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The first time Krista Pournaras, 16, remembers dieting was when she was 6 years old. She was gaining weight like “mad,� packing on 30 pounds in one year alone. By second grade, it was obvious Pournaras was fat. That's when her mother, Lynn Katekovich, a nurse, took her to a pediatrician, who put the young girl on a strict diet that didn't allow any between-meal snacks, not even an apple.

That diet didn't work. Neither did the others. Pournaras went on low-fat diets, she tried Weight Watchers, she even took diet pills. She'd bike around the neighborhood, go to the gym and swim at the local YMCA. Pournaras would lose a few pounds, but then she'd gain them back or gain even more. This year, when Pournaras, who stands slightly taller than 5' 2�, started her junior year at the local vo-tech in Conway, Pa., north of Pittsburgh, she weighed 245 pounds. She couldn't play with her dogs without becoming short of breath and feeling achy. This summer Pournaras discovered her weight had seriously affected her health: She had high blood pressure and elevated insulin levels, putting her at risk for Type 2 diabetes, and Polycystic Ovarian Syndrome, a condition in which a female has heightened levels of testosterone.

After Katekovich, who owns a medical staffing company, found out her daughter was likely to develop heart disease and diabetes, she cried. That's when she decided to talk to her about having bariatric surgery. Katekovich and her two sisters had had the drastic procedure in January 2003. Since then, the 44-year-old Katekovich, who had weighed 264, has lost 100 pounds. With bariatric surgery the stomach is reduced by 90 percent — to the size of the top joint of the thumb — and the large intestines are bypassed. On Nov. 12, Dr. Philip Schauer, director of Bariatric Surgery at Magee Women's Hospital in Pittsburgh, operated on Pournaras.

“I was against the surgery,� Pournaras says. “But my mom and Dr. Schauer talked to me and said that if I didn't do something about my health, I'd die much younger, younger than usual. I want to be happier about myself and not have as many health problems.�

Getting Worse Faster

Pournaras's extreme solution may be unusual, but her weight problem isn't. About 9 million children and adolescents in the U.S. are overweight or obese. That's roughly 15 percent of the children and adolescents between the ages of 6 and 19 who are overweight or obese, according to the latest data compiled during 1999 and 2000 by the Centers for Disease Control and Prevention's National Center for Health Statistics. Health officials and physicians blame children's poor eating habits — having supersized portions of junk food and sweetened soft drinks — and physical inactivity, such as watching TV, playing video games or clicking away on PCs, instead of playing. Just take a look at the numbers from a little more than 30 years earlier to see how rapidly children's health has deteriorated: In a similar CDC survey taken from 1971 to 1974, 4 percent of children between the ages of 6 and 11 were overweight or obese, and 6 percent of adolescents between the ages of 12 and 19 were overweight or obese.

And, the nation's obesity problem will only worsen. As today's young people grow older, it's estimated that 3 in 4 overweight children will become fat adults and will suffer from obesity-related diseases at earlier ages than previous generations. Already, about two-thirds of all adults are overweight and about 31 percent of those are considered obese. Generally, if someone weighs more than 30 pounds above his ideal weight, then he's considered obese. The CDC considers someone overweight if his body mass index, or BMI, a calculation based on height and weight, is more than 25. If a person's BMI is over 30, then he is considered obese. Health officials have now deemed obesity in America a health epidemic.

By 2010, only six years away, about 40 percent of all adult Americans, or 68 million, will be obese. If trends continue, almost every single American will be overweight, or obese, (except the few that are genetically prone to have higher metabolisms) by 2040, says John Foreyt, director of Behavioral Medicine Research Center at Baylor College of Medicine in Houston. “It may happen more quickly,� he says. “Twenty years ago, it was unusual to see a 300-pound person in my clinic, now we see it all the time. And it used to be we'd see obesity only in adults, but now we see it in children. This may be the first generation of children who will die before their parents.�

Foreyt based his projections on data collected from the CDC's Health and Nutritional Examination Surveys, which record actual weights and heights of Americans surveyed, showing that the U.S. population has become much heavier in the past 20 years. In 1980, 46 percent of the adult population was overweight or obese. In 1990, 56 percent was overweight or obese. In 2000, the percent jumped to 64.5 percent. That's 1 percentage point gain a year. Foreyt says part of the problem is that Americans eat 200 more calories a day than they did 10 years ago. Over a year, those extra calories add up to 20 pounds.

