Public Opinion and Action about Diet, Weight, Nutrition, and Physical Activity

Americans are not confused about the facts. They know obesity is a serious health threat and that being overweight can lead to diabetes, heart attacks and cancer. As the survey shows, people also know they should be getting more physical activity each week and eating more fruits and vegetables, and many are doing so. That's terrific news. The survey shows that people are knowledgeable, and most of them are motivated, and we hope that people will take even more steps to achieve a healthy weight and physical fitness for themselves and their families.

—Julie Gerberding, the director of the Centers for Disease Control and Prevention, commenting on the results of the Harvard School of Public Health Poll, July 14, 2005

A July 2007 Gallup Poll revealed that most Americans (85%) described their diet as ''very/somewhat healthy.'' (See Figure 11.1.) Just 15% described their diet as ''not too/not at all healthy.'' It appears that despite rising rates of overweight and obesity and evidence that many Americans are consuming too many calories, most believe their diets are healthy.

Similarly, even though the Centers for Disease Control and Prevention (CDC) indicates that two-thirds of Americans are overweight or obese, the July 2007 Gallup Poll found that more than half (52%) of Americans felt their weight is ''about right,'' 42% described themselves as ''overweight,'' and 5% considered themselves ''underweight.'' (See Figure 11.2.) This self-assessment of weight is surprising in view of survey respondents' selfreport of weight, which has been increasing steadily since 1990. Table 11.1 shows that the average weight of adults rose from 161 pounds in 1990 to 175 pounds in 2006. There has also been a rise in the percentage of people who weigh two hundred pounds or more—from just 15% in 1990 to 23% of adults in 2006.

An analysis of body mass index (BMI, which is a numerical expression that describes the relationship between weight and height that is associated with body fat and health risk) reveals that the Gallup Poll respondents are closer in weight status to CDC reports than to their own self-assessments. Table 11.2 shows that in November 2006, 38% of respondents had a BMI of 26 to 30, meaning they were classified as overweight, and an additional 20% had a BMI over 30, which indicates obesity.

Despite the increasing prevalence of obesity and its relationship to many chronic conditions, only 28% of survey respondents said obesity had caused a serious health problem for a relative; more than two-thirds (71%) denied having a family member with an obesitylinked health problem. (See Table 11.3.)

CONSUMER KNOWLEDGE OF NUTRIENTS AND THEIR HEALTH BENEFITS

In Experimental Study of Health Claims on Food Packages (May 2007, http://www.cfsan.fda.gov/Ȉcomm/crnutri4.html), Chung-Tung Jordan Lin of the U.S. Food and Drug Administration reports the findings from research that considered consumer perceptions of health and other claims (nutrient content claims, structure/function claims, and dietary guidance statements) on food packages. Because the study was based on survey results from an Internet consumer panel, it only represents respondents' knowledge, attitudes, and behavior, rather than the beliefs of all Americans. Still, it offers insight into consumer understanding of health claims that do not name the specific nutrients that are involved in the dietdisease relationship (e.g., ''Yogurt may reduce the risk of osteoporosis'') and health claims that name the nutrient (e.g., ''Calcium-rich foods, such as yogurt, may reduce the risk of osteoporosis'').

The study had two phases. The first phase collected information about the awareness of foods and nutrients and their possible health benefits. The second phase assessed consumer understanding of various health

claims and messages. Lin was especially eager to learn whether consumers were able to identify the nutrient linked to a specific health benefit, and whether they knew the food sources from which these nutrients might be obtained. In Phase 1, respondents were asked about their awareness of three foods (yogurt, orange juice, and

pasta), the nutrients these foods contained, and their possible health benefits.

Of the three foods, yogurt and orange juice were considered healthier than pasta, with orange juice garnering the highest percentage (58%) of ''very healthful'' ratings. (See Table 11.4.) Nearly two-thirds (62%) of respondents queried about the health benefits of yogurt named reducing the risk of osteoporosis, and reducing the risk of hypertension (high blood pressure) was identified as a health benefit of orange juice by one-quarter (24%) of respondents questioned about it. (See Table 11.5.) Just 9% of respondents asked about the health benefit of pasta associated it with heart disease.

