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Copyright © 1999. University Press of Mississippi. All rights reserved.
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Copyright © 1999. University Press of Mississippi. All rights reserved.
Understanding Childhood Obesity
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Understanding Health and Sickness Series
Miriam Bloom, Ph.D.
Copyright © 1999. University Press of Mississippi. All rights reserved.
General Editor
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Understanding Childhood Obesity
Copyright © 1999. University Press of Mississippi. All rights reserved.
J. Clinton Smith, M.D., M.P.H.
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Copyright © 1999 by the University Press of Mississippi
All rights reserved
Manufactured in the United States of America
02 01 00 99 4 3 2 1
The paper in this book meets the guidelines for permanence and durability of the Committee on
Production Guidelines for Book Longevity of the Council on Library Resources.
Illustrations by Regan Causey Tuder
Library of Congress Cataloging-in-Publication Data
Smith, J. Clinton, 1939–
Understanding childhood obesity / J. Clinton Smith.
p. cm.—(Understanding health and sickness series)
Includes bibliographical references and index.
ISBN 1-57806-133-4 (cloth : alk. paper).—ISBN 1-57806-134-2 (pbk. : alk. paper)
1. Obesity in children—Prevention. 2. Obesity in children—Psychological aspects. 3.
Children—Nutrition. 4. Behavior therapy for children. I. Title. II. Series.
RJ399.C6S63 1999
Copyright © 1999. University Press of Mississippi. All rights reserved.
618.92′ 398—dc21
98-44680
CIP
British Library Cataloging-in-Publication Data available
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Contents
Acknowledgments
Introduction
1. Why Is Obesity an Important Health Problem in America?
2. Who Is Obese, and How Do We Know?
3. How Our Bodies Obtain Energy
4. Obesity: A Disorder of Energy
5. Some Factors That May Determine Obesity
6. What Can Be Done to Prevent Childhood Obesity?
7. If Prevention Doesn’t Work
8. The Great Beyond: New Frontiers in the Treatment of Obesity
Notes
Glossary
References
Copyright © 1999. University Press of Mississippi. All rights reserved.
Index
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Acknowledgments
I am grateful to Jim Joransen, David Braden, Makram Ebeid, and Charlie Gaymes, my
colleagues in the Division of Cardiology of the Department of Pediatrics at the University of
Mississippi Medical Center, for allowing me time to write this book. Only through their
support has the Pediatric Preventive Cardiology Clinic become a reality. I am also
appreciative of the physicians, nurses, and dietitians who have made referrals to our clinics.
Without the support of the Mississippi State Department of Health, our clinics could not have
met in various communities across the state, and families would have been unable to obtain
assistance.
I would also like to thank the editor of the Understanding Health and Sickness Series, Dr.
Miriam Bloom, for her patient efforts. In spite of her many other activities in the community
and around the state, she always found time to scrutinize drafts of this book. Her suggestions
were consistently on target, and she helped me translate the scientific jargon into everyday
language (I take full responsibility for any lapses in this regard).
Two other individuals were extremely helpful in the book’s preparation. Dr. Richard
Troiano of the National Center for Health Statistics graciously provided me with unpublished
data from the National Health and Nutrition Examination Survey III concerning overweight and
obesity among children. Dr. Harold White, Emeritus Professor of Biochemistry at the
University of Mississippi Medical Center, reviewed the material on digestion and energy and
made invaluable comments and suggestions.
Copyright © 1999. University Press of Mississippi. All rights reserved.
Most of all, I am indebted to Lois, my wife of thirty years, for her unconditional love and
her even temperament. She always makes it easy for me to do what I need to do.
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Introduction
Hardly a week goes by that a magazine or tabloid newspaper doesn’t feature an article
about someone who is overweight, who is trying to lose weight, or who should be trying to
lose weight. “How-to” books about weight loss are available in great number. We know about
celebrities such as Oprah Winfrey, Elizabeth Taylor, David Letterman, and Tommy Lasorda
who have successfully dealt with their own weight problems. Others, including swimmer
Lynne Cox, musicians Kate Smith, Fats Domino, and Chubby Checker, singer Cass Elliot,
Chicago Bear “Refrigerator” Perry, and most professional football linemen, have used excess
weight to their advantage. Thanks to overweight opera singers, “It’s not over ’til the fat lady
sings” is a national aphorism. Americans seem obsessed with weight loss. We talk about how
much weight we want to lose or how much we have lost as frequently as we talk about the
weather. Our weight and what we’re trying to do about it is always a timely subject. And our
conversations about weight usually have something to do with our appearance—the way we
look to other people.
Copyright © 1999. University Press of Mississippi. All rights reserved.
Self-image is unquestionably important. But there is a far more serious aspect of being
overweight that we don’t talk about much, and that is how this condition can affect our health
and longevity. Consider the following facts:
First, about 500,000 Americans die each year from diseases of the heart, especially
coronary artery disease, or disease of the blood vessels supplying blood to the heart. This
disease doesn’t just develop overnight. It is a slow, degenerative process that can begin in
childhood. Adults who are obese, who have high blood pressure or abnormal blood
cholesterol levels, who use tobacco, and who engage in little or no physical activity appear to
be at high risk for this degenerative process (Eckel et al. 1998). Yet mounting evidence
indicates that if children who have risk factors can be identified and appropriate corrective
action taken, there might be less chance that they will have heart disease when they become
adults (Bao et al. 1997).
