Perspectives in Health Magazine The Magazine of the Pan American Health Organization Volume 7, Number 3, 2002

You’re in your car at the intersection of University Ave. and N. Mesa in El Paso, Texas, less than a mile from the U.S.-Mexico border. Suddenly your stomach growls, your mouth waters and you feel a strong craving for something to eat. No problem. Just a block up the street is Taco Bell, where this week’s special is the ‘Extreme Quesadilla’ for only $1.24. There’s a drive-through window, so you don’t even have to get out of your car.

If you’re not in the mood for Mexican, no matter. There are four or five convenience stores within half a mile offering everything from doughnuts to 44-ounce soft drinks and one-third-pound hot dogs, all at bargain prices. A bit farther, but only a couple of minutes by car, are Arby’s, Burger King, Jack-inthe- Box, McDonald’s and Wendy’s—not to mention Pizza Pro’s, Peking Garden, Wienerschnitzel and Rib Hut.

For Jose Roman, a 72-year-old pediatrician who has practiced for four decades in this west central El Paso neighborhood, the culinary abundance is much more a bane than a blessing. "Every three blocks you see restaurants advertising large portions at low prices," he says. "Two burgers for 99 cents." He and others are convinced it’s one of the reasons El Pasoans are getting fatter every year.

The trend is a disturbing one, and it is readily evident in Roman’s young, mostly Mexican-American patients. The number of obese children in his practice has increased dramatically, he says, particularly in the last five to 10 years. "Probably 20 to 30 percent of the children I see each month are significantly overweight."

The problem is even worse among adults, according to Muriel Hall, executive director of the El Paso Diabetes Association. "El Paso stands above many other communities in being chunky," she says.

In fact, however, El Paso is not alone in having what public health advocates describe as an epidemic of obesity. In the United States as a whole, the latest data show that two out of three adults are overweight, and nearly one in three is obese. What is more alarming, similar trends are emerging around the world, in both developed and developing regions. In countries as diverse as the Czech Republic, Finland, Germany, Kuwait and Jamaica, at least half the population is overweight and one in five is obese.

The health impact of this obesity pandemic can be seen most clearly in fast-rising rates of Type 2 diabetes, for which obesity is the main known risk factor. According to the Brussels-based International Diabetes Federation, the number of diabetics worldwide has grown to more than 150 million, a fivefold increase since 1985.

Obesity is also known to put people at higher risk of other serious health problems, including cardiovascular disease, arthritis, gallbladder and kidney disease, and cancers of the breast, colon, uterus, esophagus and kidneys. In the United States alone the direct health care costs of obesity now exceed $100 billion a year, according to the American Obesity Association.

Add to this the social stigma, psychological distress and economic discrimination often suffered by the obese, and the costs are heavy in terms of both health and quality of life.

"The combined impact of obesity and weight-related illness is in fact as great as if not greater than tobacco," says Neville Rigby, director of policy and public affairs for the London-based International Obesity Task Force. "We need to approach the obesity issue with the same degree of concern and vigor."

A global race

The spread of the obesity epidemic to a growing number of countries and the rapid rates of increase in recent years are what have public health advocates worried. Last year the Washington-based World-Watch Institute reported that, for the first time in history, estimates of the number of overweight people in the world rival estimates of those who are malnourished. In its 2002 World Health Report, the World Health Organization (WHO) ranked obesity among the top 10 risks to human health worldwide.

The epidemic has been well documented and extensively studied in the United States, where as early as the 1960s nearly half of Americans were overweight and more than 13 percent were obese. Today some 64 percent of U.S. adults are overweight and 30.5 percent are obese. That is double the obesity rate of two decades earlier and one-third higher than just 10 years ago.

But the United States is not even the leader in the global race to national corpulence. That distinction is held by Samoa, where two-thirds of all women and half of men are obese. In the Americas, Canada trails somewhat behind the United States, with 50 percent of adults overweight and 13.4 percent obese. But data from Argentina, Colombia, Mexico, Paraguay, Peru and Uruguay show more than half of these countries’ populations are overweight, and more than 15 percent are obese.

Even more disturbing, the trend is growing among the Region’s children. Twice as many U.S. children are overweight now than were two decades ago. In Chile, Mexico and Peru, an alarming one in four 4- to 10-year-olds is overweight.

Walmir Coutinho, professor of endocrinology at the Catholic University of Rio de Janeiro and coordinator of the Latin American Consensus on Obesity, notes that rates of childhood obesity increased 66 percent in the United States during the last two decades, but a whopping 240 percent during the same period in Brazil.

"Obesity and overweight are increasing much faster in Latin America than in North America or Europe," he says. "They are fast replacing hunger and malnutrition as contributors to mortality."

