Obesity

Obesity is a complex issue impacting every segment of the population and having many roots. The drivers and health effects of obesity are not fully understood but may be contextualized within the United States’ transition from a farm-based to an industrialized economy. Arkansas consistently ranks as one of the most obese states in the United States. Historically, most efforts to combat obesity have focused on individual-level interventions. Arkansas Act 1220 of 2003, which created the Child Health Advisory Committee, was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity by focusing on creating healthier public school environments. Similar initiatives have proliferated since obesity has become a global health issue.

Although widely discussed as a major risk factor of disease, obesity was not officially recognized as a disease until deemed such by the American Medical Association in 2013. Obesity has been linked to heart disease, stroke, type 2 diabetes, and certain cancers, among other conditions. The estimated annual medical cost attributed to obesity in the United States is $147 billion. According to the Centers for Disease Control and Prevention (CDC), data from 2015–16 showed that more than one-third (39.8%) of U.S. adults have obesity. Hispanics (47%) and African Americans (46.8%) have the highest prevalence of obesity, followed by whites (37.9%) and Asians (12.7%). The relationship between obesity and income, and obesity and education, were shown to be complex, differing among population subgroups. Overall, men and women with college degrees had lower obesity prevalence than those with less education. By race/ethnicity, the same obesity and education pattern was seen among white, black, and Hispanic women, and also among white men, although the differences were not all statistically significant. For black men, obesity prevalence increased with educational attainment, although the difference was not statistically significant. Among Asian women and men and Hispanic men there were no differences in obesity prevalence by education level. Among men, obesity prevalence was lower in the lowest and highest income groups compared with the middle income group. This pattern was seen among white and Hispanic men. Obesity prevalence was higher in the highest income group than in the lowest income group among black men. Among women, obesity prevalence was lower in the highest income group than in the middle and lowest income groups. This pattern was observed among white, Asian, and Hispanic women. Among black women, there was no difference in obesity prevalence by income. Lower levels of income and education are not universally associated with obesity; the association is complex and differs by sex and race/ethnicity.

Interestingly, the concern over rising weights in America has coincided with a change in the method for determining who is overweight. Obesity in the United States began to be spoken of as a serious public health concern after 1980, when age-adjusted mean body-mass index (BMI)—a simple formula of weight over height squared—increased significantly, leveling off after 2000. Prior to 1998, a BMI of 27.8 was considered overweight for men, while a BMI of 27.3 was considered overweight for women. In 1998, millions were made officially overweight overnight when the National Institutes of Health (NIH) lowered this standard to 25 for both men and women, meaning a BMI between 25 and 29.9 made a person overweight, with 30 marking the start of the obese range. According to the NIH, the change was made because of studies linking extra weight to health problems. However, some argue that BMI, which does not account for muscle or bone mass, is oversimplified and should not be used as a barometer for health.

The dominant view of obesity holds that it is costly and extremely harmful to people’s health. Law professor and attorney Paul Campos was among the first authors to challenge this idea in his book The Obesity Myth: Why America’s Obsession with Weight Is Hazardous to Your Health (2004). Other health professionals and scholars have questioned the obesity epidemic, pointing to the ways the diet, fitness, and medical industries profit significantly from the widespread cultural fear of fat. The National Association to Advance Fat Acceptance (NAAFA) attributes positive meanings to the term “fat” and fights discrimination.

The reasons for why obesity has increased during the last couple of decades have yet to be firmly established, and the underlying causes are not fully understood. The twenty-first-century rise of obesity may be situated within the twenty-first-century movement from a farm-based to an industrialized economy. Many scientists attribute the uptick in obesity to changes in environmental conditions, such as the abundance and cheapness of food combined with a lack of physical activity, as technology has made it possible to be productive while largely sedentary. Michael Pollan, author of the New York Times bestselling The Omnivore’s Dilemma: A Natural History of Four Meals (2006), argues that the government’s subsidizing of certain crops, such as corn and soybeans, promotes their overuse and makes cheap, unhealthy foods mainstays in America, thus contributing to obesity. Likewise, endocrinologist Robert H. Lustig argues that the food business promotes processed foods loaded with sugar and is the main driver of obesity. Others emphasize the poverty-obesity link and impact of built environments, pointing out that high-calorie, low-nutrient foods tend to be cheaper than healthy foods, and that “leptogenic” (thin) neighborhoods tend to be wealthy while “obesogenic” (obese) neighborhoods tend to be poor. Some obesity scholars ask whether being poor causes one to have obesity or if having obesity makes a person poor, highlighting the role of discrimination and stigma toward obese people. Sleep deprivation and stress have also been linked to obesity. Elevated cortisol in the body caused by stress is associated with visceral fat accumulation (mainly around the mid-section), which has the most harmful health effects. Professor and author Julie Guthman argues that exposure to environmental “obesogens” may be contributing more to obesity than eating too much or exercising too little. Obesogens include endocrine-disrupting chemicals (EDCs) and various environmental toxins in food processing and packaging. Guthman stresses the importance of addressing capitalism’s excesses through policy change to improve Americans’ overall health.

