obesity in america

Obesity in the United States

The extent of the Problem

Obesity as one commentator says, is not just a "matter of aesthetics" but has become a major public health problem in the United States. Similarly, Federal health officials have categorically stated that "the growing prevalence of obesity in the United States represents a significant health threat to millions of Americans." Obesity is seen by health officials in a serious light and is very often described as an "epidemic' that has to be vigorously controlled.

Jeffrey Koplan, director of the CDC (Centers for Disease Control and Prevention) recently stated that "the continuing epidemic of obesity is a critical public health concern" and "as a nation, we need to respond as vigorously to this epidemic as we do to an infectious disease epidemic."

These remarks are not alarmist but are supported by solid statistics that point to an increase of nearly 60% in the number of people who can be considered to be obese nationally. These facts are echoed by "The simple fact...that more people die in the United States of too much food than of too little' says Agriculture Secretary Dan Glickman.

Some 97-million American adults and 10-million American children are overweight or obese, and the problem is "literally growing before our eyes."

It is estimated that physical inactivity and being overweight account for more than 300,000 premature deaths annually in the U.S., a figure that is second only to tobacco-related deaths.

Statistics emphasize that the problem of obesity is having a profound effect on the public health profile, with one of the central areas of concern being the increase in obesity among children. "Federal health agencies say that 55% of American adults, 13.6% of school children and 8% of pre-school children are overweight -- 107-million people in all."

There is a growing sense of concern among health professionals about the alarming rate of the increase in the number of cases of obesity.

Obesity rates in the United States have skyrocketed in the last 30 years. Among adults, obesity rates have more than doubled from the early 1970s to the late 1990s. Over the same period, children's obesity rates nearly tripled. These alarming trends have received a great deal of attention in recent years.

2. Obesity: Definition and Causes

In simple terms obesity is commonly defined as a body mass index (BMI) of 30 or higher. A BMI of 30, in most cases, means that an individual is about 30 pounds over their ideal weight.

A more specific definition is the following:

Body Mass Index (BMI) is the standard measurement of choice for many health professionals. BMI is based on a weight-to-height ratio. Overweight is defined as a BMI>=25 and =30 kg/m2. Obesity correlates strongly with obesity-related co-morbid conditions and mortality."

In more practical terms obesity is 'the excessive accumulation of adipose tissue to an extent that health is impaired."

One of the most commonly given reasons for the increase in the incidence of obesity is lifestyle habits and basic overeating. Diet or the intake of food and drink is one of the central factors that have been documented as the main syndrome of obesity. It should be noted that the causes of obesity are interrelated. For example, modern living conditions, the quality of daily food intake and psychological aspects can be seen to be related. Food intake and eating habits are regarded as the main factors that are related to the increase in obesity over the past decade in the United States.

America's diet consists of hamburgers, French fries and cola drinks! Our fondness for fast food and the marketability of such restaurants overseas make these a cultural symbol to many. And many of the stereotypes are true. The most commonly consumed grain in the United States is white bread; the favorite meat is beef, and the most frequently eaten vegetable is the potato, usually as French fries.

This aspect is exacerbated by the quality of food and the preponderance of sugar-related content, which has far-reaching effects for public health.

Food-related education is badly needed say food-bank workers and fitness experts who tell stories of low-income children coming to school with "meals" of sugarcoated doughnuts, cans of soda and mayonnaise sandwiches. Food banks are also trying to increase their collection of fresh fruits and vegetables. Finding trucks to quickly deliver the produce to local programs remains a major problem.

A research study has established that, coupled with increased intake of unsuitable foods, inactivity is a central factor in the acceleration in obesity. "They rated physical inactivity as significantly more important than any other cause of obesity (p < 0.0009). Two other behavioral factors -- overeating and a high-fat diet -- received the next highest mean ratings."

There is an extensive amount of literature on the subject of the causes of obesity. These range from social and environmental factors to psychological causes and even innate factors such as hereditary. Stress has also been established as a central psychological determinant in obesity.

Obesity might follow stress and anxiety. Stress-induced binge eating occurs in laboratory rats subjected to both food restriction and stress, but does not follow food restriction alone (Hagan et al., 2002). This phenomenon suggests that anxiety can contribute to obesity. Indeed, anxious subjects who are obese consume more food than people who are not obese and those who are less anxious and obese (McKenna, 1972; Pine, 1985).

