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New guidelines recommend early, aggressive treatment for childhood obesity

A closeup of a beam scale. (Patrick Sison/AP)
A closeup of a beam scale. (Patrick Sison/AP)

Childhood obesity is at epidemic rates.

“We started seeing weights status change dramatically through the ‘90s and then it became very evident by the early 2000s that something very different was going on.”

“Every single day that I am in clinic, I’m caring for a child with obesity,” Dr. Mona Hanna-Attisha says. “I can probably only find a handful of successful stories where we were able to reverse that obesity.”

So the American Academy of Pediatrics has issued new guidelines. Things like Family counseling, healthier diets.

“I literally would tell my patients, ‘You need to eat better. Consider things like avocados and kale,'” Dr. Hanna-Attisha says. “And my parents would literally just stare at me, ‘Where am I going to get that? Like, where am I going to afford to buy that?’”

The guidelines go farther. They suggest medicines and even surgery for children at ever younger ages.

Today, On Point: How to treat childhood obesity in America.

Guests

Dr. Mona Hanna-Attisha, pediatrician at Hurley Children’s Clinic in Flint. Professor of public health at Michigan State University and founding director of the Pediatric Public Health Initiative. Author What the Eyes Don’t See: A Story of Crisis, Resistance and Hope in an American City. (@MonaHannaA)

Dr. Christopher Bolling. One of the lead authors of the American Academy of Pediatrics new guidelines on treating childhood obesity. Volunteer professor of pediatrics at the University of Cincinnati. Community Partner with The Center for Better Health and Nutrition at Cincinnati Children’s Hospital.

Also Featured

Santana Lee, mother of 9, an emotional support aide in Milwaukee public schools. She lives in a food desert.

Star Simmons, grandmother of a 13-year-old with obesity in Washington, D.C. She works with children and adults with developmental disabilities.

Transcript

MEGHNA CHAKRABARTI: Dr. Mona Hanna-Attisha is a pediatrician at Hurley Children’s Clinic in Flint, Michigan. She’s also a professor of public health at Michigan State University and founding director of the Pediatric Public Health Initiative. And she joins us today. Dr. Hanna-Attisha, welcome back to On Point.

MONA HANNA-ATTISHA: It’s great to be here with you.

CHAKRABARTI: On any given week. Dr. Mona, how often do you see children in your clinic who’d be considered technically obese?

HANNA-ATTISHA: Absolutely. Every single day in clinic I am caring for children who are obese.

CHAKRABARTI: Every day?

HANNA-ATTISHA: Every day.

CHAKRABARTI: And what ages are we talking about here?

HANNA-ATTISHA: Oh, as young as two, maybe even younger. You know, our growth charts have been unable to catch up with the weights and the BMI’s that we see in our clinic.

CHAKRABARTI: As young as two and then obviously as old as 16, 17, 18.

HANNA-ATTISHA: Yeah, absolutely.

CHAKRABARTI: Wow. And was it always like this?

HANNA-ATTISHA: It’s gotten worse. Absolutely. So I work in an underserved community. In Flint, Michigan, it’s really hard for folks to find healthy food. It’s hard for kids to go outside and play because of safety reasons. There’s, you know, a lot of reasons why these rates have been climbing year after year after year. And we just haven’t had the tools to be able to treat patients properly.

CHAKRABARTI: And so then what other kinds of health concerns or considerations are related to the child’s obesity that you see?

HANNA-ATTISHA: Yeah. So there’s all kind of a whole milieu of things that are consequences of a child being obese. It impacts their mental health. They are often bullied, made fun of at school. In the home environment, they have low self-esteem. So the mental health issue is real for children with obesity, but there’s also significant health complications, high cholesterol, hypertension, which is high blood pressure, you know, bone and orthopedic issues.

So there’s, you know, many, many complications and long-term chronic consequences of being obese. Kids who are obese grow up to be young adults who are obese, who grow up to be adults who are obese. So it’s really important that we can identify this and address it and really reverse it. Prevent it, ideally, in childhood.

