of poverty and obesity: more and more Americans are becoming overweight and obese while consuming more added sugar and fats and spending a lower percentage of their disposable income on food. (10). Despite the gloomy projections of reporters and investigators, hope for the health of the nation and its population does exist. First, the abundance of articles about the rise of obesity in the United States is a confirmation that the problem has been recognized. Second, the relationships between ill health and obesity have been established and are being utilized by health professionals throughout the country. Third, the associations between obesity and poor nutrition have been identified and are being used by nutrition advisors to assist entire segments of the population as well as the individual. Fourth, the connections between obesity and poor nutrition and socioeconomic status have been focused, providing targets for government agencies to obtain the most impact on the overall problem of obesity.

A publicized example of a targeted government initiative is First Lady Michelle Obamas Lets Move Campaign that established a Task Force on childhood obesity. Other examples of recent government initiatives include the Alliance Health Care Initiative of 2009 a collaborative effort of national medical associations, insurers, and employers for the prevention and treatment of childhood obesity. The goal is to reduce the prevalence of childhood obesity by 2015. The American Heart Association has set a national goal to reduce deaths from cardiovascular disease and strokes by 20% by 2020; the Association plans on achieving this goal partly by improving access to affordable healthy foods. A national program successful on the local level is the Racial and Ethnic Approaches to Community Health (REACH) via which the CDC supplies funds to communities to eliminate health disparities. Several of its measures have included aid to attract grocery stores and regulations to limit fast-food restaurants in low SES neighborhoods. And although no state met the Healthy People 2010 objective of reducing the prevalence of obesity among U.S. adults to 15%, the actual rise in the prevalence of obesity in adults and children has been slowed (13). Other potential solutions include attacking poor-nutritional choices with the same intensity that was used against smoking in the past years for example, energy dense foods can be taxed to make them less desirable to consumers. Furthermore, restrictions on sweet and fat contents in energy dense foods may be applied to make those foods less palatable - this may not be feasible on the national level but should be practical on a restricted scale such as federally funded school lunches. Finally and equally importantly, sensitivity to people of all weights should be rendered in the same fashion that it should be rendered to those of different races, religions, and creeds.