Our Big Problem - Obesity - Who Will Solve?

The Wall Street Journal recently published Our Big Problem: Obesity penned by a British physician Anthony Daniels, pen name Theodore Dalrymple, who feels that the weight problem is due to fragmentation of families when it comes to meal times. Families don't prepare or enjoy meals together. Fast and already prepared foods dominate the kitchen table. It is simply a consequence of the modern society we live in. He wishes that the fast-paced fragmented American family life will return to the days of home cooked meals and sit down dinners.

He recognizes that this ideal world is highly unlikely. As a result, he suggests that is that government should regulate and restrict further the food we eat. Sugar and fat content of fast foods would be an area of government intervention.

He'd better be kidding. Anyone who has been watching Jamie Oliver's show Food Revolution has seen how well intentioned government regulations on school nutrition can result in very unhealthy food that fulfills the requirements but not healthful. (Is a squirt of ketchup really a vegetable serving?). Government does have a role in society, but will be unable to fix this problem.

Unfortunately doctors can't stop the obesity epidemic either. Recent reports noted that primary care doctors lack the training and resources to address the issue with their patients, even as they feel the responsibility to provide advice. The problem is that in a survey of 290 doctors found that 72 percent had no one in the office trained to discuss weight management. Of the 90 percent of obese patients who were counseled to lose weight about a third of patients noted they weren't told how to lose weight.

Winning the war on obesity won't come from government regulation or somehow getting doctors to be better in educating and counseling patients. It won't be families resorting to a simpler slower pace of life that existed a couple generations ago.

Winning the war on obesity and turning the tide will be due to the same large multi-national organizations that are being vilified. McDonald's top chef, Dan Coudreaut, will impact more lives on a daily basis than any doctor could ever advise over an entire career based on his latest creation which graces the McDonald's menus nationally. The real question is whether our corporations will begin taking on this new social responsibility in keeping our nation healthy or would they rather wish to continue to kill their customers slowly from inside out and dump the health consequences onto an increasingly dysfunctional expensive healthcare system, other employers via escalating premiums, and ultimately destroy US competitveness by creating an unhealthy fatter workforce that is unable to meet the challenges of the future?

Although there will be people quite skeptical about businesses and corporations fixing the problem which they helped create, it appears that this is the case. The Washington Post noted that large food organizations are committed to reduce the calories in existing products, offer healthier selections and smaller portions.

The Healthy Weight Commitment Foundation, a coalition including Campbell Soup, Coca-Cola, General Mills, Kellogg, Kraft Foods and PepsiCo, will slash 1 trillion calories by the end of 2012 and 1.5 trillion calories by the end of 2015. The 16 members make 20-25 percent of food consumed in the United States. The Healthy Weight Commitment Foundation, a coalition including Campbell Soup, Coca-Cola, General Mills, Kellogg, Kraft Foods and PepsiCo, will slash 1 trillion calories by the end of 2012 and 1.5 trillion calories by the end of 2015. The 16 members make 20-25 percent of food consumed in the United States.

This is an encouraging first step. Maintaining a healthy weight is more than asking individuals to choose wisely every meal. It's about helping the public makes the right desired choices by creating products that are healthy, nutritious, and lower in calories. Restaurants and food organizations must lead the way to slow and then reverse the trend.

Otherwise with the status quo, children born since 2000 will the first generation of Americans not to live as long as their parents due to obesity related illnesses like diabetes.

Secret to weight loss is simply: Eat less. Move more. When companies get it right, eating less will be easier to do.

It will be the private sector that begins to solve the obesity problem.

Secrets to Weight Loss -- Part Two -- The Body Doesn't Lie

Now a couple days after Thankgiving, an important concept to remember is the following:


The body doesn't lie.


We've all eaten a little too much. If we've done any exercise, then it is likely standing in line during Black Friday (or clicking the mouse on Cyber Monday). We should not be shocked about some weight gain. Although my patients find it hard to believe, the body doesn't lie and are stunned that they continue to gain weight in subsequent office visits. It can't be due to anything they are doing.


It must be due to a medical problem. Aside from hypothyroidism, low thyroid levels which can be determined by a simple blood test, or other even less common illnesses like Cushing's disease, the reality is that the vast majority of individuals I see who are overweight or obese simply due to their dietary and caloric intake. Simply put, they eat more than they burn.