Efforts to Reverse Trend

In an effort to slow the rate of increase in obesity, and maybe even reverse the trend, the U.S. Surgeon General's office requested $125 million in the 2004 budget to expand the Healthier US Initiative, a campaign President George W. Bush announced in June 2002 to encourage Americans to eat healthier and exercise more. The 2003 budget was $25 million. In November, the Surgeon General teamed up with the American Academy of Pediatrics, Nike Inc. and McNeil Nutritionals, maker of Splenda artificial sweetner, to launch Shaping America's Youth. Initially, this program intends to find out the scope of children's weight problems and identify community resources available to help them.

“It's an extraordinary a project because there are children out there who are sedentary and who eat indiscriminately,� says Dr. Richard H. Carmona, the U.S. Surgeon General. “When [these children] are middle-aged and overweight, or obese, they will have Type 2 diabetes, hypertension and cardiovascular disease. We're making an unhealthy society for our children. We have to break that cycle; it affects all of us.�

Costs add up

It's difficult to put a price tag on what it costs people who are overweight to live in a society that values thinness and fitness. What's the price of a chubby teenager who is so fearful of being mocked by classmates that he decides not to go college? Yet, for more tangible expenses, the CDC estimates that in 2000, the latest figures available, obesity cost $117 billion: $56 billion in lost productivity and $61 billion in medical treatments. About 300,000 deaths a year are attributed to obesity-related diseases. “That's approaching the costs for treating people with tobacco-related diseases,� says Mary Kay Sones, a spokesperson with the CDC's National Center for Chronic Disease Prevention and Health Promotion in Atlanta.

That may be an underestimate, because obesity has so many ramifications. It contributes to higher incidences of cancer, specifically kidney cancer, and orthopedic complications, due to the excess stress on bones and cartilage. Diabetes alone costs about $130 billion a year. The disease can cause blindness, kidney failure, strokes and heart disease. It's estimated that diabetes shortens a person's life by 10 to 15 years. Dr. K. M. Venkat Narayan, chief of the CDC's diabetes epidemiology section, says the disease “has a high impact economically and in terms of suffering� for the patients.

The CDC estimates that 1 American in 3 born in 2000 will develop Type 2 diabetes, as they grow older; some while they're still young. In the past, people weren't usually diagnosed with the disease until they were in their 50s or 60s. If obesity trends continue, Narayan projects that in 50 years 28 million Americans will have diabetes, up from 17 million in 2003.

Ronald Sturm, an economist at Rand Corp., a think tank in Santa Monica, Calif., says the number of severely obese people is increasing at an even higher rate. To be considered severely obese a person has to have a BMI of 40 or higher. In 1986, 1 in 200 were considered severely obese. In 2000, that increased to 1 in 50. An average adult male would be roughly 100 pounds more than his ideal weight. For instance, a man who is 5' 10" would weigh more than 300 pounds, and a woman who is 5'4" would be more than 250 pounds. Sturm, who studied people between the ages of 50 and 60, projects that by 2020, more than half of men will be obese and about a quarter of those will be severely obese.

Sturm estimates that in 2003 medical costs for an obese man who is 50 years old are $1,000 more a year than they are for a similarly aged man of normal weight. Costs for a severely obese man would be $10,000 more. Sturm figures the costs would be slightly less for severely obese women: about $7,000 a year. That's not even taking into consideration more pricey measures. Bariatric surgery, for instance, costs about $25,000.

