During recent decades of negative trends in eating patterns and sedentary behavior, rates of obesity have doubled in children and tripled in adolescents. In West Virginia, 13.7% of high school students in grades 9-12 were overweight in 2003 with another 15.1% at risk of overweight.

Data derived from the Coronary Artery Risk Detection In Appalachian Communities (CARDIAC) Project (1998-2004) documents an alarmingly high prevalence of overweight children and adolescents in West Virginia. Nearly half (46.4%) of 5^th grade students screened and one-third of kindergarten children are greater than the 85^th percentile for body mass index (BMI), approximately double the national average. This high rate of obesity among schoolchildren in West Virginia is associated with increased prevalence of other cardiovascular disease risk factors such as hypertension, dyslipidemia and insulin resistance.

The obesity prevalence in West Virginia has been consistently higher than that in the United States as a whole since state-level monitoring began through the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System (BRFSS). In 2002, West Virginia ranked 1^st in the nation in the prevalence of obesity (27.6%) and 42^nd highest in the prevalence of overweight (36.1%). The prevalence of obesity has steadily increased since 1987. According to the 2002 BRFSS, 386,566 West Virginians are at risk by being obese and another 505,617 are at risk because they are overweight.

Obesity contributes to numerous and varied comorbid conditions. Complications can occur in many organ systems, ranging from cardiovascular to respiratory to orthopedic and even ophthalmologic. Overweight and obesity are known risk factors for heart disease, diabetes, hypertension, gallbladder disease, osteoarthritis, sleep apnea and other breathing problems, and some cancers (uterine, breast, colorectal, kidney, and gallbladder).

According to the 2002 BRFSS, West Virginia ranked 1^st in the nation in the prevalence of obesity (27.6%) and 10^th highest in the nation in the prevalence of physical inactivity. Also, according to the report an overwhelming majority of adults (78.7%) reported consuming less than the recommended five servings a day of fruits and vegetables. West Virginia ranked 19^th highest in the nation in the prevalence of this risk factor.

What’s the cause?

The causes of this epidemic are multi-layered. For the vast majority of individuals, overweight and obesity result from taking in more calories than are used. On the surface this appears to be a simple cause, with a simple solution. It is not.²

Overweight and obesity are caused by many factors. For each individual, body weight is determined by a combination of genetic, metabolic, behavioral, environmental, cultural, and socioeconomic influences. ^2,3 Behavioral and environmental factors that foster the consumption of large portions of high calorie foods and physical activity patterns that do not burn those calories are major contributors to overweight and obesity.^2,4 They also provide the greatest opportunity for prevention and treatment. ^2,3

Why is it happening now?

Researchers, health care professionals, governments, the media, educators, and parents are all asking why this dramatic increase in childhood overweight is occurring now. All the answers are not known. But there are many societal trends that help expand our understanding.^2,5,6

• Longer workdays
• Reduced leisure time
• More households with multiple wage earners
• Less time available for preparation of meals
• Increased consumption of food outside the home
• Increased advertising of high calorie, low nutrient dense foods and beverages
• Increased reliance on automobiles for transportation
• Increased time spent watching television
• Increase in the number of neighborhoods where it is unsafe to walk or play outside
• Reduced time spent in physical education in schools.
• Increased availability of low cost, high calorie foods and beverages in schools, at home, and in the community.

In addition, there are a number of social and cultural dichotomies that have major impacts on the weight status of children and youth.

• As a society we are obsessed with thinness, but overweight is becoming the norm.
• Individuals spend millions of dollars seeking effective weight loss programs, but funding to develop environments to strengthen social, cultural, and individual practices that have major roles in the prevention of overweight is limited.
• Advertising and other lifestyle influences promote eating and physical activity patterns that do not balance energy and intake and expenditures.
• Health care costs of diseases associated with overweight and obesity are skyrocketing, but education, early assessment, and treatment of overweight are infrequently covered services.

Clearly, societal norms are not in sync with health recommendations.²

SO WHAT? Why does it matter?

