From epidemic to war
Response of the U.S. government on the emergence of the obesity epidemic, 1980-2014
Hanna Tiel
studentnumber: 6045928
Master thesis
American Studies, History UvA Thesis Coördinator: dr. Manon Parry
Table of Contents
Introduction...2
1: Obesity in the 1980s...6
2: Developing the obesity epidemic...17
3: From Epidemic to war...26
Introduction
In July 2011 the Centers for Disease Control and Prevention released a video on their website called ‘The obesity epidemic’. This seven minute video tried to give a brief introduction to what obesity is, what the several causes are and what can be done about it. For one, people should eat more fruit and vegetables and get at least thirty minutes of exercise every day. Secondly, communities can take initiatives to build better infrastructure for physical exercise, and persuade schools to provide better meal plans. This very visual video perpetrates the feeling that obesity is a national threat and Americans have a responsibility as an individual and as a community to do something about it. However, the video does not explain in detail what exactly the obesity epidemic is.1
The term ‘obesity epidemic’, nevertheless, raises certain questions. First of all what is an epidemic, and what is obesity, and how has the connecting term come into life? Furthermore, it raises the question of how this has been measured, and what consequences are given to these measurements. The use of the term has had a great impact on American society, in social, cultural, medical, economic and political aspects, and critical notes have been placed at the concept of it. An important question that therefore needs to be explored is whether there is, or we can speak of an obesity epidemic. Nevertheless, as obesity continues to be medicalized and put on the political agenda, it is very much real, and because of this, deserves thorough investigation.
Thus, what exactly is an epidemic? One of the first epidemics we often learn about in our history classes is the medieval outbreak of the plague, which occurred several times in Europe during our middle ages, and cost over half the population their lives. Other than a pandemic, which is global, an epidemic is smaller in scale in the sense that it’s usually restricted by natural borders. The epidemics we learn about in our history books are usually of a strict medical nature. They do not yet serve as an adjective; wherein something epidemic is “excessively prevalent”, but embody the second definition Merriam Webster describes: “2ep·i·dem·ic noun\ˌe-pə-ˈde-mik\ medical : an occurrence in which a disease spreads very quickly and affects a large number of people : a sudden quickly spreading occurrence of something harmful or unwanted”2 For the greatest part of the 20th century this meant that epidemics were ‘outbreaks’ of infectious diseases, such as influenza.
Yet at the end of the 20th century, and at the beginning of the 21st, the term epidemic gained a broader understanding, and currently entails more medical problems than before. For example the spread of the HIV virus in the late 70’s and the 80’s was commonly seen, and most times still is, as an
1 “The obesity epidemic”, video clip on Centers for Disease Control and Prevention website, accessed 02-07-2014 <http://www.cdc.gov/CDCTV/obesityEpidemic/index.html>.
epidemic, although its characteristics and method of spreading are distinctively different from epidemics by which diseases were spread through germs. But to be fair, for most people AIDS and HIV do tick all the boxes of the definition: it is a ‘disease’, can spread very quickly, and at that time affected a large number of people. Not all those things can be said about an even more recent epidemic. The obesity epidemic is perhaps just as much a social as a medical concern. Although both AIDS and obesity could both be considered contagious, the former is considered an infectious disease whereas the latter does not have these medical properties.
But first: what then is obesity? Obesity is most simply defined as “a condition characterized by the excessive accumulation and storage of fat in the body”.3 But this definition, although
adequate, is not yet measurable. Many American and global health organizations and institutions therefore use the Body Mass Index as their bench mark. The Body Mass index gives you a number on the bases of your weight and height, wherein a BMI between 20 and 25 is considered normal. Anything under 20 is considered underweight, 25.1-30 overweight and over 30 obese. The term ‘morbidly obese’ is used for people with a BMI of 40 or over. The epidemic character of the obesity epidemic lies in the statistical data of the average BMI of male and female adults, which is notably increasing every year since it has been measured, with a rapid increase in the 1980’s and 1990’s.
This increase in BMI itself is not the cause of great concern. However, obesity has in some cases been linked to medical problems, wherein increased BMI has been linked with medical issues that are sometimes fatal. This discovery has spurned concern, such concern that medical associations and health institutions have been marking obesity as one of the focal points of attention. Obesity has been prominently on the agenda of institutions like the World Health Organization (WHO), the American Medical Association (AMA) and the American Public Health Association (APHA) for the last decade. All these organizations argue that with their anti-obesity campaign they are participating in an effort to halt the ‘obesity epidemic’.
The term ‘obesity epidemic’ is actually relatively young. Or at least, the widespread use of this term in medical and in culture and lifestyle literature as an accepted phenomenon, is a
development of late 20th and the 21st century. When looking at the use of the term ‘obesity epidemic’ in medical literature, in the years before 2000 as few as nine articles annually use the term epidemic in combination with obesity.4 This increases rapidly after the turn of the century, with the greatest increase in 2004, and 2007 till 239 articles in 2012. The term ‘obesity’ by itself is much more extensively covered, but saw a similar increase in use, starting in the late 90’s but expanding
3 Definition of “obesity” as can be found on Merriam Webster accessed <www.m-w.com> on 04-04-14. 4 As few as nine articles could be found when using search term ‘obesity epidemic’ on
massively in the following decade.5
But is this yet another case of American exceptionalism? Are the United States in fact unique in this national body mass index growth? Should and can this increase in obesity rates be seen as an American problem, or is it an international phenomenon, part of a global change, perhaps in wealth and dietary habits? A comparison between several OECD countries showed that this is definitely not the case; the United States is not the only country that has experienced great increase in average weight and obesity rates. Statistics by the OECD on Health from 2000 showed that apart from the United States, other countries such as the United Kingdom, Germany, Australia, and New Zealand have seen their percentages of obese people increase dramatically. However, some countries, like Japan and France have not seen this increase at all, whereas the United States sticks out with by far the highest percentage of obese people, leaving the number two the UK, far behind.6
Up until recently America even had the highest percentage of obese people in the world.7 Nevertheless, as the term pandemic is often taken up when speaking of the world wide prevalence of obesity, the issue is not a uniquely American phenomenon. But the obesity debate that has been going on in the United States, does reflect different typically American arguments for a small government. A lot of legislation in the United States is made on state level, and the federal
government is not supposed to interfere with this too much. Furthermore, the free market economy is quite a sacred system, and when legislation is proposed that interferes with it, it may expect heavy protests. These factors make the United States a very interesting nation for a problem such as obesity. Between 1980-2014 the prevalence of obesity increased substantially. This leads me to the question of: How did the U.S. government respond to the upcoming obesity epidemic in the United States, between 1980-2014.