The growing body of public health literature on the "globesity" epidemic places the bulk of the blame not on individuals but on globalization and development, with poverty as an exacerbating factor.

In what experts term the "nutrition transition," societies everywhere are moving away from traditional local foods and methods of preparation to mass-produced processed foods that are generally higher in fat and calories and lower in fiber and micronutrients, particularly iron, iodine and vitamin A.

The issue is not just junk food. A large part of the problem is economic. In general, mass-marketed foods are getting cheaper, particularly in urban areas, while fresh foods are becoming more expensive.

"In Latin America, maybe you can go to the jungle and pick your own fruit, but in the city, in supermarkets, fruits and vegetables are expensive," says Enrique Jacoby, an expert on obesity at the Pan American Health Organization (PAHO). Flipping through pages of country data, he observes: "In lots of countries, you can see the increases in consumption of cooking oils, sugar, sweetened drinks and cereals, primarily rice and noodles, while consumption of fruits, vegetables and legumes is going down. Having a big wallet makes a difference. The poor are forced by their limited resources to eat less healthy foods."

Along with this nutrition transition, improvements in technology and the evolution of the modern metropolis have created an "obesogenic environment" in which new patterns of work, transportation and leisure have people around the world leading less active, more sedentary lives.

"Even lower income groups have growing access to conveniences such as television, telephones and cars," says Coutinho. "These predispose people to sedentary habits and are leading to dramatic changes in lifestyle that contribute to the problem."

North meets South

In El Paso, a culturally blended city of 560,000, the largely Mexican-American population is experiencing its own nutrition and lifestyle transitions that in some ways reflect trends in both the developed and the developing world. The results are high rates of overweight and obesity, along with negative health consequences such as diabetes.

PAHO's U.S.-Mexico Border Office in El Paso collected local data on overweight and obesity as part of a study of diabetes in the border region. The results showed that 67.8 percent of women and 76.6 percent of men in the border area are overweight or obese.

Darryl Williams, director of the Office of Border Health at Texas Tech University Health Sciences Center, is one of a dedicated group of local academics and health professionals who are studying the city’s weight-related health problems and ways to address them. Williams attributes part of the obesity epidemic to the possibility that "Mexican-Americans may have a genetic predisposition." He cites the socalled "thrifty gene" theory, which holds that some groups have an inherited tendency toward weight conservation that in earlier contexts increased the chances of survival, but that in modern urban settings leads to high rates of obesity.

But cultural and other exogenous factors seem to be at least as, if not more, important. Williams notes that the average El Pasoan’s daily diet is high in whole milk, soft drinks and refined carbohydrates such as white rice and tortillas, but notably low in fruits and vegetables. Indeed, at least one study shows the city as having one of the lowest levels of fruit and vegetable consumption in the United States.

Williams also faults restaurant and fast food and what he terms "shifts in portion size…it used to be a small Coke, now it’s 48 ounces for the same amount of money." The technique, known as "value marketing," is used to increase sales by making consumers think they’re getting a bargain. Even worse, says Williams, are El Paso’s favorite all-you-can-eat buffet restaurants, where patrons inevitably "feel obliged to get their money’s worth."

Coupled with El Pasoans’ poor eating habits are what Williams and others see as the increasingly sedentary lifestyles of most of the city’s residents. In a study of childhood obesity in the region, Williams says he expected to find higher rates among children living in El Paso’s poorer neighborhoods, the colonias, since overweight and obesity are inversely related to income in most of the United States. Contrary to expectations, he found no significant differences between the colonias and better-off sectors. What did appear as significant was the age at which obesity kicked in.

"In both boys and girls, when they tracked weight and growth, it was normal up to age 7, then there was a problem with obesity. What is clear is that something happens when they go to school," he says.

Williams believes that a key factor may be the "change in activity levels at school." He notes that physical education, once emphasized in U.S. public schools, is now given lower priority. Moreover, "when kids go home, they’re not very active either. It’s all TV watching and video game playing." Especially in the colonias, says Williams, there are few parks or other facilities that promote physical activity. And with summer high temperatures in the mid-90s, air conditioning keeps many El Pasoans—adults and children alike—indoors.

Juan Carlos Zevallos, director of the Diabetes Research Center at Texas Tech University Health Sciences Center, cites similar factors. His recent research on childhood and adolescent obesity and diabetes on both sides of the border found that more than half of the region’s children watch three or more hours of television daily, while a quarter watch upwards of four hours. "And that’s not including Nintendo," he adds.

