End the war on childhood obesity.

March 10 2011 1:07 PM

Leave the Fat Kids Alone

Efforts to fix childhood obesity are aiming at the wrong target.

Read about Slate's project to generate new ideas for fighting childhood obesity here, and submit your own idea here.

A cafeteria worker supervises lunches for school children. Click image to expand.
Will it help kids more if we focus on "health" instead of "obesity"?

Let's get one thing straight: I wasn't a fat kid; I was husky. At least that's what it said on the labels of my pants. Maybe not the navy sweats I wore to school three times a week, but the other pants—the slacks, the dungarees, the husky dungarees.

Daniel Engber Daniel Engber

Daniel Engber is a columnist for Slate

Did the other kids notice my husk? Did they care? At camp one summer, a French boy called me a cochon. A third-grade jock who would later play minor-league baseball whispered about my fat ass on the bus. But while I was ready for much worse, it never came. I wasn't that big, after all—just a little wide—and then I was distractingly weird, the kind of kid who entertained himself by trying to write out the digits of a googolplex in class. A cochon, maybe, mais aussi et surtout, a nerd.

So why is this image so vivid in my mind: A rectangular grid, with dots penciled in between rounded lines, marking off my weight in six-month intervals between the ages of 10 and 13? I can summon that piece of graph paper from memory and mentally trace its growth curves—there were five of them, one for the average boy and two each for the "accelerated" kids and the "retarded" ones. I was ahead of my peers. My father, a mathematician, took the measurements and applied the dots, connecting them with a jagged line that dipped toward the mean while Reagan was in office, then surged up the Y-axis. This is how I learned about standard deviations: See Daniel at 11, in his new aviator-style glasses, weighing 45 kilograms, and fatter than 68 percent of the kids his age. Now, a year later, prepping for his bar mitzvah and approaching the 95th percentile. Obesity. Be careful with your diet, my father told me. It might be time to stop buying cranberry muffins after school; they're like slices of cake.

I didn't give up the muffins, but never mind: A growth spurt stretched me into the "normal" range, and husky pants became a thing of the past. Yet that homespun screening—the charts and measurements and recommendations for lifestyle change—didn't fail to leave a mark. They helped create in me a lasting, if mild, preoccupation with body size that's no less disturbing for its banality. Among women, at least, or the women I know, such concerns are hardly worth mentioning—they're a given. But these anxieties don't arrive encoded in our genomes. We may emerge from the womb with a propensity for overeating or fat storage. Ceaseless self-scrutiny: That's the sort of trait that develops later on, in childhood or adolescence. If most of us end up a wee bit anorexic—or manorexic, as the case may be—our early experiences write the script.

When it comes to fat, public-health officials love to talk about the formative years. We're told that three-quarters of obese children grow up to be obese adults, at which point they have a hell of a time losing weight and keeping it off. So maybe we ought to target the fatties in the bloom of youth, when their rosy cheeks are just starting to fill out with subcutaneous adipose tissue. You can change a child's habits when he's still impressionable, the argument goes, when his body is still in flux. That's one of the theories behind Michelle Obama's Let's Move! program, and it's at the core of Slate's newest Hive project: Get to kids early, and try to make a difference.

What sort of difference you'll make isn't so easy to figure. It's nice to imagine there's some critical period of development when our physiologies can be reprogrammed for thinness. But the same logic applies just as well to the mind as the body. Tell a little kid he's fat (or obese, or at elevated risk of obesity, or whatever clinical spin you put on it) and you might help him to eat his fruits and veggies—but watch what happens to his bendy little brain. Get in there early enough, and even the best intentions can metastasize into a deep-seated anxiety. What happens in the mind of an adolescent could be inscribed there for years to come.

The war on obesity includes plenty of tactics that aren't likely to make anyone feel bad. Some of the proposals that receive the most attention—increasing supermarket access, ending farm subsidies, and so forth—have nothing at all to do with individuals. But these calls for systemic change often come alongside a more insidious argument—sometimes made by public-health experts and spilling forth from other corners—that it helps to make things personal now and again. A little bit of stigma can go a long way. The problem with America, we hear, is that we're mollycoddling the heavies, too afraid of hurting their feelings to say what needs to be said. Happy, fat-themed sitcoms teach Americans that it's trendy to be fat. Obesity—ugly, life-threatening obesity—has gotten normalized.

This idea—that we've gone soft in more ways than one—has come up again and again in Slate's effort to crowdsource a remedy for overweight children. "Schools should actively stigmatize being fat," writes one member of the Hive; "few things are more terrifying to a kid than being an outcast." Another declares, "We need to stop telling children to 'love themselves the way they are.'" A third suggests that the government take custody of any child with obese parents, as a way to "get both parents and children motivated to exercise and eat healthy."