Ed Bernstein, executive director of the North American Association for the Study of Obesity in Silver Springs, Md., wants patients' who are under a doctor's care to be reimbursed for weight-loss costs. Currently, patients pay for their treatments, but then they can deduct those expenses from their federal income taxes. “We ridicule people for their health problem,� Bernstein says. “We wouldn't do that for someone with diabetes, cancer or heart disease, but we do that with people who are obese…. Your body fights you very hard when you try to lose weight. People do it; there are a few success stories. We're learning about what helps keep weight off, but it's not simple.�

Who's responsible, anyway?

Weight gain seems to be a simple calculation: more calories are consumed than are burned. But it's more complicated. Genes aren't solely responsible for the increase in obesity, but they do play a role. Forty percent of people's weight problems can be blamed on their genes, says Patrick O'Neil, a psychologist and director of the Weight Management Center at the Medical University of South Carolina in Charleston. That's because Homo sapiens evolved under conditions, requiring vigorous physical activity at a time when food supplies were uncertain.

“We're programmed to be able to store energy from our earlier days,� O'Neil says. “As far as evolution goes, it's only yesterday that human beings have been on the planet.� Today, Americans have ready access to tasty, cheap, high-caloric food. And in our modern society, we're less active. We drive instead of walking. We use a remote to change our TV channels instead of getting up to switch them. And we buy our food in supermarkets rather than hunt animals or raise crops. As he says, “Genes load the gun and the environment pulls the trigger.�

Scientific studies suggest that many modern conveniences and luxuries lead to obesity, especially in children. One showed that school-age children who drank sweetened soft drinks had a total energy intake 10 percent higher than those who did not. Fast food is also thought to contribute to obesity because it tends to be high in saturated and trans fat — which increases LDL cholesterol, or bad cholesterol — high in sugar and served in large portions. Fast food also tends to be low in dietary fiber, nutrients and antioxidants.

Local Efforts in Schools

Faced with the burgeoning number of overweight students, state and local governments have begun their own initiatives. Two of the nation's largest public school systems, New York City and Los Angeles, banned soda vending during school hours. (The L.A. ban becomes effective January 2004.) New York went a step further, prohibiting snack-food vending machines in schools and reducing the fat content in the school cafeteria food. In October, the L.A. school district followed, banning fried chips, candy and other junk foods from vending machines. The plan also calls on school administrators to end contracts with vendors who sell pizzas and burgers at some institutions.

Last summer, South Carolina started the South Carolina Nutrition Research Consortium, pooling the resources of Clemson University, the University of South Carolina and the Medical University in Charleston to tackle the state's growing overweight population. Almost 22 percent of the state's residents are obese, according to CDC data. “We were concerned about being a chubby state,� says Peter Kent, a spokesman for Clemson University. “We're a state at risk.�

Surgeon General Carmona says he would like food producers to assume a greater role in fighting obesity. He'd like them to make the nutritional contents of their products more available to consumers, make sure animals are raised under healthy conditions, promote healthy eating messages and offer healthier food options. Suing companies isn't the answer, he says. In 2002, two obese teenagers sued McDonald's, blaming the chain's poor labeling of the nutritional and caloric content in its fast food for their weight gain. The lawsuit was thrown out.

“Rather than make an enemy of corporate America, let's talk to them,� Carmona says. “Let's make them part of the solution, rather than the problem.�

Food Marketers Respond

Indeed, food companies have been taking steps to promote healthier eating habits. Kraft Foods Inc., maker of Oscar Mayer cold cuts, Velveeta and Oreo cookies, launched a global anti-obesity effort in July, which calls for smaller portion sizes and improving the nutritional content of some Kraft products. It also includes ending marketing in schools and setting up guidelines for marketing aimed at children. (A San Francisco man dropped a lawsuit last year against Kraft, after it agreed to reduce trans fat in Oreos.)

Recently, Pizza Hut added low-fat items and salads to its menu. Dubbed Fit ‘N’ Delicious, the pizzas have 25 percent less fat and 30 percent fewer calories. Ruby Tuesday, a restaurant chain, changed its cooking oil from soybean to canola and introduced a low-carbohydrate menu. Burger King began offering salads and a new low-fat chicken sandwich, and KFC has a low-fat barbecue sandwich.

