The document discusses obesity in America, providing statistics showing that obesity rates have significantly increased over the past 30 years. It defines obesity as having a body mass index of 30 or higher. The rise in obesity is due to changing environmental factors like increased availability of high-fat, high-sugar foods and a more sedentary lifestyle with less physical activity. While public health campaigns have aimed to address obesity, eating habits have not changed and obesity rates remain high.

1. 1
By Elizabeth A Shubsda, RD, CNSC
December 2, 2013
EDA/IDA 764 Planned Change
Obesity and Eating Habits In America
Abstract
It has been touted that obesity has been on the rise over the past 30 years, with the
accompanying recent media attention on obesity as an epidemic, the creation of television
programs such as The Biggest Loser and Heavy, and the national program Let’s Move
initiated by Michelle Obama to combat childhood obesity.
The definition of obesity is based mainly on BMI (Body Mass Index), excluding many
other obesity related issues/factors. Factors that many healthcare workers may be aware
of, but that the common consumer may not consider. BMI has even been used as an
indicator of body fat percentage (which it is not) in the media and popular television shows.
The danger of this singular attention in public health campaigns is an over-emphasis on the
physical attribute of obesity with a myopic focus on correcting the weight issue, possibly by
dangerous “fad dieting” and/or over-exercising, instead of focusing first on healthy
behavior changes, that will lead to a healthy weight range (most people live within a healthy
weight range rather then a singular number) foran individual.
This investigation will focus on assessing the diffusion of weight change and healthy
eating public health messages as measured by well established healthy eating behaviors
such as increases in fruit and vegetable consumption, as well as whole grains, and decreases
in added sugar and processed foodconsumption.

2. 2
Outline
I. Obesity In America
A. Epidemic as of 2001
a. Surgeon General
b. Centers for Disease Control and Prevention (CDC)
c. American Medical Association (AMA)
d. The World Health Organization (WHO)
e. Economic costs
B. Obesity Defined by BMI (Body Mass Index)
a. Trends in overweight, obesity, and extreme obesity
b. Adult BMI data for 1980 and 2008; a comparison
c. Childhood BMI data
II. Causes of Obesity
A. Changing Environment and Food Habits
a. High fat, high sugar, high sodium foods
b. Fast and industrialized food culture
c. Decreased reliance on home cooked foods
B. Technology/Decreased daily physical activity
C. Genetics and Metabolism
III. The Issue
A. Obese people are at greater risk of
a. Metabolic Syndrome
b. Type II Diabetes
c. Heart disease
d. High blood pressure
e. Certain types of cancers
f. Sleep apnea
B. The Data
a. Dietary Guidelines for American’s 2010
b. National Dietary Patterns 2001-2011 NHANES (National Health and Nutrition
Examination Surveys)
IV. Analysis
A. The State of The Nation’s Diet
a. Fruit and vegetable consumption
b. Whole grain consumption
c. Added sugar and processed food consumption
B. Sources of Nutrition Information for Consumers
a. United States Department of Agriculture (USDA) materials and website
b. MyPate.gov
c. Television
V. Discussions and Conclusions
A. Diffusion of obesity message
B. No observed change in American Eating Habits
C. Chronically ill population versus healthy population
a. Media
b. KAP Gap
c. Complexity of obesity issue is being missed

3. 3
Obesity in America
The news of the Obesity Epidemic in America started in the year 2001. It was a tidal
wave of health care officials and organizations all coming to the same conclusion, America
was in trouble, obesity in the country was of epidemic proportions for both children and
adults. Associated healthcare costs of obesity to the American economy were estimated at
$117 - $242 billion annually and 300,000 deaths per year.1
These costs and cautions were
touted from the highest levels of government, including the surgeon general, the Centers for
Disease Control and Prevention (CDC), as well as the American Medical Association (AMA).
Internationally, The World Health Organization (WHO) was concerned about a possible
obesity pandemic dating backto 2000.
“Overweight and obesity are defined as abnormal or excessive fat accumulation that
presents a risk to health. A crude population measure of obesity is the body mass index
(BMI), a person’s weight (in kilograms) divided by the square of his or her height (in
meters). A person with a BMI of 30 or more is generally considered obese. A person with a
BMI equal to or more than 25 is considered overweight.”2
This display demonstrates the
increasing rates of obesity in the
United States from 1991 – 2003, when
news of the issue started to
disseminate.
Whether the news did not diffuse
sufficiently, or if the solution was over
simplified to the equation that “energy
in equals energy out” is under debate,
but the fact that the epidemic did not
improve is not.

