by James Walvin
Designers, architects and planners have to take account of mankind’s increasing size. When the new Yankee Stadium was opened in 2009, it contained 4,000 fewer seats than the previous stadium, opened in 1923, because wider seats were required to cope with the increased average size of the fans. The older seats had been 18–22in (46–56cm) wide; today they are 19–24in (48–61cm). Similar data, apparently trivial, is available from all corners of modern American life, as institutions and businesses seek to accommodate the expanding size of the American people. Ferries in Puget Sound have also increased the width of their seats; ambulances in Colorado have been fitted with winches to handle excessively heavy patients. Even undertakers have had to respond by making larger coffins to accommodate obese corpses. A standard coffin is 24in (61cm) wide, but an extra-large version of 37in (97cm) is now available.
Such evidence – unscientific, even frivolous perhaps – offers a low-level snapshot of a major US problem. But the fundamental underlying issue is simple – and serious. An estimated one in three Americans are obese, a doubling of the figure in a mere three decades.7 More than two thirds of the current US population are overweight. Not a single state in the Union has an obesity rate below 20 per cent: twelve can claim rates of 30 per cent. And it is getting worse. By 2030, there will be a predicted 65 million more obese people living in the USA.8
The hard demographic evidence is available in any number of forms and is analysed most tellingly perhaps by the National Center for Health Statistics, located at the Center for Disease Control and Prevention. In the forty-two years to 2002, American men and women grew taller by an inch but, in the same period, the weight of the average American man increased from 166lb to 191lb; for women, their average weight increased from 140lb to 1641b. Similar increases were also recorded in boys and girls.9 In 2003, obesity in the USA was roughly 32 per cent of the adult population; a mere ten years later, it had risen to 38 per cent. By 2010, it was estimated that more than 65 per cent of Americans were either overweight or obese. There are also major ethnic differences, with African-American adults recording levels of obesity that reach 48 per cent. Women fare even worse – 57 per cent of African-American women were obese in 2011–14.10
This is not a uniquely American problem, and the cost of coping with such widespread obesity has become critical across Western societies. Everywhere, from Scandinavia to the USA, the medical cost of caring for the obese is substantially higher than for other patients. In the USA, despite variations from state to state, the annual current cost runs to $210 billion.11
The seriousness with which modern medicine takes obesity can be gauged by one simple index – there has been a massive increase in the publication of specialist medical literature devoted to the subject. The words ‘obese’ and ‘obesity’ now appear regularly in medical and academic literature. Indeed, the word ‘obese’ appears in the title of no fewer than 19,770 articles and books published in the decade ending in August 2007. Almost 13,000 of those works appear in a mere five years between 2002 and 2007.12
By the early twenty-first century, the levels of obesity in the USA were causing significant alarm at the highest levels of government. No less a figure than the US Surgeon General issued a ‘Call to Action to Prevent and Decrease Overweight and Obesity’. Even the US Department of Agriculture became involved, explaining how, between 1970 and 2010, the number of calories consumed by Americans had increased by 25 per cent. This is the equivalent of an extra meal each day and was a direct result of the type of food consumed. Put simply, Americans have developed unhealthy eating patterns and, although it is true that Americans are drinking less sugary soda, their consumption of sweeteners remains high because of the sugar added to their highly industrialised foodstuffs.13
While the USA offers some extreme examples of the modern scourge of obesity, other countries are rapidly following a similar route. This is largely because of a dramatic switch in global diets as people adapted from traditional, local and generally healthier diets to the consumption of highly processed Western food and drink. In the process, obesity has taken hold globally. Mexico worries that its children have become the fattest on earth.14 And in middle-class communities in Delhi, according to a WHO report of 2005, 32 per cent of men, and 53 per cent of women, were thought to be obese. Indeed, one Indian in five is considered overweight. Not unrelated, an estimated 75 per cent of foreign investment in India has been in highly processed foods.15
China, exposed to Western foods only in the past generation, now has 350 million people who are overweight, and 60 million regarded as obese. One quarter of the Chinese population now falls into these categories. Bizarrely, it is thought that, at the same time, about 100 million Chinese are undernourished, a reminder that obesity and malnourishment can accompany each other even in the same society.16