These proposals are so plainly ill-advised, so thoroughly at odds with the available evidence on the causes of obesity, and so utterly detrimental to the welfare of our children, that I can only indulge in the fantasy that they're meant as satire. Let's be realistic, though: They're not. And their presence in the Hive—among many other suggestions, to be sure—reflects the danger of equating a child's health with the shape of his body.

Let's consider what's known about weight stigma. If it's really true that America suffers from a lack of tough love, and that's why we got so fat in the first place, then you might expect the nation's swelling obesity rates to have arrived on a wave of warm fuzzies. But we've seen just the opposite, says Rebecca Puhl of Yale's Rudd Center for Food Policy and Obesity (a leading advocate for the soda tax, among many other aggressive anti-obesity interventions). No one has been giving fat people a free ride. In fact, the prevalence of weight-based discrimination has increased by two-thirds since the mid-1990s; even middle-schoolers are getting meaner. The Hive tells us that to fight obesity we must "go on the offensive against obese people." Just look at the data. We tried that approach, and it didn't work.

As I've argued before, it could even be the case that all this stigma is making things worse. Columbia University epidemiologist Peter Muennig has found evidence that the life-shortening effects of obesity are more severe among women than men, and more severe among white women than black women. Women and whites also happen to be the two groups most affected by weight-based discrimination. According to Muennig, it makes sense that the more shame you feel as a result of being fat, the greater the toll on your body. So a widespread war on obesity, or indeed an effort to "fix" the nation's fat children, could serve to exacerbate the problem.

But you don't have to buy into the idea that fat shame is killing us. Research also shows that stigma doesn't help anyone slim down. Nor does it encourage healthy behavior (which is, after all, very different from weight loss). At the University of Minnesota, Dianne Neumark-Sztainer recruited nearly 5,000 adolescents for a long-term study of weight- and food-related issues, and according to her data, the teenage girls who were most dissatisfied with their bodies gained more weight over a five-year stretch than their classmates. In fact, these dissatisfied girls showed triple the increase in body-mass index, controlling for the possibility that they were fatter to begin with. All that self-hate didn't turn them into gym rats, either: The same group ended up getting less exercise than their peers.

The troubling numbers abound. Neumark-Sztainer's data suggest that kids who go on a diet are twice as likely to end up overweight. (Once again, that's not because they started out heavier.) Same goes for kids who were teased about their weight—a group that's also at higher risk for binge-eating, bulimia, laxative abuse, and other dangerous behaviors. Teasing may also help explain why the percentage of adolescent girls who suffer from extreme distress about their bodies seems to be much higher than the one-sixth who show up as obese on the CDC growth charts. As for the 9.3 percent of American high-school girls who attempt suicide every year, the mere belief that they're fat turns out to be at least as important a risk factor as whether they really are overweight.

It's clear enough that a war on childhood obesity might have some unintended consequences. Now the question becomes, are they worth accepting? Tell a kid she's fat, and you'll make her feel bad, however it affects her diet and workout schedule. Now let's make the dubious assumption that you really could reduce your child's risk of chronic disease by making him more self-conscious and ashamed. Trading one affliction for the other might strike you as a wonderful bargain. It's the Tiger Mother approach, to be sure. Does that mean it should be national policy?

Granted, mainstream anti-obesity reformers are generally aware of these issues, and there's some data suggesting that body-focused interventions have not caused schoolwide epidemics of disordered eating. In Arkansas, for example, a 2003 law that established a statewide BMI screening program in schools allowed for the systematic study of both its positive and negative effects. (The law also limits vending machines in schools, promotes gym and nutrition classes, and otherwise encourages better diets and more exercise.) A five-year study of the program found that students did not become any more likely to report teasing about their weight, skipping meals, or taking diet pills. Another study, published in 2005, looked at a school-based anti-obesity program in Massachusetts, and concluded that middle-school girls did not become more inclined to use purging, laxatives, or diet pills as a result of the intervention.

Yet my own experience leaves me wondering what's left out from these crude, self-reported measures of behavior. How do we know what it's like for the husky kid who has to run a gauntlet of anti-obesity flyers on his way to class? Even if our efforts to prevent obesity don't turn children into bulimics or pill-poppers, we might still be helping to create a new generation of kids who worry over every pound, or must endure a lifelong fear of muffins. Why risk it, especially when we don't know if these interventions work at all?

Instead of looking at this Hive as a way to fix the fat kids, we should be working to help every kid. The problem—the real problem, I mean—isn't that the number of children who fall on the wrong side of an arbitrary cut-off has tripled in the last few decades. It's that the underlying causes of chronic disease have grown more prevalent. Kids are consuming too much salt, and not enough fruits and vegetables; many lack access to quality health care; more than 15 million of them are living in poverty. Even after years of anti-smoking campaigns, one in four high-school students is still using tobacco, and that rate is holding steady. These are the issues we need to address, and we're desperate for good ideas.