Currently
in the United States, there are more people who are overweight than there are
people who are of normal weight. The
words “obesity epidemic” are consistently plastered in the headlines of
newspapers, websites, blogs, magazines, television news programs, talk shows,
etc. Obesity rates have been continuously
climbing for the last few decades because the field of public health has been
ineffective in even slowing the rate of increase in our waistlines. As of 2010, 35.7% of American adults are
considered obese.1 This is the highest the obesity rate has ever
been in this country. This high rate
exists in spite of countless efforts, initiatives, national objectives and
goals, and health professionals trying desperately to decrease the statistic. More than one third of Americans remain obese
because our country’s entire approach to treating the problem is severely
flawed. Our methods of treating this
disease are ineffective because obesity is a complicated disease that requires
a multi-level public health intervention involving public opinion, Registered
Dietitians, and the food industry.
To be classified as obese, a
person’s Body Mass Index (a ratio of weight to height) must exceed 30 kilograms per meter squared.1 The causes of obesity are numerous as are the
comorbidities and complications associated with the disease. From a clinical standpoint, obesity is caused
by an imbalance in energy intake—energy consumption is higher than energy
expenditure.2 This energy imbalance leads to weight
gain. Energy imbalance in the long-term
causes obesity.2 In a broader view, obesity is an unfortunate
product of our society. Several risk
factors for obesity are far beyond the control of the individual and include
factors such as socioeconomic status, race, ethnicity, language, geographic
location, family history, gender, and age.2 Current obesity interventions focus far too
closely on the factors over which the individual has control. In order to elicit large scale change,
obesity interventions must focus on attacking external risk factors.
This critique will focus on the three main
problems with our current approach to addressing obesity. First, many current obesity interventions are
individual-level treatment interventions in spite of mounting research that
indicates individual-level weight loss methods are ineffective. Second, the gatekeepers to finding and
executing a proper solution to the problem, Registered Dietitians, are highly
undervalued. Finally, the food industry
has a tremendous amount of power over what people in our country are
eating. Most public health interventions
fail to harness consumer power and use it to their advantage.
The
Obese Stand Alone
On the individual level, the only
treatment for obesity is weight loss.
While this may sound simple, achieving significant, long-term weight
loss is difficult, has a high attrition rate, and should not be the main focus
of obesity intervention programs. Weight
loss is not going to decrease the obesity rates in the US for three main
reasons. First, the vast majority of
individuals who are obese and manage to lose weight do not lose enough weight
to be placed out of the obese BMI category.3 This means, even if a significant number of individuals
who are obese manage to lose weight, the statistic will not change. This does not mean that losing weight is not
beneficial to the individual and to the population in general. It has been shown that even a 10% weight loss
in obese individuals is related to an increase in overall health and quality of
life and a decrease in prevalence of comorbidities, regardless of post-weight
loss BMI.4 That being said, if the true goal of our
nation is to reduce obesity rates, the focus must be placed on prevention
rather than treatment of the disease. Moreover,
current approaches to weight loss are flawed.
Weight loss has the potential to help
individuals who are already obese; however,
current approaches to weight loss are not very effective and follow traditional
models of health that do not take enough external factors into account. This is evidenced by the relatively low
success rate of obese individuals.3 A review by Wing and Phelan assessed the
success rate of long-term weight loss based on the results of several
studies. The definitions of successful,
long-term weight loss varied across the different studies, but using an
algorithm, Wing and Phelan estimated that approximately only 20% of individuals
who purposely lose weight maintain their weight loss.3 Additionally, using data from the National
Weight Control Registry, they estimated that the odds of weight regain decrease
by 50% when individuals successfully maintain a weight loss for two years or
longer.3 They also identified several factors that
contribute to weight regain including loss of control while eating, decreases
in physical activity, and other lapses in healthful behaviors.3 This study shows that achieving and
maintaining weight loss is very challenging.
It is important to note that Wing and Phelan only addressed individual
behaviors that contributed to weight regain.
This demonstrates that most weight loss interventions tend to focus on
healthy changes only at the individual level.
Finally, the public strongly holds individuals
responsible for the obesity epidemic. A
study by Lusk and Ellison sought to determine the public’s perception of who or
what is to blame for the rise in obesity.5 They surveyed a diverse panel of 800 subjects
using a questionnaire that asked “who of these seven entities is to blame for
the rise in obesity”—government policies, food manufacturers, grocery stores,
restaurants, farmers, parents, or individuals?5 Overwhelmingly, respondents blamed
individuals for the rise in obesity with 80% blaming individuals.5 Combining this evidence with what was
elucidated by Wing and Phelan, it is clear that there is a major disconnect in
the treatment of obesity. The public
believes that obesity is caused at the individual level and is, therefore, an
individual problem. However, it has been
proven that individuals are relatively unsuccessful at fixing the problem on
their own. Herein lies the problem. The public’s perception of obesity needs to
change in order for other changes to occur.