4. 4
United States Adult BMI (Body Mass Index) Data 1980 and 2008
Chart1 MeanBMI BMIRange
1980 Males 25.5 24.9-25.9
1980 Females 25.0 24.3-25.7
2008 Males 28.5 28.0 -29.0
2008 Females 28.4 27.8- 29.1
This data w as extract and generated by the Global Health Observatory of the World Health Organization, it w as extracted
on 2013-10-13 03:29:08.0.
For the adult US population, trends are leveling out, but not improving, as can be
observed in Figure 1 (2008 trends and BMI data being the most recent available), while the
increase in BMI from 1980 to 2008, are shown in Chart 1.
The push to resolve the issue is strongest withits aim on children with an
approximate 17% (or12.5 million) of children and adolescents aged 2—19 years being
obese, that is about triple the amount of obese children from 1980. The incidence is highest
in low-income families and children of color(2007-2008 National Health and Nutrition
Examination Survey Data (NHANES))3 .

5. 5
Recently there has been found a decrease in the incidence of obesity in low-income
pre-school children, from 2003-2010 there was a slight decrease in obesity rates in this
demographic from 15.21%-14.94% with similar decreases in extreme obesity from 2.22%-
2.07%4.
CausesofObesity
Why the shift? Why have we as a nation been getting heavier? The reasons are
multi-faceted. Our changing environment and habits are among the chief reasons. Cheap,
low-quality food has now been abundantly available over the past 30 years or so. Fast food
and industrialized food products have proliferated our society; they have changed not only
the foods that we eat, but also the way that we eat them. For many families, gone are the
days of home cooked meals. We now rely on quick cook (or no cook) food items with
compromised nutritional quality. High fat, high sugar, high sodium foods are now the norm,
instead of the occasional “treat”. In many urban areas, this is often the only type of food
available. With this trend has come an explosion in food portion sizes, and thus people can
no longer judge what an appropriate amount of food to eat is. All of the above has triggered
in some, an inability to recognize fullness ques.
The number one factor that we as humans use to choose the foods that we eat is
taste, not nutritional quality or content. We intuitively do not eat by numbers; we select
food via its eye appeal, smell, and taste. We have a large amount of American’s that have
grown up on fast and industrialized foods that have now become staples in their diets, fresh
and whole grain foods hold little appeal, as they have very little experience with these foods.
It takes a lot of determination to over-ride this strong drive to eat these readily available
tasty foods and to experiment with foodsthat appear and taste strange and different.
Food manufacturers have become so good at making high fat, high sugar, high salt
foods taste so good that some people claim that these foods are physically addictive5.
Which keeps people trapped in a vicious cycle of eating based on a spike in blood sugar-
fullness after a meal/snack, followed by a drop in blood sugar-coupled with a sensation of
hunger, which propels further eating, which repeats, and repeats again. These foods are
very low in fiber and quality protein, two components of food, which contribute to long-
term satiety.

6. 6
Technology has also proliferated over the past 30 years, leading to a more sedentary
lifestyle. Americans rely on the automobile to go everywhere (including to pick up their
fast food) significantly impacting daily physical activity. Additionally, children in particular
are seeing more screen time by way of gaming and mobile applications. Children play less
outside, particularly in areas that parents deem as “unsafe.” Roadways have taken over
many neighborhoods, eliminating walkways/sidewalks. Our suburban neighborhoods are
usually built in isolated areas, miles away from town attractions, making the choice to walk
versus ride more difficult.
Genetics and metabolism plays a part too, you do inherit a particular body type from
your parents, which plays a large role in how large or small you are going to be. There are
theories in regards to hormonal balance, stress response, and numerous other environment
factors as is displayed in Figure 2, with studies and investigations continually underway in
an attempt to better understand the physiology, sociology, psychology, and etiology of
obesity.
Personal
Factors
Macro-Level
Environments
Physical
Environments
Social
Environments
• Societal/Cultural Norms &
Values
• Food & Beverage Industry
• Food Marke ng & Media
• Food & Agricultural Policies
• Economic Systems
• Food Produc on &
Distribu on Systems
• Government & Poli cal
Structures & Policies
• Food Assistance Programs
• Healthcare Systems
• Land Use & transporta on
• Prac ces
• Legisla ve,
Regulatory or
Policy Ac ons
• Family
• Friends
• Peers
• Role
Modeling
• Social Support
• Social Norms
• Cogni ons (such as
a tudes, preferences,
knowledge, values)
• Skills & Behaviors
• Lifestyle
• Biological – genes, gender
• Demographics – income,
ethnicity/race
• Outcome Expecta ons
• Mo va ons
• Self-efficacy
• Behavioral Capability
• Home
• Work
• School & A er School
• Childcare
• Neighborhoods &
Communi es
• Restaurants & Fast Food
Stores
• Supermarkets
• Convenience and Corner
Stores
• Access
• Availability
• Barriers
• Opportuni es
Factors That Affect
What and How
Much We Eat
Adapted from: M. Story et al; Crea ng
Healthy Food & Ea ng Environments:
Policy and Environmental Approaches
Annu. Rev. Public. Health
2008.29:253-272.
Figure 2