In the first chapter the scope is on the 1980s. In 2014 almost no day goes by without there being some news on obesity. The obesity debate has become so ingrained in our daily lives, we are used to being offered new research results and revelations on the matter through all sorts of media. It has become quite common to use the term ‘obesity epidemic’ when speaking of the significant prevalence of obesity in the United States. But this term is mostly a child of the 21st century, the development of the phenomenon ‘obesity epidemic’ takes place in the decades before 2000. Was there any concern for an obesity epidemic in the 1980s? What was the government saying about obesity? Where there other health concerns that were considered? Reports by the Department of Health and Human Services were being published, and many were concerned for nutritional
5 Results on using the search terms “Obesity epidemic” and “Obesity” on PubMed: US National Library of
Medicine National Institutes of Health <http://www.ncbi.nlm.nih.gov/pubmed> accessed on 17-03-2014.
6 David M. Cutler, Edward L. Glaeser and Jesse M. Saphiro, “Why have American become more obese” Journal
of Economic Perspectives Volume 17, no.3 2003 Pages 93–118, 93, 98, 99.
7 “Mexico obesity rates higher than U.S., says U.N. report” on Huffington Post on (07-09-2013) accessed 01-07-2014 <http://www.huffingtonpost.com/2013/07/09/mexico-obesity-rate-united-states_n_3568537.html>.
problems. The National Institutes of Health had been taking health surveys in the years before, and during the 1980s also a specific survey directed at Hispanics was held. Obesity was defined quite differently during the 1980s than in the 21st century, it is interesting to see why this is the case.
In the 1990s the prevalence of obesity gets widely known and more concern was expressed for it. Calls about an epidemic started to emerge in the first half of the decade. Despite the increase of attention of obesity, the U.S. government is not changing major policy at this point. Obesity organizations and lobbying groups are now increasingly calling for change on this matter, and pointing out the estimated billion dollar annual costs of obesity. The goal of these groups is often to have obesity recognized as a disease, or otherwise at least as a major public health problem. Health associations and governmental organizations alike, are at this time still figuring out what the definition of obesity should be and do not hastily jump to conclusions. To what extend did the governmental health institutions respond to this and how was this influenced by medical journals and the media? The hesitant response of the United States government calls for the question of what stopped them from taking rigorous action?
The third chapter focuses on the 21st century. Both internationally and in the U.S. obesity had been declared as an epidemic. During the first decade of the 21st century, the debate about obesity changed quite a bit. In this chapter I will look into the changing rhetoric when it comes to obesity. It is even so that many official health institutions have now come to a point that they have defined obesity as a chronic disease, but it has often taken these institutions a while to get there. Some of these health experts, like the American Medical Association have until quite recently been subject to debate on defining obesity. Several governmental measures against obesity were taken to reverse the rising prevalence. Nevertheless, they addressed little to none of the environmental issues. I will argue that the American society, which has strong values of individualism, was a hindering factor for government action against obesity.
With this thesis I hope to write a brief history on the governmental response to the obesity epidemic. I hope that this gives a little bit better insight in the American society and culture, and how a country can deal with the issue of obesity.
1: Obesity in the 1980s
Obesity is an important topic in the 21st century. It has become an issue of many facets, drawing on political, social and economic interests. Apart from an epidemic, the obesity problem has also been called a pandemic, as the problems which are associated with obesity are not only
apparent in one country, but affects many. One of the first countries that showed concern for the obesity epidemic was the United States. This was caused by the discovery of the great increase in prevalence of overweight Americans between the late 1970s and the 1990s. It was deduced from health surveys that the greatest increase in the percentage of overweight people in the United States occurred in the 1980s and early 1990s. This calls for the question of what the United States
government did or did not do about overweight and obesity. In this chapter this is set off against what two leading health journals wrote about it, to see if they responded to one another. To what extend was the focus of the health institutions and the media on obesity?
In this chapter I will argue that for most of the 1980s there was little governmental attention to obesity. In the earliest reports by the Department of Health and Human Services, there was some concern for overweight and obesity, it was however framed from a nutritional point of view. The reports mainly stated that the way and the amount Americans are eating is wrong. Following this line of thought, the Department of Health in collaboration with the Department of Agriculture published the Dietary Guidelines for Americans. This report was hereafter published every five years, and throughout the 1980s always constituted seven guidelines which prescribed what to eat, and to keep the right weight. But apart from the Dietary Guidelines there was no policy being made by the government concerning overweight and obesity, and only occasional concern for the disparity in obesity prevalence amongst minority groups. In the media there was not yet a concern for
overweight or obesity for most of the 1980s. However, there was considerate attention for fat, and the possible health implications of a bad diet. The medical journals seemed to have a quite steady interest in obesity during the 1980s, and there was no visible influence on the government’s policy.
In 1985 there was a slight increase in interest for obesity, as the National Institutes of Health published a report called ‘Health Implications of Obesity’. This report concerned itself with the definition and the health consequences of obesity. The report concluded that obesity was a point of concern. This conclusion however, did not reflect the attention obesity gets in the ensuing years by the government departments. Meanwhile, the journals each published an editorial devoted on the subject that call for concern of the increase in prevalence. In 1988 however the Surgeon General published a report about nutrition and health in which a large part is reserved for obesity. Although
the document does not yet describe obesity as an epidemic, it does point out the dangers of the disease and suggestions for treatment and public health policy are formulated. This development continues at the turn of the decade. This information raises the question why the U.S. government took so little action in the 1980s to stop the increase in obesity prevalence, for which I will give some arguments.
The concern for obesity started with the extensive survey data that came available on this topic, by the so called National Health and Nutrition Examination Surveys, which were held in the U.S since 1971. On the third of July 1956 the President of the United States signed the “National Health Survey Act”. This new law allowed for a continuing national survey of the nation’s health. Although there had been previous national health surveys, none were as elaborate as the surveys released under the National Health Survey Act. Furthermore by 1956 the need had arisen for a survey to include factors such as smoking history and overweight. With the acceptance of this bill federal funds were reserved for the surveys, resulting in three National Health Surveys and later in the National Health and Nutrition Examination Survey or NHANES.8
The first NHANES was conducted in between 1971-1975. By interview and physical
examination the conditions of about 30,000 Americans were measured, and the data was collected. After the first NHANES, two more were conducted in the years 1976-1980 and 1988-1994, apart from a separate HHANES in between 1982-1984 analyzing the Hispanic population. From 1999 onwards NHANES became a continuous survey, with reports every year. Since its instigation data from NHANES has been used by U.S. government’s Department of Health, but also the medical world has used the data to monitor trends in illness and disability. The trends have been used to create policy by the Surgeon General and the Department of Health, but also various medical associations have referred to data from NHANES to support their resolutions.
When the data from the HHANES and NHANES III was analyzed in the 1980’s and 1990’s, a concern arose for the strong growth in prevalence of overweight and obesity between the two surveys. Especially between NHANES II and NHANES III a great increase in obesity was measured, so between 1976 and 1994 the nation had gotten substantially heavier.9 This was cause for concern because the medical world had linked obesity to various diseases, and so the increase in obesity was a sign for a worsened health. During the 1990s the high prevalence of overweight and obesity was therefore marked as the “obesity epidemic”. This term’s popularity increased rapidly, and more and more was published in non-medical channels, such as newspapers, on obesity.
