Second in a series
Efforts to combat obesity, childhood obesity in particular, are making news. Examples include First Lady Michelle Obama’s signature public health campaign “Let’s Move!” the Home Box Office (HBO) documentary series “The Weight of the Nation,” and the popular charge to incite health providers, schools and communities to join the fight to stop the spread of obesity.
But the current attention devoted to this issue in a culture obsessed with fad diets and alarmist health news raises the question: Is this really a significant problem?
To begin with, medical experts do not universally acknowledge “obesity” as a disease, like AIDS or lung cancer. There have always been overweight people, and for many the driving concern for weight loss has been more about the aesthetics of body image than physical health.
But two significant and disturbing facts have changed over the past two decades. First, for reasons not fully understood, there has been a measurable increase in the numbers and demographic distribution of obese people. And second, there has been an accumulation of research linking excess body weight to bad health.
Data reveal our population’s progressive ponderosity over time. Medical concern over weight and obesity show up in the mid-1960s. A 1965 UC Berkeley student paper by a physician noted “Estimates run as high as 25 million overweight Americans (based on desirable weights taken from actuarial tables). Some epidemiologists might consider that we have an epidemic of obesity in America. . . A tremendous amount of time, effort, and money is being devoted to the understanding of the problem of obesity and its significance and solution. Diet foods are a multimillion dollar industry. The military attempts to legislate weight and physical fitness with compulsory standards.”1
A 1984 article in Kaiser Permanente’s KP Reporter noted that the Metropolitan Life Insurance Tables showed that a “surprising” 40% of American men and 55% of American women were overweight, currently defined as those having a Body Mass Index (BMI) between 25 and 29.9. The more serious condition is obesity, with a BMI over 30. (BMI is computed by dividing a person’s weight by the square of his or her height.)
A 1987 Planning for Health Kaiser Permanente (KP) member newsletter article stated that “Obesity is our nation’s number one nutritional problem.” Last year the Centers for Disease Control and Prevention reported that between 1980 and 2008, obesity rates had doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups — regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region — increased markedly. More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are considered obese.
The main reasons proposed for this alarming phenomenon include a more sedentary lifestyle, unhealthy diet, a proliferation in the use of sweeteners (first the “white death” sugar, eclipsed now by high-fructose corn syrup) in food products, and lack of exercise.
Even greater use of worksite microwave ovens during the 1980s was described as adversely affecting healthy eating habits. But other, more complex, causes have been proposed as well, and Kaiser Permanente has embraced a range of treatment modalities and education techniques to help keep members healthy.
Doctors advise patients to eat right and in moderation, with increasing medical evidence supporting the case that excess weight contributes to life-shortening conditions such as diabetes, heart trouble, and high blood pressure. Kaiser Permanente early on recognized that the changing dietary behaviors of its members were having a negative effect on waistlines.
Fast food chains, offering cheap high-fat, high-sugar, and high-salt meals, grew enormously during the 1960s and 1970s. Soon KP challenged this trend as an unhealthy one. A 1987 Planning for Health newsletter posed the question, “Burger King, McDonald’s, Wendy’s, Jack-In-The-Box. Everyone is familiar with the names of these fast food restaurants. But how many of us are aware of the ingredients found in their food? Take a few moments to complete our Fast Food Facts quiz.”2
Influencing young people to eat a healthy diet and control their weight is crucial. In 1975, developmental psychologist Mary Wheeler, PhD, and pediatrician Karl Hess, MD, in KP’s Ohio Region started the Optimal Growth Center to help overweight children learn new eating habits. They addressed the social stigma of being overweight, with the long-term view that if they didn’t change their condition they would face significant risks of hypertension, heart disease, and diabetes as adults.3
As early as 1956, the Oakland Kaiser Permanente staff realized that peer groups could help people lose weight, and they instituted a group treatment program for overweight patients. In small, informal, round-table support groups of eight to 10 participants, physicians offered information and the group discussed mutual problems.