7. 7
TheIssues
Statistically, as a nation, we have gotten heavier since the 1980’s. This heaviness is
usually interpreted as fat mass, as opposed to lean mass; although on the individual level, it
could be related to an increase in muscle (i.e.: body builders).
Health wise, being obese puts people at risk of many syndromes and diseases,
including metabolic syndrome (insulin resistance), diabetes, heart disease, high blood
pressure, arthritis, pulmonary dysfunction, certain types of cancers and sleep apnea (this is
not an exhaustive list). These diseases can contribute to a decreased quality of life and an
early death. As mentioned previously, the cost of treating the above diseases is significant
both at the individual and societal levels. These diseases have typically been associated
with adult on-set, however with the rise in childhood obesity, these syndromes and diseases
are now being seen in children.
Given all of the above factors, our federal and state governments have launched
campaigns to disseminate information on healthy eating and exercise habits. In some form
or another, we have had healthy eating guidelines in the past; in the form of The Basic Four
(food groups), The Food Guide Pyramid, nutrition food labeling laws, and Dietary Guide
Lines, all with varying degrees of diffusion among the populous. More recently, our First
Lady, Michelle Obama, launched the Let’s Move campaign in 2010, which coincided with the
latest revision of The Dietary Guidelines for Americans and The Food Guide Pyramid
transformation to My Plate.
The purpose of this paper is to determine if the recent national media and
government attention to obesity has diffused down to the general public in terms of
changing American eating habits for the better. To assess this, I will examine population
intakes of fruits, vegetables, and whole grains, coupled with sugar intake. If diets have
improved I would expect to see a rise in fruit, vegetable, and whole grain consumption along
with a decrease in sugar intake.

8. 8
Dietary Guidelines for Americans (Highlights) – 2010 Chart 2
1. Build A Heathy Plate:
 Make ½ of your plate
fruits & vegetables.
 Switch to skim or 1%
milk.
 Make at least ½ of your
grains whole.
 Vary your protein
choice foods.
2. Cutting Back On Foods
High In Solid Fats, Added
Sugars and Salt:
 Choose food and drinks
with little or no added
sugar.
 Look out for salt
(sodium) in the foods
you buy-it all adds up.
 Eat fewer foods that
are high in solidfats.
3. Eat The Right Amount Of
Calories for You:
 Enjoy your food, but
eat less.
 Cook more often at
home, where you are in
control of what’s in
your food.
 When eating out,
choose lower calorie
options.
 Write down what you
eat to keep track of
how much you eat.
 If you drink alcoholic
beverages, do so
sesensibly-limit to 1
drink per day for
women or to two
drinks a day for men.
4. Be Physically Active Your
Way
5. Use food lables to help you
make better food choices
Adapted from: Let’s eat for the health of it; Consumer Pamphlet;
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DG2010Brochure.pdf; USDA Publication number:
Home and GardenBulletin No. 232-CP;HHS Publication number: HHS-ODPHP-2010-01-DGA-B; June 2011
The National Dietary Guidelines are developed by the United States Department of
Agriculture (USDA) and The Department of Health and Human Services (HHS) and are
updated every five years. The 2010 edition is the latest revision of these guidelines, which
have been in existence since 1980.6 According to the USDA website “They provide
authoritative advice about consuming fewer calories, making informed food choices, and
being physically active to attain and maintain a healthy weight, reduce risk of chronic
disease, and promote overall health.”7 Chart 1 list’s an abbreviated version of the 2010
Dietary Guidelines (The/These Guidelines) as presented in a consumer pamphlet. These
Guidelines coupled with My Plate /MyPlate.Gov and fruits and veggies more matters.org, a
joint venture between The Produce for Better Health Foundation and The CDC, are the
cornerstone of the government’s advice on healthy eating. They are to be the foundation of
the evaluation of national dietary habits forthis review.

