Up to one out of every five children in the U. S. is overweight or obese, and this number is continuing to rise. Children have fewer weight-related health and medical problems than adults. However, overweight children are at high risk of becomingoverweight adolescents and adults, placing them at risk of developing chronic diseases such as heart disease and diabetes later in life. They are also more prone to develop stress, sadness, and low self-esteem.

What Causes Obesity in Children?

Children become overweight and obese for a variety of reasons. The most common causes are genetic factors, lack of physical activity, unhealthy eating patterns, or a combination of these factors. Only in rare cases is being overweight caused by a medical condition such as a hormonal problem. A physical exam and some blood tests can rule out the possibility of a medical condition as the cause for obesity.

Although weight problems run in families, not all children with a family history of obesity will be overweight. Children whose parents or brothers or sisters are overweight may be at an increased risk of becoming overweight themselves, but this can be linked to shared family behaviors such as eating and activity habits.

A child's total diet and activity level play an important role in determining a child's weight. Today, many children spend a lot time being inactive. For example, the average child spends approximately four hours each day watching television. As computers and video games become increasingly popular, the number of hours of inactivity may increase.

What Diseases Are Obese Children at Risk For?

Obese children are at risk for a number of conditions, including:

• High cholesterol
• High blood pressure
• Early heart disease
• Diabetes
• Bone problems
• Skin conditions such as heat rash, fungal infections, and acne

How Do I Know if My Child Is Overweight?

The best person to determine whether or not your child is overweight is your child's doctor. In determining whether or not your child is overweight, the doctor will measure your child's weight and height and compute his ''BMI,'' or body mass index, to compare this value to standard values. The doctor will also consider your child's age and growth patterns. Assessing obesity in children can be difficult, because children can grow in unpredictable spurts. 

How Can I Help My Overweight Child?

If you have an overweight child, it is very important that you allow him or her to know that you will be supportive. Children's feelings about themselves often are based on their parents' feelings about them, and if you accept your children at any weight, they will be more likely to feel good about themselves. It is also important to talk to your children about their weight, allowing them to share their concerns with you.

It is not recommended that parents set children apart because of their weight. Instead, parents should focus on gradually changing their family's physical activity and eating habits. By involving the entire family, everyone is taught healthful habits and the overweight child does not feel singled out.

The obesity epidemic among youth today only continues to escalate. Due to the increase in modern technology, more forms of entertainment involve sitting rather than moving.  Children are exposed to more computers, video games, movies and television than ever before, which in turn decreases the overall time spent expending daily calories. The resulting weight gain among our youth heightens their risk for possible heart disease, cancer, diabetes and more. This makes it all the more important for children to start exercising as early as possible. Besides physical benefits, such as improved bone and muscle strength, exercise is also shown to also improve one’s emotional and psychological state.

By taking up physical exercise early in life, children have the advantage of a leaner, stronger figure, with lower risks of obesity. Running, bicycling, skating and swimming are several simple options that allow for aerobic activity, which improves overall heart strength. Stretching exercises will foster a student’s flexibility and improve the functioning of joints. Push-ups and pull-ups help build muscle strength, as well as weightlifting workouts at the school gym. Kids can get a head start in managing their physical health by choosing from a wide selection of exercise options, which will only prove more beneficial as they mature.

Students spend the majority of their school day in the classroom with limited time for physical activity. As important as it is for children to be well-rounded on subjects that increase class performance, there is another type of education that is just as important for their overall well-being. Physical education is a chance for children to put down their pencils and have fun as they work toward staying fit. It can also be the ideal outlet kids need to let loose, while providing them with lifelong benefits unlike any other in their schedule.  Studies show that children who have physical outlets coupled with academics perform better in other areas of their life as well.

More schools are sharing the responsibility to encourage student fitness with their enhanced physical education programs. For example, SPARK, a well established and award-winning public health organization, is combating obesity through providing educators with research-based physical activity programs for Pre-K – 12 grade students. SPARK focuses on assisting teachers with implementing school games related to aerobics, jogging, sports and more. Teachers receive curriculum, training and equipment that outlines how to get the most out of each physical activity that their classes participate in. Emphasis is placed on proper nutrition for students, as well as the positive effects activities have on academic performance.

Schools that provide physical education for youth with an emphasis on the positive instill a lifelong motivation to stay fit.  The American Heart Association recommends that children engage in a minimum of one hour of physical activity per day, and schools can easily assist in meeting that goal by providing just half of that important time.  In addition, such classes help build teamwork among students and help participants find interests that they may choose to further pursue. It is important to note that studies have demonstrated that kids who are physically fit also perform better on standardized testing.

To offer the best physical education possible, schools should provide quality equipment, safe facilities and trained supervision. Teachers must be aware of the best, new teaching methods available to maintain student interest and enthusiasm. Variations of traditional games, as well as creating new athletic diversions can be introduced on a vast scale depending on age level and ability.  Success and diversity are key to keeping the children involved. Skills developed during school activities may form the basis for additional physical pursuits. Most importantly, when schools make physical education a requirement for graduation, kids are guaranteed the chance to be exposed to a better sense of how to live a healthy lifestyle.

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Many parents look to enroll their children in after school activities and search for the option that best suits their son or daughter’s interests. One common question is how old a child should be before engaging in certain sports or exercise. Games like flag football, soccer and t-ball are usually appropriate starting at age four, whereas gymnastics is accommodating of all age groups. Competitive activities should be reserved for the older, extroverted child. Both individual and team sports allow for motor skill development as well as promote self esteem. Starting sports at an earlier age will decrease the childhood tendency toward sedentary activities inside the home when physical alternatives are not readily available.

Establishing lifelong healthy exercise habits begins in childhood. Lack of physical activity has been correlated with the ongoing surge in obesity, as well as the development of chronic health problems. On the contrary, involving youth in both physical education as well as extracurricular sports programs is associated with increased academic success, as well as psychological and physical well being. Educators and parents alike must set the example and offer appropriate, safe programs that encourage all children, regardless of ability.  The opportunity to strive towards a healthy future that includes exercise as part of the normal, daily routine will then be anticipated with ongoing enthusiasm amongst today’s youth.

One of the common misconceptions around the obesity epidemic is that kids with excess weight have lifestyles that are much less healthy than those of their non-obese peers. 