As is concluded in the analysis of the NHANES II and NHANES III, the greatest increase in
8 U.S. National Library of Medicine, “National Health Survey Act” in Public Health Reports (January 1957) p. 1-4, 1 accessed 17-06-2014 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031124/>.
9 K.M. Flegal, M.D. Caroll, R.J. Kuczmarski and C.L. Johnson, “Overweight and obesity in the United States: prevalence and trends, 1960-1994” in International Journal of Obesity (1998) vol. 22, 39-47, p. 39.
overweight and obesity occurred in the 1980s. So did the government formulate any policy on obesity and was this in anyway influenced by the American Medical Association and the American Public Health Association? The AMA described in its policy that it wanted a voice in politics and therefore worked to “assure that medicine has a coherent voice in Washington and in order to achieve its legislative goals, the AMA often works with members of the house of medicine and other health organizations” for common causes.10 A similar strategy could be found for the American Public Health Association (APHA). It its policy the APHA described that it “works with key decision-makers to shape public policy to address today's ongoing public health concerns”.11 In other words these organizations were actively putting themselves on the political scene, using their network to create a political basis of support for their medical findings and solutions. But the government had a political agenda of its own, one that included policy on obesity.
For most of the 1980s the case was that when the problem of obesity was addressed in government documents, it was viewed as part of a nutrition problem. This was a trend that started just before the 1980s. In July 1979 Healthy People: the Surgeon general report on Health Promotion and disease prevention was published. This report stated an overview of the current health situation in the United States and how diseases could be prevented. Remarkably, this was one of the first reports by the Surgeon General which was not about smoking. In this report obesity was mentioned as a result of overeating under nutrition. Interestingly, further in the report, in the chapter on ‘Health Promotion’ an entire paragraph was devoted to obesity, under the heading ‘The Obesity problem’. They considered the problem aspect the fact that about one third of American women was at this point considered overweight. Also the fact that this percentage was far higher in the group which lived below the poverty level was a concern. Furthermore, obesity was “clearly linked” to several dangerous conditions, such as high blood pressure (hypertension) and diabetes. The report stated there was no quick or easy solution to obesity, but obesity was avoided easier for people who were better aware, and could better structure the way they were eating.12 Thus in this report obesity was mainly seen as a nutritional problem, which was a trend that continued in reports by government officials in the early 1980’s.
This also happened throughout all of the annual Health United States reports. These were reports published by the Department of Health and Human Services, which covered trends in health statistics. In the 1979 edition obesity was given a paragraph as one of several great risk factors for certain common diseases, for obesity these were hypertension and diabetes. This was part of a
10 American Medical Association, “Federal Advocacy” accessed 09-04-2014 <http://www.ama-assn.org/ama/pub/advocacy/federal-advocacy.page?>.
11 American Public Health Association, “Advocacy” accessed 09-04-2014 <http://www.apha.org/advocacy/>. 12 U.S. Department of Health, Education and Welfare, Healthy People: the Surgeon general report on Health
bigger chapter which linked diet to certain diseases. In the ‘Health United States 1980’ report obesity did not have its own paragraph, but was still mentioned under ‘nutrition’ as a risk factor for several diseases.13 In 1981 the attention was diminished, and for the next three years obesity was excluded from the annual reports. During this time the Secretary got more focused on other, more pressing health matters, such as smoking. In the second half of the decade, from 1985 onwards the attention for obesity is minimal, while the concern for overweight increased. The report of 1986 included a prevention profile. This prevention profile listed current health issues and formulated objectives which were a goal for the next couple of years. Reducing the percentage of overweight people in the United States was mentioned as one of the objectives that should be reached by 1990. Such a goal seemed to indicate that overweight was a significant issue for the Secretary. Similarly, there was a strong concern for improving the nutrition. “Of particular concern in the nutrition area is the persistence of a general profile of overweight in the U.S. population. Obesity is a significant public health problem because it affects a large proportion of the population and has adverse effects on health and longevity.“14
The importance of nutrition was further illustrated in an effort by the Department of Health and Human Services in collaboration with the Department of Agriculture. They published a booklet together in 1980 called Nutrition and Your Health: Dietary Guidelines for Americans. This 20 page long booklet contained seven nutritional guidelines for the American public. It was made by a task force of scientists who were instructed to advise about the relationship between diet, disease and health. Since 1980 these departments had published updated ‘Dietary guidelines for Americans’ every five years. In this first edition guideline number 2 was ‘maintain ideal weight’. The small chapter of guideline 2 contained a table with which someone can calculate what their ideal weight is, and instructions were given on how to lose weight in a healthy way. According to the booklet
maintaining ideal weight was necessary because obesity was associated with diabetes, high blood pressure and high cholesterol, which “in turn, are associated with increased risks of heart attacks and strokes.”15 These departments were thus in 1980 of the opinion that obesity was something that could be linked to serious conditions such as high blood pressure, which were closely linked to more serious problems and diseases, such as heart attacks. Better nutrition, and eating sufficient but not too many calories was their solution to the health risk obesity posed.
In 1985 the second edition of the Dietary guidelines for Americans was published by the Department of Health and the Department of Agriculture. Just as the first one, the second edition
13 U.S. Department of Health and Human Services, Health United States 1980, p 319 accessed 05-04-2014 <http://www.cdc.gov/nchs/hus/previous.htm>.
14 U.S. Department of Health and Human Services, Health United States 1986 p57 accessed 08-05-2014 <http://www.cdc.gov/nchs/hus/previous.htm>.
15 USDA and HHS, Nutrition and Your Health: Dietary Guidelines for Americans (1980) p. 7 accessed 08-04-2014 <http://www.cnpp.usda.gov/DGAs1980Guidelines.htm>.
similarly contained seven guidelines, and was not a complete revision but merely an updated version of the first guidelines. The second guideline had been ‘maintain ideal weight’ in 1980, but by 1985 was altered to ‘maintain desirable weight’. While ‘desirable’ weight could always mean the same as ‘ideal’ weight, it was still remarkable that in this edition the departments chose the slightly more ambiguous ‘desirable’. Perhaps the word ‘ideal’ was considered too dictating. In the United States every individual should be able to decide for themselves what their ‘ideal weight’ and thus their desirable weight is.
The third edition of the guidelines was published in 1990. Although the committee who was responsible for revising the previous guidelines deemed that the 7 guidelines that served as the basis for the two previous documents were still sufficient, they did make some alterations. The second guideline, which in 1980 was “Maintain ideal weight” and in 1985 “Maintain Desirable Weight” changed slightly in 1990 into “Maintain Healthy Weight”. This second guideline received far more elaboration than in the previous editions, but where before the word obesity was used now phrases like “being too fat” or “being too thin” were used. Instead of stating that a relatively great
percentage of Americans were overweight or even obese, the authors choose to put down “Being too fat is common in the United States.” These Dietary Guidelines also included a table with which someone could calculate if he had a ‘a healthy’ weight.16 The third edition obviously chose to exchange disputable terms for ones they thought must be less incriminating. What’s more is that there seemed to be a reluctance to use the terms overweight and obese, perhaps this was the case because there was not yet a consensus on defining obesity as unhealthy.