Arkansas consistently ranks as one of the most obese states in the United States, having an adult obesity rate of about thirty-five percent, which is only slightly lower than the national average of about forty percent. Results from the Arkansas Center for Health Improvement (ACHI) Body Mass Index Program show that twenty-two percent of all public-school-aged children were classified as obese in 2016–17. Arkansas’s poverty, rurality, prevalence of food deserts, and low rate of educational attainment, which have been correlated with obesity—combined with the strengthening forces of capitalism—may contribute to the state’s high obesity rate.

Initial efforts to combat obesity in Arkansas were part of Governor Mike Huckabee’s health initiatives. Passed by the Eighty-Fourth Arkansas General Assembly, Act 1220 of 2003 spearheaded initiatives to address obesity among school-aged children in Arkansas. This landmark decision created the Child Health Advisory Committee (CHAC) to make recommendations to the State Board of Education and the State Board of Health related to nutrition and physical activity in schools. The act also improved access to healthier foods and beverages in public schools, created local committees to promote physical activity and nutrition, and provided for confidential reporting of each student’s BMI to his or her parents. Vocal opposition to the legislation focused on the lack of state funding for schools to implement the state’s mandates, potential loss of funding to local school districts from reduction in vending contracts, parental rights, and/or the potential of the provision to shame overweight and obese children. A change initiated by Act 201 of 2007 required only even numbered grades through tenth grade to have BMI screenings, and also let parents opt their children out of the assessments. Data from five years of BMI screenings (screenings from 2012 to 2017) in each of the four categories (underweight, healthy weight, overweight, and obese) shows that childhood obesity has remained steady.

Other efforts to combat obesity in Arkansas include Gov. Huckabee’s 2003 Healthy Arkansas initiative, which targeted adults in the workplace in efforts to reduce obesity and smoking. Designed to improve the health of Arkansas residents and reduce the cost of the state’s Medicaid program, the main components of the initiative involved providing such online information as where to find healthy restaurants and places for physical activity, as well as incentives for eating healthy and being active in the workplace.

The Arkansas Coalition for Obesity Prevention (ArCOP) formed in 2007 and works at the local level to improve access to heathy food and physical activity in neighborhoods, schools, and the workplace. Some of their strategies include offering Supplemental Nutrition Assistance Program (SNAP) recipients incentives to purchase food at farmer’s markets, nutrition and cooking education for SNAP recipients, a Mayors Mentoring Mayors program, and training opportunities for individuals who want to improve health in their communities.

Weight loss surgery has become more common since the rise of obesity. In 2011, legislation was passed creating a program within the Department of Finance and Administration, Employee Benefits Division (EBD) that covers the expenses of bariatric surgery for qualified Arkansas employees and their spouses. The program was designed to combat the long-term medical expenses associated with obesity, although a 2014 study of the program did not conclude that it does. Changes to the program have made it easier for state employees to qualify for weight loss surgery.

In 2015, Governor Asa Hutchinson introduced Healthy Active Arkansas, a non-profit team of people who represent a wide variety of organizations in the private and public sector, including government agencies, healthcare providers, and community organizations, who came up with a framework to improve the health of Arkansans. The plan focused on nine priority areas—physical and built environments; nutritional standards in government, institutions, and the private sector; nutritional standards in schools; physical education in schools; healthy worksites; access to healthy foods; sugar-sweetened beverage reduction; and promotion of breastfeeding. The overarching goal of Healthy Active Arkansas is to increase the percentage of adults, adolescents, and children who are at a healthy weight.

Legislation that would increase taxes on junk foods in an attempt to reduce obesity have been introduced several times in Arkansas, including one that failed to clear the Arkansas Senate in 2017.