It’s a familiar assumption that profession­als, policy makers and the average person often make. The truth is, this assumption is not borne out by data. A report from the Canadian Health Measures Survey 2007-2009 ( released by Statistics Canada early this year ) found no marked differences in physical ac­tivity between overweight and lean kids, at least not when corrected for the increased ef­fort it takes to move larger bodies.  Based on actual measurements of physical activity using sophisticated accelerometric devices, only 5% of Canadian adults and children meet the recommended levels for vigorous physi­cal activity per week. 

Specifically, overweight and obese girls aged six to 19 years had exactly the same minutes of moderate-to-vigorous physical activity (MVPA) as girls who are neither overweight nor obese (between 44 and 48 minutes per day). Only for boys was there a discernible relationship be­tween activity and BMI, in that overweight boys had 14 minutes and obese boys had 22 minutes less daily activity than “normal” weight boys, who accumulated around 65 minutes of MVPA per day. 

So, if overweight kids are not moving less — and if, as other data suggest, they are not necessarily eating more — why are some kids overweight and others not? If the environ­mental effects are pretty much the same for everyone, why do we even have lean and obese kids? 

This question was addressed by re­searchers from the Ludwig-Maximilians University of Munich, Germany,  in a study published in PLoS One this past January . The authors analyzed data on over 7,000 three- to 10-year-olds and almost 6,000 11- to 17-year­old children from a representative cross-sectional German health survey con­ducted between 2003 and 2006. The goal was to look at the impact of maternal BMI, mater­nal smoking in pregnancy, low parental socioeconomic status, exclusive formula-feeding and high TV viewing time on BMI. 

It turns out that in both age groups, the estimated effects of all risk factors (except formula-feeding) on BMI were greatest for children with the highest BMI. In other words, it is not that lean kids don’t also watch a lot of TV or have mothers who smoked during pregnancy — rather, it’s that kids at the higher end of the BMI distribution appear far more sensitive to these factors than their leaner counterparts. 

Thus, kids who are genetically predis­posed to obesity are far more likely to pack on the pounds when spending hours in front of the TV than kids who are genetically less obe­sity prone. The same could probably be said for overeating or any of the other environ­mental drivers of obesity, which have much greater effects in terms of promoting weight gain in some kids than in others. 

From a prevention and treatment perspec­tive, this means that overweight and obese kids will have to work much harder at changing their lifestyles or avoiding obesogenic stimuli than thin kids, who can live a similar lifestyle without negative health consequences. It’s easy to see how this relates back to the topic of weight-bias and discrimination, where we so easily fall into the mode of blaming obesity largely on unhealthy lifestyles and will power, when thin people may just turn out to be genet­ically more fortunate.

This should not, of course, be used as an excuse to do nothing. Rather, it should be seen as a good reason to fully appreciate and empathize with kids who carry extra weight. Some will need to work very hard at control­ling their weight, while others seem to have simply drawn the “get out of jail free” card. 

In light of these data and the tremendous negative emotional and physical impact of weight bias, discussing inactivity (or exercise) in the context of obesity is not only obfuscat­ing the real issues, but it’s also a major distraction from addressing the real causes of the problem. 

This should in no way imply that the shockingly low activity levels of all Canadians (young and old, male and female, slender and obese) should not be cause for alarm, given the innumerable health benefits of physical activity and the increasingly recognized health risks associated with sedentariness. 

Similarly, we know that increasing physical activity and sensible exercise “prescriptions” can be important prevention and treatment strategies for weight management. 

It is, however, high time to reframe the discussion of inactivity and sedentariness as a discussion about fitness and health risk in general, rather than as a discussion on obe­sity. Continuing to link the necessary discussion about inactivity to the problem of obesity is not only scientifically unfounded but, by dangerously and unfairly reinforcing stereotypes (not reflected in the actual data), it may well do more harm than good when it comes to tackling both the epidemic of obe­sity and the epidemic of sedentariness. 

Children

• Try some low-fat, low-sugar snacks.
• Eat more fruits and vegetables.
• Record what you eat for a few days. If what you eat does not resemble the Food Guide Pyramid, make some changes.
• Be active by doing something you like to do, such as dancing or jumping rope.
• Aim for 60 minutes of moderate physical activity most days of the week.

Parents

• Set limits on TV and computer time. Time spent with these electronic devices tends to reduce physical activity and often increases consumption of high-calorie snacks. The American Academy of Pediatrics recommends limiting TV, movies, and video and computer games for children to no more than 1 or 2 hours per day.
• Offer children healthier foods. Snack foods are a great place to start. Buy more yogurt and fruits and fewer chips and cookies at the grocery. Serve more ice water and fewer sodas. Regular soft drinks add 110 to 160 calories per 12-ounce serving.
• Encourage your children to be involved in something active and enjoyable. Suggestions include organized sports (such as softball or soccer), outdoor activities (such as scouting or 4-H clubs), or active playtime at home (such as roller skating, throwing Frisbees, or biking).
• Make time for the entire family to enjoy regular physical activities together.
• Assign active chores to all family members, such as vacuuming, washing the car, or mowing the lawn. Rotate chores among family members to avoid boredom.
• Be a healthy role model for your children. Children will be more likely to eat fruits and vegetables and be physically active if parents are setting a good example.
• Let your school know that you are concerned about what your child eats at school and how much physical activity is included in the school day. Have nutrition and exercise experts come speak to the PTA, school board, or site-based council.
• Buy only 100% fruit juice. Just 1/2 cup of fruit juice will supply one serving of fruit, so be aware of calories and serving sizes.
• Eat meals together at the dinner table.
• Avoid watching TV during mealtimes.
• Limit fast food eating to no more than once per week.
• Avoid using food as a reward or using the lack of food as a punishment.

Teachers

• Incorporate some form of movement into the classroom curriculum. Active students are more alert and ready to learn.
• Ask parents to bring healthy snack options when your class is having a bake sale or class event.
• Do not reward students with food, and do not punish students by taking away recess.
• Start a program at your school to raise awareness of the importance of physical activity among students and staff.
• Have a health educator speak to your class about different programs or places in your area where students can be involved in physical activity.
• Invite the school food service director to speak to your classes about healthy meal planning.
• Host a career day to help students learn about employment opportunities in health care and promotion.