9. 9
National Dietary Patterns
US Sugar Consumption – Adults 19+
Years Amount per day/
Teaspoons
2005/06 21
2007/08 20
Chart 3
NHANES2005/06 and 2007/08 Survey Dataextracted
from JAcad Nutr Diet. 2012; 739-758.
National Fruit and Vegetable Intake Data for 2007 & 2011 – Chart 4
Year Adults18 + Adolescence(grades9-12)
2007 Percent meeting
recommendations
 32.8 % Fruit 2 or
more/day
 24.7% Veg. 3 or
more/day
 14% Fruit 2 or more
& Veg 3 or more/day
Percent meeting
recommendations
 32.2% Fruit 2 or
more/day
 13.2% Veg. 3 or
more per day
 9.5 % Fruit 2 or
more & Veg 3 or
more/day
2011 Average number of servings
per day
 1.1 Veg.
 1.6 Fruit
Average number of servings
per day
 1.0 Veg.
 1.3 Fruit
Dataextracted from: http://www.cdc.gov/nutrition/downloads/StateIndicatorReport2009.pdf
http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables-2013.pdf

10. 10
Analysis
The above data is based on the National Health and Nutrition Examination Surveys
(NHANES) covering the years from 2001 – 2011, with most data falling within the years
2004 – 2011. The eating habits portion of the survey is based on standardized questions
and is subject to margins of error that are prone to plague all recall data. These surveys are
conducted through the National Center for Health Statistics (NCHS) which is a part of The
Centers for Disease Control and Prevention.8
The data displayed in Charts 2 and 3 combined with Graph 1, when compared to The
Guidelines show significant deficiencies and excess in our eating habits. The Guidelines
recommend that at least ½ of all meals/plates be composed of fruits and vegetables, in practice
when educationg people dietitian’s will typically relay this message as “Strive for Five” or “Five
A Day”, to indicate that people should have at least 5 servings of fruits and vegetables a day.
Chart 3 (2007-2011 data) clearly indicates a lack of fruit and vegetable intake nationwide, with a
combined 2.7 servings for adults (54% of the 5 minimal), which is consistant with my experience
of talking with and teaching consumers in the city of Syracuse, NY over the span of almost 2
decades. Graph 1 (2001-2006) also indicates that American’s are not meeting the
recommendation, with basically no change with typical intake at just over 50% of minimal
recommendations.
0
50
100
150
200
250
300
Usualintakeas%GoalorLimit
Based on datafrom: USDA, Agricultural
Research Service& U.S. Department of Health & Human Services,Centers for
DiseaseControl & Prevention. What WeEat in America, NHANES2001–2004or
2005–2006.
Eat More of These Eat Less of These
Typlical American's Intake Graph 1

11. 11
Both fruits and vegetables and whole grains are high in fiber, which helps people to feel
full, improves gut motility (which can protect against certain cancers), cholesterol levels, and
blood sugar levels. It is one of the main reasons that The Guidelines tell us to increase our intake
of all of these types of food. According to Graph 1, we are failing to reach the minimum
recommendations for whole grains as well, with an intake of about 15%. What is typical in the
American/Westernized diet is what we see displayed in Graph 1 and Chart 2, large intakes of
sources of solid/saturated fats and added sugars, refined/white grains, and sodium; which is
reflective of dietery patterns based on processed and fast/convenient food sources.
Considering that The Guidelines were first published in 1980 and overweight and obesity
have been on the rise since about 30 years ago, you might say that there is a huge dissodence
here, considering the inverse relationship, and there is. This is not necessarily a dissodence
created by bad advice (that created an overweight and obesity issue; although some would argue
that it has), but one of Guideline ignorance. As you can see by looking at Graph 2, in a survey
conducted by The National Acedemy of Nutrition and Dietetics, very few, about 1% of
Americans actually get their food and nutrition advise from the USDA/My Pyramid (now My
Plate) or a Registered Dietitian that can give acurate advice and direct consumers to the USDA
sites for further information. They are not going to nurses (1%) or doctors (20%), in droves
either, although doctors are the third largest source. This survay indicates that consumers are
getting most of their nutrition information from television at 68%. Considering what I have seen
of television shows aimed at the overweight and obese, this is very disturbing news indead
0 20 40 60 80
Television
Internet
Doctors
Radio
School
Package labels
Nurses
Registered Dietitians
USDA/MY Pyramid
Percetage of Respondants
SourcesofInformation
Source: National Acedemy of
Nutrition and Dietetics;
Nutrition and You Trends 2011
Data
Graph 2