CHAKRABARTI: Now, of course, weight is such a sensitive issue, no matter who you are. So how do you how do you talk about it during your appointments with these families?

HANNA-ATTISHA: Yeah, that’s a that’s a great question. And that’s what I love about these new guidelines by the American Academy of Pediatrics is, you know, really focuses the attention on not so much the patient, but also kind of the society and the community and the policies that have created this epidemic of obesity. When I am sitting with a patient, you know, humbly kind of shoulder to shoulder with them, I am listening, I am empathizing, and I am understanding that this is not their fault, and this is not their family’s fault.

When you think about things like marketing and sugar subsidies and, you know, the impact of the built environment and racism and poverty, all of these interconnected and complex issues have created the child in front of me with this significant health issue. So the first thing I do is I empathize. I listen, I try to assess where they’re at, you know, and what they want to do about it. And it’s a long term continuity of care model that we have to follow to make sure that, you know, that we can help kids and families through this.

CHAKRABARTI: Yeah. Now, you mentioned the new guidelines that have just recently been released by the American Academy of Pediatrics. That is the reason why we’re doing this show today, because it’s the first ever set of guidelines that the American Academy of Pediatrics has put out to physicians and clinicians about how to help treat children with obesity in this country. And I’d also like to put out some numbers here, because I’m looking at some of the latest CDC data that runs through 2020.

And CDC reports that the prevalence of obesity in American children between the ages of two and 19 was 19.7% of all American kids. So 14.7 million kids and adolescents. That’s for those children considered obese, which is a body mass index at or above the 95th percentile in this country, for children of given their age and sex. When we would add in children who are not technically obese, but overweight, Dr. Mona, how many additional children would you be thinking about in your practice?

HANNA-ATTISHA: Oh, my goodness. It far exceeds the majority. So it’s well over 50% of children in our practice who are in both categories, overweight and obese.

CHAKRABARTI: So … essentially weight is a major factor in how you consider how to treat the kids who you see.

HANNA-ATTISHA: Absolutely. It’s a major factor. And we really have limited resources to be able to properly address it. You know, we notice this as an issue, you know, years ago in our practice, and we’ve tried to do preventative things. We moved our pediatric clinic to the second floor of a farmer’s market. I mean, it’s the only clinic that I know that’s co-located in a farmer’s market, to try to, you know, preventively address this issue.

Every single kid that comes to our clinic gets a prescription for healthy fruits and vegetables that they fill the farmer’s market. You know, we’re trying to address transportation barriers. We have an embedded dietitian and a social worker and psychologists. But it’s not enough. So we definitely need more tools in our doctor’s bag to be able to address this epidemic.

CHAKRABARTI: Well, I’m glad you mentioned that, because we’re already getting a lot of comments from listeners, which I’ll share a little later in the show about the food supply in this country. And we will definitely talk about that in detail. But Dr. Mona Hanna-Attisha, if you could just hang on for just a second. I now want to introduce Dr. Christopher Bolling into the program.

He is one of the lead authors of this new set of guidelines from the American Academy of Pediatrics. He is a pediatrician who just retired after 31 years in practice. Dr. Bolling, welcome to On Point.

CHRISTOPHER BOLLING: Thank you, Meghna. It’s really truly a pleasure to be here and also to be here with Mona, who’s a bit of a rock star in pediatrics for everything she’s done in Flint, really.

CHAKRABARTI: … Let me ask you. So 31 years of practice, it just so happens your experience in the clinic, Dr. Bolling overlaps almost exactly with the time period in which we’ve seen this dramatic rise in obesity in all Americans, but especially in children. So take us back to the beginning of when you first became a newly minted pediatrician. How often did you see a child who was obese, say, in the in the ’90s?

BOLLING: You’re really spot on with that. It really started, we started seeing something happen in the early ’90s. And there were a lot of things that we think were going on. The growth charts really were set in stone probably in the seventies and eighties and we saw a decoupling where we saw a real increase in the number of kids who had obesity and who had overweight statuses.