School Food Service Directors and Managers

• Make sure school breakfast and lunch options are healthy and appealing. Invite teachers and students to work on ideas for marketing healthier food choices.
• Offer fruits, vegetables, whole grains, and low-fat dairy foods.
• Reduce access to high-fat, high-calorie, high-sugar foods and excessive portion sizes.
• Use the cafeteria setting to increase awareness of healthy food choices with brochures or posters about “Five-a-Day” fruits and vegetables or “1% or Less” dairy foods.
• Seek student input for school menu plans through contests, focus groups, or classroom activities.

School Administrators

• Promote healthier eating and physical activity in your school.
• Have a registered dietitian or certified nutritionist come to your faculty/staff meeting to bring unity on this issue.
• Make wellness programs available to school faculty and staff.
• Work with your school food service director to create an environment of healthy food choices for meals.
• Give the students healthier options in the vending machines. Try the new milk machines.

Site-Based Decision-Making Councils

• Set policies for what can and cannot be sold in school.
• Re-evaluate the contracts between your district and soft drink industries. The money and perks from these agreements may not be in the best interest of your students.
• Be involved in assessing the school’s eating environment, developing a shared vision, and creating an action plan to achieve it.
• Help schools offer daily opportunities for physical activity and inclusive education.
• Work with schools and community organizations to ensure that exercise equipment and supervised programs are available to meet the physical needs and interests of all students and school staff.

Communities

• Create a community that promotes physical activity for children and teenagers.
• Increase access to food choices for a healthy diet, such as dairy products, fruits, and vegetables.
• Work with your Cooperative Extension Service office, state and local health departments, and other partners to promote community physical activity programs.
• Increase public access to gyms, playgrounds, and walking/biking trails.

Civic Leaders

• Work with city planners and engineers to plan for sidewalks and bicycle paths. In addition, widen sidewalks so that they are less crowded, safer, and more inviting.
• Designate a place for and promote a farmers’ market.
• Create a community coalition to address childhood overweight.
• Increase the accessibility of public facilities.

Government

• Create policies to promote healthy eating and physical activity.
• Provide educators with health education materials to help students develop the knowledge, attitudes, skills, and behaviors for developing healthy eating patterns and a physically active lifestyle.
• Allocate funding for health promotion and monitoring programs.

Limiting screen time and unhealthy snacks can combat obesity. Photo CreditPhotodisc/Photodisc/Getty Images

According to the Obesity Action Coalition, obesity in children more than tripled between 1980 and 2012. You can combat childhood obesity, by integrating various changes into the lifestyle of your child and family. These changes can improve your child's appearance and decrease his chances of developing health conditions such as high blood pressure and high cholesterol. Get full clearance from your doctor before making these changes.

Watch What They Eat

The amount of daily calories a child needs depends on his activity level. According to the We Can! program, a 4- to 8-year old inactive child requires about 1,200 to 1,400 calories a day, while a very active child of the same age should eat about 1,400 to 1,800 calories. Reading food labels to check the calories per serving size is a good way to monitor calories and portions sizes. Registered Dietitian Natalie Allen, a school and community health educator, suggests serving children small portions at meals. If they ask for seconds, give them nutrient-rich vegetables and fruits so they consume fewer calories. As for snacks in between meals, Allen recommends low-fat yogurt, applesauce or raw carrots.

Get in Motion

Have your child do at least 60 minutes of exercise a day. Seek out age appropriate activities. The Centers for Disease Control and Prevention claims young kids might enjoy unorganized, self-starting activities playing on a jungle gym at the park or climbing trees. More mature kids might respond best to a more structured program that includes team sports, such as basketball or football. The key is to involve kids in some kind of activity to help burn calories and keep the weight off.

Less TV, More Action

Two hours in front of any kind of screen is more than enough for kids according to The American Academy of Pediatrics. It suggests helping your child find an active hobby with gifts like a jump rope, balls, or other toys that promote physical activity. They also suggest scheduling exercise into the child's day, It won't interfere with homework and other scheduled activities that way, and it could become part of her lifestyle pattern she'll carry into adulthood.

Set the Example

The best way to motivate your child to lead a healthier and more active lifestyle is to be a good role model. Healthychildren.org suggests you show the child you're serious by being physically active yourself. The website also recommends helping your child learn new activities by taking part in the games with him.

Obesity affects close to 36 percent of U.S adults. Experts don't see obesity as a single-cause condition. Most medical experts contend obesity results from a combination of lifestyle and dietary factors that lead to energy imbalance. That said, research indicates the amount of fast food you consume plays a contributing role in developing obesity.

Frequency Factor

Fast food. Photo Credit Stockbyte/Stockbyte/Getty Images

Researchers analyzed data from the Michigan Behavioral Risk Factor Survey and published the results in the July 2011 issue of the journal "Preventing Chronic Disease." The team found a strong link between how often residents consumed fast food and obesity prevalence. Michigan residents who consumed fast food once a month had the least risk. The study found that prevalence of obesity increased significantly for those who consumed fast food three or more times per week.

Portion Size

Fish n' chips. Photo Credit Jacek Nowak/iStock/Getty Images

Researchers from New York University examined the role of fast-food portion sizes in the growing obesity epidemic. The team found fast-food portion sizes exceeded government standards. The team notes bigger that portion sizes encourage people to eat more, and the excess calories make it difficult to balance energy with physical activity. The team concluded the trend toward larger portion sizes contributes to rising obesity rates. The study was published in the February 2002 edition of the "American Journal of Public Health."

With the proliferation of fast food restaurants and convenience foods offered at grocery stores, teens face a looming health crisis -- obesity. According to an article on ABC News, “Most Americans May Be Obese By 2030, Report Warns,” more than half of all Americans will be obese by 2030 -- costing the U.S. $66 billion in disease treatment and $500 billion in lost productivity. Obesity is on the rise among teens and puts them at risk for heart disease and other chronic illnesses. Understanding the factors behind teen obesity can help parents combat the problem.

