Listen to thisImportant health issues like smoking, alcohol and drug abuse have long been part of our curriculum of care for children and youth. Our society is recognizing a new one.
Although there may not be universal agreement on what caused the increase in childhood obesity, there is fairly widespread consensus on several important points. The first is that obesity in general, and childhood obesity in particular, has serious adverse health consequences. Obesity causes many health problems, as Stephen Daniels documents in his article in this volume. Heart disease, high blood pressure, hardening of the arteries, type 2 diabetes, metabolic syndrome, high cholesterol, asthma, sleep disorders, liver disease, orthopedic complications, and mental health problems are just some of the health complications of carrying excess weight. The difficulty for children is two-fold. First, many obese children today are developing health problems that once afflicted only adults. These children thus have to cope with chronic illnesses for an unusually extended period of time. Living with type 2 diabetes beginning around age fifty is one thing; living with it from age sixteen is quite another. Second, in obese children, such health problems as heart disease begin, almost invisibly, earlier in life than they do in normal-weight children. Even if the disease is not diagnosed until adulthood, it begins taking its physical toll sooner, perhaps resulting in more complications and a less healthy life. The possibility has even been raised that given the increasing prevalence of severe childhood obesity, children today may live less healthy and shorter lives than their parents.2 Although this claim is controversial, it is dramatic enough to give us pause and reinforce the idea that childhood obesity is far more than a cosmetic concern.
The increase in obesity is an economic issue as well. Estimates of the costs of treating obese children are relatively small but rising rapidly. For example, Guijing Wang and William Dietz estimate that hospital costs of treating children for obesity-associated conditions rose from $35 million to $127 million (in 2001 constant dollar values) from 1979–81 to 1997–99.3 Costs of treating adult obesity and its attendant health problems are far more substantial. Roland Sturm estimates that health care costs (including inpatient costs and costs of ambulatory care) of non-elderly obese adults are 36 percent greater than those of the non-obese, while costs for medicines are 77 percent greater.4 The cost differences between obese and non-obese adults are even greater than those between smokers and nonsmokers. Eric Finkelstein and several colleagues conclude that in 1998 the nation spent between $51.5 and $78.5 billion on health care related to overweight and obesity among adults. The upper bound on these estimates, based on what the authors judge the better of their two data sources, corresponds to 9.1 percent of total annual medical spending in the United States.5 Roughly half of this spending was publicly funded “paid for by all Americans through Medicaid and Medicare, the government’s health programs for the poor and elderly. And ever higher rates of obesity will burden society with other costs. Obese adults may be more likely than their normal-weight counterparts to become disabled before retirement, lowering their earnings and raising the costs of the federal disability insurance system, and may require more nursing home care as they move into retirement.6
If the heaviest health and economic burdens of obesity are borne by adults instead of children, why should the focus be on childhood obesity rather than adult obesity? There are two key reasons to focus on children. First, those who are overweight and obese as adolescents are much more likely than others to become obese as adults.7 Second, it is quite difficult for obese adults and children to shed excess weight. Although the health professions have developed new drugs and medical procedures for treating obesity-related health problems, these procedures are expensive and do not counter all such problems. Preventing obesity in childhood must be the centerpiece of plans to reduce both the health-related and economic costs of obesity.
A final point of broad consensus is that childhood obesity is best viewed as a societal problem reflecting the interactive influences of environment, biology, and behavior, rather than as an individual medical illness. Most agree that the nation has seen dramatic changes in the past thirty years in the ways Americans work, live, and eat. Broad societal and environmental trends have engineered routine physical activity out of everyday life for most Americans and made low-nutrition, energy-dense foods and beverages more accessible, affordable, and appealing than more healthful foods. Although reducing obesity requires changes in behaviors surrounding eating and physical activity, strategies that rely only on individual “self-control” are unlikely to be effective in environments that are conducive to poor eating habits and sedentary activity. This is especially true for children, who don’t control the environments in which they live, learn, and play. In addition, children have a more limited capacity to make informed choices about what is healthful and what is not. For this reason, there is a clear rationale for modifying children's environments to make it easier for them to be physically active and to make healthful food choices, thus reducing their chances of becoming obese.
Defining obesity as a societal issue does not imply that all children are at equal risk of gaining too much weight. The articles in this volume indicate that some groups of children” in particular, children from low-income families and from ethnic minority groups–are at a higher risk of becoming obese. Evidence presented in this volume indicates that the obesity crisis is also a result of the interplay between people’s genes and environments. While humans may be hardwired to overeat in times of plenty, those with a greater genetic propensity for weight gain may be more likely to gain weight in an environment that promotes or encourages unhealthful eating and minimal physical activity. The idea that susceptibility to obesity is genetic has led some to speculate that it will one day be possible to tailor interventions toward those with predispositions to obesity. For now, however, broader policies that alter children's environments are the only realistic options.
Notes
Jeffrey P. Koplan, Catharyn T. Liverman, and Vivica I. Kraak, eds., Preventing Childhood Obesity: Health in the Balance (Washington: National Academies Press, 2005).
S. Jay Olshansky and others, “A Potential Decline in Life Expectancy in the United States in the 21st Century,” New England Journal of Medicine 352 (2005): 1138–45. An editorial in the same volume, however, cautioned that this claim may be overstated. See Samuel H. Preston, “Deadweight? The Influence of Obesity on Longevity,” New England Journal of Medicine 352 (2005): 1135–37.
Guijing Wang and William H. Dietz, “Economic Burden of Obesity in Youths Aged 7 to 17 Years: 1979–1999,” Pediatrics 109, 5 (2002): E81.
Roland Sturm, “The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs,” Health Affairs 21, no. 2 (2002): 245–53.
Eric A. Finkelstein, Ian C. Fiebelkom, and Guijing Wang, “National Medical Spending Attributable to Overweight and Obesity: How Much, and Who’s Paying?” Health Affairs, Supplemental Web Exclusives: W3-219-26.
Darius N. Lakdawalla, Jay Bhattacharya, and Dana P. Goldman, “Are the Young Becoming More Disabled? Rates of Disability Appear to Be on the Rise among People Ages Eighteen to Fifty-Nine, Fueled by a Growing Obesity Epidemic,” Health Affairs 23, no. 1 (2004): 168–76; Darius Lakdawalla and others, “Forecasting the Nursing Home Population,” Medical Care 41, no. 1 (2003) (Point/Counterpoint): 8–20.
Robert C. Whitaker and others, “Predicting Obesity in Young Adulthood from Childhood and Parental Obesity,” New England Journal of Medicine 337 (1997): 869–73.
This feature: Christina Paxson, Elisabeth Donahue, C. Tracy Orleans, and Jeanne Ann Grisso (2006) Introduction to issue entitled Childhood Obesity. The Future of Children, Volume 16, Number 1 Spring 2006