It isn't necessarily due to a lack of willpower. The majority of patients who are obese (body mass index or BMI of 30 or greater) report to me that they were normal weight at the end of high school. Decrease activity, disability, and pregnancy are some reasons patients are heavier than years past. Many not only are surprised about their weight gain, but also on how difficult it is to lose.


Why is it more difficult to lose? Caloric intake or eaten exceeds that which is expended or burned off. It doesn't take much.


A typical American is supposed to take in only 2000 calories per day. Sounds like a lot, but it isn't. An In and Out cheeseburger with cheese, fries, and a soda is 1100 calories. A Subway 6" cold cut combo, mayonnaise, soda, and chocolate cookie will add another 950 calories. Eat one for lunch and the other for breakfast and one has already exceeded the 2000 calorie daily limit. Not a lot of food.


Many of my patients who work construction don't realize how many calories they eat when going out to lunch. A typical Burger King double whopper with cheese, large fries, and large regular soda equals 1890 calories! Yet, they don't feel like they overeat. Nevertheless, the body doesn't lie and neither does the scale (although many of my patients swear that our office scale isn't accurate).


Portion sizes have increased over the past couple of decades. Despite well meaning public initiatives like having nutritional and calorie information available on menus, it is doubtful that alone will help change behavior. What is needed isn't the calories, but how much physical activity one needs to do to burn off the extra calories.


Image if a slice of pizza came with the disclaimer, each slice requires a 30 minute walk. With activity listed rather than calories, individuals would begin asking themselves whether second helpings, supersizing meals, or even finishing the entire meal (rather than taking it home) would be a good idea.


Since it only takes 3500 calories to equal a pound. Any calories left unused the body dutifully begins storing for a rainy day (which doesn't occur as much industrialized countries as it does other places around the world). Since the rainy day never comes, your increased fat stores result in a heavier weight.


Unless the food and restaurant industry voluntarily decreases portion sizes, then expect more Americans to be heavier and less healthy. Cases of obesity and type 2 diabetes are occurring at an alarming rate. It is expected that children born since 2000, will be the first generation of Americans not to live as long as their parents. While type 2 diabetes affects about 1 in 4 adults over age 65, for children born at the beginning of this century the rate will be 1 in 3.


Is it the food and restaurant industries fault for the obesity epidemic? Regardless of what you believe, it is unlikely that significant changes in health will be the result of those organizations making substantial changes. Americans demand cheap food that is quick and convenient.


So the world is against you in maintaining a healthy weight (or losing weight if you are overweight or obese).


What can you do? Some simple ideas:

• Purchase some frozen lunches / dinners with the Weight Watchers, Healthy Choice, South Beach labeling. Save the containers and use those as your new plates. Don't pack in the food. Don't go for seconds.
• Switch to diet sodas or zero calorie drinks like water or tea.
• If drinking fruit juices, consider diluting the amount with water.
• Never ever supersize anything. Consider having children sized meals or smaller versions.
• Avoid packaged foods like chips, cookies, candies etc., and opt for fruits.
• Hold off on second helpings (and don't simply double the size of the first helping).

Learn more about calories and more importantly how much activity you must do to burn off the calories to maintain or lose weight by reviewing the Portion Distortion quiz by the National Heart, Lung, and Blood Institute and other information by the U.S. Department of Human and Health Services.


Remember, the body doesn't lie.


Check with your doctor if you have special dietary needs or diabetes whether the above dietary adjustments are safe to do. Make the changes permanent. It's a lifestyle change. Don't expect friends or family necessarily to follow suit. It really is building a system that you can do consistently daily in response to a society which encourages more food and calories.


Any other helpful tips or ideas?

Secrets To Weight Loss - Part One

It's disturbing that in the United States, two-thirds of Americans are either overweight or obese. As a doctor, it is one of the most common problems I address, even if a patient doesn't ask me to. Got a cold? Feeling stressed? Want a physical? Rolled your ankle?

Has anyone ever discussed your weight? Are you concerned about your weight? What have you tried for weight loss? What did you find successful?

In this series, I'll reviewed my discussions with patients so you understand what it will take to lose weight and keep it off.

Losing weight is hard work and frankly can be a difficult and lonely experience since the majority of Americans are overweight or obese. The problem of heaviness in this country is only becoming worse.

First some basic concepts. Overweight is defined as a body mass index or BMI greater than 25 and less then 30. Obesity is a BMI greater than 30. Morbid obesity is a BMI greater than 40. Calculate your BMI. Although BMI isn't perfect, unless you are a high performing athlete (not a weekend warrior) and have significant muscle mass, BMI is a reasonable way of determining which category you fit into.