12. 12
Television, in particular, reality television, is the worst source of accurate diet and
nutrition information that there is. Shows such as The Biggest Loser (NBC), Heavy (A&E),
Extreme Weight Loss (ABC), Shedding for The Wedding (CW), Diet Tribe (Lifetime), Super
Size Versus Super Skinny (from the United Kingdom), Too Fat for 15 (Style Network/E!
Entertainment Group), present weight loss and obesity issues as entertainment; they are
not sources of serious, accurate, health information that the typical consumer can adapt for
home use. Actually, it is virtually impossible to get the weight loss results at home, that are
glorified in these shows. Because they opperate on the margins, in the extremes. If you go
back and look at Figure 1, in the beginning of this report, while 60% of us may be
overweight or obese, not even 5% of us are extremly obese, which is the subset of the
population that these shows contrate on, to show more dramatic results, to get higher
ratings. Many of these shows don’t even bother to hide their extremeism, in fact they flaunt
it, it’s right in their titles, Biggest…Extreme…Too Fat…Super.
So they through a carrot out to the extremely obese television veiwer, promising
dramatic and quick weight loss, that is accomplished by taking the extremely obese person
out of their normal environment, making them do in-human amounts of painful, dangerous
exercise, (that cannot be replicated with the demands of work, home, school once they get
back to their regular routein) and drastically underfeed them in relation to their physical
activity. I’ve personally watched many of these shows, for the purpose of this review. I’ve
heard quotes of people burning 3000-4000 calories a day by intense exersize, being
sustained on only 1500 calories a day, some not actually consuming all of the allowed food,
in order to lose more weight, quicker because many times, it is a competition and money is
at stake, such as on The Biggest Loser. Fifteen-hundred calories a day or less, with this type
of expenditure, equals a very low calorie diet (VLCD), these diets are not recommended
unless you are under the direct supervision of a doctor. Diet is often presented as a
secondary stratagy for weight loss, even though it is much easier to cut back on 500 calories
a day, then it is to burn off 500 calories a day via physical activity. Exercise is great for
building muscle, which increases metabolism, but it takes more time and effort then the
typical American has in a day to actully use exercise as the main component of a weight loss
regimine. Additionally, food is presented as lifeless, discusting, unsatisfying, punishing, in a
good-food bad-food mentality, definatly not the way that I want to eat, and I am almost

13. 13
100% sure that it is not the way that the general public wants to eat either. This may
actually hurt the consumer, by making “healthy” eating seem unappealing and overly
restrictive, counteracting any serious thoughts of making lasting behavior changes, ditto on
the exercise part of the equation.
Discussionand Conclusions
It has been observed by increasing trends in BMI from the 1980’s through to 2008,
the lastest available data to date, that as a nation, we are getting bigger. This is interpreted
as a gain in fat mass versus lean tissue, which means that overwieght and obesity are on the
rise.
Although some healthcare workers may know the definations of overweight,
obesity, and extreme obesity as defined by BMI; this cannot be so for the general public, as
major media outlets and even government public health representatives often speak in
terms of overweight and obese as synonimous and lack to speak about the extremly obese
at all, when these are the people that are most at risk of disease and complications from
obesity. I believe that this creates an undertone of unwarrented fear for the public at large.
BMI is a crude (WHO) public health screeening tool and that’s it. It is one measure, it does
not in and of it’s self define good health.
If you type in “obesity epidemic” into an internet search engine, you will get some
where around 9,170,000 results, this combined with the multitude of television shows
based on the epidemic premise, via national channels, suggest that the innovation that an
obesity epidemic has infaltrated the world has diffused down to the general populous. This
idea is consistant with diffusion research that indicates that marketing and mass media
channels aid and propel the diffusion of innovations.9
Unfortunetly, this knowledge of a problem has not had a positive impact on dietary
habits. Before starting this review, I believed that it was due to a very large KAP Gap10, and
there definitely is one, however I now believe that it is much smaller then I initially thought.
Having had the experience of taking care of sick people, many with chronic illnesses such as
diabetes, anorexia nervousa, AIDS, obesity, lung disease, heart disease, kidney disease; I
formed a squed picture of diet knowledge of the general population from my experience
with the ill population.