A step in the process of defining obesity was taken at the end of the 1980s, although the government’s focus on obesity was still linked exclusively with nutrition. This was clear with the publication of the Surgeon General’s Report of 1988, Surgeon General’s Report on Nutrition and Health. The Surgeon General claimed that the report’s “main conclusion is that overconsumption of certain dietary components is now a major concern for Americans.”17 In order words, people ate too much. This Surgeon General’s report was nevertheless a milestone for the 1980s, since it was the first of that decade to focus so specifically on the broad topic of Nutrition and Health. The over 700 pages long report on nutrition and health was the first of its kind. Furthermore, it included an entire chapter on obesity. Obesity is listed in this report as one of the eight conditions attributable to diet. Some of the other conditions include diabetes, heart disease, high blood pressure and cancer. Remarkably, obesity is in this work both related to and listed as a cause of getting a condition like stroke, hypertension, diabetes etc., besides being seen as a condition itself. Marking obesity as a
16 USDA and HHS, Nutrition and Your Health: Dietary Guidelines for Americans (1990), 8-9 accessed 09-05-2014 <http://www.cnpp.usda.gov/DGAs1990Guidelines.htm>.
17 U.S. Department of Health and Human Services, Surgeon General’s Report on Nutrition and Health (Washington D.C. 1988) U.S. Government Printing Office, III.
separate condition was a step into defining it as a disease.
The issues that came forward in the chapter on obesity were the definition, the health consequences, the causes and the treatment of obesity. These key issues posed a slight problem because “despite rapid advances in the definition and epidemiology of obesity, of adipose cell metabolism, and of the causes and consequences of obesity, disagreements still prevail on almost every key issue.”18 In other words, there was no complete clarity on the causes and health
consequences of obesity and subsequently no clear definition or treatment of the condition. Nevertheless, suggestions for treatment and public health policy were still formulated. In this chapter the recommendation for an average weight loss for the entire population was formulated. This was due to the “extraordinarily high prevalence of obesity in the United States-one-fourth of American adults are overweight and nearly one-tenth are severely overweight.”19 Even though this document was full of warning against obesity, and linked obesity with all known conditions, it was not yet imminent enough to see obesity as an epidemic. The problem of obesity was in this document still mostly linked to problems of nutrition, out of which all these conditions followed.
Apart from relating obesity to nutrition, there was slightly more attention for obesity when minorities were concerned. In between 1982 and 1984 a national survey was held amongst the Hispanic population. The so called Hispanic Health and Nutrition Examination Survey or HHANES. This separate survey was held because although in previous surveys Hispanics were interviewed, they were not represented in sufficient numbers. Furthermore, the Secretary of Health Margaret Heckler commissioned a task force in 1984 on ‘Black and minority Health’ which published their report in August 1985. In this document there is a broad attention for birth weight and prenatal care, but obesity was also a great concern since it is apparently quite prevalent amongst the minorities. Heckler stated that her reason for writing specifically on black and minority health was because: “there was a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation's population as a whole.”20
One of the disparities that were repeatedly pointed out was the higher rate of obesity amongst these minority groups. This document points out amongst the various minority groups (African Americans, Native Americans and Hispanics) that there could be a link between the high obesity rate amongst these groups and a high prevalence of disease such as hypertension and diabetes. This report described that a part of the problem that explained the high rates of obesity could be the cultural attitudes towards nutrition and obesity. Perhaps for these groups education on
18 U.S. Department of Health and Human Services, Surgeon General’s Report on Nutrition and Health (Washington D.C. 1988) U.S. Government printing office, 275.
19 Ibidem, 299.
20 U.S. Department of Health and Human Services, Report of the Secretary’s Task Force on ‘Black and Minority
Health’ U.S. government printing office (August 1985 ) p. 7 accessed 01-05-2014
this topic was a solution: “Patient education programs are particularly critical and needed for several health problems where the impact on minority health is greatest, such as hypertension, obesity, and diabetes.”21 In this time period researchers characterized obesity as most prevalent amongst
minorities.
This particular focus on obesity amongst minorities continued throughout the late 1980s and early 1990s. In 1990 the new Secretary of Health and Human Services, Louis W. Sullivan, created the first Healthy People objectives, in his Healthy People, 2000. This was a plan which formulated objected improvements on health levels in a span of ten years. Although it was not as clearly formulated as in the 2010 and 2020 objectives, Healthy People 2000 did include overweight and obesity in its objective on nutrition and physical fitness. The report contained special targets for minority groups, such as Hispanics and African Americans.22
In the news the disparity between the health of the entire population and the minorities was also noticed. But did the news media also follow the trend in the focus on nutrition? Although overweight and obesity were not mentioned until the end of the decade, nutrition was a topic in the news of the 1980s. But more was written specifically on the topic of fat. Daily newspapers such as The New York Times and The Washington Post often wrote articles on fat, and the dangers of fat, for example the link between fat and certain diseases and obesity. This increased rapidly from 1985 and onwards. “‘We must remember that it's the total amount of fat in the diet that has the greatest impact on heart disease, cancer and obesity,’” Joan Hudiburg, a leading dietician was quoted saying in 198723. From an article published in 1989 by The New York Times it appeared that the public opinion of fat was at this time very dismal. The author Karon Cooney argued that what people feared most in life was fat, and that fat people should pay extra when they have the need for an extra chair on a bus or airplane.24
In 1982 an article by United Press International reported on the lack of interest of the Reagan administration to promote Dietary Guidelines, which were introduced by the Carter
administration in 1980. The General Accounting Office felt it was the job of the government to make use of the available resources, and thus had to promote the pamphlet about the Dietary Guidelines.25 In 1985 The Washington Post reported on the debate of labelling products, because in the 1980s
21 U.S. Department of Health and Human Services, Report of the Secretary’s Task Force on ‘Black and Minority Health’ P. 13.
22 U.S. Department of Health and Human Services, Health, United States, 1990. Pub. No. (PHS) 89-1232. Public Health Service. Washington. U.S. Government Printing Office Printing Office, March 1991, p. 27 accessed 09-05-2014 <http://www.cdc.gov/nchs/hus/previous.htm>.
23 “Dietitians issue 10-point plan to cut fat, reduce disease risk” in PR Newswire accessed 26-06-2014 through LexisNexis.com.
24 Karon Cooney, “Connecticut opinion: Solutions to the Fat Problem” in The New York Times (August 6, 1989) accessed 26-06-2014 through LexisNexis.com.
25 Sonja Hillgren, “On the farm front” in United Press International (June 14, 1982) accessed 26-06-2014 through LexisNexis.com.
labelling products was a voluntary choice unless a nutritional claim about a product was being made. At that time the FDA was debating whether labelling of content and nutritional value should be mandatory, since it was at that time unclear about many products of how they were composed. 26 These calls urged the government to supply better information about nutrition, or even to create laws that would force the suppliers to do so.