In the late 1980s, Kaiser Permanente Nutrition Services Departments hosted workshops for members on subjects such as “The Right Way to Good Nutrition.” One Health Plan member who benefitted from the program commented, “When I had a physical last fall, my physician said I was showing signs of arteriosclerosis (hardening of the arteries). After taking three nutrition workshops, I recently had another physical. My cholesterol count was down 20 points and I’ve lost 11 pounds.”4
One successful medium for reaching youth is KP’s Educational Theatre Project. For 25 years the troupe has used live performances at public schools to engage youth audiences on a range of health subjects, including childhood obesity in “1½” and “Give Peas a Chance.” In 2007 KP partnered with educational publisher Scholastic, Inc., to launch an online game based on another play, "The Amazing Food Detective," teaching children about healthy eating and maintaining an active lifestyle. The game automatically shut off after 20 minutes and encouraged players to get up and exercise or perform some activity away from the computer screen.
Kaiser Permanente was also quick to acknowledge the role that gender and social (rather than medical) standards played in defining “desirable” weight. Second-wave feminism of the 1970s challenged the standard guidelines, noting that women were particularly susceptible to exaggerated concerns about weight that could have negative health consequences of their own.
A 1984 KP Reporter article “Fear of Fat” asked: “Why have we saddled ourselves with an ideal of beauty which torments most women over the age of 20, not to mention many teenagers? One reason is purely commercial. Fifth Avenue has chosen human clothes-hangers who can model any style of clothing.” It goes on to say: “Kaiser-Permanente offers weight-loss programs that do not make a fetish about fat but rather stress good nutrition, exercise, and behavior modification.”
Another connection between self image and weight came out of research conducted by the Southern California Permanente Medical Group. In 1982 Vincent J. Felitti, MD, then a San Diego Kaiser Permanente internist, developed a program to help obese people lose weight, which matured into the Positive Choice Weight Loss Program in 1985. He was confounded by the observation that many of those who experienced success began to drop out. After studying hundreds of patients he learned that many were unconsciously using their obesity as a shield against unwanted sexual attention, a behavior based on experiencing physical or sexual abuse as children.
Subsequent research resulted in a comprehensive assessment protocol, Adverse Childhood Experiences (ACE), that examines the hidden legacy of childhood trauma and helps identify patients for whom conventional weight reduction programs don’t work. More than 17,000 San Diego KP members have been diagnosed using ACE and the study has produced 72 scientific publications thus far.
As Dr. Felitti describes it, “The program involves the essential linkage of two disparate elements: prolonged absolute fasting using the supplement “Optifast” to preserve health in the absence of food intake, and a psychodynamic approach whose function is to help each person discover the unconscious forces underlying their use of eating for its psychoactive benefits and the possible advantages of obesity in their life. Using this approach it is possible to reduce a person's weight about 300 pounds in a year and help them tolerate that emotionally.”5
Kaiser Permanente has supported efforts to make fresh fruits and vegetables available to more people, helping local convenience stores stock healthier products and bringing grocery stores to “food desert” neighborhoods. Preston Maring, MD, started the first KP-sponsored farmers' market at Oakland Medical Center in 2003. These efforts are now successfully replicated in many community and KP facilities, often coupled with nutrition information and other healthy lifestyle outreach. For more about KP farmers' markets: https://members.kaiserpermanente.org/redirects/farmersmarkets/in-northwest.htm
Next time: Kaiser Permanente was about fitness before fitness was cool
1 "Obesity and its Measurements as it Relates to a Multiphasic Screening Program," by Clarence F. Watson, MD; student paper from UC Berkeley public health class PH274A, Fall, 1965. Dr. Watson’s essay makes the case that “skinfold measurement” using calipers rather than BMI is a more accurate indicator of obesity.
2 “Fast Food Facts,” Planning for Health newsletter (Richmond edition), Winter 1987–1988
3 "Helping Overweight Children," KP Annual Report 1979
4 “The Path to Good Nutrition,” Planning for Health newsletter (Vallejo/Napa/Fairfield edition), Summer 1988
5 Email correspondence from Dr. Felitti 3/22/2012. For more about Dr. Felitti's California Institutes for Preventive Medicine.