14. 14
In the hospital setting (where I have worked for almost two decades) all diets are
ordered via a physician’s order, just like a medication. Patient’s are not allowed to eat
without a “diet order.” I have spent much of my time recommending particular diets,
writing policies and procedures regarding specific diets, and teaching specific diets. It is all
very institutional, medical, scientific, and evidence-based. Admists all of this science (with
some art as well) I have forgetten that people outside of medicine and our healthcare
system don’t necessarily get their advice from reliable sources. Now don’t get me wrong, I
am not nieve, I know that everyone thinks that they know about food and nutrition, because
we all eat right? We all have our personal stories of battling some food demon and
absolutley knowing that we know what we are talking about. I’ve heard this a million times
before, but I have heard it from a sub-set of the greater population, that has also heard my
song and dance routine a million times before.
I’ve been thinking about it and over my seventeen year career in hospital dietetics I
have probably spoken to/taught maybe 15,000 people on various diets. I used to teach
Surgical Open Heart Classes, daily and then twice a week. The surgeons would do at least
1000 surgeries a year and I was responsible to see them all, plus speak to other people on
other hospital units about proper diet. Multiply that by 12 years (I spent my last years in
management) and the numbers are staggering. I bring this to the forefront of the discussion
as I want to explain that a typical hospital patient has access to a dietian, at least while they
are in the hopital, and they have seen many of them, because they have disease that is
chronic in nature, and they contiually come in and out of the hospital. So many times, my
patients would already know what I was going to say, they were not doing it, but they knew
their diet and what they should be doing. That’s why I was so excited when I read in Roger’s
Diffusion of Innovations about the KAP Gap10, it was like a little light bulb went off in my
head. I thought, there is actually a name for this phenomina, a phenomina that I had born
witness to for my entire career. This is it! The people know what to do, they just choose not
to change their behaviors, for whatever reason. The KAP Gap became my new favorite
phrase, I wanted to tell all of my hospital friends that there was a name to our collective
experience. In my exuberance, I thought that this would be a perfect thing to write my
paper about. I’ll write about how BMI’s are escalading and how people are not making

15. 15
behavior changes, even when the message of the overwight and obesity issue has
disseminated/diffused down to the general populous.
However, in review of the evidence as presented in Charts 1-4, Graph’s 1-2, and
Figures 1-2, along with the proliferation of reality television’s extreme distortion of the
obesity issue, I conclude that the KAP Gap exists in the chronically hospitalized patient and
perhaps those that habitually utilize community and public health sites, otherwise there is
no KAP Gap. American people know how to follow an Americanized/Westernized diet
based on industrialized, processed, cheap, fast, nutritionally compromised food sources.
They either don’t know how to, and/or don’t care to access nutrition resources that are at
least partially evidenced-based (Industry has lobbies in Washington that attempt to
marginalize the harmful effects of industrilized food, often succeeding in blocking some
recommendations that they feel would be harmful to their business) from government sites.
Directions to these sites are not visable via national media outlets and therefore cannot
compete with misinformation pertaing to diet and weight loss that appear on those
channels.
Personal
Factors
Macro-Level
Environments
Physical
Environments
Social
Environments
• Societal/Cultural Norms &
Values
• Food & Beverage Industry
• Food Marke ng & Media
• Food & Agricultural Policies
• Economic Systems
• Food Produc on &
Distribu on Systems
• Government & Poli cal
Structures & Policies
• Food Assistance Programs
• Healthcare Systems
• Land Use & transporta on
• Prac ces
• Legisla ve,
Regulatory or
Policy Ac ons
• Family
• Friends
• Peers
• Role
Modeling
• Social Support
• Social Norms
• Cogni ons (such as
a tudes, preferences,
knowledge, values)
• Skills & Behaviors
• Lifestyle
• Biological – genes, gender
• Demographics – income,
ethnicity/race
• Outcome Expecta ons
• Mo va ons
• Self-efficacy
• Behavioral Capability
• Home
• Work
• School & A er School
• Childcare
• Neighborhoods &
Communi es
• Restaurants & Fast Food
Stores
• Supermarkets
• Convenience and Corner
Stores
• Access
• Availability
• Barriers
• Opportuni es
Factors That Affect
What and How
Much We Eat
Adapted from: M. Story et al; Crea ng
Healthy Food & Ea ng Environments:
Policy and Environmental Approaches
Annu. Rev. Public. Health
2008.29:253-272.
Figure 2

