Dear Mrs. Obama,
I've been reading about the new initiative you launched yesterday, "Let's Move!" and I want to tell you, I think it's about 90 percent terrific: Improving nutrition in schools, increasing opportunities for physical activity, bringing grocery stores into "food deserts." We need those things so badly. Thank you, and good luck with all that.
But it's about that other 10 percent. Specifically, my issues are with how you're framing this as a strategy to "solve the epidemic of childhood obesity within a generation," rather than to improve health and well-being across the board, and whipping up fear and disgust of the very fat children you're supposedly trying to help. You've gotten so much right, but here are five things I think you and your partners are getting wrong.
Fear-mongering part 1: Exaggerating the crisis
The president's memorandum on establishing a childhood obesity task force, your remarks at the Let's Move launch, and countless news reports about fat kids uniformly paint the situation as horrifyingly out of control, nigh onto hopless. "Across our country, childhood obesity has reached epidemic rates and, as a result, our children may live shorter lives than their parents," begins the memorandum."Nearly one third of children in America are overweight or obese -- a rate that has tripled in adolescents and more than doubled in younger children since 1980."
Now, let's unpack that a little bit. According to the CDC, for children, "Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex." 12.5 percent of preschool-aged children, 17 percent of kids 6-11, and 17.6 percent of adolescents up to 19 are obese by those criteria. So the key words in that one-third stat are "overweight or" -- combining the two categories makes the "childhood obesity epidemic" sound a lot more dramatic than it is. Granted, there has been a big jump in the childhood obesity numbers since 1980 (up from 5 percent, 6.5 percent and 6 percent, respectively), but the good news is, there's evidence that it's already leveled off. Which means -- good news for you -- this is the perfect time to launch a childhood obesity initiative, since a population that's been so thoroughly convinced we're all headed straight for a Wall-E scenario will think the intervention was a rousing success if all it does is maintain the status quo. But it's kind of disingenuous to act as though you're stepping in to stop an increasing problem that's not actually increasing at the moment. That just confuses people.
As for the threat that this could be the first generation not to outlive its parents, with all due respect, I'll believe it when I see it. So far, the U.S. lifespan keeps increasing like nobody remembered to tell it what a bunch of lazy gluttons we've been turning into since the mid-20th century (when, as we all know, nobody had unhealthy lifestyles). Could that turn around? Sure. Is there any reason to think the current number of overweight and obese people (oh yeah, the rates have leveled off for adults, too) will cause that, especially when research has shown that overweight is not associated with excess mortality (in fact, it carries a lower risk of premature death than so-called normal weight) and "the relative risks of mortality associated with obesity were lower" (emphasis mine) in more recent years? Let's just say I'm not convinced.
Fear-mongering part 2: Exaggerating kids' laziness.
Says the press release about the Let's Move launch: "Children need 60 minutes of active play each day. Yet, the average American child spends more than 7.5 hours a day watching TV and movies, using cell phones and computers, and playing video games, and only a third of high school students get the recommended levels of physical activity." That sounds horrible! But wait, let me think about that for a minute. You've told me how long the average child spends passively consuming media, not how active he or she is. You've told me two-thirds of high-schoolers aren't getting enough exercise, but said nothing about younger kids. I like a good "video games! cell phones!" tsk-tsk session as much as the next geezer, but could we see some more data here?
For instance, we could look at a study published in the Journal of the American Medical Association in 2008, which found, according to the Associated Press, that "90 percent of 9-year-olds get a couple of hours of exercise most days" -- in fact, an average of three hours of "moderate to vigorous activity" -- and "[t]hrough age 12, well over half the children got at least the government-recommended amount of activity every day." There is a dramatic drop-off in activity levels when kids hit high school, but I'm still waiting to see the proof that it's because of video games or laziness and not, say, the fact that older kids have far more intense workloads (which demand a certain amount of time in front of the computer, I might add). Researchers interpreting a 2007 Statistics Canada survey "tallied the hours that teens aged 15-19 spent at school, doing homework, working part-time jobs and doing chores, and found that they did an average of 7.1 hours of unpaid and paid labor per day in 2005," according to Scripps Howard News Service. "That adds up to a very adult 50-hour workweek."