Nearly all the respondents (99%) who linked yogurt to osteoporosis named calcium as the nutrient that might help reduce the risk; three out of four (74%) of those who associated orange juice with hypertension said potassium might help reduce the risk; and about 17% of those who associated pasta with heart disease said the fictitious compound lysoton might help reduce the risk. (See Table 11.6.)

Interestingly, just 15% of respondents said they were dieting to lose weight. (See Table 11.7.) Nineteen percent of respondents were following low-fat diets, 16% were on low-carbohydrate diets, 13% were adhering to low-sodium diets, and 11% each chose low-cholesterol and low-sugar diets. Because respondents were permitted to choose more than one diet, some may be adhering to more than one plan. For example, it is likely that many people who are on low-fat diets also aim to consume a diet that is low in cholesterol. Similarly, low-carbohydrate diets are generally also low-sugar diets.

AMERICANS KNOW OBESITY IS HARMFUL

The American public is, however, certain that obesity is harmful. As Table 11.8 shows, in 2007 nearly five out of six (83%) Gallup Poll survey respondents said they felt obesity was ''very harmful,'' and an additional 15% considered it ''somewhat harmful.'' Interestingly, survey respondents' own self-reported weight did not appear to influence their belief that being overweight is harmful. The vast majority of both respondents who considered themselves about the right weight (86%) and those who said they were overweight (79%) were aware that being significantly overweight is very harmful. (See Table 11.9.)

In fact, Americans equate the health risks associated with obesity to those of smoking. The overwhelming majority of Gallup Poll survey respondents said that being obese was ''very harmful'' (83%) or ''somewhat harmful'' (15%) to one's health. (See Table 11.10.) Comparable percentages of respondents deemed smoking ''very harmful'' (79%) or ''somewhat harmful'' (14%) to health.

Americans Understand That Obesity Is a Public Health Problem

According to the press release ''Despite Conflicting Studies about Obesity, Most Americans Think the Problem Remains Serious'' (July 14, 2005, http://www.hsph.harvard.edu/news/press-releases/archives/2005-releases/press07142005.html), the Harvard School of Public Health conducted a June 2005 opinion poll and found that three-quarters of Americans at that time considered obesity an ''extremely'' (34%) or ''very serious'' (41%) public health problem in the United States. Most Americans believed that scientific experts have been accurately representing (58%) or even underestimating (22%) the health risks of obesity. A scant 15% of the survey respondents thought that the health risks were being overstated by scientific experts.

The poll found that about one-third (35%) of Americans were monitoring the fat and carbohydrate content in their daily diet. Like the Gallup Poll, this survey found that even though more than half (54%) of those surveyed considered themselves to be overweight, less than one-third (32%) were attempting to lose weight.

Americans are aware that being moderately overweight leads to serious health problems; however, they remain unconvinced that overweight and obesity lead to premature death. Half (51%) of the respondents in the Harvard poll thought that someone who is moderately overweight would be more likely than someone of healthy weight to die prematurely. Nearly three-quarters (73%) believed that a moderately overweight person would be more likely than someone of healthy weight to develop a chronic illness such as diabetes or hypertension.

In view of apparently conflicting reports of the supremacy of one diet over another, it is not surprising that the Harvard poll found differing sentiments about the credulity of obesity researchers and nutrition experts. About half (48%) of respondents said they had a ''great deal'' (14%) or a ''good amount'' (34%) of trust in the advice scientific experts offer about how to lose and control weight. Sixty-one percent of respondents said they paid ''a lot'' (13%) or a ''fair amount'' (48%) of attention to nutritional recommendations from medical and scientific experts about how to manage their weight.

Americans Sympathize with People Who are Obese

There is considerable sympathy for people who are obese. Nearly three-quarters (74%) of Gallup respondents expressed sympathy for people who are obese and understanding of the difficulties associated with losing weight. (See Table 11.11.) Furthermore, as with the belief that obesity is harmful, sympathy for people who are obese seems independent of whether respondents' view themselves as about the right weight or overweight—79% of respondents who described themselves as overweight and 73% of those who said they were ''about right'' were sympathetic toward people who are obese. (See Table 11.12.)