So we saw it really begin to accelerate. And if you look at CDC data over those many years, there just was a steady progression. You know, certain areas were affected more severely than others. As Mona very eloquently stated, some of our kids of color or some of our kids in lower socioeconomic status groups really suffered disproportionately, but it really affected the entire country.

There were little pockets that looked better, but it was just a continuous march. And we really saw an abrupt worsening with the pandemic as well. It’s just been a constant move toward greater and greater number of kids who suffer from this chronic disease.

CHAKRABARTI: So for you, in your personal experience, it sounds like it wasn’t necessarily that central of an aspect of how you treated children in your practice 30 years ago. Or should I say, was it? Versus how central the issue of being overweight or obese was in your practice upon your retirement?

BOLLING: Oh, it definitely became much more of an issue as we went along. I have been involved in this work for about the past 20 years or so. I have a bit of a background in preventive cardiology and fitness and health, and I revisited that about 20 years ago and started doing some work in pediatric obesity. And that was when we really started seeing a large increase in the number of patients. We started seeing kids with co-morbidities of obesity that we had not seen in children before, children with type two diabetes, children, as Mona mentioned, with high blood pressure, children with sleep apnea, children with orthopedic complications from their obesity, just a wide variety of complications that we had never seen in kids before.

CHAKRABARTI: So we’re going to talk about the guidelines specifically here in just a few minutes. But Dr. Mona, can I turn back to you? I have to say, it’s so heartbreaking to hear that there are children in this country and many of them who even before they enter the creepiness of middle and old age are suffering from things like high blood pressure. I mean, it’s astounding to hear.

HANNA-ATTISHA: Yes, and it’s totally preventable. And I think that’s what’s most maddening. You know, we shouldn’t have to be caring for so many children with this chronic disease. We can prevent it, especially when we address kind of the public health and the policy solutions. And I know it wasn’t part of this guideline. And there’s a forthcoming guideline that specifically looking at the prevention aspect.

But we spend billions, trillions of dollars addressing things like hypertension and diabetes and chronic disease in all these chronic diseases. But, you know, if we spend a little more on preventing this, making sure kids do have access to healthy foods and they do have that economic stability to be able to provide for their families and transportations and, you know, safe places to play. So, you know, this is touched on in the guidelines, which is fantastic. But I really look forward to those conversations where we’re not talking so much about kind of the consequences, but really getting at the prevention.

CHAKRABARTI:  So, Dr. Bolling, let’s go through these guidelines sort of step by step here. And it seems as if the first intervention, if I can call it that, that the American Academy of Pediatrics recommends, is really about healthy habits and lifestyles and even therapy, not just for the child, but for the family. So explain what that is.

BOLLING: So a bit of it gets back to what Mona said right before the break. There’s a not a lot in here about prevention, and that’s because we don’t exactly have enough evidence to make a clinical practice guideline on some of those prevention strategies. However, we know that those early feeding habits are incredibly important as pediatricians. Those are things that we are good about talking with our families.

We wanted to stress that it’s important for pediatricians to take the time like they do with their families, to talk about nutrition, to talk about activity, to talk about healthy lifestyles, making a healthy choice, the easy choice, you know, snack foods, screen time, all these things that we know modify weight status in our patients are very readily available and very easy to access. So we’re trying to get healthy habits onto an equal footing with some of these less healthy habits. So life is easier [for parents], basically, and kids can have a better shot at maintaining health through life.

CHAKRABARTI: I mean, Dr. Mona, are they easy to access?

HANNA-ATTISHA: It’s very hard for some patients, you know, And in my community, we have a child poverty rate that exceeds 50%. I tell my patients, you know, I used to tell my patients naively, you know, eat healthier, like just go and buy, you know, fresh apples and, you know, kale, all these things. And the response I would get was like, there is nowhere we can find that. And there’s no way we can afford that.