Second, the body does not lie. Unless you have some sort of medical problem like a low functioning thyroid (hypothyroidism) or other less common hormone problem, your body does not lie. If you eat exactly the same amount as you burn, then you will not lose or gain weight. Eating less and burning more consistently will cause weight loss. Eating more and burning less will result in weight gain. Simple concept. What goes in must equal what goes out to maintain weight. Any alteration in this simple equation causes weight loss or weight gain. The body does not lie.

Third, I don't think you overeat to the degree you think I do. Patients invariably tell me that they eat very little and certainly a lot less than their friends or family. While I know individuals aren't eating a Thanksgiving dinner or eating an entire large pizza for lunch daily, weight loss requires a caloric intake less than the output. Note the previous point the body does not lie. If a person did eat a lot, he would continue to gain weight, not maintain.

Fourth, you need to understand basic math. Know this number. 3500. An addition of 3500 calories equals one pound. If your body has 3500 calories left over, then you gain a pound. Burning 3500 calories, then you lose a pound. Sounds like a lot of calories, doesn't it? But it's not. If you drank a can of regular soda daily (and yes, diet doesn't count as it has zero calories), then that is an extra 130 calories per day. In 27 days less than one month you would gain a pound (3500 / 130 = 27). In one year you would be 12 pounds heavier.

Fifth, think of calories as money and your weight as a savings account. Your savings account goes up or down depending on how much you save. Put more into the bank and withdraw less? More in your savings account. Taking out more than you put in, the amount in the savings account falls. Your bank doesn't care if you deposit $100 in pennies or in a crisp C-note. Skipping the discussion of nutritional value, your body doesn't care if the 2000 calories you are supposed to ingest comes all via salad greens or the equivalent of a box of chocolates. Money is money. Calories are calories regardless of how you get them.

Sixth, your body is built for survival and isn't stupid. Go back to the previous point. Your weight is a savings account and to keep it level what goes in equals what goes out. If all of a sudden, your income gets cut then to make ends meet you must take withdrawals from your bank account. If the income doesn't return to previous levels, then the savings account continues to get smaller.

Faced with this situation of being unable to restore deposits to previous levels, would you continue to spend as much? Of course not. To avoid bankruptcy you would make hard choices like downsizing your expenses and making adjustments. As a result you slow down the outflow of money so that eventually the amount that you spend is equal to the new decreased amount coming in.

Your body is built for survival and isn't stupid either. Faced with a budget crisis, that is a diet where calories coming in is less than what is burned, initially the body hasn't had adequate time to make adjustments. It depletes its savings resulting in weight loss. But since it is built for survival, it will make adjustments necessary to that its expenditures exactly made your diet. You no longer lose weight. Your body doesn't know whether it is on a desert island or living in the United States where food is plentiful, but all it knows is that its caloric budget was cut. It needs to keep you alive until it can find its next meal. Adjustments are made. Weight loss stops. Naturally, it will deplete fat first, then muscle. So don't worry about that being a reason not to being weight loss.

Seventh, the vast majority of patients I see weren't overweight or obese to being with. Weight gain typically occurred after high school or college, job change which was less physically demanding, after pregnancy, and as they got older. Sadly this isn't the case today where children are increasingly obese and will be the first generation of Americans not to live as long as their patients because of weight related medical problems.

Finally, the success to long term weight loss is permanent reduction in calories and increase in physical activity. It's not a diet but a lifestyle change. You can lose weight in the short-term with fewer calories, which is the reason why gastric bypass works. However, long-term weight loss requires physical activity.

Save money on medical care, prescription drugs, and more

A new year means a new opportunity to do better. This year, in particular with a new president, there has been a lot of talk about healthcare reform. Even under the most optimistic situation , if legislation passed tomorrow , significant changes would still be years away. What can you do to make sure you are around and not bankrupt to see these reforms occur? Healthcare and medical expenses are the leading cause of personal bankruptcy. Do the following:

• Get preventive screening tests done. Even if you feel well, find out what tests you should get done even if you feel well. You do get routine maintence for your car don't you? Why? So it doesn't break down. Well how about your body?
• Pick a primary care doctor to be your healthcare advocate. Either an internist or family doctor will do. Research consistently shows patients who have a primary care doctor coordinate care and who is the first logical step to access the healthcare system not only are healthier but also spend less to get there.
• If you need medications, always insist on generic medications. They aren't inferior. They are medications that previously were branded but no longer have patent protection. This means other pharmaceutical companies can manufacture the medications resulting in decrease prices. Recent generic medications over the past few years include allergy medications CLARITIN, ZYRTEC, cholesterol lowering medication ZOCOR, and heartburn medication - "the purple pill" PRILOSEC. Notice how before they went generic, companies plastered the airwaves and print with advertising. Now that they are generic, no one seems as enthusiastic, yet the medications work just as well for a lot less.
• Consider getting medications at Wal-mart or Target. At $4 copays for many generic medications and $10 copays for a 3 month supply, these are often cheaper than the plans offered by insurance companies.
• Eat less. With the economic crisis, people are more careful with their money. With 2/3 Americans already overweight or obese, changing your diet by eating less not only might save money, but also help you get healthier. Fewer calories in means less likely to add weight. It takes 3500 calories to equal 1 pound.
• Invest in walking shoes or other cheap forms of exercise. Forget the gym, unless you already do it regularly. Go for a regular walk. Realize that a 30 minute walk only burns about 200 calories, which means to lose weight, not only do you need to move more but also eat less.
• Quit smoking. Drink in moderation (if you want to).

With all of these tips, not only will you improve your physical health, you might also help for financial health. By being healthier, you might be around long enough to see true healthcare reform and not be bankrupt in the process.

Full Disclosure - Calorie Counts

The New York City Health Department had a press release announcing their campaign in making the public aware of the number of calories individuals should have daily to maintain a healthy weight. Dubbed "Read ’em before you eat ’em" and with ads in NYC subways, the health department is trying to make aware how portion sizes have increased.

Recently California Governor Arnold Schwarzeneggar signed into law a proposal which requires restaurants operating more than 20 sites to have calorie counts posted on the menus by 2011, becoming the first state in the union to do so.

Will calories displayed prominently help consumers make wise decisions about their eating habits and decrease the numbers of individuals who are now overweight or obese? While both the NYC and California proposals are excellent (and note that the restaurant industry is fighting the NYC plan and yet seems on board with the California one), perhaps they could take it a step further and indicate how much activity it takes to burn off calories. After all, calories are simply numbers. To make people fully appreciate their caloric intake, illustrate how much time and what type of exercise would be needed to burn off a muffin or hamburger.

Since few of us have free time, if these groups showed us that we needed to exercise for four hours to maintain our weight, I'm sure most of us would be much more careful about how much we eat. After all, who has four hours to exercise everyday?

Michael Phelps' Diet - Don't Try This at Home

Like everyone else, I've been in awe of Michael Phelps' accomplishments at the Beijing Olympics with his unprecedented eight gold medals at a single olympic game. Certainly, it doesn't hurt that he appears to be a team player, grounded, as well as being hypercompetitive.

What is more fascinating is the amount of calories he ingests daily to keep up with his training regimen. If anyone of us tried to eat the same amount he does, we would gain about 3 pounds per day and definitely would not have his sculpted physique!

He has 12,000 calories per day. A typical American is supposed to have 2,000 calories per day. Given the increasing numbers of obese children and adults it would be safe to assume many of us are exceeding that suggestion.

For breakfast he has:

• three fried-egg sandwiches loaded with cheese, lettuce, tomatoes, fried onions and mayonnaise.
• two cups of coffee
• a five-egg omelet
• a bowl of grits
• three slices of French toast topped with powdered sugar
• three chocolate-chip pancakes

And that's just breakfast!

As a quick reminder, it takes about 3500 calories to equal a pound. So for those of us who are inspired to lose weight, a brisk 30 minute walk uses about 200 calories. Therefore, if one walks this amount three times a week for a total of 600 calories, it would take six weeks to lose one pound! It's no wonder weight loss is so difficult.

Of course, you could do what Michael Phelps does and swim his intense training schedule where he burns 4,000 calories per day!

The Myth of Moderate Exercise

A recent article in Time magazine titled "The Myth of Moderate Exercise" I hope catches the attention of the public. It shows why moderate exercise, that is 30 minutes of activity most days of the week, is NOT enough to lose weight. It is no wonder why so many people feel frustrated they aren't losing weight fast enough. With the obesity problem now prominent among children as well as adults, it is important we all learn the following.

Although it is clear that more physical activity not only helps lose weight, but also it is important that the increased activity is sustained lifelong to maintain the weight. Calorie restriction also helps immensely as well. The trick also is that is too must be lifelong.

