CHAPTER 1
SEDENTARY LIFESTYLES AND UNHEALTHY EATING: THE PUBLIC HEALTH PERSPECTIVE
Today's sedentary lifestyle is a recent phenomenon in human history. Regular vigorous physical activity was a necessity for primitive man, who had to hunt, gather, and eventually farm his food. The ancient civilizations of China, Persia, and India all understood the health benefits of physical activity. Susruta of India, who lived around 600 BC, may have been the first physician to recommend moderate daily exercise to his patients. He proclaimed that "diseases fly from the presence of a person habituated to regular physical exercise." In the East Han dynasty of China, a surgeon named Hua T'O (c. 140-208 AD) prescribed "frolic exercises" for his patients, which mimicked the movements of deer, tigers, bears, cranes, and monkeys.
But perhaps no civilization has esteemed physical fitness so highly as the ancient Greeks. After all, they did invent the Olympic Games, which continue to captivate attention as the world's premier celebration of physical achievement. The Spartans placed a huge emphasis on physical fitness and endurance, requiring rigorous physical training for all males in order to produce highly fit warriors. By contrast, in Athens, Hippocrates (c. 460–375 BC) extolled exercise for its overall healthful benefits, writing that "eating alone will not keep a man well; he must also take exercise." He was the first physician we know of to give a written prescription for exercise to a patient.
Fitness was also a highly valued part of a good education. The Greeks believed a strong body and a sound mind were closely linked, so they emphasized physical training as a fundamental part of every boy's schooling. Plato (c. 428-348 BC), who was a particularly skilled wrestler, advocated sport to build character and, along with music, to bring harmony to the soul. For Plato, athletics cultivated the attributes needed — endurance, focus, and perseverance — to progress toward knowledge and wisdom.
The Romans also placed a premium on physical fitness. Like the Spartans, they valued fitness more for its military application than for any intrinsic appreciation of sport or mind/body balance. During the glory years of the Roman Empire, all Roman citizens between the ages of seventeen and sixty were eligible for the draft, so they needed to be physically ready for military service. Such training included running, marching, jumping, and discus and javelin throwing. But Roman physicians, especially Claudius Galenus, known as Galen (c. 130-200 A.D.), did recognize the usefulness of exercise in medical treatment, and his thinking remained influential until the end of the Middle Ages. As Rome became richer and its people more self-indulgent, eventually the Roman Empire fell in 476 AD. People have debated the reasons for Rome's decline ever since. Many factors undoubtedly led to the demise of its civilization, but one of them was surely its army's declining physical condition. According to Flavius Vegetius Renatus, who wrote a treatise on the Roman system of warfare around 400 AD:
Footsoldiers [sic] wore breastplates and helmets. But when, because of negligence and laziness, parade ground drills were abandoned, the customary armour began to seem heavy, since the soldiers rarely wore it. Therefore, they asked the emperor to set aside first the breastplates and mail, and then the helmets. So our soldiers fought the Goths without any protection for chest and head and were often beaten by archers. Although there were many disasters, which led to the loss of great cities, no one tried to restore breastplates and helmets to the infantry. Thus it happens that troops in battle, exposed to wounds because they have no armour, think about running and not about fighting.
Fast-forward from ancient Rome to the early years of our own country, when fitness was a functional requirement as we pioneered and settled the land. Felling trees, clearing rocks and underbrush, walking long distances, rowing down rivers, and building homes from what stone and wood could be found all demanded a high level of physical fitness and mental fortitude. Thomas Jefferson wrote extensively about the importance of exercise, recommending people give "about two of them [hours] every day to exercise, for health must not be sacrificed to learning. A strong body makes the mind strong."
We seem to have lost the wisdom of past generations when it comes to physical fitness, and as a result, we are imperiling the nation's future.
A public health visionary speaks out
Happily, there are many key leaders today, Dr. Jonathan Fielding prominent among them, who are striving to recapture the ancients' appreciation for physical fitness. Dr. Fielding clearly revels in his work as one of the country's most distinguished experts on public health. However, even after a long and storied career, he is not content to rest on his laurels. "We still have such an enormous preventable burden of disease. While we have made progress, it's important not to be satisfied and always to look ahead to what more can be accomplished to improve our individual and community health," he says.