But not much legislation concerning obesity was made during the 1980s. Although the debate about labelling of products had been current in 1985, it was not until 1990 that the FDA passed a law about it. The law that was passed was the Nutrition Labelling and Education act. From this moment on it was mandatory for most of the FDA regulated foods to carry a nutrition label. Quantitative intake recommendations had to be aligned with guidelines in reports such as The Surgeon General’s Report on Nutrition and Health and the Dietary Guidelines. Which meant for example that a recommended serving would contain a maximum amount of fat that would take up no more of 30 % of the total calorie intake.27 So, this labelling law was an important step towards addressing some environmental issues of obesity, but for most of the 1980s this was not yet of particular public health significance. Imperative for change in U.S. policy was a change in the definition of obesity, for a great part of the 1980s there was not yet a consensus that obesity was harmful for the health of individuals.
A great step in defining obesity was taken in 1985. The National Institutes of Health (NIH), which is part of the Department of Health and Human Services, held a consensus meeting in
February 1985 on the topic of obesity. This meeting was part of a series of “Consensus Development Conferences”. A report was published as a result of that consensus meeting called Health
Implications of Obesity. 28 The reason for the meeting was concern for the growing prevalence of obesity among many layers of U.S. society and to establish a clear view of the phenomenon. Furthermore, “obesity was considered to be fully explained by the single adverse behavior of inappropriate eating” but this notion could not hold anymore, due to new knowledge on obesity.29 Therefore questions such as ‘what is obesity’, ‘what is the evidence that obesity has adverse effects on health?’ and ‘What should be the directions for future research in this area?’ were formulated
26 Carole Sugarman, “Looking for clues on product labels; Finding the Fat in America’s Diet” in The Washington
Post (February 6, 1985) accessed 26-06-2014 through LexisNexis.com.
27 Virginia Wilkening, “The Nutrition Labelling and Education Act of 1990” (Speech given at the 17th National
Nutrient Databank Conference, Baltimore, Maryland, on June 7-10 1992) National Nutrient Databank Conference accessed 28-06-2014 <http://www.nutrientdataconf.org/PastConf/NDBC17/toc.htm>.
28 It was not the first consensus meeting on obesity, in December 1978 there had been such a meeting on the topic of “Surgical treatment of morbid obesity”. In the meeting of 1978 the consensus was reached that surgical treatment should only be applied to those people who are morbidly obese. The 1978 meeting did not have the purpose to investigate and formulate obesity more generally, which is something that was established in the meeting in 1985.
29 National Institutes of Health, Health Implications of Obesity. NIH Consensus Statement 1985 Feb 11-13:1-7 accessed 06-05-2014 <http://consensus.nih.gov/1985/1985Obesity049html.htm>.
and answered during the meeting.
This report established a consensus that obesity is often related to various diseases. Furthermore it recommended the Body Mass Index as an additional measurement of obesity, because previously the standard methods for measuring obesity had for example been by measuring skinfold thickness. Further research into genetic factors of obesity and studies of energy regulation was also one of the recommendations of the meeting. This meeting thus established the consensus that obesity was not a lifestyle choice, but related to various harmful diseases. . “Obesity is an excess of body fat frequently resulting in a significant impairment of health.” The meeting also called for more focus on this topic30 According to Donna Maurer and Jeffrey Sobal, authors of Eating Agendas: Food and Nutrition as Social Problems (1995), one of the reasons the NIH chose obesity as the topic of their 1985 consensus conference was because private medical organizations lobbied for the medicalization of obesity. They argued that after the conference of 1985 other conferences followed which “increased official support for the medicalization of obesity.”31
These private medical organizations were organizations such as the International Association for the Study of Obesity (IASO), which has since changed its name to World Obesity. The IASO has hosted International Congresses on Obesity since 1974. One of their goals was to work with governments and non-governmental organizations to influence their policies and practices on obesity. They wanted to guide the debates and promote the facts on obesity.32 For this organization a meeting such as the consensus conference of 1985 was very important, since at this conference the National Institutes of Health established that obesity was linked to serious diseases. Because before obesity had been considered to be fully explained as a result of a lifestyle choice. And now a new consensus about this matter had been reached.
Thus, helped by the lobbying of private medical organizations, the U.S. government was taking a bit of action here against obesity, by formulating a new definition of the phenomenon. Nevertheless, no great policy changes were being made. In the Health United States reports obesity did not get extra attention after the consensus meeting of 1985. So, the question arises of why the U.S. government was not taking firm action, and moreover what then was the focus of the U.S. government. One of the reasons the Department of Health and Human Services might not have been too concerned with obesity is because there was no great pressure to take immediate action. First of all, NHANES III had not been released yet. This meant that the knowledge about the current
prevalence of overweight and obesity was based on NHANES II. Although this survey already showed a substantial increase in obesity prevalence, it was less shocking than the rise in prevalence which
30 Health Implications of Obesity, p1-7.
31 Donna Maurer, Jeffrey Sobal, Eating Agendas: Food and Nutrition as Social Problems (New York 1995) 72-73. 32 “Policy and Prevention” on World Obesity accessed 27-06-2014 <worldobesity.org>.
was shown in the earlier third survey. So, although the Health Department was aware that
overweight and obesity had increased, there was no evidence yet that this was a continuing trend. Logically, this meant it was not yet their greatest concern. Secondly, the U.S. government did receive some pressure to attack other pressing health issues. This naturally drew the urgency away from a matter that was considered to have serious health implications, but not yet considered epidemic.
A topic which received considerably more attention in the governmental reports than obesity was smoking and its effects on health. In the Surgeon General’s Reports smoking was a recurring theme. The very first Surgeon General Report was published in 1964 and was about smoking. Since then it had been the subject of a Surgeon General Report every few years. During the 1980s it was considered the number one cause of preventable death in the United States by the governmental health officials, with approximately one in every six deaths being caused by smoking.33 For obesity such numbers were not yet registered, and therefore smoking was at this point considered a very major public health problem.
One of the other major issues of the U.S government was the spread of a disease which occurrence was cause for it to be called an epidemic from 1983 onwards. AIDS was a topic that with increasing numbers of victims, got more and more attention in the 1980s. This happened even though Reagan’s government was eerily quiet on the matter for several years, which produced a lot of criticism on the otherwise generally liked president. It was no coincidence that in 1987 the Surgeon General published a report on AIDS, the first of his reports since 1979 which did not specifically concern smoking. In an editorial of the January-February issue of Public Health Reports then Surgeon General C.E. Koop presented his report, and urged every adults American to read it. He further called for education about the disease in schools, because “much remains to be done to stop this epidemic, and the Public Health Service will continue to work together with all elements of public and private sectors and use all our joint resources to the fullest to eradicate AIDS.”34 At this point, obesity was not considered an epidemic, AIDS however, most definitely was.