We have no very limited field, full-service grocery stores in our community. It is much easier to go to a fast food or liquor store to fill a child’s belly. So some of these recommendations, you know, are obviously, you know, what we should be doing. And what we do tell our patients are all time. But it’s very difficult for patients to comply because of these socioeconomic issues.

CHAKRABARTI: Now, when you say liquor store, you mean like getting some food items from the liquor store for the child?

HANNA-ATTISHA: Yeah, yep.

CHAKRABARTI: So, Dr. Bolling, want to give you a quick chance to respond to that.

BOLLING: Oh, and I got exactly the same blank stares. You know, it’s one of those things that parenting is hard. It is very difficult. And we need to not be in the position of blaming parents for these choices, because parents are trying to get by. We can’t make plans for them that they can’t follow through on. And part of the responsibility on this is us as a society trying to make these things more available.

Our families face so many hurdles in life, and it’s virtually impossible, as Mona said, to go ahead and make a kale salad. How would they even know how to do that, for starters? So it’s a discussion and it’s something that we have to meet parents where they are. We have to help them figure out ways that may be better. You know, we don’t want perfect to be the enemy of good here. We want them to be able to do things that they can do and to partner with them. But yeah, we can’t be sitting there telling them to do impossible things.

CHAKRABARTI: Well, so let me let me just focus, let me just dig a little deeper here, because from what I understand, we’re not just talking about like a conversation in the doctor’s office, right? I mean, these sort of healthy habits, creation or lifestyle changes involve like very intensive intervention.

I’m seeing, you know, reporting here that says even 26 hours over 3 to 12 months of in person behavior and lifestyle treatment from health care providers so that parents can learn, can get coaching on nutrition, physical activity, better their own role modeling. This sounds like a very intensive process, Dr. Bolling.

BOLLING: So and that’s a good place to sort of step off into what these clinical practice guidelines really address. So the first step in these guidelines is really to evaluate and assess kids, where are they on their growth curve, what is this excess weight potentially having? What kind of effect is it having on their health? So that’s the first step and that doesn’t apply to everybody. We’re talking about the kids who are already suffering from obesity. And the first step in this evaluation and assessment is to really use very non stigmatizing language, non-stigmatizing statements.

About obesity not being, Mona mentioned it earlier, this is no one’s fault. This is not about placing blame. Kids are who they are. They’re a product of many things. So the first step in the guideline is really trying to identify those kids who have health complications. And then we move into the second part of the recommendations, which are that for places that can provide it. Intensive behavior modification does help. So we’re not talking about every child. There’s no way you could do that. Mona and I live on a schedule of, you know, seeing patients every, you know, 20 minutes in an hour on a good day. So we can’t possibly do this with every patient.

But patients who need it, patients who are suffering from obesity, patients who are having health complications, intensive health behavior changes work. And that was sort of the first major piece of the clinical practice guideline with regard to treatment.

CHAKRABARTI: Okay. So let me turn back to you, Dr. Mona. Because I heard Dr. Bolling very clearly emphasize for the places who can provide it. It makes me wonder, is it possible that some of these guidelines, you know, they need to meet some kind of clinical standard. I understand that. But because of that, do they risk sort of reaffirming the inequities that are part of the differences that we see in childhood obesity rates?

Like I’m seeing obesity prevalence is 19% amongst children in America’s lowest income groups, and then it drops down to 10% in the highest income groups. So, you know, when we say for the places who can do it, are the kids who most need this kind of help living in the places that can’t do it?

HANNA-ATTISHA: That’s a great question. And the guideline talks quite a bit about inequities and disparities and how these resources really should, in a very equitable way, be focused and placed in these communities that need it the most. Right now, they’re not there.

But I hope that these guidelines encourage payers and health systems to create these systems, to create these really intense programs that we don’t have today, in a very data driven way to address health inequities. So, yes, there is a concern if we don’t see these intensive evidence-based programs in the communities that need it the most. But I hope that these guidelines will really push, once again health systems and health insurers who should fully reimburse these things to put them in places that need them.