Additionally, current approaches to weight loss must shift from
individual to group interventions.
RD: Two letters after my name that mean seem to
mean nothing
When most people meet a Registered Dietitian,
they do not quite grasp exactly what an RD does. According to the Academy of Nutrition and
Dietetics (AND, the professional organization of RDs), a Registered Dietitian
is “a food and nutrition expert who has met the minimum academic and
professional requirements to qualify for the credential ‘RD.’”6 These academic requirements include the
attainment of a bachelor’s degree in nutritional sciences from an accredited
program, the completion of a six month dietetic internship, and the passing of
a national examination in order to obtain a license. Once a license is obtained, RDs must continue
their education for the remainder of their careers by earning continuing
education credits. Although it is
currently not required by the AND, many RDs go on to earn advanced degrees or other
certifications. It is important to point
out that there is currently no regulation on the word “nutritionist.6” Anyone who has even the most basic knowledge
of nutrition can legally refer to themselves as a nutritionist. A nutritionist’s education level could range from
earning a collegiate degree in nutrition to simply reading about nutrition on
the internet. Registered Dietitians are
frequently referred to as or are confused with nutritionists. This confusion greatly undervalues the
profession.
Because of RDs are trained to be
nutrition experts, RDs play a critical role in addressing the obesity
epidemic. However, it is difficult for
RDs to step into this role when the profession is so unrecognized. This lack of recognition exists for a variety
of reasons. First, the AND does not require
a Master’s degree in order to obtain an RD license. Many other health professions already require
the attainment of a higher degree beyond that of a bachelor’s degree. Not requiring at least a Master’s degree for
the practice of dietetics does a disservice to the profession as a whole. If all members of this profession had a
higher education, the average pay of RDs would increase. Currently, the average starting salary of an
RD is between $42,000 and $55,000 a year.6 This is significantly less than the starting
salary of other health professionals.
Registered Nurses who also only need a bachelor’s degree make an average
starting salary between $50,000 and $60,000.7 Physical Therapists and Occupational
Therapists are required to achieve at least a Master’s degree and have an
average starting salary between $56,000 and $80,000.7 This information shows that if RDs were
required to hold a Master’s degree, their starting salaries would logically be
higher.
Second, the current population of RDs is very
homogenous. As of 2008, 89% of RDs
identify themselves as Caucasian.8 Additionally, around 96% of RDs are female.9 This lack of diversity has several
implications. In the US, there is still
a large gap in the salaries of men and women.9 This gap exists in the RD profession. On average, the few males working in the
dietetics profession earn around $5000 more a year than their female
counterparts.9 Because the profession is mostly made up of
females, the majority of RDs are underpaid
because of their sex. Lack of diversity
also affects how RDs are viewed by the public.
Research has shown that individuals are more likely to receive a message
effectively and take action when the message is given to them by someone similar
to themselves. For example, a study by Halliday-Boykins
et al. looked at therapist ethnic similarity on youth outcomes.10 The study found that “youths whose caregivers
were ethnically matched with their therapists demonstrated greater decreases in
symptoms, longer times in treatment, and increased likelihood of discharge for meeting
treatment goals relative to youths whose caregivers and therapists were not
ethnically matched.”10 This means therapists were more effective
when their patient was of the same ethnicity.
RDs often see patients in the same type of counseling setting; therefore
this theory likely also applies to the field of dietetics. This implies a significant portion of the
population will not connect effectively with the current RDs. It can be
hypothesized that counseling by an RD will not be as successful for minorities
or males because they are dissimilar from the average white, female population
of dietitians.
The education of Registered Dietitians has a
strong focus on treatment of the individual.
The core courses that are included in accredited dietetics programs have
very little focus on community nutrition.
Of the long list of coursework required to obtain an RD license, few
courses teach a community-based or population level approach to improving
health.11 This is why a large portion of RDs pursue
clinical careers in the hospital setting or outpatient careers involving
one-on-one counseling.6 As previously stated, this individual level
approach has not been effective in reducing the obesity rates in the US. If RDs are truly essential for an effective
intervention in this epidemic, their education must change to place a greater
emphasis on population-level health improvement.
Big
Business in our Mouths
The food industry is a very powerful
driving force behind what types of foods are consumed in America. Through advertising and pricing strategies,
the food industry dictates who consumes what type of food in our country. Currently, there is a perception that eating
healthier food is a lot more expensive.