Recently a research project has suggested that obesity in the United States might be the result of a virus.

A virus may bear part of the blame for the epidemic of obesity in this country, University of Wisconsin scientists say. Two Wisconsin researchers, Dr. Nikhil Dhurandhar and Dr. Richard Atkinson, say their preliminary findings suggest a bug called Ad-36, from an adenovirus family that typically triggers mild respiratory symptoms, may put some people at risk for obesity, just as other viruses cause colds, flu, hepatitis and AIDS.

However, the central and most predominant cause of obesity lies within the ambit of contemporary lifestyles. The general causes of obesity are not hard to discern with even a cursory analysis of contemporary third world eating habits and sedentary behavior.

It has become a crusade to change the way Americans live. The nation's landscape they argue is littered with junk food masquerading as health food; candy and candy-like cereals featuring kids' favorite cartoon characters and toy-like packaging; schools that shamelessly hawk soft drinks and snack foods, and multimillion-dollar advertising campaigns to promote such unwholesome products. Schools, in particular, "have become nutritional disaster areas"... "we've created environments that are hostile to physical activity," says psychologist James Sallis, director of the Active Living Research Program at the San Diego State University.

3. Related illness

Obesity has a concomitant affect on an individual's overall health and can subsequently be connected to other illness and ailments and is also an exacerbating factor in many common diseases. "As obesity rates continue to grow at epidemic proportions in this country, the net effect will be dramatic increases in related chronic health conditions such as diabetes and cardiovascular disease,"

Obesity also has an effect on many common illnesses such as diabetes, particularly type-2 diabetes. This form of diabetes is usually diagnosed in patients over 40 years of age and is caused by the body's inability to process insulin correctly. This form of diabetes is directly linked to obesity and physical inactivity.

At first, your body overproduces insulin to keep blood sugar normal, but over time this causes your body to lose its ability to produce enough insulin to keep blood sugar levels in the normal healthy range. The result is sugar rises in your blood to high levels. Over a long period of time, high blood sugar levels and diabetes can cause heart disease, stroke, blindness, kidney failure, leg and foot amputations, and pregnancy complications. Diabetes can be a deadly disease: over 200,000 people die each year of diabetes-related complications.

High blood sugar levels can also result in further health complications. The problem for overweight people is that they are much more likely to develop the type-2 form of diabetes than those who carry normal weight. It is estimated that the correlation between obesity and type-2 diabetes is as much as ninety percent. The reason for this is that "being overweight puts added pressure on the body's ability to properly control blood sugar using insulin and therefore makes it much more likely for you to develop diabetes." It is significant that the rapid increase in the number of cases of diabetes is strongly related to the prevalence of obesity in the larger American population.

There is also a strong correlation between obesity and being overweight and certain types of cancer. It has been established that there is an increased risk of kidney cancer in overweight men and women. In obese women there is also the increased risk of endometrial cancer as well as postmenopausal breast cancer. There is also a higher risk of colorectal cancer, gall bladder cancer as well as thyroid cancer in overweight people.

There is a long list of illnesses associated with obesity, including hypertension; dyslipidemia and respiratory problems such as asthma, sleep apnea and depression. It was only recently discovered that there exists a strong and direct correlation between heart failure and obesity. The following study makes this correlation clear.

In 2002, Kenchaiah et al. examined the relationship between overweight and lesser degrees of obesity on the risk of developing heart failure in 5881 participants in the Framingham Heart Study. Heart failure developed in a total of 496 (8%) subjects (258 women and 238 men). After adjustment for known risk factors, overweight women with a body mass index of (BMI) 25.0-29.9) had a 50% greater risk of heart failure, and obese women (BMI & gt; or =30.0) were twice as likely to develop heart failure compared with normal weight individuals. Overweight men had a 20% increase in heart failure risk, whereas obese men had a 90% higher increased risk. With each increase of 1 unit of BMI, a woman's risk of heart failure increased 7% and a man's risk of heart failure increased 5%. More importantly, obesity alone was estimated to account for 14% of heart failure cases in women and 11% of heart failure cases in men.

This correlation is reiterated in another study entitled: Obesity and Heart Failure, from The Journal of Cardiovascular Nursing.