Find out how much activity you must do if you eat certain foods by reviewing the fun, interactive, and eye-opening experience Portion Distortion Quiz.

If we as a country are going to be healthier, then we all need to realize that the way to lose weight and keep it off is simply and as hard as eat less and move more.

What is Your Waist Score?

The NY Times reports that in Japan companies and local governments will need to measure waist sizes of their population. Those considered "metabo" or overweight will be educated on how to lose weight and then measured later. If they still aren't at healthy weight, the companies and governments will be charged more for healthcare costs. (Japan has a publicly financed healthcare system).

It will be interesting to see how this program will do. Will people be healthier because the entire nation is focused on not being “metabo”, the preferred Japanese word for overweight? Will companies and local governments, who are responsible for measuring waist lines and ultimately financial penalties if their population, help change the lifestyle in Japan to be more healthful? For example, if your company produces food for the nation, do you promote smaller serving sizes? If you are a local government, do you greenlight more parks and neighborhoods that promote physical activity? Measuring waistlines gives us a starting point and a proxy of the health of a nation.

What will be fascinating to see is what they do with that data. It will be more, however, than simply re-educating people. We all should know that being overweight or obese, which is the status of 2/3 adult Americans, is not healthy, but the challenge is how do we make our increasingly hectic 24/7 lifestyle more supportive for staying active and eating well?

We're 42nd! We're 42nd! We're 42nd!

An analysis by a team from Harvard Public Health found that life expectancy not only may have hit a peak, but for many Americans has fallen.

Counties in the South found that more deaths were due to risk factors like smoking, obesity, and high blood pressure which caused more cancers, emphysema, and diabetes. Obviously the causes could be multifactorial. Certainly the counties with worsening life expectancy were poorer. Do those individuals have adequate health insurance or ability to get preventive healthcare? Do they have access to healthy food choices like fruits and vegetables? Can they afford them? Is there access to parks and other forms of recreation that allow physical activity or are the areas devoid of them and instead require people to drive more?

As the nation with the most financial and intellectual resources, we should do better than a life expectancy of 42 in the world. Increasingly, our country is becoming into two Americas, those that reach their full potential and those that are left behind. We need a serious system overhaul.

From the article:

• Last September, the U.S. Centers for Disease Control and Prevention reported that U.S. life expectancy had risen to almost 78 years in 2005 -- up from 75.8 years in 1995 and 69.6 years in 1955. The United States ranks around 42nd in the world in life expectancy.
  
• "The majority of these counties were in the Deep South, along the Mississippi River, and in Appalachia, extending into the southern portion of the Midwest and into Texas," Ezzati's team wrote.
• "One of the questions we are asking is whether our ranking in the world is getting increasingly worse because we are not doing a good job of taking care of the worst-off," Ezzati said.
• "Life expectancy decline is something that has traditionally been considered a sign that the health and social systems have failed, as has been the case in parts of Africa and Eastern Europe," said Christopher Murray of the University of Washington, who worked on the study.
• "The fact that is happening to a large number of Americans should be a sign that the U.S. health system needs serious rethinking."
• The study is available at http://medicine.plosjournals.org/perlserv/?request=get-document& doi=10.1371/journal.pmed.0050066.

Knowing How To Reform Healthcare Is Easy. Doing Is Hard.

Like most things in life there is a big difference between knowing and doing. Most of us know what to do to stay healthy. Don't smoke or quit smoking. Exercise regularly. Eat a diet balanced with all of the different food groups in reasonable portion sizes. Maintain a healthy weight. Get screened for various medical problems early. One study suggested that doing these simple interventions extended life by 14 years!

Yet despite these seemingly boring yet simple lifestyle changes, there obviously there is gap between knowing and doing. About two-thirds of Americans are either overweight or obese. This trend is now affecting children. We all know what to do, but often it is we don't go about doing it.

The same applies to healthcare reform. A recent editorial in the NY Times noted that the cost of providing high quality medical care varied substantially among hospitals. The least costly were the famed Mayo Clinic and the Cleveland Clinic. The most expensive? UCLA, John Hopkins, and Mass General. The reason was that doctors at the most costly hospitals were paid fee for service. Do more and get paid more. On the other hand, doctors at the Mayo Clinic were on a salary. Health outcomes were the same. If all hospitals performed at the level of Mayo Clinic, then Medicare would save billions.