As a professor at UCLA, Dr. Fielding, with his public health mentor, Dr. Lester Breslow, developed a data-driven course on the determinants of health in populations. To this effort, he brought sixteen years of experience as the visionary founding director of the Los Angeles County Department of Public Health. No fewer than five academic degrees and several decades of service have shaped Dr. Fielding's perspective on public health. UCLA's School of Public Health was named after Dr. Fielding and his wife in 2012.
As a high school student, Dr. Fielding won a competition that enabled him to be "director of public health for a day" in the populous suburb of Westchester County, just outside of New York City. This experience, although brief, introduced him to a broader view of health than the practice of medicine provides, one concerned with the health of populations and the differences among subpopulations. Still, after completing Harvard Medical School in 1969, he set out to become a pediatrician because he felt that by caring for children, he could have a positive long-term impact on their health as adults.
During his training, he found that many of his patients' problems arose from poverty, food insufficiency, neglect, and violence, which he felt helpless to solve in clinical practice. As a result, he decided he wanted to tackle systemic issues like these rather than care for individual patients. So he returned to Harvard for his master's degree in public health and took up work as medical director for the US Department of Labor's Job Corps. There, he was responsible for the health of fifty thousand adolescents and adults per year living in Job Corps residential centers, hoping to get high school equivalency certification and training for jobs with marketable skills. "These were mostly high school dropouts who came from very difficult, often desperate circumstances," Dr. Fielding told UCLA Public Health magazine. "You could see the effects of poverty and other social forces on their life trajectory, and the importance of prevention. It made me think hard about what I wanted to do, and it just seemed logical that if I wanted to really make a difference at a broad level, I should go into the direction of public health."
And make a difference he did. At the Los Angeles County Department of Public Health, his many accomplishments included a reduction in tobacco use, better emergency preparedness, efforts to bring down the threat of lead poisoning in low-income areas, and a restaurant grading system that reduced restaurant-related foodborne illness outbreaks and hospitalizations by up to 20 percent. He and his team also developed programs to increase physical activity among county residents and halt the increase in the childhood obesity rate.
Obesity's life-threatening and preventable consequences
Indeed, childhood obesity is one of Dr. Fielding's greatest concerns. In an article that appeared shortly before Dr. Jerome Adams was sworn in as United States surgeon general in September 2017, Dr. Fielding urged Dr. Adams to use his public megaphone to help Americans who suffer from obesity and related health problems. He wrote, "[M]ore than one-third (35.7 percent) of adults in the [United States] are considered obese; more than 1 in 20 (6.3 percent) have extreme obesity. The Centers for Disease Control and Prevention note that about 17 percent of children ages two to nineteen are obese. Obesity affects about 12.7 million children and adolescents nationwide."
Obesity has put us in the grip of a diabetes epidemic that threatens the lives of millions of Americans. Dr. Fielding sounded the alarm in a 2017 U.S. News and World Report article in which he noted that 85.2 percent of people with type 2 diabetes are overweight or obese, and that people with diabetes have twice the risk of death compared to others of the same age. In total, he said, about 208,000 youths under twenty have type 2 diabetes. Tragically, these young people are "increasing their lifetime susceptibility to heart attacks, strokes, kidney failure, amputations, and blindness."
Particularly frustrating to Dr. Fielding is that type 2 diabetes can be prevented. "Most Americans should be able to stave off type 2 diabetes by maintaining healthy weight through good diet, exercising regularly, and monitoring health through regular doctor visits."
Complex roots of obesity and its intergenerational aspect
As Dr. Fielding writes in a report of the Los Angeles County Department of Public Health, the causes of obesity are complex, rooted in "an interactive mix of biological, behavioral, environmental, and socioeconomic factors." He notes that "prevalence differs greatly by race/ethnicity" and that "economic hardship is one of the major underlying factors contributing to the obesity epidemic." Low-income areas often lack full-service grocery stores with affordable, healthy foods, and safe outdoor play spaces are also scarce. Moreover, the report observes, such families do not always get the medical attention they need to identify preventable problems that can adversely affect their mental, physical, and social health.
This confluence of factors frequently leads to childhood obesity. Unfortunately, being overweight or obese early in life is a "bad portent," Dr. Fielding says. "It greatly increases your risk of having the same problem when you're older. If you're obese as a child, then you're four or five times more likely to be obese as an adult."