Media Influence

An article on the Centers for Disease Control and Prevention website, “Childhood Obesity Facts,” states that the obesity rate for adolescents aged 12 to 19 increased from 5 percent to 18 percent from 1980 to 2010. During this time period, advertising for popular fast food and snacks has exploded on television, the Internet and social media. According to an article from the National Center for Children in Poverty, “Adolescent Obesity in the United States,” food marketers spent $1 billion dollars in 2006 marketing food to adolescents using the television, Internet and media devices like smartphones.

Poor Food Choices

With school, homework assignments and after-school activities, teens often eat on the go, which can mean selecting unhealthy foods like burgers and fries. According to an article on ABC News, “Obesity in America: Is It Out of Control?” Dr. Stacey Brethauer reports that a generation of teens has grown up on fast food. Fast food is usually calorie dense and high in fat, which makes it a poor substitute for regular meals. Additionally, teens and their families consume more prepared foods from restaurants and supermarket chains. As a result, teens are eating more calories and saturated fats.

Inactivity

In addition to unhealthy food choices, teens have reduced their physical activity levels. An article on the National Center for Children in Poverty website, “Adolescent Obesity in the United States,” reports that less than 20 percent of high school students participated in the recommended one hour per day of physical activity in 2006. Many teens also engage in sedentary activities, such as playing video games and surfing the Internet. This lack of regular physical activity gain cause weight gain because teens are not expending the high calories they consume.

Food Insecurity

Some teens live in “food deserts,” which are areas where people lack access to fresh produce and other healthy food. Living in a food desert can impact a teen psychologically by causing food insecurity, as reported by the National Center for Children in Poverty. Low-income teens and children who feel insecure about their food choices may purchase cheap, high-fat food, despite the bad effects it has on the body.

Effects of Obesity

The effects of the teen obesity crisis are staggering. An article on the National Center for Children in Poverty, “Adolescent Obesity in the United States,” states that one out of every six adolescents is overweight and one of three is at risk for becoming overweight. Obese adolescents are at risk for heart disease, diabetes, asthma, high cholesterol and sleep apnea. According to an article on the Let's Move website, “Health Problems of Childhood Obesity,” in a sample of 5 to 17 year olds, 60 percent of overweight children had at least one cardiovascular disease factor, while 25 percent had two or more factors for heart disease.

Teenage obesity increased substantially in the last decade of the 20th century and the first decade of the 21st century to something approaching epidemic proportions. The future health consequences from the rise in teen obesity is dire. Teens who are obese often become obese adults, putting them at a higher risk of heart disease, high blood pressure, diabetes and some types of cancer. Sixty percent of overweight and obese kids between the ages of 5 to 15 have at least one risk factor for heart disease, such as high cholesterol, high blood pressure and abnormal glucose tolerance. The psychological costs of teen obesity also are profound. Obesity impairs self-esteem and sometimes leads to stress and clinical depression.

Increase

In the last 30 years, from 1980 to 2010, the obesity rate among children and teens tripled, according to Let's Move, the campaign against child and teen obesity led by the White House, the Department of Health and Human Services, the Department of Agriculture and the Department of Education. An obese child or teenager is one who weighs at least 20 percent more than their ideal body weight. One out of every three children in America is overweight or obese. Forty percent of kids and teens in Afro-American and Hispanic communities are overweight or obese. If the trend continues, one out of every three children born in 2000 or later will suffer from type 2 diabetes, a disease largely caused by obesity.

Obesity Causes

A lack of exercise and unhealthful diets are the prime causes of obesity. According to Let's Move, kids and teens from the ages of 8 to 18 spend 7-1/2 hours per day using computers, watching TV, playing video games and using other electronic media. Teens in high school get just 33 percent of the recommended level of physical fitness. Portion sizes of food have increased by two to five times from 1980 to 2010. Kids and teens ate an average of one snack in 1980. In 2010, they ate an average of three snacks. Plus, the consumption of sugar and fast food by teens is at an all-time high.

Teens to Adults

According to the American Academy of Child & Adolescent Psychiatry, obese kids between the ages of 10 and 13 have an 80 percent chance of becoming an obese adult. If one parent is obese, their child or teenager has a 50 percent chance of being obese, and the chances are even higher if both parents are obese. Fewer than 1 percent of obesity in kids and teens is caused by inherent physical problems. The other 99 percent of obesity is caused by poor eating habits, lack of exercise, a family history of obesity, and other factors such as low self-esteem and depression or other emotional problems.

Health Effects

Obesity weakens the health of teens. It can shorten life expectancy. It causes stress -- overweight adolescents often are subjected to ridicule and bullying. Body image is important to teens, and obesity can lead to teen depression and other forms of mental illness. Some studies indicate that obese kids and teens do not learn as well as other kids. Parents and their obese children can take steps to change the status quo. For example, changing the way the whole family eats may reduce the incidence of teen obesity because a strong correlation exists between the amount of whole grains consumed over a four-year period and healthier weight.

According to the Centers for Disease Control and Prevention, one third of all adults and 17 percent of all children in the United States are obese. Obesity rates doubled for adults in the past three decades and tripled for children, and show no signs of decreasing in the near future. The CDC lists some of the health problems that stem from obesity as type 2 diabetes, coronary heart disease, several types of cancer, stroke and high cholesterol. Obesity needs to be addressed by individuals, communities and government.

What Is Obesity?

Obesity is defined as a body mass index, or BMI, of 30 or more, according to the Obesity Society. You can calculate your BMI by dividing your weight in pounds by your height in inches squared, then multiplying by 704.5. Obesity results from consuming more calories than the body uses, which results in stored fat. Super-size portions and sedentary lifestyles, say nutrition experts Marian Nestle and Michael F. Jacobson, have contributed to a public health epidemic.

Individual Solutions

Fast food, soda, hot dogs and other high-calorie food products like potato chips and sugary cereals are ubiquitous and cheap in the U.S. dietary landscape. Unfortunately, most are also nutritionally empty. To prevent overweight and obesity, the U.S. Surgeon General recommends a nutritious diet that follows the 2010 USDA Dietary Guidelines for Americans. The Surgeon General also advocates that adults get 30 minutes of exercise most days, and children a full hour. Easy ways to incorporate more physical exercise include taking the stairs instead of the elevator, using a push mower instead of a power mower and parking the car at the far end of a store's lot to get in more steps. Encourage children to play outside instead of watching TV after school.