Second, in the years 1988–94, about 35 percent of American adults over 20 years of age
(nearly 60 million people) were obese, up from 25 percent in the years 1976–80. The news
concerning children was also startling: the proportion of overweight children (6-to 11-yearolds) climbed from 20 percent in the period 1976–80 to 27 percent between 1988 and 1994;
the proportion of overweight adolescents (12-to 17-year-olds) rose from 16 percent to 27
percent over the same time. Approximately 5 million children and adolescents are now
classified as being obese. Many, but not all, obese youngsters become obese adults, and many
obese adults can trace their excess weight to faulty nutrition and physical activity patterns
established during childhood.
A glaring incongruity exists in Americans’ ideas of health care. On the one hand, we have
great expectations: we know that when we become ill or injured, we will receive the very best
care available in the world, and that our doctors and hospitals will be paid by our insurance
programs. If we survive a heart attack, we go to state-of-the-art coronary care units, have
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
coronary artery bypass grafts, take drugs that help keep coronary arteries open, and receive
rehabilitation services for damaged hearts. Astonishing, but costly, technological advances in
health care since 1950 have made such interventions possible, and we have welcomed them
and now take them for granted.
The incongruity is that we don’t seem to realize that it is within our power as human beings
to prevent, or at least delay, some diseases. Many heart attacks, strokes, cancers, and other
diseases and conditions would not occur if we were effective in preventing obesity.
My purpose in writing this book is to suggest that childhood is the best time to prevent
obesity and its later consequences. The book is intended to assist families, teachers, health
providers, and other friends of children in understanding better why some children become
obese, how being obese can result in health problems in childhood and in adulthood, and what
can be done to help youngsters become healthy adults. I have drawn on the wisdom and
contributions of professionals in many different fields who are serious students of the problem
of obesity, including basic science researchers, dietitians, exercise physiologists,
psychologists, and physicians. I hope that readers will use the book to expand their knowledge
of this critical public health issue.
I begin with a discussion of the major ways in which obesity is an important health problem
and why we need to do something at both the individual and the population levels. The first
chapter also explains some of the consequences of obesity in children and in adults.
Copyright © 1999. University Press of Mississippi. All rights reserved.
In the second chapter I explain the process of classifying a child’s weight and height as
“normal” or “abnormal,” how a diagnosis of obesity is made in children, and what the
difficulties are in comparing different populations of children. I also identify groups of
children and adolescents who are most likely to become obese adults.
Chapters 3, 4, and 5 are concerned with how energy is taken into the body and used and
with how energy imbalance leads to obesity. In chapter 3 I review how food is broken down
into molecules in the digestive tract and how these molecules are absorbed into the
bloodstream, enter the cells of the body, and are then either used as immediate energy sources
or stored for future energy needs. In chapter 4, I explain how energy from food is supplied and
used. I also introduce the energy balance equation, which is the basis for measuring energy
intake and expenditure. Some of the possible reasons for obesity in childhood are presented in
chapter 5, including evidence from both behavioral and metabolic research. The chapter
focuses on the importance of genetic and environmental factors associated with obesity.
Chapter 6 examines the question “Can obesity be prevented in American children?” I try to
emphasize the difference between hoping that prevention can take place because of successful
demonstration projects and realistic expectations within the context of the powerful
environmental influences affecting children’s daily eating and exercise habits. I cite examples
of the ways in which parents, government, schools, and health professionals have attempted to
prevent obesity, and comment on the likelihood that prevention efforts will be expanded.
Techniques used in treatment of obese children are discussed in chapter 7. Several
approaches are defined, and the traditional elements of treatment, such as nutrition education,
decreased calorie and fat intake, increased physical activity, and behavior modification are
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
detailed. Examples of aggressive medical and surgical management, including a discussion of
drugs to treat obesity, are presented. I also introduce the reader to the “continuous care and
problem solving model” of treatment, and explain how this works in our pediatric treatment
clinics at the University of Mississippi Medical Center.
Finally, chapter 8 contains a summary of exciting new developments that have taken place in
obesity research in recent years, including the discovery of leptin and the leptin receptor and
the promising genetics research that may finally explain why obesity develops in some
individuals but not in others.
I have cited references only to sources other than material that can be found in standard
textbooks of basic science and clinical medicine.
Copyright © 1999. University Press of Mississippi. All rights reserved.
For me, the richest source of information has been the hundreds of obese children and their
families in Mississippi who have sought assistance in our clinics. In getting to know them,
learning about their family and school environments, and identifying with their struggles to
change their eating and physical activity patterns, I have come to realize how little is known
about the origins and treatment of obesity in childhood. Without knowing those children, I
would have had little incentive to write this book. They continue to be superb teachers.
