Photo: Bill Wilson/The Anniston Star
Well, in one dubious category, Alabama is closing in on the Magnolia State in its southward slide: We're running a closer second for which state is the fattest in the country, according to the latest federal statistics on obesity and nutrition. While that may not seem initially like cause for consternation, the size of Alabama's girth is more than just numbers on a scale or statistics at the health department.
It is an indicator of several things about a population: its overall health, the health of its children, the long-term productiveness of its workforce and, at the most basic level, the mindset of its residents.
"One of the things that is not crystal clear is what is the nature of the relationship between obesity and socioeconomic or just social status," says Dr. David Allison, a professor of biostatistics and director of the Clinical Nutrition Research Center at the University of Alabama at Birmingham. "What cannot be denied is that there is a relationship between a state's income and obesity."
A person is considered obese when the Body Mass Index — an equation of weight, height and frame size — is 30 or greater. The question about obesity's effect on the nation will be the topic of a conference the Centers for Disease Control and Prevention is hosting in Washington July 27-29. The conference targets obesity, especially the growing percentage of obese children, as a looming public health disaster. It pegs obesity's advance as a sinkhole for long-term economic productivity in the United States.
Conference organizers hope to focus on deeper causes of obesity and how to get all levels of society — from pre-schools to employers — to target what makes us heavy and how we can slim down. If not, public health officials say, the current generation of children under age 25 will be the first in more than a century to have a shorter life expectancy than its parents. There are 9 million obese 6-year-olds in the United States, and overall rates of being overweight for those under 19 have tripled.
"We're seeing some horrible statistics," says Dr. Erika Schwartz, who is medical director of Cinergy Health and has built her New York practice around the idea of preventative medicine. "We're seeing children with diseases — hypertension, orthopedic problems — these are illnesses of older people.
"Preventing this rise in childhood obesity is a national priority."
Fat states, lean states
Society will also see an increase in obesity-related health problems, ranging from diabetes to arthritis, certain cancers and heart disease. Factor in lost work potential, wages and lost taxes from those produced goods and wages, and the fiscal cost to the public could be staggering.
"There are a whole range of social problems associated with obesity, ranging from social discrimination to lower wages," Allison says. "With respect to health, they need to be free to enjoy not only a long life, but a life free of disability — one that is productive."
The latest 2008 data on nationwide obesity rates support Allison's assessment that poor generally equals fat — a point that the CDC has been highlighting for five years. Of the six states that have the highest percentage of obese adults, most are at the bottom of the nation in terms of median household income.
Among them: Mississippi, which has 32.8 percent of its adult population classified as obese. Its median household income for a family of four, $47,726, Mississippi is a full $20,000 below the national benchmark. The others in the bottom six of obesity rankings, all of which have more than 30 percent of adults classified as obese, are Alabama, Oklahoma, South Carolina, Tennessee and West Virginia. Their median household incomes hover around $58,000.
Flip to the top of the list, the leaner states in the Union: Colorado, Massachusetts, Connecticut, Rhode Island and Utah. Colorado was the only state in 2008 that had less than 20 percent of its adults classified as obese, and its median household income is $70,300. The remaining states hover around the national income midline.
Even when factoring in such things as cost of living and higher taxes in those wealthier states, the overall earning and spending potential in those leaner states outweighs those of their heftier siblings.
Researchers like Allison are trying to figure out why.
Factors in obesity
Theories have abounded for years, including the idea that wealthier people can afford healthier food. There's also something to be said for wealthier people living in safer neighborhoods, so people can walk more and get outside to be more active. Entire public-health campaigns have been forged on the idea that educating people to eat healthier will curb obesity, so most programs have focused on education levels, which can be directly tied to income and earnings.
While all of those theories are plausible, the researchers who study data and information on generations of populations are skeptical. They believe the cause may go deeper.
For instance, the CDC began tracking obesity figures and mapping them in 1985. It divided states into groups based on what percentage of their adults were obese. Each group encompassed 5 percentage points; every time a state had 5 percent more adults tipping the scale to obese, it went up to a higher group. There are 26 states in the largest group, which has 25 percent to 29 percent of adults classified as obese.