Obesity and heart disease are closely associated as obesity is a primary contributor to hypertension, diabetes, and dyslipidemia, all risk factors for the development of coronary artery disease (CAD). Coronary artery disease and hypertension have long been accepted as contributors to heart failure. Hypertension, diabetes, and left ventricular hypertrophy account for up to 90% of the risk for heart failure in the U.S. population.

What is of concern is that obesity is not seen only as a contributing factor to heart failure but as a cause in its own right.

With recent advances in cellular technology, it is clear that not only is obesity an interwoven thread in the fabric of CAD, but it also stands alone as an independent risk factor of heart failure. Chronic heart failure continues to be a major cause of cardiovascular mortality and morbidity in the United States, currently affecting 4.8-million Americans and reaching another 550,000 people each year.

A further study also serves to corroborate these findings.

Obesity is known to have significant adverse effects on many of the coronary artery disease (CAD) risk factors, including arterial pressure, insulin resistance, plasma lipids (especially increasing triglycerides and decreasing high-density lipoprotein cholesterol), physical activity, inflammation, exercise capacity, and LVH. (19,20) Despite adversely affecting all of these individual risk factors, data from both the Framingham Heart Stud (21) and a large cohort of female U.S. nurses (22) have indicated that obesity is an independent risk factor for major CAD events in men and, particularly, women. Several studies indicate a progressive increase in all-cause mortality associated with overweight and, especially, with frank obesity.

Obesity is therefore seen as an independent risk factor in heart failure. There is also evidence that dyslipidemia and arterial inflammation together play an important role in the development of coronary artery disease, in which obesity is an important factor. "Dyslipidemia and markers for arterial inflammation (cardiac C-reactive protein (CRP), interleukin 6 (IL-6)) rise with diabetes and hypertension. They also rise with obesity. Obesity is characterized by an increased prevalence toward hypertriglyceridemia."

There are many other factors to consider in the relationship of obesity to other health issues and diseases. Suffice to say that this relationship is becoming more pervasive with the increase in obesity as both a contributory and direct factor in the understanding of health and disease.

Research has clearly shown the deleterious impact of obesity in relationship to increased health risks, negative factors associated with psychosocial functioning, increased risks of disability and lost productivity, and rising costs of medical care and weight loss treatment. The overall health of our society is at risk due to the increasing prevalence of obesity.

4. Public Health

The cost of obesity is reflected in its effect on public healthcare figures. While rates may differ from state to state, the cost of obesity is reflected in the percentage amount spent by Healthcare.

Medical expenditures due to obesity range from a high of 7.4% of total healthcare spending in Puerto Rico to a low of 4% in Arizona. The eight states with the largest commitment of their healthcare dollars use, on average, 42% more of their healthcare funds for obesity than the eight states with the lowest commitment.

These figures are expanded upon in the following study.

Obesity is responsible for at least 300,000 deaths per year, and the 2003 direct health cost of obesity has been tagged at $75-billion. That is approximately $350 per year for every American adult. A 2003 report found that 5.3% of annual health costs were medical expenses attributable to obesity. And it has been estimated that if you are an American aged 18 to 36 and obese, you will on average generate 36% more medical expenses per year than if you were not obese.

The extent of the financial cost of the treatment of obesity and related illnesses can be seen in the statistics for the year 2000. During this year, obesity generated health costs of $75-billion, which amounted to 6% of the total health expenditure. Obesity accounted for $18-billion in cost, or 7% of the Medicare budget.

During this period there were also "approximately 80,000 stomach and intestine stapling surgeries in 2002, costing an estimated $2.4-billion."

The cost to the public sector cannot be estimated in pecuniary terms alone. The cost in terms of death and disability as well as the loss of working hours and productivity has to be assimilated into the overall equation. The complicating factor when calculating the cost of obesity to public health is the fact that obesity engenders and is linked to a wide range of other diseases and ailments that also increase the cost, in all sense of the word, to the public sector and healthcare in general.

Consider the fact that obesity is fertile breeding ground for chronic diseases like type-2 diabetes, cardiovascular disease and arthritis; that it is causally connected to cancers including endometrial cancer, some breast cancers, colon and kidney cancer; and that it is also an instigator of sleep apnea, gall bladder disease, back and joint disorders, and depression. Now go through the list again and think about the emergency room visits, hospitalization, surgery and rehabilitation. The paralyzing impact of obesity on the health care budget and the need for true health system reform becomes obvious.