ACHI has initiated many programs designed to combat obesity and other health problems in the state. ACHI focuses on four areas: population health policy, healthcare system transformation, access to quality healthcare, and research and health data initiative. Some of their programs include the Child Wellness Intervention Project (CWIP), Delta Garden Study, EnergizeNWA, Fresh Fruit and Vegetable Program (FFV), School-Based Health Centers (SBHC), and Summer Food Service Program (SFSP). The center’s activities also include analyzing data to inform solutions and convening stakeholders and policymakers across multiple disciplines to reach consensus.

Conclusion
Obesity is complex, crossing lines of race, class, and gender and having socioeconomic, genetic, psychological, and environmental roots. Arkansas pioneered efforts to combat obesity in 2003, though the state continues to have one of the nation’s highest obesity rates. Some suggest that current public health strategies are ineffective, as they ignore the widespread failure of diets to result in significant weight loss and are unable to address broader systems influencing obesity and overall health. Many obesity prevention efforts focus on improving access to healthy food and exercise, emphasizing making healthy choices while failing to recognize the ways obesity is shaped by social forces that go beyond the individual level. Considering the prevalence of eating disorders, some call for more-sensitive approaches that focus on holistic health rather than alleviating obesity, a term that offends many and has become a catch-all for a number of diseases. Some argue that a shift in focus from obesity to issues such as poverty and institutional racism, which directly impact health, would better serve the United States.

For additional information:
Act 1220 of 2003. Arkansas State Legislature. http://www.arkleg.state.ar.us/assembly/2003/R/Acts/Act1220.pdf (accessed January 31, 2019).

Arkansas Coalition for Obesity Prevention. http://arkansasobesity.org/ (accessed January 31, 2019).

“Assessment of Childhood and Adolescent Obesity in Arkansas Year 13 (Fall 2015–Spring 2016).” Arkansas Center for Health Improvement.

Brewis, Alexandra A. Obesity: Cultural and Biological Perspectives. New Brunswick: Rutgers University Press, 2011.

Cozier, Yvette C., et al. “Racism, Segregation, and Risk of Obesity in the Black Women’s Health Study.” American Journal of Epidemiology 179, no. 7 (2014): 875–883.

Davis, Andy. “Arkansas’ Obesity Rate Yo-Yos Back to 3rd Place.” Arkansas Democrat-Gazette, September 13, 2019, pp. 1A, 5A.

Farrell, Amy Erdman. Fat Shame: Stigma and the Fat Body in American Culture. New York: New York University Press, 2011.

Finucane, Mariel M., et al. “National, Regional, and Global Trends in Body Mass Index since 1980: Systematic Analysis of Health Examination Surveys and Epidemiological Studies with 960 Country-Years and 9.1 Million Participants.” National Center for Biotechnology Information 377 (February 12, 2011): 557–567. Online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4472365/ (accessed January 31, 2019).

Flegal, Katherine, et al. “Trends in Obesity among Adults in the United States, 2005 to 2014.” Journal of the American Medical Association 315 (June 7, 2016): 2284–2291. Online at https://jamanetwork.com/journals/jama/fullarticle/2526639 (accessed January 31, 2019).

Graff, Samantha K., Manel Kappagoda, Heather M. Wooten, Angela K. McGowan, and Marice Ashe. “Policies for Healthier Communities: Historical, Legal, and Practical Elements of the Obesity Prevention Movement.” Annual Review of Public Health 33 (April 2012): 307–324. https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031811-124608 (accessed January 31, 2019).

Guthman, Julie. Weighing In: Obesity, Food Justice, and the Limits of Capitalism. Berkeley: University of California Press, 2011.

“Obesity.” Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/ (accessed January 31, 2019).

Rothblum, Esther, and Sondra Solovay, eds. The Fat Studies Reader. New York: New York University Press, 2009.

Ryan, Kevin W., Paula Card-Higginson, Suzanne G. McCarthy, Michelle B. Justus, and Joseph W. Thompson. “Arkansas Fights Fat: Translating Research Into Policy to Combat Childhood and Adolescent Obesity.” Health Affairs 25 (July/August 2006): 992–1004. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.25.4.992 (accessed January 31, 2019).

Ulmer, Amy. “Fat Shaming the Delta: How Social Issues Become Individualized via ‘Delta Obesity Talk’.” PhD diss., Arkansas State University, 2018.

Whitehorn, Hillarie. “Exploring the Relationship between Obesity and the Prevalence of Food Deserts in Arkansas.” PhD diss., Arkansas State University, 2012.

Amy Ulmer
El Dorado, Arkansas

Last Updated: 01/31/2019