A meta-analysis was recently published by the Harvard School of Public
Health demonstrating this exact phenomenon.
However, the media got hold of this article and press release and
twisted the results of the study to create a sensationalized story that
strongly implies eating healthier is not significantly more expensive.12,13,14
The meta-analysis done by Rao et al.
looked at the results from several studies analyzing the prices of healthier
versus less healthy foods and diet patterns.15 The studies included in the review were
conducted in many different countries and all had developed some sort of model
for quantifying the average difference in price of healthy foods versus less
healthy foods.15 Rao et al. combined the results of the
studies and came up with a mean difference in price between eating healthy
foods and eating unhealthy foods. Using
random effects models, the researchers determined that healthier diets cost, on
average, $1.50 more per person per day.15 The media is using this statistic to say that
it really does not cost that much more to consume a healthier diet because $1.50
is not that much money.12,13,14 However, as the Rao analysis astutely points
out, for individuals and families of low socioeconomic status, this $1.50 per
person per day makes a big difference.15
Using basic math, several conclusions can be
drawn. According to the United States
Department of Labor, the yearly salary making Federal Minimum wage is $15,080. In a household with two individuals earning
minimum wage, there is a total household income of $30,160 a year. For a family of four, if it costs $1.50 per
day per person to eat healthier, the total cost will be $2190 for a whole year. Based on a household income of $30,160, eating
healthier food will cost 7.3% of yearly income.
This percentage does not account for the total cost of food. This 7.3% only accounts for eating healthier. According to the USDA, as of October 2013 a
family of four with young children on a “thrifty” or less expensive meal budget
will spend an average of $556.30 on food per month. For a whole year, cost of food would be
$6,675.60. Assuming this family is only
making minimum wage, they are already spending 22% of their yearly income on
food. Add the 7.3% to make their food
healthier, and they are spending almost 30% of their yearly income on
food. Most families cannot afford to be
spending this high a percentage of their income on food.
The media has taken the $1.50 extra a day
statistic and is twisting into an individual problem. Many news websites state that this extra amount
of money is much less in the long run compared to medical bills associated with
the outcomes of eating an unhealthy diet.12,13, 14 However, families making minimum wage cannot
afford to pay extra to buy healthier food.
Therefore, they have to consume lower quality products, will likely
develop obesity, and will suffer from associated health problems. They cannot afford to avoid future medical
bills because they have other expenses such as clothing, housing, and car
payments that take priority over eating healthier. This demonstrates yet another way that the
media is blaming individuals for a public health problem even though
individuals do not have control over the issue.
Low income families are not choosing to eat unhealthy food; they simply do
not have a choice.
This is where the food industry plays a major role
in helping reduce obesity rates. The
food industry has the ability to make healthier, affordable food available to
low income families. If Walmart can make
a 100% whole wheat loaf of bread the same price as a loaf of regular white
bread and make inexpensive fruit and vegetables available the same price
equality can be achieved for other foods.16
Proposed
Intervention: If obesity is a national problem, it should be treated like one
It is clear that the current public
health interventions for the treatment of obesity and reduction of obesity
rates in America are not working. In
order to fix this, a new approach to the problem must be taken. A successful obesity intervention cannot
target individuals because individuals are not to blame for the obesity
epidemic. Currently, it is the view of
the public that individuals are responsible for the spread of this disease, but
several external factors are at work and must be addressed. The proposed intervention has three
components that are different from previous plans. First, individual approaches to weight loss
must transition to group level approaches in order to produce long-term weight
loss and change the public’s view about the root causes of obesity. Second, the value of RDs must increase in
order for them to participate fully in the new approaches and to be able to
deliver effective messages to the public.
Finally, changes in the food industry must occur in order to elicit
large-scale changes in the diet of the nation.
If all three of these changes were to take place, the obesity rates
would steadily begin to decline and quality of life for all Americans would increase.
Changing
the Obesity Perception
As previously stated, individual
level weight loss strategies have a relatively low success rate in terms of maintenance
of long-term, significant weight loss. Therefore,
alternative weight loss methods must be employed in order to provoke a
significant decrease in the number of individuals who are already obese. Currently, Weight Watchers (WW) is viewed as
one of the more successful methods for weight loss.17 In 2006, the state of Tennessee partnered
with WW to offer the program at a discounted rate to Medicaid beneficiaries.17 A retrospective study was published in 2012
assessing the effectiveness of this partnering which lasted from January 2006
to January 2009.17 Mitchell et al. assessed the association
between WW meeting attendance and weight loss.