The above statement also means that the treatment and study of obesity is absorbing resources and time that could rather be used to improve the healthcare system in general. An indication of the direct cost and effect of the increasing cases of obesity can be seen when compared to the cost of tobacco smoking to public health. According to a number of reports the medical costs associated with obesity have in fact overtaken the costs associated with smoking.

The nation's obesity epidemic has gotten so bad it has overtaken tobacco as the leading cause of preventable deaths. Health-care costs linked to obesity and resulting conditions such as diabetes and heart disease are greater than those related to smoking and problem drinking.

The cost to the economy and to production is self evident when one considers that Individuals who are obese have a 50 to 100% increased risk of premature death from all causes compared to individuals with a BMI in the range of 20 to 25. This means that the costs associated with obesity have both direct and indirect effects on the overall economy.

Overweight and obesity and their associated health problems have substantial economic consequences for the U.S. health care system. The increasing prevalence of overweight and obesity is associated with both direct and indirect costs. Direct health care costs refer to preventive, diagnostic and treatment-services related to overweight and obesity (for example, physician visits and hospital and nursing home care). Indirect costs refer to the value of wages lost by people unable to work because of illness or disability, as well as the value of future earnings lost by premature death.

These costs can be seen in the escalating amounts attributed to obesity.

In 1995, the total (direct and indirect) costs attributable to obesity amounted to an estimated $99-billion. (27) In 2000, the total cost of obesity was estimated to be $117-billion ($61 billion direct and $56 billion indirect). (28) Most of the cost associated with obesity is due to type 2-diabetes, coronary heart disease and hypertension.

The level of seriousness of obesity can be seen in the recent change in Medicare legislation. Obesity is now classified as an illness, which may be covered by Medicare. Health and Human Services Secretary Tommy G. Thompson announced "...that the Centers for Medicare and Medicaid Services would remove language in Medicare's coverage manual that states obesity is not an illness."

In announcing this significant change Thompson reiterated the growing concern about the impact of obesity on both personal and public health. "Obesity is a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely..."

Conclusion

The alarm bells with regard to public and private healthcare and obesity have been ringing for some time now. However, this alarm has been raised to a new and more strident level by the increasing number of children and adolescents who are overweight or obese. "In the past 30 years, the occurrence of overweight in children has doubled and it is now estimated that one in five children in the U.S. is overweight. Increases in the prevalence of overweight are also being seen in younger children, including pre-schooler's." Consequently, the issue of childhood obesity "is regarded as the most common prevalent nutritional disorder of U.S. children and adolescents, and one of the most common problems seen by pediatricians."

This has also raised concerns that obesity should become an issue of government policy. "In particular, we argue that children's weight is an appropriate area for government intervention for all the reasons that the government acts to protect children's health more broadly, for example, by barring them from purchasing cigarettes and alcohol."

The subject of childhood obesity is particularly important as it is also an indicator and a precursor of later health development trends in the United States. This is also the case when it comes to psychopathological issues.

Patients with early onset obesity demonstrated a greater frequency and higher levels of motional distress and psychiatric symptomatology than patients with late onset obesity. Individuals who developed obesity in childhood showed more psychopathology than those who developed obesity later in life. Overall, these findings support the belief that obesity is characteristically associated with greater internal psychological conflict. These findings further suggest that childhood obesity could serve as a predictor variable for possible future psychological disturbance in obese populations.

In the final analysis there can be no doubt of the seriousness and long-term implications of this issue. As many commentators stress "It is important to address the alarming increase of this disease because of the myriad of health problems and increased costs...."

Many health professionals believe that the battle for public health has shifted decisively from cigarette smoking to obesity. Health economist Kenneth Warner, director of the University of Michigan Tobacco Research Network states that "... fighting obesity today is similar to where we were with cigarettes in the early '60s: We've identified a health-risk factor, but we're only now starting to get serious about conveying its importance and magnitude to the public."

Notes

Lou Marano., "Is obesity a U.S. public policy issue? United Press International, [database online]; available at http://www.upi.com/view.cfm?StoryID=20-5081r;Internet; accessed 14 August 2004.

