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Do We Need a 'Fattitude Adjustment?'

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In my public speaking, I routinely note that obesity remains the last bastion of socially acceptable prejudice in our society. I keep waiting for the statement to become obsolete, but it hasn't happened yet.

The very definition of "obesity" in children -- a body mass index at or above the 95th percentile, adjusted for age and sex -- is willfully exclusive, rather than inclusive because we prefer to leave many overweight children out for fear of stigmatization

The official definition places the national prevalence of childhood obesity at around 20 percent. Look around, and ask yourself if you believe it. I don't. I believe it is much higher.

None have done a better job of cultivating awareness of fat bias than my friends and colleagues at Yale University's Rudd Center for Food Policy and Obesity. This is important work, for we have long placed blamed on victims of epidemic obesity themselves, attacking people with the problem as assiduously, if not more so, than we have attacked the problem itself.

Some of you are doubtless already starting to get dubious about where this column is going, thinking that fatness is a tale of laziness and sloth, that staying lean is simply a matter of personal responsibility. Lest I lose your interest, let's address that now.

If you are among those who think this is all a tale of will power, self control, or personal responsibility, consider that we have rampant obesity among children under age 10, and ask yourself this: is there any evidence to indicate that the current generation of children-under-10 has somehow been endowed with less 'will power' or 'personal responsibility' than every prior generation of under-10-year-olds? Is it even plausible? Are we manufacturing seven-year-olds from some new mold?

If not, simply extend the thinking to adults who are, as well, much the same as Homo sapiens ever were. It is the modern environment that is as it never was before. It is powerfully obesigenic. Throughout most of human history, calories were relatively scarce and hard to get, and physical activity unavoidable. We have devised a modern environment in which physical activity is scarce and hard to get, and calories are unavoidable.

That assessment, by the way, does not exonerate us of personal responsibility. At the end of the day, how we use our feet and our forks is up to each of us -- and it is up to us to guide our children to salutary use of these master levers of both weight and health as well. But the environment that dictates our options for their use, and that lays before us the paths of least and greater resistance is not of our own devising. To take responsibility, we must be empowered, and the modern environment is mightily disempowering where weight control is concerned.

In most modern buildings, elevators are far more attractive and easier to find than stairs. The message that sends about societal norms and expectations is unmistakable. My wife and I once went for a walk in Houston (one of America's fatter cities, by the way; Houston, indeed, we have a problem!) and got looks from drivers as if we were extraterrestrials. No one walks in Houston! Even our neighborhood in suburban Connecticut lacks sidewalks.

The food supply is even more disempowering. A dizzying array of claims, often misleading at best, undermine the best intentions of even the most health conscious shoppers. Fat reduced, salt reduced, sugar reduced products are not necessarily better for you, because as that one nutrient is adjusted favorably, several others may be adjusted unfavorably. This is common practice, but the package is mum on the topic. Will power cannot help with this; it requires skill power most people don't have.

All of this can, and will, be fixed. It is what I and many others have devoted our careers to. But, don't hold your breath.

In the interim, our attitudes about fatness -- our "fattitudes," if a neologism will do -- are not just problematic. They are between the proverbial rock and hard place.

While I rail routinely against fat bias, I cannot sign up with the "OK at any size" crowd. The anti-bias goals of organizations like the National Association to Advance Fat Acceptance are laudable, but the connotations in their entirety are not. Because we cannot and should not simply "accept" fat.

This is not a sudden about-face on my part. It's not hypocrisy. We must stop attacking people burdened by the problem of obesity. But we must NOT stop attacking the problem of obesity. Or, to use gentler terminology, we must not stop acknowledging obesity is a problem, even as we strive to stop blaming people for having the problem.

Why so adamant? Because obesity is, among other things, the reason why what I learned in medical school to call "adult onset" diabetes is now called "type 2." What was, less than a generation ago, a chronic disease of mid-life, is now a pediatric scourge. Epidemic obesity is the reason why a 17-year-old boy in Missouri had a triple coronary bypass. It is the reason we will see more of the same, and worse should current trends persist. And that, simply, is unacceptable; current trends cannot persist.

Fat bias is wrong. So is complacency about a societal plague that is propelling our children toward the chronic diseases of mid-life before ever they reach puberty. Between this rock and that hard place, we must find our way forward.

Dr. David L. Katz; www.davidkatzmd.com

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