CHAKRABARTI: So we got to talk about insurance here. And any conversation about the American health care system. We’ll get to that. But, you know, my mind is still drawn back to the listener who sent us the comment about just stop letting your kids have whatever they want, Find some personal discipline and pass it on to them.

Well, okay. We’ve talked to family members who have children in their families who are obese, and one of them is Star Simmons. She works with children and adults with special needs in Washington, D.C. and she’s also a grandmother. Her 13-year-old grandson has several health challenges, including being severely overweight.

STAR SIMMONS: The doctors do say that he fits in the category of obesity. They always tell me he needs to lose weight. I need to just make sure he’s having that healthy diet, make sure he gets exercise and everything else. And I do try to feed him healthy on my budget. So, one, I’m offended by that because we have what we can afford. … But number two, I tell her that I do the best I can on my income. And then she says, well, you know, you can cut back on this or cut back on that, as if they know what our household can afford.

CHAKRABARTI: Star lives in southeast Washington, D.C. Her neighborhood is what is known as a food desert.

SIMMONS: There is really no healthy food places to shop at all. We did have one store that we rallied for. We actually rallied to the mayor. We rallied and said we want to have the grocery store over here. They actually put a store called Mom’s Organic. It did not last long because we could not afford to shop in it.

CHAKRABARTI: Well, so Mom’s organic didn’t last, but there still are two other supermarkets in her neighborhood.

SIMMONS: So when I walk down in the produce section of my supermarket, you see lettuce. I definitely tell you about this. Try to get a bag of salad. You see brown lettuce, yellow tomatoes. We went in the grocery store the other day and I couldn’t even find a good tomato at all.

And right now, if you can find really anything that’s good, the cucumbers are old. You know, we find some carrots and stuff. So literally, my staples have had dogs, Oodles of Noodles, canned vegetables. So I would like to get some fresh Brussel sprouts. I would like to get some fresh vegetables. But if I only have $30 to spend for definitely two weeks, that’s what I’m going to do.

CHAKRABARTI: Now, about that $30. Star says she is one of America’s working poor. That’s what she calls herself, because after she pays off all of her recurring bills, including mortgage and utilities. She says she’s got $30 left for food every two weeks. That lack of affordable, healthy food that she’s also talked about hurts kids in her neighborhood in two ways.

SIMMONS: In this area, half our children are overweight. And I just say it like this. We have some that are overweight, but we also have some malnutrition because they’re not even getting the food that they should be getting, or the nutrients they should be getting either.

CHAKRABARTI: So that’s Star Simmons, a grandmother and a special needs worker in Washington, D.C. area schools. Dr. Mona, I’d love you to respond. Love to hear you respond to this, because again, it just links back to that listener who has the not uncommon critique, a critique of get some personal discipline here.

HANNA-ATTISHA: Oh, Star is brilliant. And that’s, you know, the lived experience of most of our patients that I care for. You know, when we started this fruit and vegetable prescription program, you know, we did qualitative assessments of families and what they thought of it. And we had families tell us that it was the first time their kid had a fresh blueberry or, you know, the first time they got to try a new vegetable because they couldn’t try new foods on a limited budget.

Because if they didn’t like it, then it was wasted. So there are so many challenges of having so many of our nation’s children who live in poverty or near poverty that directly impact their ability to eat healthy.

CHAKRABARTI: So, you know, all the headlines when the American Academy of Pediatrics guidelines first came out really cottoned on to two things. The recommendation possibly for surgery for children at younger ages and medicines as well. I want to be clear about something. The reason why we did not start the show with that is because I see those specific guidelines as treatments of symptoms that come out of an underlying system.

Sorry, I’m having trouble articulating today, but that underlying system is the food system and the environment that we’re all living in. So we’re going to come back to that. But Dr. Bolling, I guess we have to touch that third rail here. Why did the American Academy of Pediatrics even go so far as to recommend surgery for children at younger ages who are suffering from obesity?