The medical journals of two leading health associations, the Journal of the American Medical Association and the American Journal of Public Health wrote quite steadily on obesity during the 1980s. The frequency of their articles was quite modest nevertheless, with no more than a dozen articles per year on obesity. This did not seem be influenced by the government reports, and the topics of the articles did not seem to influence major policy changes. Nevertheless, there were common themes in the journal articles and the reports. Obesity amongst minorities for example was
33 U.S. Department of Health and Human Services, Reducing the Health Consequences of Smoking: 25 Years of
Progress. A Report of the Surgeon General (Washington, 1989) p. i, accessed through
<http://www.surgeongeneral.gov/library/reports/> on 28-06-2014.
34 C. Everett Koop, “Editorial” in Public Health Reports (January-February 1987), Vol. 102, No. 1 p.1-3, 3 accessed 08-05-2014 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477712/>.
also a theme in the journals. The AJPH published an article in February 1980, which concluded that black children with a high blood pressure were three times more likely to be obese.35 The conclusion of the journals was similar to that of the government reports, obesity was more prevalent amongst minorities.
Some topics that the journals addressed were not reflected in the governmental reports. For example, childhood obesity is already a recurring theme in the AJPH and the JAMA while for the government this only becomes a true focus in the 21st century. In 1983 the AJPH published an article on childhood obesity, investigating questions as whether the obese infant becomes an obese child, and does the obese child become an obese adult. In the article it was established that there is a clear link between childhood and adult obesity.36 Such research was probably at the basis of later
governmental focus on childhood obesity, because if childhood obesity was diminished so would adult obesity.
But just as the government was preoccupied with other health concerns during the 1980s, the medical journals also focused on different topics considerably more than on obesity. AIDS is a topic which received increased attention, especially when the Surgeon General issued a report about it in 1987. Within a journal like JAMA, AIDS got just a little attention in 1983, but the number of articles expanded in 1984 and continued to do so in 1985 and 1986. In 1987 there were about a hundred articles devoted to various aspects of the acquired immune deficiency syndrome in JAMA and just about as many in the AJPH.
In hindsight we can say that there was not yet a great sense of urgency when it comes to obesity in the 1980s in the U.S. government politics. The first newspaper article calling for concern of obesity dates from 1993, after that there were just several mentions until 1997 and 1998. In the 1980s daily newspapers did write occasionally about multiple aspects of fat, which indicates there was some public concern for fatty foods and large bodies. Yet there was no indication that the American public felt concern for an obesity epidemic. In the 1980s there was a relatively constant attention for overweight and obesity, especially when nutrition was concerned, both in the journals of the American Medical Association and the American Public Health Association and in the
documents of the Department of Health and Human Services. The little governmental attention for obesity may firstly be explained by the fact that NHANES III was not yet published. And secondly at that time smoking and the AIDS epidemic were a greater concern. Although the journal publications on obesity are much more numerous in the 21st century than in the 1980s and we can say the same about the government attention towards obesity, for the 1980s there was no clear link between the
35 Barbara Gentry Lynds, Suzanne Klopp Seyler, and Brenda Martin Morgan, “The Relation between Elevated Blood Pressure and Obesity in Black Children” in AJPH (February 1980) vol.70 no 2, p. 171-173, 172.
36 M. Joan Mallick, “Health Hazards of Obesity and Weight Control in Children: A Review of the Literature” in
publications of the journals and the publications by the Department of Health and Human Services. In the next chapter I will illustrate that a sense of urgency, or of an epidemic is really emerging, as more organizations and authorities are calling for more attention for obesity.
2: Developing the obesity epidemic
Although in the 1980s there was constant attention for obesity in medical journals as the AJPH and the JAMA and amongst governmental health departments, there was not a yet any talk of, or any notion of an obesity epidemic. Instead, there was a great focus on a more imminent and pressing health matter, the ‘AIDS epidemic’. But as the nineties progressed we saw that more and more concern rose regarding the problem of obesity. The term obesity epidemic was not so prominent in the early nineties, but the end of the decade saw a steady and quick rise in use, as the phenomenon gained more ground on social, economic, cultural and political levels. More newspapers and
institutions started speaking of the obesity epidemic, until this term eventually seemed
institutionalized in the 21st century. How did this develop in the 1990s? Who was calling for more attention to obesity, the Surgeon General? Or did perhaps the American Medical Association and the American Public Health Association voice a concern in this matter? Or were there other institutions who believed obesity had grown into a real health crisis?
In this chapter I will argue that with the publication of NHANES III the increase in prevalence of obesity got widely known. Because of this more and more institutions started to stress the health implications of obesity, and the impact it had on society. Nevertheless, the Department of Health and Human Services did not take immediate action. No concrete policy to fight obesity was made, although the topic did gain attention in governmental reports. Whereas these reports focused solely on the nutritional aspects of obesity in the 1980s, the focus slightly shifted in the 1990s to include physical activity. In 1997 the WHO took a leading role in the obesity debate by recognizing obesity as a disease, viewing it as a problem of epic proportions, and installing the BMI as an international standard for weight classification. When a year later the Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults were published by the National Institutes of Health, serious action seemed to be taken by the government. The medical journals report and applaud these guidelines, and JAMA and the AJPH both showed an increase in research articles on obesity in 1998.
Even so, the Clinical Guidelines did not address any environmental issues that contributed to obesity. The report was rather of practical use for general practitioners and other health
an imposition on the free market economy, and therefore the government was not willing and able to take such a step. The official recognition of obesity as an epidemic came in 2001. After the WHO had released a report in 2000 called Obesity: preventing and managing the global epidemic, the U.S. government followed with The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001. In this report overweight and obesity were recognized as a problem of epidemic proportions, and steps were outlined on how to fight and decrease the prevalence of obesity in the United States. This reports marked a turning point for the government response to the obesity debate.
Some notion of public concern started to arise in the early nineties. Several institutions that concerned themselves with obesity agreed that little was being done by the government about the ‘growing’ issue. The first news article mentioning obesity dates back to 1993, before then there were no articles published by newsmagazines or agencies. The Associated Press, published an article in October of that year headed “Health system wrongly ignores importance of obesity”, as it covered the sentiments that were expressed during an annual meeting of the North American Association for the Study of Obesity. Attendees argued obesity should be defined as a disease and health insurances companies should also include medical treatment in their coverage.37 From this moment on there were calls to the U.S. government to take obesity seriously. A year later the PR Newswire announced the 7th International Congress on Obesity, who would “bring together an outstanding line-up of international experts to discuss the growing epidemic of obesity among western nations.”38 Although this was not the first congress on obesity, the fact that the chair used the term ‘growing epidemic’ did suggest that experts on obesity were increasingly stressing its importance.