Community Solutions

The burden of solving the obesity problem has largely fallen on individuals, report Nestle and Jacobson, but communities must also pitch in. For example, the Centers for Disease Control and Prevention, or CDC, recommends that communities make fresh fruit and vegetable stands available at workplaces instead of vending machines carrying high-fat, empty-calories snacks. Nutritionist Isobel R. Contento reports on the success of programs that connect schools with local farms, which supply fresh produce for the school menu or stock cafeteria salad bars. One study, notes Contento, saw a 200 percent increase in sales of carrots in a school cafeteria when prices were lowered 50 percent. In another study, raising the price of higher-fat cafeteria options boosted sales of more nutritious items. The CDC also suggests communities improve outdoor recreational areas.

Government Solutions

Government, too, must get involved in solving the obesity problem, say Nestle and Jacobson. Some of the policy changes they recommend include requiring that calorie, fat and sugar content be clearly marked on snacks sold in movie theaters; creating an incentive program to encourage those who receive food stamps to use them for healthy food choices; and providing more funding to communities for physical recreation centers and bicycle paths. Launched in 2010, First Lady Michelle Obama's national initiative, "Let's Move," recommends that local municipalities take actions such as forming a committee to investigate the barriers to healthful eating in the city or town, and offering incentives to stores to stock healthier food and drink choices, especially in underserved areas.

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Obesity is a serious, chronic disease and is not a simple condition.

Nearly 1 in 5 Australians are obese and are at risk of suffering major medical, physical and social problems because of their obesity.

Obesity reduces a persons life expectancy. There are many illnesses that are either caused by obesity or made worse by obesity. These include high blood pressure, diabetes, heart disease, blood vessel diseases and sleep apnoea. Obesity stresses the joints leading to arthritis in hips, knees and ankles. Obesity may also cause less well known problems such as fertility, pregnancy problems, gall bladder disease, some cancers and depression.

Having to carry this increased weight means that obese people find physical activity difficult and this aggravates the obesity problem and can lead to social isolation from family and friends.

Treatment of obesity starts with diet and exercise, weight loss programs and can include appetite suppressants, hypnosis and counselling. The results of these programs rarely last and the obese person falls into what is called the “yo- yo syndrome” where they continually lose and gain weight.

A surgical procedure called Laparoscopic Adjustable Gastric Banding has been developed to help these people achieve significant weight loss, in turn improving their general health and quality of life.

The advantages of this procedure are that it can be performed laparoscopically ( key – hole surgery), the band is adjustable and it can be reversed. The band creates a small pouch which fills quickly with eating and suppresses the appetite. The procedure is carried out as part of a team approach including Surgeon, Dietician, and other health professionals.

“Band placed around the top of the stomach”

To learn more about Laparoscopic Gastric Banding, please contact the Shepparton Surgical and Endoscopy Group. There are three surgeons currently performing this surgery at Shepparton Private Hospital for private, DVA and self paying patients.

There are information nights held during the year and their staff are happy to answer questions for you if they can, prior to your attendance at an information session or consultation with a surgeon.

Since 1982, the Southern California Permanente Medical Group's Positive Choice Weight Loss Program in San Diego has treated more than 30,000 adults, predominantly middle-aged, for obesity—some successfully, some not. This has been an extraordinary experience and provided us with numerous counterintuitive observations. We now are convinced that obesity is widely misunderstood, and we realize that the unusual program we have operated safely and effectively for more than a quarter century is often misunderstood as well. There is growing interest in our program and in using our approach as a model for other Kaiser Permanente (KP) Regions. We therefore share an overview here of our experience with this specific program. Consequently, most referenced works in this report are publications emanating from our program, sometimes contrasting those findings with conventional views on the subject.

The Positive Choice Weight Loss Program has two integrated components:

• Prolonged absolute fasting, with the use of a supplement to support health and to prevent death from such fasting.
• A lengthy and complex group program to explore the basis of each participant's unconscious compulsive use of food, as well as to explore the hidden benefits of obesity for that individual.

Given that the average weight loss of someone completing our 20-week program is 62 lb (28 kg) and that approximately 5000 patients each have lost more than 100 lb (45 kg), we realize we have challenged the belief systems of some who assume either that such weight loss cannot commonly be achieved or that the process of supplemented absolute fasting must be dangerous. In fact, the process has been notably safe, and major improvements in biomedical outcomes have been the norm. This article addresses four basic issues:

1. The safety of properly supplemented prolonged absolute fasting in obesity
2. The observed origins of obesity, and their implications
3. The components of a relevant treatment program
4. Outcomes of the Program.

Overview of Unsupplemented Starvation

The Irish hunger strikers of the early 1980s illustrated the outcome of unsupplemented, prolonged, absolute fasting. They only drank water, and it was clear after six weeks that all involved had sustained significant weight loss and were mortally ill. By seven weeks, all were dead. They died because of profound potassium and magnesium deficiency, with consequent lethal cardiac arrhythmia. Had they received electrolyte supplementation and had the hunger strikers been obese, they could have lived for several months longer before dying because of major protein deficiency. Supplementing two essential fatty acids and the essential amino acids needed for anabolic protein turnover would have prevented such a death. Had this been done, the hunger strikers would have died toward the end of a year because of beriberi, pellagra, and scurvy. Preventing these diseases by vitamin supplementation would be straightforward. To simplify the example, we have left out the problem of calorie deficiency in these nonobese individuals. In obese individuals, body fat stores of course resolve this problem; the metabolism of these fat stores is obviously the basis for weight loss. Details of unsupplemented starvation can be found in the famous work of Ancel Keys, described in his two-volume Biology of Human Starvation.1

Safety of Supplemented Fasting

The nutritional supplement Optifast 70 was created by Sandoz Pharmaceuticals to supply electrolytes, amino acids, two essential fatty acids, and vitamins. At 420 cal/d in five feedings, this superbly designed product allows a sufficiently morbidly obese individual to cease eating all food and caloric beverages for at least a full year. In our entire experience, no death or biomedical harm has occurred in any of these individuals.

