By Elizabeth A Shubsda, RD, CNSCDecember 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) for an 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 food consumption.

1

OutlineI. Obesity In America

A. Epidemic as of 2001a. 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 ObesityA. Changing Environment and Food Habits

a. High fat, high sugar, high sodium foodsb. Fast and industrialized food culturec. Decreased reliance on home cooked foods

B. Technology/Decreased daily physical activity C. Genetics and Metabolism

III. The IssueA. Obese people are at greater risk of

a. Metabolic Syndromeb. Type II Diabetes c. Heart diseased. High blood pressuree. Certain types of cancersf. Sleep apnea

B. The Dataa. Dietary Guidelines for American’s 2010b. 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 ConclusionsA. Diffusion of obesity messageB. No observed change in American Eating HabitsC. Chronically ill population versus healthy population

a. Media b. KAP Gap c. Complexity of obesity issue is being missed

2

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 back to 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.

3

United States Adult BMI (Body Mass Index) Data 1980 and 2008

Chart 1 Mean BMI BMI Range

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 was extract and generated by the Global Health Observatory of the World Health Organization, it was 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 with its aim on children with an

approximate 17% (or 12.5 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 .

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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.

Causes of Obesity

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 foods that 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.

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

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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.

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The Issues

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.

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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 solid fats.

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 Garden Bulletin 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 for this review.

8

National Dietary Patterns

US Sugar Consumption – Adults 19+Years Amount per day/

Teaspoons2005/06 21

2007/08 20

Chart 3NHANES 2005/06 and 2007/08 Survey Data extracted from J Acad Nutr Diet. 2012; 739-758.

National Fruit and Vegetable Intake Data for 2007 & 2011 – Chart 4

Year Adults 18 + Adolescence (grades 9-12)

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

Data extracted from: http://www.cdc.gov/nutrition/downloads/StateIndicatorReport2009.pdf

http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables-2013.pdf

9

0

100

200

300

Chart Title

Based on data from: USDA, Agricultural Research Service & U.S. Department of Health & Human Services,Centers for

Disease Control & Prevention. What We Eat in America, NHANES 2001–2004 or 2005–2006.

Usu

al in

tak

e as

%G

oal o

r Li

mit

Eat More of These Eat Less of These

Typlical American's Intake Graph 1

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.

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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

Television

Internet

Doctors

Radio

School

Package labels

Nurses

Registered Dietitians

USDA/MY Pyramid

0 10 20 30 40 50 60 70 80

Percetage of Respondants

Sou

rces

of I

nfo

rmat

ion

Source: National Acedemy of Nutrition and Dietetics; Nutri-tion and You Trends 2011 Data

Graph 2

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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

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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.

Discussion and 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 Gap 10, 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.

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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

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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.

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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.

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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; Division of 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; 20136. 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.htm9. Rogers EM; Diffusion of Innovations 5 th ed.; Free Press; New York, NY; 2003; 87. 10. Rogers EM; Diffusion of Innovations 5 th 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.

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