So, here's another way to describe children's activity levels: "The vast majority of younger kids and more than half of young adolescents are getting plenty of exercise; many are getting more than the government's recommended levels. This is fantastic! But as kids get older, their activity levels drop -- at the same time their schoolwork becomes more challenging and their responsibilities increase." Problem is, addressing that would involve looking closely at what we demand of older kids and how it affects their ability to care for themselves -- sleep deprivation is another health issue at that age -- instead of blaming technology and couch-surfing.
I realize that getting people's attention requires a bit of drama, but when it borders on flat-out lying -- implying that obesity rates are still increasing apace, or that most children (as opposed to most teenagers) are getting less than the government's recommended amount of exercise -- you're going too far.
Conflating fitness with thinness, and using BMI as a measure of individual health
"Normal weight" and "cardiovascular fitness" are two different things. It is possible to be fat and fit. It is possible to be thin and unfit. Cardiovascular fitness is associated with improved health outcomes for people of all sizes. These statements are not controversial.
Population-wide, the overweight and obese BMI categories are associated with increased "cardiometabolic risk factors," but nearly a quarter of normal-weight adults are "metabolically abnormal" and a third of obese people are normal, while it's about half and half for those in the overweight category. BMI doesn't tell you anything about body composition, and a 2000 large-scale study of children found that one in six normal-weight kids had excess body fat, while 25 percent of "high-BMI children" had a normal percentage of body fat. BMI also doesn't tell you how muscular your child is, if that suddenly chubby kid is due for a growth spurt that will even things out, or whether she's gaining weight at a consistent rate for her own body.
Yet you insist on targeting fatness instead of fitness, heaping stigma on healthy people with high BMIs and neglecting the needs of many of those within the "normal" range. Richard Telford, research director of the Lifestyle of Our Kids study at Australia's Commonwealth Institute summed up the problems with that kind of thinking in a 2009 article,, "Measure for Measure, BMI Has Big Flaws":
Given the difficulty of measuring fat, especially in children, evidence that inactivity rather than weight alone puts children at risk of ill-health, and that natural changes in body composition are hard to predict as children grow, politicians and education authorities should think carefully about any proposal to measure the BMI of schoolchildren.
Let's get off kids' backs about possibly being fat and let's get them active.
Indeed.
Assuming that people will respond to all this hullabaloo in a reasonable, healthy way
"Before governments and other agencies leap into actions that they assume to be beneficial in the battle against child obesity, we must remember to employ one of the most important principles of modern medicine and prevention science, ‘First, do no harm,'" wrote Jennifer A. O'Dea in a 2005 Health Education and Research article. "There are many examples of perfectly reasonable and well-intentioned health messages being partially misconstrued or misunderstood by members of the general public, resulting in the inadvertent production of undesirable effects in the implementation of supposedly health-promoting activities."
In a 2006 review of childhood obesity prevention literature, Dr. Margaret B. Brown of the University of Delaware gives us the bullet points: "Well meaning efforts to prevent obesity may unintentionally
- create body image issues even for youth who are not overweight (O’Dea, 2005)
- result in unsupervised weight control attempts which interfere with proper development by limiting energy intake, engaging in vomiting and use of laxatives, and adopting “quick fix” diets and fads (O’Dea, 2005)
- further stigmatize overweight children (Latner & Stunkard, 2003; Strauss & Pollack, 2003)
- result in avoidance of health care visits (O’Dea, 2005)
- leave overweight people and unsuccessful dieters feeling like failures (O’Dea, 2005)
- further victimize low SES parents and children"
So there's that. Which brings us to:
Underestimating the impact of body shame and fat hatred
I'm sure you don't have anything against fat kids, Mrs. Obama. But you know who does? Other kids. And a lot of adults, including parents who see their fat children as reflections of their own failings, as disappointments, as embarrassments, and doctors who see them as problems to be solved. You said in your speech yesterday, "Teachers see the teasing and bullying; school counselors see the depression and low-self-esteem." But your solution to that is to get rid of the fat, not the hate.
And that worries me a lot, not only because I care about the fat kids enduring that torture right now, or because, frankly, I'm not optimistic that any of these interventions are really going to eliminate childhood obesity, or because, generally speaking, it's not ideal to teach kids who are bullied for being different that they should just try harder to be normal. It also worries me because body shame can lead to disordered eating and self-destructive behavior in kids of all sizes and -- are you ready for this? -- it might even make them fatter.