During a year of supplemented absolute fasting, a weight loss of approximately 300 lb (136 kg) will occur (Figure 1). To the degree that this does not occur, it means that the patient is consuming food, regardless of denial. Surprisingly, hunger is not a problem. However, the desire to eat is variable, ranging from minor to uncontrollable. Interestingly, this desire to eat is an issue separate from hunger. Indeed, it attests to the profound psychoactive benefits of food, as illustrated by a commonplace observation that is even built into our language: “Sit down and have something to eat; you'll feel better.” There is truth for many in the phrase “comfort food.”

Figure 1.

Patient who lost 277 lb in 51 weeks

Origins of Obesity

In the early years of the Weight Program, we naively were taking morbidly obese individuals down 300 lb (136 kg) at a time, a rate of loss distinctly exceeding that of bariatric surgery. The striking results perhaps understandably led us to believe that we understood what we were doing. Counterintuitively, some of our most successful patients forced us to realize we were merely in possession of a powerful technology and had no idea what we were doing in other regards. They did this by demonstrating that massive weight loss could precipitate divorce, severe anxiety, and sometimes suicidality. Some patients, sensing these outcomes early, fled their own success in the Program. Surprisingly, our high dropout rate was mainly limited to patients who were successfullylosing weight. By contrast, we had other patients who were eating during the Program, routinely denying it, and losing no weight while paying a fairly significant fee, seemingly to accomplish nothing. With these patients, it took some time for us to realize that we were supplying an important support system with our group approach. It turned out that many of our obese patients had no functional support systems at home.

The striking and frankly annoying conflict between our ability quickly and safely to reduce a person's weight and what patients appeared capable of tolerating emotionally led us to detailed exploration of the life histories of 286 of our patients. Here, we unexpectedly discovered that histories of childhood sexual abuse were common, as were histories of growing up in markedly dysfunctional households. It became evident that traumatic life experiences during childhood and adolescence were far more common in an obese population than was comfortably recognized.2 We slowly discovered that major weight loss is often sexually or physically threatening and that obesity, whatever its health risks, is protective emotionally. Ultimately, we saw that certain of our more intractable public health problems such as obesity are often also unconsciously attempted solutions to problems dating back to the earliest years but hidden by time, by shame, by secrecy, and by social taboos against exploring certain areas of life experience. The antecedent life experiences of the obese are quite different from those of the always-slender.3 Eventually, these Program findings led to the 17,000-member Adverse Childhood Experiences (ACE) Study, in which we established that the developmental damage initially discovered in our obese patients was broadly applicable to many aspects of everyday medical practice.4,5

Ultimately, we learned from our patients that in obesity, we are dealing with two core problems:

• The unconscious, compulsive use of food for its psychoactive benefits
• The unrecognized and unspoken benefits of obesity.

These two core problems are markedly at variance with conventional thinking about obesity, starting with the government's food pyramid. Worse yet, these two basic problems are uncomfortable to deal with. In reviewing the medical literature, one quickly notes that most articles purporting to discuss the causes of obesity quickly switch to describing the unhealthy consequences of obesity and never pursue their stated goal. One also notes the tendency to confuse intermediary mechanism with basic cause. For instance, several years ago, leptin deficiency was proposed as the cause of human obesity. Although that idea has now been discarded, someday the “real leptin” will be discovered, but it will no more be causal than increased levels of epinephrine are the cause of anxiety. Each is a necessary intermediary mechanism, not a basic cause. Understanding the difference is as essential to progress in treatment as it is to primary prevention.

It became evident that traumatic life experiences during childhood and adolescence were far more common in an obese population than was comfortably recognized.2

Any physician choosing to validate in his patients the points being made here will be in the position of asking about topics that we have all learned are not discussed by polite people. Incest, rape, family suicides, and parental brutality are not readily brought up. That being the case, we physicians typically have no basis for opinions on the frequency or rarity of such life experiences. We documented these experiences as surprisingly common among our patients, but we did not know that before we began routinely inquiring about them. Counterintuitively, we learned that discussion of these experiences is usually not uncomfortable to those who have had them, if they are supported by someone comfortable with their discussion. Patients often find a great sense of relief in discussing their life experiences. As one patient wrote, “The shame, guilt, and pain for the abuse and molestations of childhood, and being raped, was so great that I had to come forward or die. If your questionnaire had been put in front of me, it would have shown me that people existed in the medical profession who knew about the sad things that happen to some people.” This poignant statement imposes a huge responsibility on us that we can of course avoid by falling back on lack of time or lack of training as being the factor that precludes our inquiry.

The now internationally recognized ACE Study was initiated to determine the prevalence and outcomes of ten categories of such life experiences in more than 17,000 consecutive adults from KP's San Diego population.6These experiences are common, and their consequences are devastating in terms of emotional damage, biomedical disease, and the costs of health care. Like a child's footprints in wet cement, the consequences are lifelong. Putting it plainly in regard to obesity, we have seen that obesity is not the core problem. Obesity is the marker for the problem and sometimes is a solution. This is a profoundly important realization because none of us expects to cure a problem by treating its symptom.

Treatment

Given the nature of our observations about the causes of obesity, repeatedly documented in thousands of responses to our preprogram questionnaire (Seehttp://xnet.kp.org/permanentejournal/spr10/PreprogramQuestionnaire.pdf to view the questionnaire) and in more than 50 videotaped interviews, it was inevitable by the early 1990s that we revise our program to fuse two separate goals: weight loss by supplemented fasting, and helping patients identify and resolve the life experiences underlying obesity. By far the easier of the two goals is the medical management of supplemented absolute fasting. Weekly checks of potassium levels, blood pressure measurements in patients taking antihypertensive medications, and blood sugar levels in patients with diabetes are our most common tracking measures other than weight itself. Other details of biomedical management are equally straightforward but are not the point of this article. Chronic disease is not a reason for exclusion from the Program; most such patients should actually be sought for Program inclusion if obese. Our only absolute exclusions are pregnancy and recent myocardial infarction or stroke. Optifast 70, drunk five times daily for a total daily intake of 420 cal, is a remarkable material that makes biologically safe the otherwise unthinkable. The remainder of the day's caloric needs come from body fat stores as long as those fat stores exist. It is important to understand that Optifast 70 has one function only: the prevention of death from prolonged absolute fasting. It does not take weight off people; not eating does that. And it has nothing to do with whether lost weight is regained or kept off; that outcome is solely a function of what is accomplished or not accomplished by the group work of the Program.