France, too, has registered a sharp rise in obesity, from 5.5 per cent in 1992 to 14.5 per cent in 2009.17 But the British top the European league table, closely followed by their Irish neighbours. In the space of little more than a single generation – thirty years – obesity has tripled, and threatens, at the current rate of increase, to have half its population recognized as obese by 2050. With very good reason, one recent publication described Britain as ‘the fat man of Europe’, with one Briton in four classed as obese in 2013. Medical researchers argue that Britain has already become an ‘obese society’, where being overweight is ‘normal’.18 The estimated cost of all this to the NHS – which bears the brunt of obesity and related illnesses – by 2050 will be an estimated £10 billion.19 The cost is already enormous – currently £5 billion.20
Even more startling is how quickly this has come about. In the USA, for example, the number of overweight Americans doubled in a mere twenty-five years.21 Today’s levels of British obesity are three times the levels of 1980. Then, only 6 per cent of men and only 8 per cent of women were obese; today, 25 per cent of the British population is obese. The broad outlines of this story are well known because it is so obvious and unavoidable. Anyone under the age of thirty, perhaps, might not be so acutely aware of the problem for the simple reason that they have grown up with it. But any observant middle-aged or older Briton need only cast their mind back to their own childhood to realise how differently they studied, played, worked, travelled, dined and enjoyed themselves. As the nation became more sedentary, more inactive, more addicted to convenience food and drink, individuals have become heavier, and society is ever more beleaguered by the consequences.
Today, people walk less and drive more. In Britain, one in five journeys by car are for less than one mile. The British also spend six hours a day in sedentary pleasures – TV, computers, reading – and eat high-calorie, mass-produced foodstuffs that often contain huge quantities of sugar. This mix of inactivity and unhealthy diet has resulted in the British becoming a nation that consumes many more calories than it requires for its increasingly sedentary lifestyle.
Despite differences between men and women, and variations between ethnic groups, the overall trend is indisputable. So, too, are the consequences: obese people run the risk of catastrophic illnesses. An international study confirmed that obesity leads to type 2 diabetes, hypertension, myocardial infarction, angina, osteoarthritis, stroke, gout and gall bladder disease, colonic and ovarian cancer. It is also thought that obesity places great mechanical stress on the body and may even lead to sleep problems, breathing difficulties and back trouble. This cluster of health issues for overweight people is known as ‘metabolic syndrome’.22 And all this is in addition to the problems of social stigma, low self-esteem and an overall poor quality of life. In Britain alone, it is estimated that 30,000 deaths each year are caused by obesity, and 18 million days of sickness and absence from work are directly attributable to obesity and its adverse effects.
When parents of obese children are asked for an explanation for their children’s size, they readily point to their offsprings’ lifestyle, and especially to the amount of time watching TV, or using a tablet, l
aptop or computer.23 It is there that they are exposed, for hours on end, to cleverly devised adverts promoting food and drink which is nutritionally worthless, but which is often rich in sugar.
The problem is now so severe and widespread that health services and a coalition of medical experts regularly urge government to act. They are not only desperate now to persuade the population at large to adopt a healthier lifestyle, but also to influence that powerful lobby of commercial interests – ‘Big Food’ – whose products have encouraged the stampede towards unhealthy choices over food and drink. The aim of such critics is to reduce the volumes of sugar, fats and salt currently saturating the mass-produced, processed foods and drinks which contribute so significantly to national obesity.24
Though few doubt the evidence of the rapid increase in obesity, the precise causes remain contentious, even among medical and scientific experts working in the field. There are even those who choose to see the entire issue as yet another ‘moral panic’, one of those periodic social alarms which have gripped societies over the centuries. Some sociologists have been keen to tease apart the social origins of different waves of mass anxiety in very different historical and social settings. Where once it was witches, communism, muggings, football hooliganism, mods and rockers or AIDS, some have now turned their attention to those who are grossly overweight. And although it is true that the debate about obesity has generated a huge and growing scientific literature, much of it is dogged by disagreement, and by the special pleading of vested interests.25 For all that, the core, demographic evidence is irrefutable. Time and again, doctors and medical sociologists point to simple but persuasive data of the rise in numbers of obese patients.