Table 11.13 reveals that more women (78%) than men (70%) expressed sympathy for people who were obese. Table 11.14 shows that overall, there is more sympathy for people who are obese (74%) than for those who smoke (58%).

Even though the Gallup Poll results do not reveal why the public feels more sympathy for people who are obese than for smokers, it may be because rates of obesity are increasing among people of all ages, race, and ethnicity, whereas smoking has declined. Because increasing numbers of Americans are overweight or obese, perhaps they are more inclined to feel empathy for others who share the problem. In ''Americans Put Obesity on Par with Smoking in Terms of Harmful Effects'' (July 20, 2007, http://www.gallup.com/poll/28177/Americans-Put-Obesity-par-Smoking-Terms-Harmful-Effects.aspx), Frank Newport of the Gallup Organization opines that ''the public is more willing to believe that obesity is a condition more under one's voluntary control than is the case for smoking.''

MANY AMERICANS WANT TO LOSE WEIGHT

The Gallup Poll reports that trying to lose weight is a common activity among the U.S. adult population— more Americans than ever before say they are seriously trying to lose weight. Table 11.15 shows that in November 2006, 28% of Americans said they were seriously trying to lose weight, up from 17% about fifty years earlier, in 1955. A February 2006 Gallup Poll found that Americans wanted to lose ''a lot of weight'' (18%) or ''a little weight'' (38%), whereas 39% wanted to maintain their weight and just 4% were seeking to gain weight. (See Table 11.16.)

Women were much more likely than men to be making serious efforts to lose weight. In November 2006 less than one-quarter (24%) of men said they were making serious attempts to lose weight, compared to 32% of women. (See Table 11.15.)

Significantly more survey respondents who wanted to lose weight indicated that they would be more likely to try exercising (61%) rather than dieting (36%) to lose weight. (See Table 11.17.) Three-quarters of the survey respondents who indicated that they would like to lose weight said they would never have bariatric surgery, and another 20% said they would consider surgery only as a last resort. Despite the increasing popularity of bariatric surgery, just 3% of those surveyed said they would definitely like to have surgery (2%) or might be interested it (1%). (See Table 11.18.)

AMERICANS' CHANGING SHAPES AND SIZES

The results of a national size survey that gathered measurements from more than ten thousand people across the United States confirmed that Americans are not only getting heavier but also are changing in proportion. The ''SizeUSA'' project is an anthropometric research study (it studies human body measurements and makes comparisons of these measurements). Using a three-dimensional body scanner, researchers compiled measurements and analyzed them by gender, age group, and four ethnicities, as well as by geography, annual household income, marital status, education, and employment status.

The survey was performed to assist apparel manufacturers in producing clothing that will offer a better fit to more consumers. In ''Sizing up America: Signs of Expansion from Head to Toe'' (New York Times, March 1, 2004), Kate Zernike reports that the last such national survey of Americans was performed in 1941 by the U.S. Department of Agriculture (USDA). The USDA survey described the average American woman as a size 8, with a 35-inch bust, a 27-inch waist, and a 37.5-inch hip circumference. The 2003 ''SizeUSA'' survey found that the average white woman's bust, waist, and hip measurements in inches were 38-32-41 for women aged eighteen to twenty-five, and 41-34-43 for women aged thirty-six to forty-five. On average, African-American women measured 43-37-46, Hispanic women 42.5-36-44, and an ''other'' category, composed primarily of Asian-American women, measured 41-35-43. Based on the ''SizeUSA'' survey, the average American woman wears a size twelve or fourteen, rather than a size eight.

American men have also increased in size. The size 40 regular, which measures 40 inches at the chest with a 34-inch waist, a 40-inch hip, and a 15.5-inch collar, once considered the average, would be too small for many American men. The 2003 ''SizeUSA'' survey found that white men aged eighteen to twenty-five measured 41-35-41, and older white men aged thirty-six to forty-five measured 44-38-42. African-American men measured an average of 43-37-42, Hispanic men 44-38-42, and an ''other'' category, composed primarily of Asian-American men, measured 42-37-41.