In a 2007 study of over 2,000 teenagers, researchers found that many of the same risk factors -- including teasing about weight -- are predictive of disordered eating, "extreme weight-control behaviors" and overweight itself. It's not just normal weight kids who take unhealthy risks when they're encouraged to freak out about their weight -- it's fat kids, too. Only, as long as they stay fat, people aren't so likely to notice them starving or purging or replacing lunch with a cigarette. "We usually look for these behaviors in very thin girls, but here we see a very high prevalence in overweight girls," said lead author Dianne Neumark-Sztainer in an interview. And considering your goals here, Mrs. Obama, I'd ask you to pay special attention to the fact that being shamed about weight predicts overweight status. Weight-teasing by family members was found to be especially damaging. You think that's going to go down when parents are being lectured at the annual BMI check and made to feel like failures if they can't control their children's bodies?
Says Neumark-Szteiner, "We have seen over the years that it does not work to make people feel worse about their bodies. The data are striking — talking about weight, worrying too much about diet, focusing on it increases risk not only of eating disorders, but also of being overweight." That's why the paper concluded, "Support for a lifestyle that is based around healthful eating and physical activity behaviors, and not around weight per se, may prove to be most effective in decreasing the high prevalence of overweight youth, without leading to an increase in an unhealthy weight preoccupation and disordered eating behaviors." My emphasis. Couldn't resist.
It's all well and good to say you don't intend to shame fat kids or their parents, but the reality is, by framing this as an obesity prevention initiative rather than one with benefits for children of all sizes, by emphasizing BMI over fitness and setting a goal of, quite literally eliminating fat children -- could you send a clearer message to big kids that they're unwanted? -- you're tapping into a deep vein of fat hatred running through this culture.
This is a culture in which fat people can't get health insurance or adequate medical care because of prejudice, where teachers, nurses and medical students report having "very strong anti-fat attitudes," including that "obese people lack self-control and are lazy, obesity is caused by character flaws, and failure to lose weight is due only to noncompliance." And in addition to parents, educators and medical professionals are at the heart of many of the strategies you're proposing. O'Dea writes that the problems of "transference and misinformation" among those people can cause more problems than they solve:
Health professionals may need to examine their own beliefs and attitudes towards fat people and fat children before embarking on any child obesity prevention activities, and they may need specific training in order to undertake any role in child obesity prevention. The potential for inadvertent transference of misinformation, inappropriate advice and prejudice from educator to child needs to be examined during the design of health education and health promotion strategies for the prevention of child overweight. In a recent study of the teachers most likely to be involved in school-based obesity prevention activities, we found a low level of nutrition knowledge and knowledge of weight control, a great deal of misinformation being conveyed from teacher to students, and a very high level of body dissatisfaction and self-reported eating disorders, particularly among the young women teachers.
Children raised to hate and fear fat grow up to become teachers with eating disorders who recommend "strict calorie-controlled diets to their overweight students" and doctors who neglect, misdiagnose and disdain larger patients. As long as fat people remain scapegoats for everyone's fears about overconsumption, illness and mortality, our health will remain at risk because of ignorance and prejudice as well as physical illnesses correlated with obesity. And by framing this as a strategy to eliminate childhood obesity rather than a positive nutrition and fitness strategy for people of all sizes, you're contributing to the problem. You're using people's fear and disgust of fatties to sell this project -- because who could get excited about simply making nutritious food more accessible or increasing opportunities for physical activity because it would be good for all of us? No, history has shown that the public only gets excited about boring stuff like that if you tell them it will rid us of the monstrous scourge of obesity. So hey, who cares if it means more fat kids get bullied by gym teachers and fellow students, and berated by parents who are ashamed of their inability to produce "normal" children, and harangued by medical professionals who think fat is not just dangerous but repulsive?
I'm sorry, Mrs. Obama. I shouldn't get so snippy with you, when it's prejudice and hatred that really anger me. Like I said, I think what you're doing here is great for the most part. But gosh, I wish you'd consider focusing on Health at Every Size instead of childhood obesity.
Sincerely, Kate
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