The most troubling aspect of the entire story is the extent of childhood obesity. The warning bells first sounded in the USA. In the twenty years to 1995, the number of overweight children increased from 15 to 30 per cent. A decade later, researchers thought that the problem had spun out of control’ in Europe. Indeed, it had increased twice as fast in England as it had in the USA. But most other European countries – Poland, Spain, Italy, Albania and Greece – were following close behind. Even France, fiercely protective of its cuisine and associated lifestyle, had begun to succumb. Similar data began to emerge from Asia. In Japan, childhood obesity doubled between 1974 and 1994. In Thailand, it increased by 3 per cent in three years between 1990 and 1993. Even in Saudi Arabia, 16 per cent of boys aged 6–18 were found to be obese in 1996.26
What linked these very diverse geographical locations was a curious but critical fact. Childhood obesity rose fastest, and remains most tenaciously rooted, among low-income groups. It has settled into a universal law: those who are most susceptible to developing obesity tend to be those with low incomes. ‘Only the very poorest inhabitants of the poorest countries offer an exception to the fate formula . . .’ These are the very people who lack the money for (and even the access to) fresh fruit and vegetables; they are ‘struggling households’ which ‘stock up on sugar, starch, oil and other processed foods – high energy and low costs’. One study puts the matter bluntly: ‘Slimness is becoming an unattainable luxury for the poorer families in our midst.’27
This had become very striking in Britain. By the early years of the twenty-first century, the data was astonishing. In 2011, three in ten British boys and girls aged 2–15 were overweight or obese. Astonishingly, perhaps, between 2011 and 2013, sixty-two children under eighteen underwent weight-loss surgery. There had been only one such case in 2000.28 Although children’s overall health improved dramatically in the course of the twentieth century, by the twenty-first century childhood obesity presented a startling setback. It was recorded in all fifty US states, among boys and girls – although it was most prominent among African-Americans and American Indians. Again, the hospital costs of caring for obese children and youths were excessive and had risen from $35 million in 1979–81 to $127 million in 1997–99.29 Moreover, obesity continues to rise among American children; between 2006 and 2008, it rose from 15 to 20 per cent among 6–11 year olds. Critics pointed their finger at sugar. The American Heart Association became so alarmed in 2009 that it issued a recommended level for sugar: ‘High intakes of dietary sugar in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects of excessive consumption of sugars.’ The recommended limits – five teaspoons of sugar for sedentary women, nine for men – sit uncomfortably with the actual intake of twenty-two teaspoons. These suggestions prompted a broadside of commercial and of sponsored scientific denunciation from all corners of the US food industry. Sugar had become so central to ‘Big Food’ – in effect it had become the lifeblood of a massive, multi-milliondollar industry – that it was not about to be staunched by the reasonable but ineffectual pronouncements of the medical lobby.30
A report for the WHO found that childhood obesity was rising the world over; it stood at perhaps 2–3 per cent of all children aged 5–17. It was highest in the Americas (30–35 per cent) and in Europe (about 20 per cent). In sub-Saharan Africa, it was a mere 1 per cent. ‘In most countries, there has been documentation of a rapid increase in the prevalence of obesity among children.’ Between 1980 and 2000, it rose sharply in Australia, Brazil, Canada, China, Spain, the UK and the USA. The report concluded that, among children, ‘as in adults, overweight and obesity are common and becoming increasingly common in populations throughout the world’.31
In the autumn of 2016, the World Obesity Federation painted a very gloomy picture indeed of a contagion of childhood obesity worldwide. Pacific islands – Kiribati, Samoa and Micronesia – had easily the worst statistics in terms of proportion of populations, but they were closely followed by Egypt with 35 per cent of people under the age of seventeen obese or overweight. There followed, in order, Greece (31 per cent), Saudi Arabia (30 per cent), the USA (29 per cent), Mexico (29 per cent), and the UK (28 per cent), followed closely by France and the Netherlands. Not surprisingly, then, an estimated 3.5 million children worldwide have type 2 diabetes. Many, many more have ailments which are directly linked to obesity.