The researchers found that individuals who attended two or less meetings
only lost 0.5% of their original weight while individuals who attended 13 or
more meetings lost 6.4% of their original weight.17 They also found that weight loss increased
with increasing meeting attendance. While
this study has a few limitations including a homogenous sample (female,
minority, low income) and a limited follow-up period, it still has important
implications.17 This study demonstrates that when given the
opportunity to join a structured, group weight loss program, low income
individuals were able to lose more weight successfully.17 Based on this finding, if all other states
offered a similar Weight Watchers/Medicaid program, a significant portion of
the US population could potentially lose weight. The Tennessee study demonstrates that being
involved in a support group with other individuals aspiring to a similar goal
(weight loss) can help people modify their behavior more effectively. Individuals who are obese need support from
others in similar situations, as well as support from the public.
In order for drastic changes to occur, the
public’s opinion about individuals who are obese must change. In a study performed by Puhl et al., more
than 370 videos from news websites were analyzed to determine the portrayal of
the obese to the public.18 The study concluded that, in the 370 videos,
“65% of overweight/obese adults and 77% of overweight/obese youth were
portrayed in a negative, stigmatizing manner across multiple obesity-related
topics covered in online news videos.”18 As previously mentioned, the public generally
blames individuals for the obesity epidemic so these results are not entirely
surprising. This public view of obesity
needs to change and the stigma needs to fade away before obesity rates can
drop. In order for this to happen, individuals
who are obese need to know that they are not alone and need to be portrayed in
a more positive light in the media. For
example, Puhl et al. states that many camera angles of obese individuals are
purposely unflattering and zoom in on specific body parts rather than showing
the whole person.18 Instead, obese individuals could be portrayed
as actual, full human beings rather than simply unflattering body parts. Public health interventions need to have a
stronger voice in that convinces the public that obesity is not an individual
problem. I believe that Registered
Dietitians can provide this voice.
Increasing
the Value of an Invaluable Profession
As previously mentioned, Registered
Dietitians make significantly less money than other health professionals of similar
importance with regards to patient health.
Additionally, the current population of RDs is homogenous and made up
mostly of white females. In order for
RDs to have a greater impact on eliminating the obesity epidemic, several
aspects of the profession need to change.
First of all, the Academy for Nutrition and Dietetics needs to require
the attainment of a Master’s degree in order to obtain a dietetic license. The AND agrees with this statement. According to their 2012 visioning report, “RD
salaries were 40-45% less than salaries of other non-physician health
professionals” and “Education beyond the bachelor’s degree continues to be
associated with hourly wage gains.”19 Based on this information, the AND needs to
enforce this new educational requirement in order to increase the value of the
profession. Moreover, requiring RDs to
pursue a higher education will increase their knowledge of other aspects of
nutrition beyond a clinical scope. An RD
with a Master’s degree will have more education and more experience working in community
nutrition, non-profit organizations, and public health promotion.19 Increasing the value of the profession will
attract more students to the profession and will, therefore, increase the
diversity of RDs. When the diversity of
the RD population increases, a greater variety and proportion of obese
individuals will be effectively reached and treated.
Furthermore, RDs need to become the voice
of people who are obese. RDs have the
opportunity to talk to and counsel many people who are obese about their
disease, their possible weight loss goals, and their struggles. Therefore, RDs are likely much more sensitive
to the issue than other healthcare professionals, the media, or even the
government. Part of the education of a
Registered Dietitian includes practicing counseling techniques that can elicit
motivation and change in an individual without creating blame for the
individual’s current state of health.
RDs need to become more present in the media and deliver these positive
counseling techniques to a larger audience.
This can be done on a large scale, such as on national television, or on
a smaller scale through social media or blogging. When RDs create a stronger public presence,
more recognition will be gained for the field of dietetics as a whole both from
the public and other healthcare professionals.
If RDs can steer the public towards attributing the obesity epidemic to
policies and the food industry and place a greater emphasis on prevention, a
true impact in the obesity rate will be seen.