By contrast with the simplicity of fasting, the weekly two-hour group meetings of the Program are a complex endeavor that is difficult for some patients to engage in and is difficult to train staff to pursue vigorously. By the mid-1980s, we had learned that our initial goal of teaching people to “eat right” was totally irrelevant to obesity, although it seemed a reasonable thing to do when we did not know what to do. In retrospect, we should have known better because most of us knew that overweight, middle-aged women commonly know enough about calorie content to give a dietitian a run for his or her money any day of the week. Nutrition is an interesting and important subject that has no more relationship to obesity than it does to anorexia. The role of the Program is to help people recognize and find an acceptable alternate solution or resolution to the underlying problems being treated with food. We are at an early stage of success; the work is difficult because it is resisted by some patients and can awaken personal ghosts in staff, but we have clearly established a beachhead on the right beach and slowly are moving inland.

In the course of detailed interviewing of about 2000 obese patients over the past 20 years, in-depth and often repetitively over time, we have noted several recurrent findings:

• It is rare for anyone to be born obese. In 2000 adult obese patients, only one individual was born overweight, at 14 lb (6 kg), to a 550-lb (250-kg) mother, and she was slender throughout childhood and adolescence until age 20, when she married an alcoholic and suddenly began massive weight gains, ultimately matching her mother's weight. “Born fat” is a defensive concept.
• A significant minority of our Program participants are born at subnormal weight because of prematurity.
• Obesity indeed runs in families, as does speaking the same language. It is the distribution pattern of body fat deposition that is genetically determined, not its presence.
• Major weight gain is typically abrupt, episodic, and life-event related.
• The forces underlying extreme morbid obesity are relatively easy to discern for those seeking them. They are qualitatively similar to those underlying mild overweight, though they are much harder to discern in the latter.
• The age at which weight gain first began is critically important because it allows one to inquire why it began then. Some patients will know and others will not want to know, but this is an essential point not to be dropped because of patient avoidance.
• Obesity commonly is beneficially protective: sexually, physically, and socially. This is an uncomfortably difficult point for many nonobese individuals to accept.
• Major weight loss may present a significant threat, usually to the person involved, but sometimes to others.
• Emotional support from others for major weight loss is uncertain.

With adequate medical monitoring, there is no biologic risk to supplemented absolute fasting. Supplemented fasting has two treatment advantages:

• When large amounts of weight are to be lost, it reduces weight quickly enough to provide positive and supportive feedback.
• By removing eating as a major coping device, we expose the underlying issues that are being treated by the psychoactive properties of food.

The main work of the Program enters personal territory that is comfortably off-limits to polite people. It is therefore difficult and demanding, though conceptually simple. Doing the work in groups is essential because of the implicit support of the group and because participants quickly learn from each other's self-observations. To the degree that counselors pose meaningful questions to their groups, and insist on answers to the questions asked and not to some enfeebled version of their questions, they are successful. To the degree that they teach by lecturing, they fail. In actual fact, our task is to help the participants discover what they already know at some level, and then to use that discovery for their own benefit. To illustrate the process, some seemingly simple questions may be offered for our readers to try, understanding that this works best in small groups and initially will be stressful for the group leader:

1. Why (not how) do you think people get fat?
2. How old were you when you first began putting on weight? Why do you think it was then and not a few years earlier or later?
3. Sometimes people who lose a lot of weight regain it all, if not more. When that happens, why do you think it happens?
4. What are the advantages of being overweight?

Patients' answers to these questions are staggeringly counterintuitive to conventional thinking about obesity. Moreover, their answers have been consistent over the many years we have posed these questions in group sessions. For instance, answers to question 1 routinely are: “stress, depression, people leave you alone, men won't bother you.” There are of course occasional escapist responses like “I just like food.” In that case, the following response to the answer given for question 2 is helpful: “Really? Can you tell us why you suddenly liked food more at 22 when you first began putting on weight?” Responses to question 3 always are versions of “If you don't deal with the underlying issues, the weight will come back.” About 60% of the time, someone in a group will also propose that regain occurs because major weight loss is threatening. Answers to question 4 repeatedly fall into three categories: obesity is sexually protective; it is physically protective (eg, “throwing your weight around”); and it is socially protective—people expect less from you.

… a physician has to become part of the problem by authenticating as biomedical disease that which is actually the somatic inscription of life experience onto the human body and brain.

Ultimately, we were forced to recognize that patients in a supportive setting speak of things that we ourselves may find it easier not to know. This embarrassing recognition exposes the tempting opportunity that a physician or group leader has to become part of the problem by authenticating as biomedical disease that which is actually the somatic inscription of life experience onto the human body and brain. The frequent reference to “the disease of obesity” is grossly in error, diagnostically destitute, and apparently made by those with little understanding of the antecedent lives of their patients. Obesity, like tachycardia or jaundice, is a physical sign, not a disease.

What we have learned about obesity has been more widely applicable in everyday medical practice than we would ever have contemplated. The general principles underlying the unconscious, compulsive use of food as a psychoactive agent are common to any of the addictions. We unwittingly recognized this at some level in the early years of the Program by giving as gifts, coffee mugs bearing the inscription, “It's hard to get enough of something that almost works.” The psychoactive benefits of food are profound though not curative: “Sit down and have something to eat; you'll feel better.” Hunger is not at issue in that saying. Whether we are talking about the next mouthful, the next drink, the next cigarette, the next sexual partner, or the next dose of whatever psychoactive chemical we might buy on the street, the concept is equally applicable: It's hard to get enough of something that almost works.