Viewed globally, there has been a 60 per cent rise in childhood obesity since 1990, and the patterns once thought peculiar to the West are now replicated worldwide. In a mere decade, the proportion of children who are obese or overweight have increased from one in ten, to one in eight. In Britain, obesity is growing twice as fast among children as among adults. It is thought that one third of all Europe’s obese children are British. But the problem is far worse in the USA: an estimated 32 per cent of American children were thought to be overweight or obese in 2009–2010. Among British children aged 2–11 years, 14 per cent were found to be obese in 2004. For 11–15-year-olds, it rose to 25 per cent. By the early years of the new century, ‘obesity is now the most common disorder of childhood and adolescence’.32 The problem, again, is diet. Most of the victims are from low- or middle-income groups. Wherever researchers looked, the pattern of causation was the same – fast food and carbonated drinks, and even a global decline in breastfeeding in favour of baby formula milk. Today, one half of the world’s inhabitants live in urban areas and most children do not get adequate exercise. And everywhere, they favour sweet, fizzy drinks (the sales of which have increased by one third in the past ten years), and fast food from Western-style outlets. Sugar is everywhere. In Egypt, it is heaped in tea five or six times a day.33
The likely medical consequences for obese children are well documented: psychological ill health (bullying seems to be a common hazard); heart trouble; breathing difficulties; inflammation; diabetes; orthopaedic problems; and liver disease. In addition, childhood obesity not only brings its own health problems, but lays the foundations for obesity in adult life. People do not ‘grow out’ of obesity; obese children are highly likely to become obese adults – with all the related ailments. Each of these illnesses may have their own medical solution, but the attack on the root cause – obesity – is not so much a medical as a
social question.
The core problem is diet. We also know that eating preferences endure for a lifetime, and this simple fact is critical and basic to the activities of food and drink manufacturers, and the advertisers who promote their products among the young. Advertisers and food manufacturers know that if they can capture a child’s loyalty – if they can cultivate a child’s taste and commitment to their products – they will have them for life.34
One of the early consequences of children’s eating habits – of consuming sweet foods, notably breakfast cereals – is the early onset of dental problems. Among British children, for instance, the story of dental health provides an extraordinary example of the impact of the modern diet, and especially of the role of sugar in that diet. British medical authorities have become increasingly alarmed about children’s poor dental health. In fact, concerns about dental issues first emerged more than a century ago, but today they illustrate much wider anxieties about children’s diet, and especially about the levels of sugar in that diet. Even in the earliest days of dentistry in the nineteenth century, British dentists regularly complained about the levels of tooth decay and poor oral hygiene among the nation’s young. The problems came into sharp focus with the late-century establishment of compulsory schooling and the obligatory medical inspection of all children in schools. Medical examinations confirmed what many had long suspected – the existence of a wide range of health problems, notably, of course, among the poor. Time and again, doctors and dentists recorded high levels of poor dental health. The extent of ill health and of poor health facilities (plus the cost of medical care) in time became a powerful political impulse behind the determination to improve the nation’s health by the introduction of a free national health service. Despite the post-war NHS, and despite the subsequent seventy years of free medicine, serious dental problems continue to plague large numbers of British children.