The health consequence of overweight and obesity is among the most burdensome public health issue faced by the nation. ^2,3 It manifests itself in premature death and disability, in health care costs, in lost productivity, and in social stigmatization. The burden is far from trivial and has the potential to skyrocket as increasing numbers of overweight youth become overweight or obese adults at earlier ages. Studies show that the risk of death rises with increasing weight. Even moderate weight excess (10 to 20 pounds for a person of average height) increases the risk of death.^2,7 Unhealthy dietary habits and sedentary behavior together account for more than 300,000 deaths each year in the U.S. ^8,9

Not for adults only

Obesity is not an issue for adults only. Sixty percent of overweight children, 5 to 10 years of age, have at least one cardiovascular risk factor such as hyperlipidemia, elevated blood pressure, or increased insulin level.^2,10 Type II diabetes, formerly called adult-onset diabetes and seen primarily in middle age, is increasingly being diagnosed in children and young adults. Many overweight children and adolescents have impaired glucose tolerance, a condition that often appears before the development of type II diabetes.^{2, 11} High blood lipids and hypertension, as well as early maturation, orthopedic problems, and sleep apnea also occur with increased frequency in overweight youth.

Another common consequence of childhood overweight is psychosocial – specifically, discrimination.^{2, 12} Children and youth that are overweight or at-risk for overweight increasingly suffer from depression, anxiety and social angst.^{2, 13} In addition to being an increasing health problem during childhood, overweight perpetuates the upward spiral of adult overweight and obesity and earlier onset of associated chronic disease risks. Overweight adolescents have a 70 percent chance of becoming overweight or obese adults.^{2, 10} This chance increases to 80 percent if one or more parent is overweight or obese.²

During recent decades of negative trends in eating patterns, rates of obesity have doubled in children and tripled in adolescents. A CDC study published in the May 2002 Pediatrics found that nationally, costs related to childhood obesity have more than tripled in the past 20 years, reaching $127 million by 1999. In West Virginia, 12.2% of high school students in grades 9-12 were overweight in 1999 with another 15.9% at risk of becoming overweight. Only 20.4% of adolescents reported eating the recommended 5 or more fruits and vegetables daily. Only 25.4% of adolescents reported engaging in moderate physical activity on a weekly basis.

A number of convergent factors contribute to the current crisis:

• Between 56% and 85% of children in school consume at least 1 soft drink daily, with the highest amounts ingested by adolescent males. Of this group, 20% consume 4 or more servings daily. Each 12-oz sugared soft drink consumed daily has been associated with a 0.18-point increase in a child’s BMI and a 60% increase in risk of obesity. (Source: American Academy of Pediatrics Policy Statement, January 2004)

• Sweetened drinks constitute the primary source of added sugar in the daily diet of children, each 12-ounce serving of a carbonated, sweetened soft drink contains the equivalent of 10 teaspoons of sugar. Additional health problems associated with high intake of sweetened drinks are dental cavities and potential enamel erosion. (Source: American Academy of Pediatrics Policy Statement, January 2004)

• According to the Healthy Hearts website, children’s participation in physical activity has declined over the years. Almost one-half of 12-21 year olds do not participate in physical activity on a regular basis (NASPE). A recent study conducted by the Centers for Disease Control showed 61.5% of children ages 9-13 do not participate in an organized physical activity outside of school, and 22.6% do not participate in any free time physical activity.

• A recent study has shown a correlation between the SAT-9 test results with the Fitnessgram indicating that the physical well-being of students has a direct impact on their ability to achieve academically. Students with the highest fitness scores also had the highest test scores.

• Among fourth grade students, those having the lowest amount of protein in their diet had the lowest achievement scores. Children who suffer from poor nutrition during the brain’s most formative years score much lower on tests of vocabulary, reading comprehension, arithmetic, and general knowledge. (Source: Action for Healthy Kids.)

Economic Consequences

The national economic consequences of overweight and obesity are enormous. In 2000 the total cost was estimated to be $117 billion ($61 billion direct and $56 billion indirect).^{2, 14}

Most of the cost associated with obesity is due to type II diabetes, coronary heart disease and hypertension.^{2, 15} Obesity may have more negative health consequences than smoking or heavy drinking, and it affects many more people.^{2, 16} While 61% of adults in the U.S. are overweight or obese, only 6% are heavy drinkers and 19% are daily smokers. Despite these facts, Americans haven’t given obesity the same attention as other health risks. Prevention and treatment of overweight in children and youth have received even less attention.²

The Social Capital and the Built Environment: The Importance of Walkable Neighborhoods by Kevin M. Leyden PhD., suggest that America’s built environment has been moving in a direction that is likely to have a negative effect on social capital.