Change
the Market, Change the Waistlines
The food industry is a consumer-driven
business. Major food companies will
respond to public demands for a certain kind of food. A perfect example of this phenomenon is the
development and distribution of trans fats in our food supply. Back in the 1960s, research indicated that
the consumption of excess saturated fat increased the risk of heart disease.20 In response to this discovery, the public
began to avoid saturated fats such as those found in butter, baked goods, and
other processed foods. This is what
drove the food industry to produce trans fats—hydrogenated, unsaturated fats
with similar properties to saturated fats.20 At this time, the health risks associated
with excess consumption of trans fats were not yet known. The food industry exploded with products
boasting that they were free of saturated fats and began feeding Americans
margarine, Crisco, and baked goods made with hydrogenated oils. Finally, in 1993, the Nurses’ Health Study
elucidated the relationship between trans fat intake and increased risk for
heart disease.20 In 2006, food manufacturers were required to
add trans fats to the Nutrition Facts label.20 Eventually, the risks of trans fat
consumption became widely known by the public and people did not want to
consume this type of fat. In response,
the food industry removed trans fats from their products and came up with
alternatives.20
Presently, in 2013, the FDA removed trans fats
from their “Generally Recognized as Safe” list.21 This is a prime demonstration of the power of
the consumer over the food industry.
When people did not want saturated fat, the food industry gave the
public trans fats. Now, people do not
want trans fats so the food industry is giving the market un-hydrogenated
alternatives. Several other examples of
the consumer driven nature of the food industry include the increased
availability of Greek yogurt, products free of high fructose corn syrup,
organic products, whole grain products, convenience foods, and frozen foods
just to name a few. These products are
now at nearly every grocery store because the public wants them. Public health campaigns need to harness consumer-power
to their advantage.
If public health interventions can
convince the public that they want healthier, more affordable products, the
food industry will respond by producing them.
There are several ways to accomplish this. As previously mentioned, a disproportionate
amount of individuals of low socio-economic status are obese. These low income individuals and families are
often eligible for food assistance programs such as Women, Infants and Children
(WIC) and Supplemental Nutrition Assistance Program (SNAP). WIC and SNAP differ in several ways including
who is eligible for benefits and the type of food that can be purchased. WIC only allows certain types of food to be
purchased that tend to be healthier options—whole grains, fruits, vegetables,
low fat dairy, etc.22 Additionally, only pregnant women, breastfeeding
women, infants, and children under the age of 5 are eligible for WIC benefits.22 SNAP, which is afforded to a greater number
of people, does not regulate the type of food for which the assistance can be
used.23 SNAP benefits can be used to purchase an
apple or a candy bar. In fact, the USDA
website states “Soft drinks, candy, cookies, snack crackers, and ice cream are
food items and are therefore eligible items.”23 Low SES individuals are going to be more
attracted to items like this because they are less expensive. SNAP benefits need to change its list of
eligible food items to encourage healthier eating habits. Because WIC only allows the purchase of
healthier foods, the country is holding pregnant women and young children at a
higher standard than the rest of the low income population. This is not just. All low SES families should be held at this
high standard. Everyone deserves to eat
healthy food, even low income individuals.
The USDA must change the SNAP policies and frame the change using the
core value of justice. This change in
SNAP will lessen the purchase of cheap, unhealthy food. The food industry will respond to this by
making less expensive, healthier products available so that they do not lose
money. This change in the food market
will then have positive benefits for the whole population, including those not
eligible for SNAP.
Public health campaigns can increase
public demand for healthier products in other ways. Television and internet advertising are
powerful tools used by the food industry to sell less healthy products. These tools can also be used by public health
campaigns to sell healthier foods. Using
similar strategies to those used by the food industry will be more powerful in
swaying the public towards favoring healthier products. Rather than boasting the healthy benefits of
fruits and vegetables, public health campaigns should highlight other benefits
including increasing one’s freedom and independence, increasing one’s
attractiveness, consumption by celebrities, or increasing one’s
popularity. If food companies can use
these methods to get people to buy products, public health should use them too.
Concluding
Remarks
This intervention will help reduce the impact of
external risk factors for obesity including low SES, race, gender, ethnicity,
language, and geographic location. Increasing
the value of Registered Dietitians will earn them greater respect in the
healthcare field and from the public and they will therefore be able to have a
stronger voice in the media. The
dietetics profession will become more diverse and be able to reach out to a
larger portion of the population effectively regardless of race, ethnicity, sex,
or language. Once we convince the public
that individuals are not to blame for the obesity epidemic, public call for a
larger scale intervention will occur.
This will increase the demand for healthier food at affordable prices,
which will dictate what the food industry is producing. As healthier, affordable food becomes
available, it will be easier for individuals who are obese to lose weight and
will prevent future obesity.
References
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Disease Control and Prevention. Prevalence
of Obesity in the United States, 2009-2010. NCHS Data Brief.
Hyattsville, MD: National Center for Health Statistics 2012.
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IL: AND, 2012.
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22. United States Department of
Agriculture. Women Infants and Children. WIC
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23. United States Department of
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http://www.fns.usda.gov/snap/eligible-food-items.
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