Obesity in America," Mayo Clinic; available from CNN, http://www.cnn.com/2000/HEALTH/mayo/10/05/obesity.america/;Internet; accessed 11 August 2004.

Cheryl Wetzstein, "America's Quiet Epidemic," Insight on the News, 28 December 1998, 41 [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004.

Obesity in America," Mayo Clinic; available from CNN, http://www.cnn.com/2000/HEALTH/mayo/10/05/obesity.america/;Internet; accessed 11 August 2004

Cheryl Wetzstein, "America's Quiet Epidemic," Insight on the News, 28 December 1998, 41 [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004. www.questia.com/PM.qst?a=o&d=5002010099

Patricia M. Anderson, Kristin F. Butcher, and Phillip B. Levine, "Economic Perspectives on Childhood Obesity," Economic Perspectives 27, no. 3 (2003) [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004.

Obesity in America," Mayo Clinic; available from CNN, http://www.cnn.com/2000/HEALTH/mayo/10/05/obesity.america/;Internet; accessed 11 August 2004.

What is Obesity?," NASO; available at http://www.naaso.org/information/what_is_obesity.asp;Internet; accessed 11 August 2004.

Combating Obesity in America"; available at http://www.u.arizona.edu/~adonovan/;Internet; accessed 9 August 2004.

Cheryl Wetzstein, "America's Quiet Epidemic," Insight on the News, 28 December 1998, 41 [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004.

Gary D. Foster et al. "Primary Care Physicians' Attitudes about Obesity and Its Treatment,"

The North American Association for the Study of Obesity; November, 20003; database online]; available at http://www.obesityresearch.org/cgi/content/abstract/11/10/1168?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexacttitle=and&andorexacttitleabs=and&fulltext=causes&andorexactfulltext=and&searchid=1092404962005_341&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=obesityres/;Internet; accessed 13 August 2004.

Conrad Swartz, "Obesity as Psychiatric Disorder"; Psychiatric Times; 8/1/2003; www.questia.com/PM.qst?a=o&d=5001589619

Joyce Price, "Research Links Virus to Some Obesity: Microbe May Also Lower Cholesterol," The Washington Times, 12 April 1997, 5 [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004.

Wallis, Claudia. "The Obesity Warriors: What will it take to end this epidemic? These experts are very glad you asked.(Cover/Critical Condition: America's Obesity Crisis / The Solutions: Activists)," Time, June 7, 2004.

Obesity in America," Mayo Clinic; available from CNN, http://www.cnn.com/2000/HEALTH/mayo/10/05/obesity.america/;Internet; accessed 11 August 2004.

What is Obesity?," NASO; available at http://www.naaso.org/information/what_is_obesity.asp;Internet; accessed 11 August 2004.

Cancer and Obesity," NASO; available at http://www.naaso.org/information/cancer_obesity.asp;Internet; accessed 11 August 2004.

Robert Deusinger, "Obesity: overview of prevalence, etiology, and treatment," Physical Therapy, 3/1/2003.

Jessica Coviello, "Obesity and Heart Failure," Journal of Cardiovascular Nursing; 11/1/2003

Franz Messerli, "Obesity and the heart: an ever-growing problem," Southern Medical Journal; 6/1/2003;

Jessica Coviello, "Obesity and Heart Failure," Journal of Cardiovascular Nursing; 11/1/2003

Gregory Spence-Jones, "Overview of obesity' Critical Care Nursing Quarterly; 4/1/2003; Volume: 26

Number: 2. Page: 83.

Mike Maggee. "The Cost of Obesity in America," Health Politics; available from, http://www.healthpolitics.com/program_transcript.asp?p=prog_47;Internet; accessed 11 August 2004.

Obesity overtakes smoking for medical costs," visiongain Anti-Obesity report, M2 Presswire; 8/20/2003.