Researchers found a clear and consistent pattern on how and when states got fatter. A country that was pretty lean — no state had more than 20 percent of its adults as obese before 1997 — began to get fatter in generally the same order. Mississippi, Kentucky and Indiana were the first states to top 20 percent. Alabama joined that list in 1998.
Any time states moved up to another group by gaining fatter adult populations, they always moved up in the same order: Southern states led by Mississippi and its neighbors were first, followed en masse by the Midwest, then eventually the Northeast and West Coast. Rocky Mountain states were always the last.
Those statistics become grimmer when the economic relationship to obesity — fatter tends to equal poorer — is included, Allison says.
Starting in the 1960s, researchers began to study obesity. One of the first clear patterns to emerge was that of white women, who have the strongest tendency to have a lower household income if they are obese than if they are thinner, Allison says. One reason is that fatter women were more likely to marry a man below their education and income level, stymieing their household's earning potential.
That relationship has not played out in black women, meaning there isn't a strong connection between a black woman's weight and her household income.
Another element is that obesity has been shown to affect wages and salaries, also contributing to the income gap between thinner and fatter people. Again, Allison says, no one knows why, but there is a link.
The self-confidence question
To answer these questions, researchers studied social and societal habits in the animal kingdom. Looking at monkeys, rats and birds, scientists have found that the more confident and strong an animal is in its place in the pecking order, the more likely it is to be lean. The least-confident animals, or the ones that are lower in the pecking order, were the ones that had the most food and were the fattest. That has been interpreted to show that animals confident in their ability to find food and assert themselves don't feel the need to hoard food and are therefore less likely to be fat.
"It's the weaker animals who tend to be fatter, almost as if they're afraid that food supply is going away," Allison says. "Perhaps that carries over in a human model."
Psychological studies of overweight adults in the United States have found that most do report lacking self-confidence, a trait generally considered essential for workplace success. The question is whether that lack of confidence was hardwired there first as children, and led them to being obese, or if it's simply a side effect of being overweight.
"It may be the 'socio' as much as the 'economic' aspect that drives this behavior," Allison says.
Certain kinds of social stress also lead to obesity in animals, Allison says. It could be that condition plays out in humans as well. If a family is under stress financially, then there may be an instinct to consume more food as a way of alleviating that stress.
Studies are also under way to see what might be causing children to become obese at higher rates than other members of the population. Schwartz says it's especially important to tackle this end of the country's weight problem, simply because a chunky child is likely to be an obese adult. An overweight girl has a 40 percent chance of being overweight or obese her entire life; a boy has a 30 percent chance.
Those rising numbers pose a public-health crisis, Schwartz says, as obesity-related health problems start to affect younger and younger patients.
"Unless you stop kids from getting fat in the beginning, you are fighting an uphill battle that you are never going to win," she says.
The environment of obesity
Pediatricians and bariatric medicine practitioners say poor eating habits and sedentary lifestyles are why children are fatter than they used to be. However, as Allison points out, that doesn't fully explain the income gap between poor and wealthier children. Researchers are trying to see what other factors might affect childhood weight — and what factors might shed light on why that income gap between fat and lean persists down to the youngest among us.
As with adults, the same traditional arguments can be made: poor education of parents, little outdoor activity, cheap junk food and mirroring parental eating habits.
But, Allison says, studies and data indicate those simple factors alone might not address all the disparity of why poorer children tend to be fatter. Some researchers are wondering whether environmental factors — things the medical field calls "endocrine disruptors — might be more prevalent in some communities than others.
In Denmark, studies are following generational trends in increased body mass index in children. There's a connection between a rise in obese women, who already have some reproductive challenges, developing gestational diabetes. Their babies are more likely to become obese children and, consequently, obese parents when they get older.
"The intrauterine environment does have an effect," Allison says, adding that simply spending most of our time in climate-controlled environments can affect the way our bodies process energy.
The rise in obesity has raised concern among health officials for the past decade, but it's only been in recent years that it has moved outside the public health arena. The CDC conference emphasizes economic as well as physical health.
"It's an interesting question," Allison says of the connection between money and weight. "It's interesting, because maybe there are things that go on at a state level that affect why people are obese."