Aggravating the situation, particularly for adults, is the fact that El Paso, like many other cities, is largely a product of unplanned urban sprawl. Walking and biking are simply not practical ways of getting around. Moreover, "our public transportation is terrible," says Zevallos. "You need a car—you need your own car."

Zevallos and other members of El Paso’s public health community are doing more than studying the city’s obesity problem. They are working to curb the trends through health promotion efforts, some of the most promising of them aimed at children.

One of these is an obesity prevention program known as El Paso CATCH (Coordinated Approach to Child Health), based on a national program of the same acronym. Funded with $5.6 million in grants from the local Paso del Norte Health Foundation, the program promotes active lifestyles and healthy eating among schoolchildren and has been implemented in more than 100 El Paso–area elementary schools.

Karen Coleman, a specialist in childhood obesity and assistant professor of health psychology at the University of Texas at El Paso, evaluated the program and considers it a success. In its first year, CATCH managed to boost moderate-tovigorous physical activity more than 50 percent and reduce the fat content of school lunches to less than 30 percent of total calories. Now rates of overweight in El Paso CATCH schools are lower than those recently reported among Mexican-American children at the national level.

"I think dealing with it in children is the key," says Zevallos, "because one of the greatest risk factors for being an overweight adult is being an overweight adolescent. But you can’t just deal with the kids; you have to deal with the mindset of the families and the schools."

Pediatrician Jose Roman agrees. He notes that in El Paso’s schools, many cafeteria workers, teachers and administrative staff are themselves overweight or obese. They also tend to be staunch members of the "clean-plate club."

"School lunch programs are designed to get kids to eat more, not to eat healthily," says Roman. "They’re told, ‘you have to eat all your food.’ We’re pushing food on children."

Roman notes that El Paso parents tend to be even more difficult targets than schools. Most Hispanics grow up believing that fat children are healthy children, he says. "The more they eat, the better the parents feel. Parents are afraid to limit what their children eat."

Beyond the soft touch

While prevention programs such as those in El Paso hold promise, they may not be enough to counter the fast-growing worldwide epidemic of obesity. Rigby, of the International Obesity Task Force, says the "soft approach of more education about food at school and encouraging exercise" is no longer enough. "We need to tackle the root causes with ambitious initiatives to counteract the huge changes we’ve seen in recent years."

A key target of this newer get-tough approach is the multibillion-dollar global food industry. Critics argue that the industry’s advertising, marketing and pricing practices actively promote excessive consumption of high-calorie, low-quality foods. To counter the trends, Rigby and others are urging such measures as requiring nutritional information on restaurant and fast-food menus. They also favor restrictions on advertising, particularly ads aimed at children, and using public pressure to make the food industry "part of the solution."

"In Europe, McDonald’s stopped using transfatty acids years ago because Europeans wouldn’t stand for it," says PAHO’s Jacoby. "Now, in the U.S. they’ve promised to do the same."

Others have called for placing so-called "fat" or "Twinkie" taxes on unhealthy foods and using the revenues for counter-advertising or subsidies on healthier foods. Supporters cite studies showing that people will opt for healthier foods over unhealthy ones when the price differential is significant.

Advocates are pursuing these issues at both the national and global levels, working to incorporate them, for example, into international trade talks under the auspices of the World Trade Organization. The parallels with anti-tobacco efforts are clear, but many hope the multinational food industry will be more cooperative toward such efforts than the tobacco industry has been.

"Unlike tobacco, food itself is not a poison," notes Jacoby. "It’s just a question of quality and the amount that’s consumed. So there is real potential for cooperation with industry."

Rigby agrees: "The idea of public health collaboration with the food industry isn’t really new. We’ve had iodine-enriched salt, for example, and some sectors of the food industry have espoused the idea of sending out public health messages as part of their product marketing….But a large part of the processed foods we eat today are still part of the problem and not yet part of the solution. So we are challenging the food industry to deliver truly healthy options—not just to niche markets, but to all consumers."

At least as difficult a challenge is finding ways to address the other side of the obesity equation: energy expenditure through physical activity.

"There are already too many megacities and urban environments where the car is king and it is impossible for people to get around easily on foot or bicycle," says Rigby. "We need to create physical town environments that sustain and support good health." This means incorporating the "healthy cities" approach into urban planning, promoting parks, bike paths and pedestrian malls; restraining suburban sprawl; increasing funding for public transportation; and making car use less attractive and less necessary.

Getting countries around the world to sign onto such an ambitious agenda may require a rethinking of what constitutes a higher standard of living, akin to the increasing acceptance of the idea that economic development must be socially and environmentally sustainable. "It is tempting for developing countries to believe that much of the environmental change that produces the huge public health burden of obesity is inevitable," says Rigby. "It is our job to persuade them that they can act now to steer a different course."

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