Liz Castells-Heard, president of Castells & Asociados Advertising in Los Angeles, says she used reports on the alarming number of overweight Hispanic youngsters to convince McDonald's to reach out to Hispanic customers with healthier menu items in its California and Texas markets. As a result, Castells-Heard says, the fast-food giant developed three new salads, a veggie burger, a chicken sandwich on whole wheat bread and yogurt parfaits.

Castells-Heard approached McDonald's after noticing that a higher number of Hispanics, especially youngsters, were overweight or obese than the overall U.S. population. According to the NCHS, 27.3 percent of Mexican American boys between the ages of 6 and 11 are overweight, compared with 12 percent of white non-Hispanic boys of the same age. For Mexican American males between 12 and 19 years old, 27.5 percent are overweight, compared with 12.8 percent of white non-Hispanics males in that age group. For Mexican American girls between the ages of 6 and 11, 19.6 percent are considered overweight. For Mexican American females between 12 and 19, about 19.4 percent are considered overweight, compared with 12.4 percent of their white non-Hispanic counterparts. “It's part of the Hispanic culture,� says Castells-Heard. “They don't have that obsession that younger females have about getting so skinny, or being anorexic or bulimic — that's the good news. The bad news is that we have a higher rate of obesity.�

Yet, Americans think that they are slimming down. In its latest survey, released in October, Port Washington, N.Y.-based NPD Group found that Americans said they weren't gaining weight. Of the 5,000 people in the study, 55 percent said they were overweight, compared with 56 percent the year before. “I've never seen that,� said Harry Balzer, NPD's vice president, in a statement. “Looks like we're focusing on health again, a return to the ‘80s. People are interested in a balanced diet; they ate more fruits and vegetables last year than the year before and snacked less in the evening.�

NPD survey's respondents were more concerned with fat, cholesterol, sugar and food additives. Thirty-five percent said they plan nutritious meals, up from 32 percent in 2001. And 66 percent said they were strenuously exercising at least once a week, up from 63 percent in 2002. Fifty-three percent said they check food labels to avoid harmful substances, that's up from 51 percent in 2002. But Belzer added: “The question is which trends are the beginning of a new direction and which are short-term disruptions.�

Tougher Measures Needed

The nation's anti-smoking campaign may be an indication of how hard it is to change people's lifestyles. The Surgeon General warned about the dangers of cigarette smoking in 1964. “Forty years down the line and we're still seeing 440,000 smoking-related deaths a year,� says Dr. Carmona. “Obesity kills over 300,000. So, it's rapidly catching up and becoming the fastest growing killer of Americans. It will eclipse smoking in the near future. People are used to eating a certain way from their family and friends. We're talking about changing American culture. It's not cool to be the Marlboro man, but look how long it took us to get to that point.�

Kelly D. Brownell, director of the Yale Center for Eating and Weight Disorders, doesn't think the Surgeon General's new anti-obesity program goes far enough. Americans have been bombarded with public service messages to eat healthier and exercise more for years with disappointing results. Brownell, coauthor of Food Fight (Contemporary Books, 2003) about America's food industry and the growing prevalence of obesity, thinks banning soft drinks and fast food in schools is a step in the right direction. But he says food advertising geared toward children must change. The average child is inundated with ads for fast food, candy, sugared cereals and soft drinks. “If parents ate every meal with their children and persuaded them to eat healthier, then that would be 1,000 messages for the parents and 10,000 for them,� he says. “The advertisers have Britney Spears, Shaquille O'Neal and Beyoncé Knowles. It's not a fair contest.�

Brownell thinks food and drink ads marketed toward children will eventually change, just as cigarette ads did. “Our nation is quick to respond when it feels children are being victimized and American children are suffering in record numbers with poor diets and physical inactivity,� he says.

For some children, these changes can't come soon enough. After her bariatric surgery in November, Krista Pournaras hopes her life will improve. She thinks that she will be a better student when she is thinner, because she won't be afraid to participate in class discussions. Pournaras thinks other obese teens could benefit from this surgery. “I figure if this can help me, and make me happier, why not help other adolescents?�

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