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Always the Fat Kid: The Truth About the Enduring Effects of Childhood Obesity

Always the Fat Kid: The Truth About the Enduring Effects of Childhood Obesity

by Jacob Warren

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Childhood obesity in the United States has tripled in a generation. But while debates continue over the content of school lunches and the dangers of fast food, we are just beginning to recognize the full extent of the long-term physical, psychological, and social problems that overweight children will endure throughout their lives. Most dramatically, children today


Childhood obesity in the United States has tripled in a generation. But while debates continue over the content of school lunches and the dangers of fast food, we are just beginning to recognize the full extent of the long-term physical, psychological, and social problems that overweight children will endure throughout their lives. Most dramatically, children today have a shorter life expectancy than their parents, something never before seen in the course of human history. They will face more chronic illnesses such as heart disease and diabetes that will further burden our healthcare system. Here, authors Jacob Warren and K. Bryant Smalley examine the full effects of childhood obesity and offer the provocative message that being overweight in youth is not a disease but the result of poor lifestyle choices. Theirs is a clarion call for parents to have "the talk" with their kids, which medical professionals say is a harder topic to address than sex or drugs. Urgent, timely, and authoritative, Always the Fat Kid delivers a message our society can no longer ignore.

Editorial Reviews

From the Publisher

“A chronicle of the painful, long-term effects of being a "fat kid."… [And a] useful call to arms in the fight against childhood obesity.” —Kirkus

“Children are growing up in an environment that simultaneously glorifies super skinny bodies and eating unhealthy junk food, leading to many children's unhealthy relationships with food and their bodies. Parents need all the help they can get understanding the problem and what they can do to help their children resist or recover from these harmful forces. A book for our times, Always the Fat Kid deals with the issues in a comprehensive and highly practical way. It will help all parents do a better job promoting healthy food and eating habits with their kids for life.” —Diane E. Levin, Ph.D., professor of Early Childhood Education, Wheelock College and co-author of So Sexy So Soon

“A page-turner. Always the Fat Kid is a must-read for parents or anyone who works with children.” —Kelly Dorfman, M.S., clinical nutritionist and author of the award winning What's Eating Your Child?

“This is a book we can all relate to, some painfully so. Issues of weight, body image, culture, and identity are critical for healthy development, a process often curtailed by the media. A much needed book that helps us unpack the complexity of information in the culture about our bodies, ourselves, the complications it leds to in relationships. A must read for parents, clinicians, and anyone interested in the effects of childhood obesity.” —Debra Merskin, professor, University of Oregon

Always the Fat Kid comprehensively explores the underlying causes of childhood obesity and the impact this condition has on children, the adults they become and the social structure they exist within. It is an excellent resource for parents, educators and all individuals concerned with understanding and ultimately halting this very personal and very public problem.” —Rafael Cervantes, professor, St. Catherine University

Kirkus Reviews
A chronicle of the painful, long-term effects of being a "fat kid." With the rise of childhood obesity rates comes a new set of challenges for families and communities, write Warren and Smalley, co-directors of the Rural Health Research Institute at Georgia Southern University. Obese children face a combination of physical and psychological problems resulting in what the authors call "The Fat Kid Syndrome." Not only do these children often suffer from diabetes and high blood pressure, but they may also develop low self-esteem and compulsive behaviors. Further, they will likely experience depression and anxiety in greater numbers than their thinner peers--not to mention discrimination based on their appearance from colleagues, potential mates and even employers. The authors touch briefly on the causes of childhood obesity, including easy access to fast food, increased portion sizes and decreased emphasis on exercise. They also argue that parents are unwilling to speak honestly to their children about weight and that even doctors are instructed to avoid the topic out of fear of insulting or upsetting children. Warren and Smalley focus on raising awareness about the dangers of childhood obesity, and a short concluding chapter offers advice on how to help children and their families. They also include a helpful resource guide that includes nutrition, fitness and weight-control programs geared toward children. While childhood obesity is a trendy topic, even the authors acknowledge that there hasn't been enough time to research the long-term effects of the current epidemic. Therefore, much of what Smalley and Warren write about is speculation. They also come dangerously close to overgeneralizing the experience of obesity; certainly not all "fat kids" will suffer the extremes they describe. A flawed but useful call to arms in the fight against childhood obesity.