Slowly, we have come to recognize that overeating is not the basic problem. It is an attempted solution, and people are not eager to give up their solutions, particularly at the behest of those who have no idea of what is going on. Nor is obesity the problem. Obesity is the consequence, the marker for the problem, much in the way that smoke is the marker for a house fire. Often enough, obesity is even the solution—to problems that are buried in time and further protected by shame, by secrecy, and by social taboos against exploring certain areas of human experience. A memorable response comes to mind from 1985 when a patient, going with us through a timeline of her life in which weight, age, and events were matched, told us that at age 23 she was raped and that in the subsequent year she gained 105 lb (48 kg). Looking down at the carpet, she then muttered to herself, “Overweight is overlooked, and that's the way I need to be.” Not knowing how to respond at the time, we said nothing. A few weeks later when she had lost 35 lb (16 kg), enough to be noticeable, she abruptly disappeared for 2.5 years, quickly regaining the weight. When she attempted to rejoin the Program after that hiatus, we discovered that she had no recollection of this conversation. Prompted by this to look into the issue of amnesia, we found in a sample of 300 consecutive obesity program patients that 12% acknowledged a history of focal amnesia, typically for the few years antecedent to the onset of weight gain. Amnesia is a high-grade marker for dissociation, which is a high-grade marker for abuse.7

Just as no one becomes amnesic because of good experiences, no one becomes fat out of joy. Depression is common in the Program and is a major stumbling block to weight loss. Not surprisingly, until the recent advent of pharmacologic blockers of fat absorption, every single “diet pill” save one has had potent antidepressant activity. The exception was fenfluramine, whose potent antianxiety activity was linked with the antidepressant phentermine as the first component of fen-phen. These medications can play a useful supportive role, but it should be understood that what is being treated is depression or anxiety, the consequences of antecedent life experiences, and not obesity per se. Overall, we have found and documented that the antecedent life experiences of the obese are quite different from those of the always-slender.3

Subsequent to the 20-week weight-loss phase of the Program, we have a 12-month Maintenance Phase. Initially thinking that this was necessary to teach people how to eat right, we slowly came to see that Maintenance indeed is essential, but for other reasons: to provide group support when major weight loss is threatening, usually to the person involved but sometimes to those who are close. Some of our patients regain all their weight, and others do not. The question we posed was: What are the differences between those who regain and those who do not? We have identified two major predictors of regain: a history of childhood sexual abuse and currently being married to an alcoholic.8 The latter can probably be generalized into having a significantly dysfunctional marriage, but that concept was too nebulous to study as an outcome.

Today the prevalence of obesity is rapidly increasing in children. Although our experience with obese children is quite limited, we are impressed by the number of adults who date the onset of their initial weight gain to coincide with parental loss in childhood, usually by divorce. Our most obese female patient, weighing 840 lb (381 kg) at age 29, was born weighing slightly less than 2 lb (0.9 kg) and was thin until her parents divorced when she was 11 years old and she never again saw her father. By age 17, she weighed 500 lb (227 kg). This correlation with parental divorce has escaped general attention, although a search in Google Scholar using the phrase childhood obesity divorce quickly indicates its presence in the literature. Given the high prevalence of divorce in the US, we suspect that “McDonald's” may be a more comfortable explanation for childhood obesity, although it obviously misrepresents mechanism as cause.

Bariatric surgery has been increasing in popularity since its initiation in 1967 by Edward Mason, the remarkable Iowa surgeon who introduced gastric bypass surgery to the US.9 Our own experience in the Program with bariatric surgery is biased because we see a disproportionate number of cases where “the surgery failed” and patients consequently enter the Weight Loss Program. We have found alternate explanations that are not usually considered. An unexpectedly clear insight was provided by a recent patient comment: “The antidote [sic] to bariatric surgery is Karo Syrup.” The psychological implication is blatant; the physiologic insight is ingenious. One may not be able to chew one's way through a lot after bariatric surgery, but the ability to ingest highly caloric liquids is unlimited. The question, of course, is: Why would a patient do that? A different take on bariatric surgery is depicted in a brief video clip of an interview with a patient available at: http://public.me.com/vjfmdsdca. These comments from patients are, once again, counterintuitive to conventional views about obesity. We have slowly learned that our average patient on the one hand wants very much to lose weight but on the other hand often has significant unconscious fear of the changes that major weight loss will bring about. In keeping with this unexpressed conflict, it is worth remembering that opposing forces are routinely present in biologic systems.

Outcomes

We have measured our Program outcomes in three categories:

• Weight loss
• Maintenance of weight lost
• Benefits of weight loss.

The average weight loss in one 20-week cycle of our program has been 62 lb (28 kg). The most anyone has ever lost in our former 26-week cycle was 157 lb (71 kg). This was a highly motivated man with a large underlying muscle mass.

Eighteen months after completion of the Program, half of our patients are keeping off 60% or more of the weight lost. These are old data and have probably improved with the revised Program, but we have not restudied the point. Instead, we have studied the differences between those who regain and those who do not. Our ability to predict regain offers the possibility for preventive treatment in advance.

The biomedical benefits of such major weight loss have been dramatic. Of 400 consecutive patients taking medication for hypertension who completed the Program, 62% were able to discontinue all medication and no longer had hypertension. Of 400 consecutive patients with hypercholesterolemia, the average starting cholesterol level was 285 mg/dL; the average cholesterol level for those completing the Program was 204 mg/dL. Most impressively, of 320 patients with Type 2 diabetes who completed the Program, 71% were able to discontinue medication and had normal fasting blood sugars. In terms of health care economics, there is a 25% reduction in physician office visits while patients are in the Program and a 40% reduction in such visits in the subsequent year. Certainly, some of this is due to a reduced disease burden, but we suspect that a significant portion is due to reduced emotional distress in patients who have been helped in supportive settings to speak of the worst secrets of their lives and have been enabled to emerge feeling still accepted as human beings.

Summary

We have had an unusual opportunity to become deeply involved in the treatment of major obesity since 1985. What we have counterintuitively learned from that experience is that obesity, though an obvious physical sign and easily measured, is not the core problem to be treated, any more than smoke is the core problem to be treated in house fires. Supplemented absolute fasting is a highly effective treatment for obesity, but only if it is combined with a meaningful program that is designed to help patients explore the psychodynamic issues that underlie overeating as a coping device, as well as exploring the possible protective benefits of obesity itself. The work is difficult because it threatens social conventions and beliefs and often awakens personal ghosts in staff. This can lead to nonalignment of purpose and reminds us of Michael Balint's famous comment, “Patients see doctors because of anxiety, while doctors see patients because of disease. Therein lies the problem between the two.”10 Although our work with obesity is difficult to carry out, we have nevertheless found that the work we have described can be done and that the benefits are major.