At the end of 1994 PR Newswire published another article, in response to the launch of a health campaign called “Shape up America!”, by former Surgeon General and pediatrician C. Everett Koop who had served under Reagan from 1982-1989. He launched this campaign in December of 1994 on the basis of a report “Weighing In For America's Health: Elevating Healthy Weight and Physical Fitness as a National Priority” which was released on a White House party hosted by First Lady Hillary Clinton. Dr. Koop released this campaign because of the ”mounting evidence that the United States is experiencing an unprecedented epidemic of obesity among but adults and children”. Among his main concerns were the problem that unhealthy weight is "a multibillion dollar drain on the U.S. economy" and was responsible for a large percentage of the total Health Care costs.39
37 Paul Raeburn, “Health system wrongly ignores importance of obesity” in The Associated Press (October 23, 1993, Saturday) accessed 14-05-2014 through LexisNexis.com.
38 “New study finds genes linked to body fat: Congress to learn fat cells talk to each other and encourage or inhibit the growth of fat cells” in PR Newswire (August 16, 1994) accessed 14-05-2014 through LexisNexis.com. 39 Cindy Karra, “Dr. C. Everett Koop Launches as new “crusade” to combat obesity in America” on Shape
Up.org (December 6, 1994) accessed 14-05-2014 through
Although during his tenure as Surgeon General, C. Everett Koop focused mostly on the epidemic of AIDS, after his time in office he addressed a new epidemic in obesity, which was something he had already included in his Surgeon General Report on Nutrition and Health in 1988.
The campaign by C. Everett Koop was, due to his former position, a strong signal that steps needed to be undertaken to stop the increase in obesity prevalence. Most calls were made however by private medical organizations. In November 1997 PR Newswire published two articles about it. The first was a short report on the results of the annual conference of the North American
Association for the Study of Obesity. Although it had various outcomes the main conclusion of the conference was that there was need for long-term weight management strategies for severely obese people.40 The second article which was published more than a week later reported on an call by a council of obesity experts on the Surgeon General to lead the “fight” against the “growing national obesity epidemic”. The message of the Interdisciplinary Council on Lifestyle and Obesity
Management was not only meant for the Surgeon General, but also for other “leaders from the private and public sectors” to recognize obesity as a major public health crisis. The Surgeon General was however specifically called on to create a special Task Force devoted to the problem. The goal of the Task Force should have been to “ take the lead in generating support for obesity research and education initiatives, elevate awareness of obesity as a treatable disease and encourage adoption of obesity management models.” The council’s chairmen stated that obesity was only second to smoking when it came to causes of preventable deaths in America. The council advocated using BMI and waist circumference as standards to evaluate someone’s medical status.
The Interdisciplinary Council on Lifestyle and Obesity Management was formed earlier in 1997, and funded by Hoffmann-La Roche Inc., a health insurance and pharmaceutical company. Apparently this company had a great enough interest in having obesity marked as a health crisis, because they were willing to fund this council. And they certainly did, because at this time Hoffman-La Roche was testing a new obesity drug, called ‘orlistat’ also known by its brand name ‘Xenical’. Later in mid-1999 the drug was approved by the FDA for obesity management.41 In order to gain approval it makes sense that Hoffmann-La Roche was trying to lobby for taking a firm position in fighting the obesity epidemic.
During the 1990s government documents concerning obesity were being published. In these reports there was a shift from focusing on overweight and obesity solely from a nutritional aspect, to including a factor of physical activity. In this decade overweight started to be viewed from diverse
40 “Long-term weight management a recurring team at North American Association for the Study of Obesity (NAASO) annual conference; Key research presented focuses on promising new treatment options” in PR
Newswire (November 11, 1997) accessed 21-05-2014 through <lexisnexis.eu>.
41 Stuart L. Nightingale, “Orlistat approved for obesity”, in JAMA (June 2, 1999) vol. 281, no. 21, p. 1978: accessed 14-06-2014 doi:10.1001/jama.281.21.1978.
aspects. For example the 1994 campaign “Shape Up, America” by C. Everett Koop focused on physical fitness. But the new focus on physical activity was also visible in a document published through a collaboration of the Department of Agriculture, and of Health and Human Services. The Dietary guidelines for Americans, which were published every five years since its first edition in 1985, got a major makeover in 1995. In the previous editions these guidelines had been based on a list of seven focal points, which were listed as rules, such as the second guideline ‘maintain healthy weight‘. Although these points were not thrown out in the 1995 edition, they were transformed from short rule-like sentences to broader areas of attention. So whereas previously the second guideline had been ‘maintain desirable weight’ now it read ‘Balance the food you eat with physical activity- maintain or improve your weight’. In this new guideline the focus was similarly on physical activity instead of solely on nutrition. The advice in the guideline chapter confirmed this idea; the chapter stated that the more someone is physically active the better, but any activity was preferable to none.42 Challenging overweight had transformed into a broader problem than just a nutritional issue.
This focus on a more active life was also visible in 1996 as the Surgeon General published a report called “Physical activity and Health”. This report was already in subject matter a great turn from the Surgeon General’s report of 1988 called “Nutrition and Health”. In this report obesity got a contribution in the chapter “The Effects of Physical Activity on Health and Disease”. Although obesity was in this document not yet defined as a disease, it was analyzed as such in relation to physical activity. In the paragraph on obesity the magnitude was related as “a major public health problem in the United States,”.43 On its relation with physical activity it was said that “It is commonly believed that physically active people are less likely to gain weight over the course of their lives and are thus more likely to have a lower prevalence of obesity than inactive people”. However “few data (…) exist to evaluate the truth of these suppositions”. Nevertheless the conclusions on obesity in this report were that low levels of activity contributed to the high prevalence of obesity in the United States, and “physical activity may favorably affect body fat distribution”.44 The notion that obesity was a public health problem in the US signified the growing governmental attention for obesity. For the government treating obesity was now not just a question of changing a person’s nutrition, but combining this with increasing physical activity.
Nevertheless, as the calls for taking action against obesity grew louder, it became more important to have a better definition of obesity. Both the governmental organizations as the medical journals seemed to struggle with current definitions which left it unclear if obesity should be
42 USDA and HHS, Nutrition and Your Health: Dietary Guidelines for Americans (1995), p. 21 accessed 18-05-2014 <http://www.cnpp.usda.gov/DGAs1995Guidelines.htm>.