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Always the Fat Kid

The Truth About the Enduring Effects of Childhood Obesity

By Jacob C. Warren, K. Bryant Smalley

Palgrave Macmillan

Copyright © 2013 Jacob C. Warren and K. Bryant Smalley
All rights reserved.
ISBN: 978-1-137-32419-1


The Battle of the Bulge

By Numbers

Chances of a child being struck by lightning: 1 out of 1,000,000

Chances of a child being in a car accident: 4 out of 100

Chances of a child graduating from college: 30 out of 100

Chances of a child becoming fat: 33 out of 100

Chances of a fat child becoming a fat adult: 80 out of 100

Think for a moment about these odds, and the amount of time and energy we put into either preventing or encouraging those outcomes. We ticket parents who do not have their children in seatbelts, and have extensive school-zone speed limit laws to protect them from motor vehicle injury. We have entire national systems in place to encourage education and support our children in attaining a college education, even putting a significant portion of our tax money into it — in essence mandating that it is our civic duty. In some states, we even pay for college to help as many students as possible to receive a college diploma. But we do very little to prevent childhood obesity, the most likely of these outcomes.

We have certainly arrived at the point where our children are experiencing near-irreparable harm as a generation, but we did not get to this point overnight. The causes of the continuous shift toward weight gain are deep rooted and incredibly complex, but much of the problem has come from a history of ignoring both the presence of the issue and its long-term impact.


Why has the seemingly innocuous bathroom scale become our enemy? It is always there in your bathroom, just waiting for you to call on it. It always tells you the truth, no matter how much you don't want to hear it. And it never, ever, tells someone else your secret weight. But we've become so weight sensitive that we want to hide from the scale — if we don't know our own weight, then we can't get upset about what it is. In essence, we can keep our weight secret even from ourselves.

About that "secret," though — weight is not secret. It is one of the most obvious and plainly visible facts about ourselves, no matter how hard we might try to mask it in dark colors, vertical stripes, or multiple pairs of Spanx. And by masking it, not talking about it, pretending it's not there, we have created an environment of weight ignorance. And weight is like a wild animal — you should never turn your back on it.

In the case of our children, we have most definitely turned our backs on the beast. The weight of our children has slowly progressed to the point of being a true public health crisis. Many researchers saw the problems coming years ago, but we were either unable or unwilling to consider the fact that we were truly harming our children — that it wasn't just a little extra weight, but something that was going to have a dramatic and systemic impact. The cumulative health effects are so pronounced that obesity is quite literally taking years off children's lives, and that represents an ultimate failure on our part as a society.

To help frame the rest of our discourse, let's first take a look at definitions of fatness for children. You may be surprised at how complex these definitions are, but as we move through this book it will help give us a vocabulary for both describing weight and for seeing what role misperceptions and simple semantics have had in sustaining our children's weight problems.


So how do we actually determine if someone is or is not fat? In general, most methods separate individuals into four groups: underweight, normal weight, overweight, and obese. For our purposes, the two levels of "fat" are, of course, overweight and obese. In scientific terms, being "overweight" means that an individual is at increased risk for health-related complications because of their elevated body weight. People in this range are generally no more than 35 pounds overweight. Individuals past this range are considered "obese," meaning that they are at high risk for health-related complications (particularly diabetes and a variety of heart diseases) due to elevated levels of body fat. At the high end of obesity lies "morbid obesity," which indicates an individual is at severe risk for health-related complications and, more often than not, already has one or more medical conditions directly related to their weight.

There is no precise way to determine the exact point at which someone transitions from being normal weight to being overweight, or from overweight to obese. Weight is a continuum, and a person's "ideal weight" is as individual to them as a fingerprint. Unfortunately, the lack of a universal "cutoff" allows people to somewhat ignore the problem until it becomes extreme.

Much of the difficulty in classifying people by their weight comes from the fact that when looking at health, we cannot simply consider an individual's weight by itself; other factors, such as height and body composition (amount of muscle vs. fat), are essential in determining a person's ideal weight. Defining obesity is a tricky concept in general because of this, and countless methods ranging from newfangled "impedance machines" (which estimate your body fat by sending a jolt of electricity through your body) to submersion tanks (which determine your body volume and by proxy the amount of fat in your body by seeing how much water you displace when you are submerged in a tank) have been invented in an attempt to clarify the topic. As these methods are obviously not suitable for widespread use, a more simplistic method had to emerge. The main consideration with weight is that a method of determining if someone is overweight must be able to say that for a given height, that individual has too much weight. As a result, the most common method of measuring the appropriateness of weight is the body mass index (which is calculated directly from an individual's height and weight alone).