Interestingly, measurements did not vary significantly by geography, education, or even income. The most significant variations in body shape were attributed to race, ethnicity, and age. For example, 11% of white women were described as having protruding stomachs, compared to 3% of Hispanic women and 4% of African-American women. More Hispanic women (20%) were described as having ''full waists'' than white (10%) or African-American (15%) women. Nearly one-quarter (24%) of African-American men were described as having a ''prominent seat,'' compared to 9% of white men and 8% of Hispanic men.

The study concluded that along with expanding waists, American men over age forty-five were the most likely to have increased abdominal girth—''pot bellies''—and women older than thirty-six were the most likely to have big hips. Nearly 20% of men were described as ''portly'' and another 19% had ''lower front waists,'' meaning the researchers had to look behind the overhanging belly to find the waist.

AMERICANS' ATTITUDES ABOUT OVERWEIGHT

Despite escalating media coverage of overweight and obesity, and their associated health risks, many Americans do not appear to be overly concerned about overweight and obesity—their own or others'. They demonstrate little support for policy initiatives intended to prevent and combat obesity, and persist in the belief that obesity results from individual personal failings rather than a combination of genetic and environmental factors.

Taeku Lee and J. Eric Oliver examine in Public Opinion and the Politics of America's Obesity Epidemic (May 2002, http://ksgnotes1.harvard.edu/Research/wpaper.nsf/rwp/RWP02-017/$File/rwp02_017_lee.pdf) the prevailing sentiments about weight-related issues. Lee and Oliver sought to characterize Americans' attitudes about obesity to determine how attitudes and beliefs affect support for obesity-related policy changes. They assert that the concept of ''moral failure'' is at the root of public opinions that hold obesity as a personal choice and responsibility. They posit that obesity violates the valued American trait of self-reliance. Characterizing people who are obese as lazy, undisciplined, and lacking self-control enables the public to hold them responsible for their condition and may be used as justification for bias and discrimination. Lee and Oliver also posit that when obesity is understood as resulting from a lack of individual motivation, there will be little support for policies such as government regulations, civil protections, or taxes to prevent and decrease it.

Lee and Oliver observe that because obesity in the United States is a relatively recent phenomenon, public opinions about it are still forming, and most proposed policy changes—including taxes on sugary or high-fat snack foods, strengthening civil protections for individuals who are obese, and increasing the availability of public land for exercise—are unsupported or are actively opposed by a majority of Americans. In contrast, growing support exists for measures that regulate food advertising to children and that provide more nutritious school lunches. Lee and Oliver attribute the lack of enthusiasm for policy changes to low levels of awareness of the severity and scope of the problem and to deeply held negative stereotypes about people who are overweight and obese. They assert that as Americans learn that the rapid rise in obesity during the past two decades did not result from moral failure, they will be more inclined to advocate policies aimed at preventing and reducing obesity.

ARE AMERICANS GETTING ENOUGH EXERCISE?

In ''Only One-Third of Americans Are Frequent Exercisers'' (November 22, 2006, http://www.gallup.com/poll/25546/Only-OneThird-Americans-Frequent-Exercisers.aspx), Frank Newport indicates that Americans' self-reports of the frequency and intensity of the exercise they engage in has remained constant since 2000 and continues to fall short of basic health recommendations. He notes that 65% of Americans surveyed reported that they did not participate in vigorous or moderate exercise five days a week or more. (See Figure 11.3.) Nearly half (45%) of the survey respondents reported that they never engage in vigorous exercise for at least twenty minutes. Just 12% of Americans say they exercise vigorously at least five days of the week. The average American engages in vigorous exercise less than two days per week.

More Americans engage in moderate exercise. Most survey respondents (84%) claimed that they occasionally obtain some type of moderate exercise. The average American engages in moderate exercise three days a week, and 29% get moderate exercise at least five days a week. Newport reveals that more respondents who engage in regular moderate or vigorous exercise also report excellent physical health, but cautions that the data do not determine causation—whether good health allows people to exercise or exercise creates good health—or whether poor health prevents people from exercising. (See Figure 11.4.)