43 U.S. Department of Health and Human Services, Physical Activity and Health: A Report of the Surgeon
General (Atlanta,1996) p. 133 accessed 19-05-2014 <http://www.cdc.gov/nccdphp/sgr/index.htm>. 44 U.S. Department of Health and Human Services. Physical Activity and Health, p. 7.
considered a major health problem. In October 1996 an article on obesity came out by PR Newswire concerning obesity research and options for treatment which testified to this. The article reported on the outcome of the annual North American Association for the Study of Obesity conference that was held two weeks prior. The researchers present maintained that obesity was a manageable disease. However, the insurance companies did not yet cooperate to the same end, which was according to the researchers because the “regulators in Washington” and the insurance companies do not yet agree on a definition of obesity.45
The second Guide to clinical preventative services which came out in 1996 by the hands of the United States Preventive Services Task Force (USPSTF) slightly reflected this. Whereas the first Guide from 1989 did pose the question of what a definition of obesity might be, in the second edition the question of definition was avoided. Instead obesity was described as “a chronic disorder that requires continuing treatment”.46 Apparently the Task Force felt the need to give a workable definition of obesity. The AJPH published a long editorial on obesity in 1996, reflecting on its
definition and the research that had been done the last thirty years. The editor started of by pointing out that obesity could be defined as an excess of body fat, but that this definition was not clear enough because when was body fat an excess? Did it need to be present at such a level to cause illness? Most medical institutions and associations defined obesity precisely so, because studies showed that when a person is 10-15% above his ideal weight his or her chances for getting certain linked diseases were greatly increased.47
However, for many private medical organizations the clinical definition of obesity as an excess of body fat was not enough. Several obesity groups were lobbying for obesity to be
considered a disease, whereas other medical groups had not gathered enough conclusive evidence for obesity to be defined as such. But in the last decade of the 20th century more and more
institutions were taking a stance in the matter, and were ‘recognizing’ obesity as a disease. It came to no surprise thus, that the International Council on Life and Obesity Management, just formed a year prior, participated in the obesity debate. In June 1998 they issued a statement applauding the American Heart Association for acknowledging obesity as a chronic disease and a major risk factor
45 “Obesity research offers insight into early signs and treatment options” in PR Newswire October 17, 1996, accessed 19-05-2014 LexisNexis.
46U.S. Department of Health and Human Services, Office of Public Health and Sciences and Office of Disease Prevention and Health Promotion, Guide to clinical preventative services: Second Edition; Report of the U.S. Preventive Services Task Force (1996), 223, 224 accessed 20-05-2014
<https://www.ncbi.nlm.nih.gov/books/NBK15435/>.
47 Myron Winick, “Editorial: Understanding and treating obesity” in American Journal of Public Health (July 1996) vol. 86 no. 7, p. 925-926, 925.
for heart disease.48 And not long later, the American Obesity Association (AOA) applauded the National Institutes of Health on their guidelines on treatment of obesity. They saw these guidelines as a good step toward their goal: “AOA's mission includes promoting the recognition of obesity as a disease” Better prevention and treatment would, according to the AOA improve health and decrease the medical costs of obesity.49
In 1997, the World Health Organization took a clear stance in the obesity debate during a conference on the matter. In June 1997 an expert consultation on obesity convened in Geneva to review “current epidemiological information on obesity,” and to give recommendations for policy on managing and preventing obesity.50 The conference made a few important decisions which later on influenced many other organizations. For example the WHO acknowledged obesity as an epidemic of global proportions, furthermore it recognized obesity as a disease, and recommended,
international standards for classification of overweight and obese. These standards were to use the Body Mass Index and then to globally classify a BMI of 25> as overweight and a BMI of 30> as obese. Earlier a BMI of 27> had occasionally counted as overweight, but hereafter many institutions and associations used the standards as defined by the WHO.
The U.S. government immediately implemented the standards that had been set by the WHO. In 1998 they issued their Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults, which constituted the first guidelines made by the American Federal Government. Their classification of obesity and overweight was adapted from the WHO report of 1997. The goal of these guidelines was to offer evidence based treatment options for obesity, and to focus on providing tools for the primary care practitioner. The Institution viewed the local health professionals as vital for preventing and treating obesity. Weight loss was recommended in this report both for treating patients with obesity-related diseases to reduce their symptoms, as to prevent them from obtaining these conditions. 51
Although in this report steps were taken by the Federal Government to reduce obesity, the method at this point was to address the clinical solution instead of targeting environmental
influences. In other words the “report by nature focuses almost entirely on therapies for weight loss
48 “Experts Applaud American Heart Association Call to Action on Obesity; AHA recognizes obesity as a major risk factor for heart disease” in PR Newswire (June 1, 1998) accessed 16-05-2014 through LexisNexis.
49 “American Obesity Association Applauds New Guidelines on Treatment of Obesity” in PR Newswire (June 17, 1998) accessed 16-05-2014 through LexisNexis.
50 World Health Organization Obesity, Preventing and managing the global epidemic: Report of a WHO
consultation on obesity (19 June, 1998) xv, accessed 29-05-2014 through
<http://whqlibdoc.who.int/hq/1998/WHO_NUT_NCD_98.1_(p1-158).pdf>.
51 National Institutes of Health, Clinical Guidelines on the Identification, Evaluation and Treatment of
Overweight and Obesity in Adults (September 1998) xi-xvii, accessed 30-05-2014
in individuals, including dietary changes, exercise, pharmacotherapy, and surgery”.52 Whereas it did not restrict the number of fast food restaurant or established stricter regulations on what is allowed in soda. Up until this point the governments obesity policy mainly addressed clinical issues, and occasionally made policy on a behavioral and educational level. The Dietary Guidelines for Americans was an example of such an educational report, which tried to influence the behavior of the nation’s population.
These types of policies were described as counteractions in an article from The Lancet called “The global obesity pandemic: shaped by global drivers and local environments” (2011). They counteracted existing mediators that would increase obesity, by for example motivating people to make healthier food choices. This was the opposite of policy intervention, which required rules and regulations such as increasing the cost of unhealthy food. The authors argued that although counteractions could be effective they “do not address the underlying drivers of the epidemic”.53 Policy based solutions were much more effective in reducing obesity because they tended to be sustainable, systematic, and affect the whole population.
Then why did the American government only address the clinical and behavioral influences of obesity? According to the authors of “The global pandemic” this was because addressing
environmental factors would probably result in a lot of resistance. It would disturb the free market economy. “The degree of political difficulty for implementation of policy and regulatory interventions is typically much higher than that for programme-based and education-based interventions”54 The U.S. government seemed reluctant to take the step to implement these environmental policies. One of the reasons that this was so difficult was because there was a great lobbying force of food and food related industries. This would even increase massively in the first decade of the 21st century.
Another reason why the government was reluctant to implement such regulations was that it would have harmed the nation’s individualism. The educational and behavioral policies had always been directed at the individual, to sway the individual to make better food choices. However, the recommendations and guidelines were never enforced by laws that motivated the healthier food choices. This was because whether to eat healthy or not should remain a personal choice and not be imposed on the nation. But it simultaneously also lay the responsibility at the individual. Doctor in political science, Regina G. Lawrence, wrote that ”Individualizing frames limit the causes of a problem to particular individuals (…)Defining a problem in individualized terms limits governmental
52 Nicole L. Novak and Kelly D. Brownell, “Role of Policy and Government in the Obesity Epidemic” in Journal
of the American Heart Association 126 (2012): 2348 , accessed 31 May 2014, doi:
10.1161/CIRCULATIONAHA.111.037929.
53 Boyd A Swinburn et. al, “The global obesity pandemic: shaped by global drivers and local environments” in The Lancet (27 August-2 September 2011) p. 804-814, 810, accessed 29-06-2014 DOI: 10.1016/S0140-6736(11)60813-1.