BOLLING: Well, I definitely want to talk about that. I’d also like to say thank you very much for putting Star’s opinions out there. She speaks volumes. As Mona said, she’s brilliant in identifying a lot of the challenges that we face. So I’m very grateful that you put her out there. I would also say that, you know, the reason we went to those areas with regard to pharmacology and surgery for certain patients is because there are many patients.

The biggest group of that is growing in terms of prevalence, are children with severe obesity. So we see patients who have these very severe complications from obesity and they are suffering currently. Those are children who can be benefited. The evidence demonstrates to us that these are kids who can receive very effective treatment with either pharmacologic agents or with surgery. As you said, Meghna, this is not the answer for the obesity crisis in the nation. This is a treatment for kids who suffer the greatest, who have severe obesity. And there are very specific parameters on how we define that and how we evaluate them for significant co-morbidities.

CHAKRABARTI: So let me press you here a little bit, because you could also, given the American health system, given what it is, my first response to those, you know, the surgery and pharmacological guidelines was, frankly, isn’t it the most American thing in the world that part of the guidelines had to include methodologies that might benefit big pharma or hospitals that are just, you know, costly and involve a lot of influence from insurance companies? Like isn’t there a better way?

BOLLING: Well, certainly we know that intervening early is desirable and being able to prevent kids from getting to severe obesity is very important. However, we know there are a lot of kids that have genetic reasons, have other causes for their severe obesity. And we have kids that are in those situations. So I look at it very much from my individual patients.

I have wonderful kids who are absolutely beautiful people who really need our help. And these methodologies, while not used very frequently, are very important for those patients who need that kind of assistance. It’s a sad fact that they have to have this, but they are therapies that are tested now that we have enough evidence on them that are very effective.

CHAKRABARTI: Okay. So, Dr. Mona, what do you think about seeing surgery and potential medications in the guidelines?

HANNA-ATTISHA: Well, I know that when the American Academy of Pediatrics releases guidelines that they are based on science and evidence. So I welcome these recommendations. We need more tools in our doctor’s bag to be able to address severe obesity, especially. I think the guidelines mentioned that, you know, severe obesity is an epidemic within an epidemic. Like Dr. Bolling said. So we need more tools. We need more tools that work. And that’s what the science has told us. It works.

CHAKRABARTI: We do have some questions coming in, though, about how much insurance is going to play a role here, whether insurers would even approve those kinds of treatments because of, you know, biases in the medical system against treating obesity as a medical problem versus a behavioral one.

So, for example, Bich-May Nguyen is a family doctor and professor at the University of Houston. And we reached out to ask her what she thinks about the guidelines. And she likes what she sees on paper, but she wonders:

BICH-MAY NGUYEN: If you were to prescribe these medications for a kid like some of these more expensive, newer drugs. How would that work? Would it get approved? We had to fill out some kind of prior authorization? The insurance companies have to come up with tiers like they probably try to make people use metformin first before they jump to some of the other medications. And I would worry about the surgical approval and access to it.

CHAKRABARTI: So, Dr. Bolling, your response to that?

BOLLING: That’s exactly why we wrote this clinical practice guideline. There are so many barriers to this, and insurers are able to say, Oh, this is not recommended. This is, you know, experimental. And really, the data says it has worked, it’s effective. Are there limitations? Absolutely. Do we need to learn more? We positively need to learn more. However, these things work. And so part of the reason for the clinical practice guideline, it’s a bit of a call to say we need to increase capacity and we need to increase appropriate payment for these services. Patients need them.

One of the other things that I think is an important take home message from this clinical practice guideline is to start thinking about obesity as a chronic disease. You know, when we have a patient with asthma, for example, we of course talk about lifestyle things, not being around smoking, not smoking yourself, but also we have medications that are available for us.

We have other interventions that are available for us. And it’s the same way with obesity. Certainly there are lifestyle modifications that need to be made, but for certain patients, with the help of people who are specialized, sometimes in the care of children with obesity, they need other modalities to achieve a healthier status.