Estimating what portion of an individual's weight is attributable to fat has been a target of science for over 150 years, long before obesity was perceived as a threat to the health of the population. In the first half of the nineteenth century, Adolphe Quetelet proposed what was then referred to as the "Quetelet Index," which was a simple ratio of a person's weight in kilograms to their height in meters squared. This method was among the first to attempt to take the individual's height into account when determining a "normal" weight. This index was coined the body mass index (or BMI) more than one hundred years later. Nowadays, countless websites offer "free BMI calculators" that claim to tell you what the ideal weight is for a person of your height, and "BMI" has started to become a part of our general vocabulary. While its utility in describing groups of people has been well-recognized, the BMI was never intended to be used to diagnose individual health. In essence, it was designed to tell us how overweight a group of people is, not a single individual. But because of its relative simplicity and its ability to combine height and weight into a single health indicator, it has become by far the most widespread measure of weight ranges currently in use.

To calculate BMI, you take weight in pounds, divide it by height in inches twice, then multiply by 703. For instance, the BMI for a 180-pound man who is 5'8" tall (or 68 inches) would be: 180 ÷ 68 ÷ 68 x 703, which would be a BMI of 27.4.

The range of BMIs considered "normal" has changed over time, and has only been concretely defined for adults (not children). Currently, adults with a BMI between 25 and 30 are considered overweight, and adults with a BMI of 30 or greater are considered obese. These cutoff levels were revised under the recommendation of the National Institutes of Health (NIH) in 1998, perhaps in response to growing concerns over the weight of the nation. Prior to 1998, a BMI had to exceed 27.8 for an individual to be classified as overweight — with the change in BMI cutoffs in 1998 an estimated 25 million Americans who were previously considered normal weight were instantly reclassified as overweight to reflect the latest scientific evidence for the risk their weight was placing on their overall health. Prior to the new cutoffs, despite being at risk because of their weight, they were told they were normal and did not need to lose weight. This early misperception of healthy weight helped put in place a culture that was more accepting of higher weights, skewing our perception of what is "normal." Further reflecting the cultural nature of notions of ideal weight is the fact that some countries, such as Japan and Singapore, have even stricter BMI cutoffs than the U.S. revised standards; for instance, both of these Asian countries use a BMI of 23 as the transition point between normal weight and overweight.

Let's consider the standardized overweight cutoffs in weight for an average-height man. For the average man who is 5 feet 9 inches tall, a BMI of 27.8 (the original cutoff) was about 190 pounds. For a BMI of 25 (the current cutoff), overweight is reached at 169 pounds (a 21-pound difference). For Japan's definition of a BMI of 23, overweight would be reached at 156 pounds, representing a difference of nearly 35 pounds between the original U.S. definition of overweight and the current Japanese definition. The cutoffs are constantly debated, but the variation that exists indicates the wide range of weights that are considered "normal" even using a standardized measure — it's no wonder none of us knows what an ideal weight really is.

As you can see, while it gives a nice, tidy number, BMI is not easy to interpret. Even beyond the relative arbitrariness of the cutoffs, one of the main challenges that the BMI presents is the fact that the number doesn't have any meaning in and of itself. If I know my BMI is 26, it doesn't tell me how much weight I need to lose, or how much my risk has increased. This severely limits its usefulness in everyday practice, but despite this fact it has become widespread not only in the research community, but also in the general public.

For lack of another option, in the remainder of this chapter we will consider an adult BMI of 25 as the cutoff for overweight and an adult BMI of 30 as the cutoff for obesity (as these are the federally defined criteria used in the United States today). BMI cutoffs for morbid obesity are less clear, and vary by agency, but typically involve BMIs of 40 or higher; a common definition of morbid obesity is also being more than 100 pounds overweight (regardless of actual BMI). These definitions only apply to adults though — measures of obesity in children are even more complicated (if you can believe that).


Measuring weight status in children is significantly complicated by the fact that children's bodies change over time. If a four-year-old has gained five pounds, is it developmentally related, or is it excess weight? When you think about it, it's even possible that the five-pound weight gain is not enough for where the child is developmentally. How can we determine if that child's weight gain, and therefore the underlying weight itself, is appropriate?

The first set of childhood weight standards was used in the United States in 1977 to help parents determine if their child was growing appropriately. They were based upon data that had been collected for decades by the National Center for Health Statistics within the Centers for Disease Control and Prevention (CDC). As the federal agency tasked with actively protecting the nation's health through prevention, CDC has been one of the most active federal agencies in addressing childhood obesity. CDC researchers are also responsible for monitoring the overall health status of the nation, and as such have unique resources and continuous research studies that allow them to best quantify where children's weights stand for the purposes of developing population norms. Based on their data drawn from tens of thousands of U.S. children, the CDC developed comprehensive growth charts that defined where any child's height and weight fell in comparison to others of their age.