CHILDHOOD OBESITY

Public health professionals and practitioners are researching and evaluating interventions aimed at preventing children and teens from becoming overweight as well as programs to help them lose weight. Children's and teen's attitudes about food, exercise, and weight influence the success of prevention and treatment programs.

In ''Adolescents' Attitudes about Obesity and What They Want in Obesity Prevention Programs'' (Journal of School Nursing, vol. 23, no. 4, 2007), Louise F. Wilson seeks to characterize adolescents' attitudes about overweight and obesity and to identify the features and attributes they value in prevention programs. She used a written questionnaire to survey middle school students to determine the program characteristics students felt would be most effective. Wilson finds that adolescents would be more likely to participate in, and adhere to, programs encouraging them to consume more water, fruits, and vegetables, eat less junk food, and exercise more. They expressed unwillingness to forgo soda, videogames, computer activities, or watching television to improve their health.

Obesity Is among the Top Ten Concerns for U.S. Children

In March 2007 the C. S. Mott Children's Hospital and Knowledge Networks, Inc., conducted the National Poll on Children's Health (May 2, 2007, http://www.med.umich.edu/mott/research/chearhealthconcernpoll.html), a national online survey with a random sample of 2,076 adults. Of seventeen different health concerns for children, obesity was ranked number three, following smoking and drug abuse.

The poll found that Hispanics were more likely to express concern about obesity (42%), than whites (31%) or African-Americans (36%). The researchers opine that greater concern among Hispanics and African-Americans may reflect overall higher prevalence of obesity among Hispanic and African-American children and teens. Respondents with higher educational attainment (bachelor's degree or higher) rated childhood obesity as the number-one health issue for children, with 40% viewing it as a significant problem. In contrast, respondents with less than a high school education ranked childhood obesity tenth, with just one-quarter describing it as a major problem.

Parents May Not Accurately Gauge Children's Weight

Parents play a pivotal role in terms of preventing childhood obesity by shaping their children's early eating and physical activity habits. Anjali Jain et al. observe in ''Why Don't Low-Income Mothers Worry about Their Preschoolers Being Overweight?'' (Pediatrics vol. 107, no. 5, May 2001) that mothers of overweight preschoolers frequently appear unaware of, or unconcerned about, their children's weight. To explore mothers' perceptions of overweight in children, why children become overweight, and barriers that prevent effective treatment of childhood obesity, the investigators conducted group interviews with low-income mothers of preschool children (aged twenty-four to sixty months old) who were overweight and determined to be at risk for obesity.

Jain et al. find that unlike health professionals, who assess children's weight status by plotting height and weight on standard growth charts, mothers were more likely to express concern about children's overweight when their children were teased by peers or unable to participate in physical activities. The mothers did not consider their children overweight if the children were active, had a good appetite, and ate a healthy diet. Instead of describing their children as overweight, mothers described them as ''thick,'' ''strong,'' ''big-boned,'' or ''solid.'' The interviewed mothers also believed that an inherited tendency to be overweight, in terms of inherited metabolism or body type, practically guaranteed that the child would become overweight regardless of environmental factors. Given this perception, it is not surprising that the mothers believed they were unable to affect a child's biological predisposition to be overweight.

In ''Perception versus Reality: An Exploration of Children's Measured Body Mass in Relation to Caregivers' Estimates'' (Journal of Health Psychology, vol.12,no. 6, 2007), Anna Akerman, Marsha E. Williams, and John Meunier compare parents' reports of their children's height and weight against the measurements the researchers obtained. The researchers find that their measurements varied from the parents' perceptions of their children's body status. Parents of overweight children consistently underreported their children's BMI, and parents of underweight children overestimated their children's BMI. Akerman, Williams, and Meunier believe that parents have a ''positive bias in cognition'' that enables them to selectively interpret and correct for their children's deviations from a healthy body weight. In turn, this creates an alternative reality for them, one in which undesirable imperfections in their children do not exist.