16. 16
At this point I would like to redirect you to Figure 2, look a it; try to grasp all of the
complexity that goes into our daily decisions on what and how much we eat. We have a big
problem, created by an industrialized food system that is ubiquitous and insidiously
intertwined with every aspect of American Culture; solely the individual cannot fix this for
the individual is a product of their environment. Until we find ways to change and reshape
our environment and culture for the health of our nation, any message that frames the
overweight and obesity problem as simple, and that remains fixated on crude tools such as
BMI, and the pursuit of a decrease in weight versus an emphasis on positive behavior
changes with practices that we know to improve health, independent of weight; such as
exercise and a plant and whole grain based diet, that can also accommodate the foods that
we love, is in my opinion, going to fail. Additionally, we need our public health officials to
stop lying to us, as I leave you with the words of Richard H. Carmona, MD, MPH, FACS
Surgeon General “The crises is obesity. It’s the fastest-growing cause of disease and death in
America. And it is completely preventable.”11 We don’t have a cure or an effective long-term
population based preventative solution to the problem of obesity.

17. 17
References
1. Richard H. Carmona, M.D., M.P.H., F.A.C.S., Surgeon General (Statements of); The Obesity
Crises in America; Testimony Before the Subcommittee on Education Reform Committee on
Education and the Workforce United States House of Representatives
http://www.surgeongeneral.gov/news/testimony/obesity07162003.html; July 16, 2003.
2. World Health Organization (WHO) – Health Topics Obesity;
/www.who.int/topics/obesity/en/
3. Ogden, C. and Carroll. M.; Publications and Information Products; NCHS Health E-Stats;
Prevalence of Obesity Among Children and Adolescents: United States Trends1963-1965
Through 2007-2008; Divisionof Health and Nutrition Examination Surveys;
http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm
4. Trends in the Prevalence of Extreme Obesity Among US Preschool-Aged Children Living in
Low-Income Families, 1998-2010. JAMA Highlights. 2012; 308 (24): 2563-256
http://www.cdc.gov/obesity/data/childhood.html
5. Moss, M; Salt, Sugar, Fat; Random House, New York, NY; 2013
6. 2010 Guidelines For Americans – Backgrounder History and Process;
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Backgrounder
.pdf
7. Dietary Guidelines for Americans http://www.cnpp.usda.gov/dietaryguidelines.htm
8. About the National Health and Nutrition Examination Survey;
http://www.cdc.gov/nchs/nhanes/about_nhanes.htm
9. Rogers EM; Diffusion of Innovations 5th ed.; Free Press; New York, NY; 2003; 87.
10. Rogers EM; Diffusion of Innovations 5th ed.; Free Press; New York, NY; 2003; 70;176.
11. Richard H. Carmona, M.D., M.P.H., F.A.C.S. Surgeon General (Statements of); The Obesity
Crises in America; Testimony Before the Subcommittee on Education Reform Committee on
Education and the Workforce United States House of Representatives
http://www.surgeongeneral.gov/news/testimony/obesity07162003.html; July 16, 2003.
12. All charts, graphs,and figures are referenced within the graphic.
Additional Resource List
1. Bacon, L. PhD.; Health at Every Size, Bena Bella Books; Dallas, Texas; Revised 2010
2. Pollan, M; In Defense of Food; Penguin Group (USA); New York, NY; 2008.
3. Saguy, AC. What’s Wrong with Fat; Oxford University Press; New York, New York: 2013.