Wang and Dietz analyzed data from the National Hospital Discharge Survey from 1979-1999 to estimate the increasing economic burden of obesity in youths ages six through seventeen.^1,17 Principal diagnoses of diabetes, obesity, sleep apnea, and gallbladder disease were examined, as well as other diseases for which obesity was listed as a secondary diagnosis. Discharges with diabetes as the principal diagnosis nearly doubled, obesity and gallbladder diseases tripled, and sleep apnea diagnoses increased fivefold over the 20-year period. The associated hospital costs more than tripled, from $35 million in from 1979-1981 to $127 million in 1997-1999.¹

Likewise, the economic costs of obesity in West Virginia are enormous. For example, during fiscal year 2000, The West Virginia Medicaid program estimated medical and pharmacy costs associated with obesity-related diseases was more than $135 million. During the same time period, the West Virginia Public Employees Insurance Agency’s estimated medical and pharmacy costs associated with obesity-related diseases was more than $68 million. Just two years later (fiscal year 2002-2003) these costs rose to $72 million.

So what should we do?

According to the report Healthy People 2010^{18, 19} about 75% of Americans eat too little fruit, 95% eat too few vegetables, and 64% eat too much saturated fat. In addition, 12% of households are food insecure. The diets of many population subgroups exceed recommendations for diet elements such as total fat, saturated fat, and calories, and their diets fall significantly short of the recommendations on other important elements such as calcium for adolescent girls.

Just one in four adults gets sufficient regular physical activity to provide health benefits; another one in four reports no regular physical activity at all. In effect, 60% of American adults do not get the recommended amount of daily physical activity.^18,19 The trend is not promising for our youths: Physical activity rates drop off sharply in junior high school for girls and in high school for boys. By the end of high school, rates for girls and boys are comparable to adult rates.¹⁸

While it is well recognized that making small, lasting improvements in eating patterns and increased physical activity will lead toward a healthy weight, the societal barriers to an individual’s making those improvements are enormous. The social, environmental, and behavioral factors responsible for the epidemic of overweight and obesity are firmly entrenched in our society.²⁰ Identifying and dislodging these factors will require deliberate and persistent action on multiple levels.²

To advance this action, increasing emphasis is being placed on environmental and policy change that supports individual behavior change. The Surgeon General’s Call to Action to Prevent Overweight and Obesity cites behavioral and environmental interventions as providing the greatest opportunity for successful change. A recent publication of the Association of State and Territorial Directors of Health Promotion and Public Health Education and the Centers for Disease Control and Prevention described policy and environmental change as new directions for public health.^{2, 21}

The Healthy Communities workgroup used an ecological perspective as the foundation for its recommendations and strategies.^2,22 The ecological perspective highlights the importance of approaching public health problems at multiple levels and stressing interaction and integration of factors within and across levels.¹⁸

According to the Socioecological Model, individual behavior can be influenced at multiple levels: individual, interpersonal, organizational, community and public policy. The model combines individual behavior with social and physical environments. The strategies in the plan recognize the level of self-responsibility that individuals have to take for positive lifestyle change and the outside forces such as schools, worksites, and community settings that influence individual behavior.

The Role of the Environment

More and more researchers agree that social networks and community involvement have positive health consequences. Persons who are socially engaged with others and actively involved in their communities tend to live longer and be healthier physically and mentally. (Kevin M. Leyden, PhD)

Americans have developed more sedentary habits in their daily routines as well as participating in less leisure time activity. As such, physical activity has been engineered out of daily life and replaced by more sedentary behaviors. Over the past several decades a greater dependence on automobiles for transportation has occurred replacing trips by bike or foot. Studies have shown that the environment influences physical activity levels in adults. Those who live and/or work where there is greater availability and access to walk and exercise tend to be more active. Healthy People 2010 objectives recommend government polices that increase the availability and accessibility of walking and biking trails, and healthy food choices.

As society has moved to a service and information economy, occasions for physical activity during work hours and at school have decreased. Most people avoid regular and vigorous physical activity during leisure time, and laborsaving devices limit their ability to burn calories during the daily routine of living. At work, the promotion of physical activity opportunities can lower stress, increase productivity, and improve the health of workers. It can also reduce health-care costs and reduce absenteeism. In schools, physical activity opportunities and sound nutrition programs can help students better academically. An increase in screen-time including television, computers and video games contributes to the lack of physical activity.

References
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