Even worse news, Dr. Fielding stresses that obesity is intergenerational. "If you have an obese mother who gives birth to a child, when that child becomes an adult, he or she is more likely to become obese." This could be for a number of reasons, including genetics, learning poor habits that get passed on to one's own children, or seeing being overweight as the accepted norm. "One's peer network, one's family, is important, and what people see as normal really does affect how they feel about themselves. So if everybody in your family is obese, you probably are not going to be as sensitive to it as somebody who comes from a family that generally has a lower level of body fat," Dr. Fielding points out.
Today's sedentary lifestyles
Today's obesity epidemic is correlated with the inactive lives so many Americans lead. "I think the sedentary lifestyle is a problem," Dr.
Fielding says. "We talk about physical activity as if it's separate from the rest of your life, something you do differently at a specific time you carve out. But we need to integrate physical activity into our daily lives, not just set aside special time for it."
A perfect storm of circumstances has diverted far too many children from a healthy future. These include the following:
Undervaluing physical activity in schools: Schools face tremendous pressures today in allocating scarce resources of time and money. Too often, they cut back significantly on recess and physical education in order to spend more time on academics. State education authorities frequently ignore the mountains of evidence showing that active students do better academically and fail to fulfill their responsibility to set kids on a healthy path in life. The need for more physical education in schools is of central concern to this book, and readers will learn more about this in the pages that follow.
Urban living and safety: Parents are understandably concerned about the safety of their children in urban environments. In cities, this often means taking public transportation to school rather than walking or biking — and playing indoors rather than risking unsafe parks and playgrounds. Nor are walking and biking good options in heavily trafficked areas, which often lack sidewalks. Whatever the reasons, it is striking that whereas 40 percent of US schoolchildren walked or rode their bikes to school in 1969, only about 13 percent did so by 2001.
High cost of recreational sports: Unaffordable fees for memberships and equipment make sports too expensive for many families. As children get older and progress in sports, travel teams are priced beyond the means of many. Even school-based sports teams cost an average of $381 per year for each student, and although there may be other factors in play, 67 percent of teens in low-income families do not participate in school sports. This is particularly troubling when one considers that obesity is more prevalent among low-income children. Therefore, we have a situation where some of the children who most need physical activity have less access to it than children of higher income families do.
Movement-minimizing modern conveniences: We think of elevators, escalators, and moving walkways as good things. And they are, when you have heavy luggage or a meeting in a skyscraper. However, they have also reduced the need to walk and climb stairs. Similarly, other conveniences are blessings in one context and curses in another. For instance, air-conditioning causes us to want to remain indoors, and we'd often rather hop in our cars than walk ten minutes to a nearby store. All these modern conveniences mean we move less in our everyday lives — so it's even more important for kids to be active in school.
Hurried lives: Famous British economist John Maynard Keynes predicted in 1930 that technology and the growth of capital would permit us to work only about fifteen hours a week by about this time. Things have not turned out that way, and the average hours worked in the United States are significantly longer than in most other industrialized countries. While more leisure would not necessarily translate into healthier behaviors, many hurried families — especially when both parents work — prefer to save time by piling kids into the car or onto a bus rather than walk to a destination. It can also be quicker to cook high-calorie processed foods or to eat unhealthy fast food than to prepare a balanced meal.
Screen-focused entertainment: With a vast number of 24-7 entertainment choices and televisions that are five feet across, it is tempting for kids to become couch potatoes. Video games, on screens large and small, and social media browsing are more enticing to many kids than going outside to play actively. According to a 2015 report by Common Sense Media, tweens age eight to twelve and teens age thirteen to eighteen spend an alarming six and nine hours, respectively, looking at screens every day, and this excludes time spent using media for school or homework! Teens become absorbed in social media in their spare time instead of in activities that keep them moving. Tired and busy parents are often reluctant to limit screen time because it keeps the kids happily occupied.
Clearly, a broad range of factors contribute to today's inactivity epidemic. These factors, if not addressed, will only further the sedentary trends we are seeing in our children. "The research results are in," Dr. Fielding writes in U.S. News and World Report, "and they confirm that the newest generation of young people is in trouble. Post-millennials don't exercise, and that is the pathway to chronic diseases and lowered life expectancy," as well as to soaring health-care expenditures. Generally speaking, the older people get, the more sedentary they become. But shockingly, a research study to which Dr. Fielding refers in the article found that "19-year-olds showed the same amount of inactivity as 60-year-olds."