CHAKRABARTI: So, Dr. Bolling and Dr. Mona, I would like you to listen along with me because I cannot help but still dwell in this mental and intellectual space about, in a sense, what a tragedy it is that we’ve come to the point in this country where the American Academy of Pediatrics has to go so far as to put surgical options in its guideline guidelines for, you know, a disease that was basically nonexistent amongst children, some, you know, 50 years ago.

So I want to just take a few minutes to look deeper into some of those numbers now. And I’m going to be quoting numbers from the National Center for Health Statistics. And they’ve conducted a national health and nutrition examination survey for years. And so according to to the National Center, from 1963 to 1974, childhood obesity rates in this country were about 4%. And that number didn’t really budge much throughout that decade plus.

But then something happens. The rate starts rising. Suddenly in the mid-seventies, between 1976 to 1980, then 6.5% of kids aged 6 to 11 were obese. 1988 to 1984, the number rises to 11.3%, 1999 to 2000, 15.1%. 2003 to 2004, 18.8%. And as mentioned earlier, by 2020, the obesity rate topped 20% for 6- to 11-year-olds.

So when you look at the trend, it really forces the question, was America’s childhood obesity epidemic created? Perhaps not intentionally, but created nonetheless. I mean, what happened around 1974? Well, the answer in part begins with this man. Who in the early 1970s told American farmers to get bigger, get out and plant fence row to fence row.

EARL BUTZ: I probably said it. I said a lot of things when I was secretary, and I expect I did say it, but it was the market who dictated the farmers plant fence row to fence row. Prices were up, exports were good. And the market dictated, expand your production. They not only planted fence row to fence row, they tore out the fence row. I can’t even find the fence rows out there. Now I guess that’s because of large tractors and large combines.

CHAKRABARTI: This is Earl Butz. He served as the U.S. Secretary of Agriculture from 1971 to 1976 under Presidents Nixon and Ford. When first appointed. He had also served on the boards of several agribusiness firms. But Butz denied the criticism that those ties would influence his work at USDA. But actions speak louder than words, of course, and the actions Butz took transformed American agriculture.

Because since the Roosevelt administration and the New Deal era, the government had managed prices by managing supplies. So essentially they paid farmers not to flood the market. Now, Earl Butz equated that to a form of socialism. So in 1973, as secretary, he helped usher in the farm bill, a massive piece of legislation that shifted government influence from supply management to subsidies. So the USDA was now supporting farmers with direct payments if market prices fell below production costs.

And apparently, Butz did not see that as a form of socialism. And to this day, the U.S. government continues to subsidize rice, cotton, wheat, soybeans and corn. So, unsurprisingly, production of these grains rose dramatically in the mid-seventies, as did the corporatization of American farming. Its impact was immediate.

And in 1977, Indiana’s Manchester College held a remarkable debate between Earl Butz and Wendell Berry. Now, Berry was the well-known writer, activist and farmer who just published The Unsettling of America, a scathing critique of American agribusiness. And in the debate, Wendell Berry described the changes he’d seen in his home state of Kentucky as agribusiness bought more and more farmland.

WENDELL BERRY: Planting them to corn and soybeans. They’re not showing any cover crops. They’re plowing up the waterways, cutting the fences. They’re driving in, producing the crop, loading it and driving out with it. In other words, in their practice, the industrialization of farming is complete. They’re treating the farm exactly as you would treat a factory or a mine.

CHAKRABARTI: Well, Agriculture Secretary Earl Butz agreed wholeheartedly with Berry on this point. Hyper productive corporate farming meant that Americans were spending less on food than ever, just 17% of their income in the mid-seventies, a huge step forward. It also allowed America to feed itself and the world, Butz said in the debate. So he welcomed the innovations that industrial farming brought to America’s food supply.

BUTZ: You get the frozen TV dinners that you poked in the oven the night before you came down here. You see, you take that ounce and half of those TV dinners multiplied up to price per pound. It’s not for cheap. It’s all these frozen pot pies we get. I was out in Idaho a couple of weeks ago and it took me one of these potato processing plants, and they said we now process at or near the point of production two thirds of potatoes we eat in America.