At the same time an article on the Wall Street Journal blog noted that a congressional advisory committee recommended that Medicare should pay primary care doctors more and less to specialists because of a shortage of primary care doctors, which if unresolved will result in increasing healthcare costs and worsening outcomes. In other words, pay primary care doctors more but have specialists be reimbursed less for each procedure. What will happen? Specialists will do more procedures to maintain their standard of living.

If Mayo Clinic can attract doctors and patients to their system. If doctors are salaried and patients do as well at less cost, then doesn't it make sense to have doctors paid to think instead of simply doing procedures?

Dutch Study Suggests that Obese Patients Cheaper to Treat

A Dutch research study found that perhaps over the long-term smokers or obese patients are less expensive to treat than thin and healthy individuals. Although many have assumed that addressing obesity and smoking would save money, this study suggests otherwise. Researchers believe that obese patients, who had more cases of diabetes, and smokers and diabetics, who had more cases of heart disease, died sooner. Those that were healthy lived longer but suffered from debilitating illnesses like Alzheimer's or strokes which in the long run ended costing more. Findings were as follows:

• healthy people lived 84 years, cost from age 20 on about $417,000
• smokers lived about 77 years, cost about $326,000
• obese people lived about 80 years, cost was $371,000

What does this mean? A couple of caveats. First, the research was done on Dutch data, both on how common various diseases were as well as the cost of illness. These values don't necessarily mean the same result would occur in the United States. Since the Netherlands ranks better than the United States in keeping people healthy, it is likely that even the healthy group doesn't live as long as we would expect. The second caveat is perhaps an intervention needs to be made for those that are thin and healthy to prevent them from having strokes and Alzheimers.

Is Obesity a Lifestyle Choice?

A new book, "The Fattening of America", suggests that obesity is a lifestyle choice. From the article:

* "Obesity is a natural extension of an advancing economy. As you become a First World economy and you get all these labor-saving devices and low-cost, easily accessible foods, people are going to eat more and exercise less," health economist Eric Finkelstein told AFP.
* "When you have a first-rate medical system that can cure the diseases that obesity promotes, you no longer need to worry so much about being obese," he told AFP.
* "People make choices, and some people will choose a weight that the public health community might be unhappy about. Why should we try to make them thinner?" Finkelstein said.

I have a couple of problems with the above comments. While clearly more Americans are overweight and obese than previous generations. I doubt that it people are choosing an unhealthy weight. The issue is that the environment around them, specifically the food options are far larger in size and loaded in calories than in the past. Check how serving sizes have changed over the past two decades by taking the Portion Distortion quiz.

In my experience, many of my patients who are obese actually didn't have a weight problem as a young adult (i.e. high school graduate), but years later. The most common cause was inactivity and eating too much (i.e. supersizing everything). Many didn't see much of a problem until I calculated their body mass index.

A first-rate medical system does undoubtedly fix the problems caused by obesity. A first-rate healthcare system, however, should prevent the obesity problem to begin with. Unless we focus on keeping people healthy instead of treating the problems after they have occurred, the next generation of Americans will be the first not to live as long as their parents.

War on Obesity - at the Workplace and School

A report in the journal Circulation found that around the world, except for East Asia, the majority of individuals are overweight or obese. The study looked at nearly 170,000 patients across 63 countries, but excluding the United States, to see if their body mass index was in the overweight or obesity range. The report was somewhat skewed as the researchers look that those individuals who were seeing their primary care doctor.

Researchers found that of men 24 percent of men were obese and 30 percent were overweight. For women the numbers were higher at 27 percent of women were obese and another 40 percent were overweight.

These results are not surprising as many countries are opting the Western lifestyle of fast food and inactivity. It is unfortunate that one of our country's major export is to make people fatter.

Perhaps stemming the tide of this international epidemic of obesity will rely on innovative programs that are occurring in the workplace and at schools in the United States. Increasingly employers are trying to slow their health care costs by encouraging employees to quit smoking or lose weight. A few have actually terminated individuals who were found smoking. More Americans feel that those who adopt unhealthy habits should pay more for health insurance than those who are healthy.

The other area of opportunity is changes in food options available to school children. A CDC report found that the number of schools that offered french fries as their only vegetable fell by half from 40% in 2001 to under 20% in 2006. Schools are removing sodas and other junk food from their vending machines and cafeterias. Physical education programs, once cut because of inadequate funding or time due to additional academic requirements, are being re-introduced to get students more active.

Providing environments that are supportive of healthy choices and lifestyles may help current and future generations avoid the overweight and obesity problems currently plaguing too many individuals.