David Satcher, " Overweight + Obesity: U.S. Surgeon General Call to Action to Prevent and Decrease";.IDEA Health & Fitness Source; 11/1/2002;

Higgins Marguerite, " Obesity is classified as an illness that may be covered by Medicare," The Washington Times Knight Ridder/Tribune Business News; 7/16/2004

Childhood Overweight. NASO; North American Association for the Study of obesity; available from;

http://www.naaso.org/information/childhood_overweight.asp;nternet. Accessed 11 August 2004. www.questia.com/PM.qst?a=o&d=5002010099

Patricia M. Anderson, Kristin F. Butcher, and Phillip B. Levine, "Economic Perspectives on Childhood Obesity," Economic Perspectives 27, no. 3 (2003) [database online]; available from Questia, http://www.questia.com/;Internet; accessed 13 August 2004. www.questia.com/PM.qst?a=o&d=76933134

Jon K. Mills, and George D. Andrianopoulos, "The Relationship between Childhood Onset Obesity and Psychopathology in Adulthood," Journal of Psychology 127, no. 5 (1993): 547.

Wallis, Claudia. "The Obesity Warriors: What will it take to end this epidemic? These experts are very glad you asked.(Cover/Critical Condition: America's Obesity Crisis / The Solutions: Activists)," Time, June 7, 2004.

Bibliography http://www.questia.com/PM.qst?a=o&d=5002010099

Anderson, Patricia M., Kristin F. Butcher, and Phillip B. Levine. "Economic Perspectives on Childhood Obesity." Economic Perspectives 27, no. 3 (2003): 30+. http://www.questia.com/PM.qst?a=o&d=99704135

Bruch, Hilde. Eating Disorders; Obesity, Anorexia Nervosa, and the Person within. New York: Basic Books, 1973.

Cancer and Obesity," NASO; available at http://www.naaso.org/information/cancer_obesity.asp;Internet; accessed 11 August 2004. http://www.questia.com/PM.qst?a=o&d=5000703580

Chappell, Kevin. "Diabetes: A New Look at a Killer Disease." Ebony, March 2002, 121+. Database online. Available from Questia, http://www.questia.com/.Internet. Accessed 15 August 2004.

Childhood Overweight. NASO; North American Association for the Study of obesity; available from;

http://www.naaso.org/information/childhood_overweight.asp;nternet. Accessed 11 August 2004.

Combating Obesity in America"; available at http://www.u.arizona.edu/~adonovan/;Internet; accessed 9 August 2004. http://www.questia.com/PM.qst?a=o&d=5001121509

Courtenay, Will H. "Behavioral Factors Associated with Disease, Injury, and Death among Men: Evidence and Implications for Prevention." The Journal of Men's Studies 9, no. 1 (2000): 81. Database online. Available from Questia, http://www.questia.com/.Internet. Accessed 15 August 2004. http://www.questia.com/PM.qst?a=o&d=5000623062

Cristol, Hope. "Predicting Obesity: Researchers Weigh in on Ethnicity's Role in Obesity." The Futurist, January-February 2003, 10. Database online. Available from Questia, http://www.questia.com/.Internet. Accessed 15 August 2004. http://www.questia.com/PM.qst?a=o&d=5001522820

Cusumano, Dale L., and J. Kevin Thompson. "Body Image and Body Shape Ideals in Magazines: Exposure, Awareness, and Internalization." Sex Roles: A Journal of Research 37, no. 9-10 (1997): 701+. Database online. Available from Questia, http://www.questia.com/.Internet. Accessed 15 August 2004.

Coviello Jessica, "Obesity and Heart Failure," Journal of Cardiovascular Nursing; 11/1/2003

Deusinger Robert, "Obesity: overview of prevalence, etiology, and treatment," Physical Therapy, 3/1/2003. http://www.questia.com/PM.qst?a=o&d=5000936568

Farley, Tom, and Deborah Cohen. "Fixing a Fat Nation: Why Diets and Gyms Won't Save the Obesity Epidemic." Washington Monthly, December 2001, 23+. Database online. Available from Questia, http://www.questia.com/.Internet. Accessed 15 August 2004. http://www.questia.com/PM.qst?a=o&d=85702926

Farquhar, John W. The American Way of Life Need Not Be Hazardous to Your Health. Reading, MA: Perseus Publishing, 1987.

Foster Gary D. et al. "Primary Care Physicians' Attitudes about Obesity and Its Treatment,"

The North American Association for the Study of Obesity; November, 20003; database online]; available at http://www.obesityresearch.org/cgi/content/abstract/11/10/1168?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexacttitle=and&andorexacttitleabs=and&fulltext=causes&andorexactfulltext=and&searchid=1092404962005_341&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=obesityres/;Internet; accessed 13 August 2004 http://www.questia.com/PM.qst?a=o&d=76924807