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
Copyright © 1999. University Press of Mississippi. All rights reserved.
Understanding Childhood Obesity
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
1. Why Is Obesity an Important Health Problem in America?
Leave gormandizing. Know the grave doth gape For thee thrice wider than for other men.
William Shakespeare, Henry IV, Part II (quoted in Bray 1985)
Twentieth-century Americans have enjoyed a standard of living unparalleled in history. We
are well nourished, we live in attractive and affordable houses, we have clean water and milk
and good sewage systems, and we are largely free from the scourges suffered by so much of the
rest of the world, such as malaria, yellow fever, rheumatic fever, blindness due to parasites,
and malnutrition. We are a well-educated nation. Many of us work 40-hour weeks, have
guaranteed vacations, and are free to enjoy the fruits of our labor before we grow too old. Our
health care system has provided us with powerful drugs and technologies that cure illnesses
and prolong lives.
Copyright © 1999. University Press of Mississippi. All rights reserved.
Yet we are not entirely well. The health problems dominating the early part of this century
have been replaced by a new morbidity—diseases brought on by our living habits. Like other
industrialized countries, we now have high rates of heart disease, cancer, strokes, and obesity.
Nearly 60 million American adults between the ages of 20 and 75 years—1 in 3—are obese.
One of every 4 U. S. adults smokes cigarettes regularly, a habit usually acquired in
adolescence and linked to several fatal conditions. Since most of us are now city dwellers, we
can’t conveniently walk to work or to visit our neighbors. And, thanks to labor-saving
technologies, we have discovered how to work without sweating.
We reward ourselves at the end of the day with big meals and evenings of watching
television. We are sports enthusiasts and spectators, but frequently avoid physical activity
ourselves. A fourth of adult Americans have high blood pressure or high blood cholesterol.
Many don’t realize it because they haven’t taken the time to find out, while others know but are
unwilling or unable to take available medications.
The fact is that many Americans want to have good health but don’t want to pay the personal
price to achieve it. We undertake to live what we see as “the good life,” and, if something goes
wrong, we rely on our doctors and hospitals and technology and drugs to fix us up and get us
going again. And since we don’t want to worry about the expense, we say “just bill my
insurance company.” Those of us in the health professions do a pretty good job of treating
disease, but we’re not always doing so well at getting the message out that a lot of death and
disability can be prevented. Government and health insurance companies give lip service to
the idea of prevention, but education in this area is infrequently compensated, and it has not
been a high priority among health practitioners. Managed health care may eventually modify
this deficiency.
Many of us have not yet connected obesity to possible poor health. Obesity is a chronic
condition—not an acute, urgent, and headline-grabbing disease like AIDS or meningitis—and
Smith, C. (1999). Understanding childhood obesity. Retrieved from http://ebookcentral.proquest.com
Created from lynnu on 2017-10-16 19:21:49.
is therefore likely to receive less attention. Its effects are insidious, its origins are complex and
poorly understood, and its treatment is often discouraging. But obesity can be prevented if the
American people will that it be so (National Institutes of Health 1985; Lew 1985; Pi-Sunyer
1991; Dietz et al. 1993; Alpert et al. 1993).
This chapter explores a number of ways in which obesity is a major health problem among
Americans. Some of the complications of obesity, such as heart disease, begin in childhood,
but do not become apparent until adulthood. If we are to understand why some adults are
healthy and others are not, we must first understand how habits that we acquire early in life can
affect our health later.
Obesity and Overall Mortality
Obese people do not live as long as other people. Life insurance company studies done
early in the 20th century showed that, as the weight of individuals increases above an optimal
level, the probability of dying increases, too. In 1979 the American Cancer Society confirmed
that finding in a 12-year study of 750,000 people which took into consideration their state of
health and whether they smoked. The study also found that men and women who were 5-15
percent below average weight were likely to live longest. The most common causes of death
among men in the American Cancer Society study were diseased coronary arteries, stroke, and
digestive diseases. The same was true in women, except that diabetes was also common.
Obese men and women were also more likely to die of cancer than were those who were not
obese.
Let’s find out why obesity is an important health problem among Americans. Which organs
or systems can it affect, and what happens then?
Copyright © 1999. University Press of Mississippi. All rights reserved.
Effect of Obesity on the Heart and Blood Vessels
Obesity is strongly associated with diseases of the heart and blood vessels in several ways.
First, obese people appear to be more likely to develop disease of the coronary arteries, which
are the vessels that supply the heart muscle with blood. Blood flow in those arteries can be
blocked due to a complex process called atherosclerosis, which is more common in obese
than in nonobese adults. Blockage of coronary arteries can cause part of the heart muscle to die
(a myocardial infarction, or heart attack). After a heart attack, the heart may not be able to
pump adequate amounts of blood to other vital organs, such as the brain, lungs, and kidneys,
and death or disability may result.
Second, obesity also can directly affect the heart muscle, independent of its effect on the
coronary arteries. This condition is called obesity cardiomyopathy. Third, heart disease can
occur when obesity causes abnormal function …
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