Americans Blame Parents, Schools, and the Food Industry for Children's Weight Gain

In ''Poll Shows Growing Concern about Role of Advertising in Child Obesity'' (Wall Street Journal, August 20, 2007), Beckey Bright reports on the Wall Street Journal /Harris Interactive August 2007 poll that surveyed attitudes about childhood obesity among 2,503 adults. The survey found that most Americans (84%) viewed childhood obesity as a major problem and 78% of parents with children under age twelve saw it as an ''issue of growing concern.'' Eighty-three percent believed that parents have the greatest impact in terms of reducing childhood obesity.

Most of the survey respondents blamed the lack of exercise as a cause of children's overweight and felt that encouraging more physical activity will help solve the problem. The overwhelming majority (94%) felt schools should promote regular exercise. Nearly the same proportion (89%) favored parental efforts to limit time spent using computers, playing videogames, and watching television to encourage children to spend more time being physically active.

Most respondents also felt that children's diets must change. They believe schools and parents should restrict children's access to snack foods, sugary soft drinks, and fast food—88% said schools must do more to ensure that healthy foods are available and 83% felt parents must be more vigilant about their children's diets.

More than three-quarters (78%) of respondents cited food advertising targeting children as a ''major contributor'' to the problem, up from 65% the previous year. Despite the recent move of major food industry companies to improve the nutritional value of many of their offerings and engage in more responsible marketing and advertising practices, 60% of respondents favored government regulation of food industry advertising aimed at children.

There was strong support for measures the food industry might take to address the problem. Ninety-one percent of respondents expressed support for ''using child-friendly characters to promote healthier foods like fruits and vegetables,'' and 73% favored ''limiting advertising to children to healthier foods that are lower in calories, fat and/or sugar.'' About two-thirds (64%) said that ''no longer using popular characters from television shows and movies to market products to children'' would help.

Parents Feel Schools Should Offer Healthier Food Choices

An August 2007 Gallup Poll found that nearly twothirds of parents described their children's school lunches as ''very nutritious'' (21%) or ''somewhat nutritious'' (42%), whereas more than one-quarter rated them ''not too nutritious'' (17%) or ''not at all nutritious'' (10%). (See Figure 11.5.) Two-thirds (66%) of the parents surveyed felt their children's schools should offer more healthy foods such as whole grain breads, fresh fruits, and vegetables. (See Figure 11.6.)

Despite their expressed dissatisfaction with schools' food choices and offerings, parents do not assign schools disproportionate responsibility for childhood obesity. Just 9% blame school lunches a ''great deal'' for the problem, whereas 22% think school lunches contribute a ''moderate amount'' to the problem. More than a third (37%) of respondents assigned ''not much'' blame to school lunches, and 30% said they were not at all to blame. (See Figure 11.7.)

The Cost of Healthy Foods Plays a Role in Children's Weight Gain

Roland Sturm and Ashlesha Datar of the Rand Corporation confirm in ''Body Mass Index in Elementary School Children, Metropolitan Area Food Prices and Food Outlet Density'' (Public Health, September 2, 2005) that the cost of fresh fruits and vegetables is closely associated with weight gain among children and has a better predictive value for overweight than whether they live near or frequent fast-food outlets. Sturm and Datar examined the weight gain of 6,918 children of varying socioeconomic backgrounds from fifty-nine U.S. metropolitan areas as the children progressed from kindergarten to third grade. The investigators did not analyze the children's diets but instead compared their weight gain to the price of different types of foods and the number of food outlets in their area.

Sturm and Datar find that young children who lived in communities where fruits and vegetables were expensive were more likely to gain excessive amounts of weight than those who lived in areas where produce costs less. On average, children in the study gained twenty-nine pounds. In Mobile, Alabama, the region with the highest relative price for produce, children gained about 50% more excess weight as measured by BMI than children nationally. In contrast, children in Visalia, California, the area with the lowest relative cost for fruits and vegetables, experienced excess weight gain that was about half the national average. The researchers opine that providing free fruits and vegetables to schoolchildren would improve their diet. The USDA launched such a program in about one hundred schools, Sturm and Datar observe, and it was met with enthusiastic support from parents and teachers. It is not yet known, however, whether the program has influenced participating children's weight.