Unfortunately, at the original construction of the national growth charts in 1977, childhood obesity was so far off the federal radar that a chart was not even created for BMI. At the time, all you could do was compare the weight of your six-year-old to the weight of other six-year-olds; you could not compare BMIs, which would take the children's height into account. While there were height-to-weight charts included in the 1977 release, they were not based on any scientific standard, such as the BMI, and were of limited utility. Again, at the time, federal officials were not focused on the need to establish overweight and obesity cutoff scores, so it simply did not happen. This oversight in the original 1977 charts left no true national comparison point that could be used to set a standard for childhood weight. These 1977 charts remained the "gold standard" for assessing healthy childhood growth for more than twenty years, during which time children as a whole became heavier and heavier (without any comparison point for us to truly measure what was happening).

As the childhood obesity epidemic began to grow, medical experts realized that the lack of an established system to classify the appropriateness of children's weights was dramatically impairing their ability not only to track the growing problem, but even to tell a parent if their child was overweight. In a vivid display of what can happen when scientists and policy-makers become so bogged down in the details that they lose sight of the big picture, the debate over the relatively straightforward question "When is a child fat?" has raged on for decades. In the process, the issue has become so obfuscated that it is absolutely no surprise that as a society we missed what was happening. Case in point: almost exclusively because of arguments over semantics (literally), until the year 2010 there was no BMI that a child could reach that would lead them to be classified as obese using federal standards. The worst a child could be called was overweight, and even that label required unreasonably high levels of excess weight.

How did this happen? Well, the effort to define appropriate weight for children started out with the best of intentions. As of the 1990s there were no widely functional measures to determine the appropriate weight of a child; techniques that attempted to move beyond a child's simple weight relied upon methods that actually physically measured body fat using calipers (pincers that measure the thickness of the fat layer under the skin) or through other physical measures of the actual quantity of fat, not weight. This unfortunately left not only physicians, but also the general public, without an easy method to determine if their child had reached a concerning weight.

What to do? Naturally, form a committee. Mirroring the movement toward the use of BMI in adults (and thereby height-adjusting the associated weight), a federal expert committee was appointed in the mid-1990s to decide what official measure and what cutoffs of that measure should be used to determine at what point a child has reached obesity (with BMI identified as the most likely candidate). The panel included leading obesity experts and was populated and shaped by the American Medical Association, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, the National Center for Education in Maternal and Child Health at Georgetown University, and the Maternal and Child Health Bureau of the federal Health Resources and Services Administration. After much deliberation, the committee came to the conclusion that, despite its known limitations, BMI should be the official measure used to determine the weight status of children.

Ironically, in the first of many steps that would only serve to mystify the process, the committee tasked with creating an official federal measure for obesity got so bogged down in precision that they entirely rejected the use of the word "obesity" for any level of BMI (their own chosen measure). Stating that BMI is technically a measure of weight and not of body fat, the committee decreed that the traditional "overweight" and "obese" continuum used for adults should not be used for children, and instead created two levels of childhood fatness: "at risk for overweight" and "overweight." Their argument for not using "obese" to describe the highest BMIs? You couldn't be "sure" that a child at any BMI technically had too much body fat; there could always be a child with extreme muscle mass or another non-fat related issue that skewed their BMI.


Excerpted from Always the Fat Kid by Jacob C. Warren, K. Bryant Smalley. Copyright © 2013 Jacob C. Warren and K. Bryant Smalley. Excerpted by permission of Palgrave Macmillan.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Meet the Author

Jacob C. Warren, PhD and K. Bryant Smalley, PhD, PsyD are the co-executive directors of the Rural Health Research Institute at Georgia Southern University. They have published numerous scientific articles on health behaviors, social influences on mental health, and the impact of obesity on children.
Jacob C. Warren, PhD is the co-executive director of the Rural Health Research Institute at Georgia Southern University. He has published numerous scientific articles on health behaviors, social influences on mental health, and the impact of obesity on children. He is co-author of Always the Fat Kid.
K. Bryant Smalley, PhD, PsyD is the co-executive director of the Rural Health Research Institute at Georgia Southern University. He has published numerous scientific articles on health behaviors, social influences on mental health, and the impact of obesity on children. He is the co-author of Always the Fat Kid.

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