A young graduate student from Purdue and I stopped out here at McDonald’s a while ago to get our supper. A third of the meals eating outside the home. That’s all in the 17%. That means we got 83% as a nation left to do something else with besides feed ourselves. This is the very basis of strength in America. Never forget it.

CHAKRABARTI: Well, there’s another way of looking at it. Agribusiness had found a way to create massive amounts of corn and soy in order to profitably produce convenience products for Americans to eat. And of course, there’s one ingredient in particular that I think deserves special attention, as we think about the childhood obesity epidemic kids are enduring now, because recall that obesity rates began that sharp upward turn around 1980. Well, in the mid 1970s, ag giant Archer-Daniels-Midland began developing a technology originally created in Japan, a concentrated liquid sweetener made out of corn, high fructose corn syrup. And by 1999, Americans were eating more than 63 pounds of high fructose corn syrup per person per year. It is virtually inescapable in the American diet.

SANTANA LEE: A majority of the kids, when I say snack time, it’s just a whole bunch of sugary snacks, not really having access to healthy snacks. And even if you give them a choice of healthy snacks and unhealthy snacks, they probably don’t choose a sugary snack just because that’s what they’re accustomed to.

CHAKRABARTI: This is Santana Lee, a mom of nine. She lives in Milwaukee and also works with teens at her local schools. And she says changes in the American food supply have made it nearly impossible for many families to cut the amount of sugars in their diet.

LEE: Even with the healthy foods, they’re more expensive than the unhealthy foods. You know, you can go to the store with $100 and buy a whole bunch of unhealthy food, have access to unhealthy foods, the abundance of that. But then you get the fruits and vegetables that everything is just upcharge and is really expensive. So a lot of families just try to decide, do I maximize this amount of money that I have to spend on food, or do I just buy like a couple of healthy meals and then figure out how to get the rest later? That’s a lot of what’s happening, too. Not only is it not access to healthy foods, but the prices for healthy foods are more expensive as well.

CHAKRABARTI: So Dr. Mona and Dr. Bolling, as we kind of turn the corner to the last few minutes of this conversation, here’s what I wonder. If the obesity crisis, childhood obesity crisis specifically was created, even if not intentionally so, can it be unmade through the same mechanisms, through national policy?

So, Dr. Bolling, it makes me wonder why the American Academy of Pediatrics, instead of coming out with guidelines that say, focus on clinical or medical treatments for childhood obesity. And in a sense, it means the responsibility is still focused on families. Why not instead declare an all-out campaign, even a war for the transformation of the American food supply? Dr. Bolling.

BOLLING: Well, first of all, we need to advocate for our patients who are sick currently, and we definitely want to help those children who are suffering from obesity at this point. And that is absolutely essential to the American Academy of Pediatrics. Mission is for the health and welfare of all children. So your other statement about, you know, do we need to address these things?

We absolutely do. Star’s comments earlier. Some of the things that you laid out are absolutely affecting childhood health. And the American Academy of Pediatrics is very active in trying to lobby for those sorts of things as well. I would love to have healthy foods be on an equal footing with unhealthy foods. When you have a limited budget and you have shelf stable items that are ultra processed but are very unhealthy. Parents are going to do what they can to feed their kids. So you’ve identified a crusade that many of us feel like we have to be on to make the environment more healthy for our families and children.

CHAKRABARTI: But if I could if I could just push a little more here. You know, organizations such as the American Academy of Pediatrics and also, you know, the American Medical Association, etc., actually do have a lot of sway and influence beyond the doctor’s office.

I mean, just the existence of these new guidelines has forced once again, sort of publicize an important conversation in this country. So, I mean, do you think the American Academy of Pediatrics has some plans to … start this kind of campaign that I talked about?

BOLLING: Well, you know, this is not a zero-sum game. Now, we are trying to raise attention about this health crisis. And there are many solutions to this health crisis. We need to help our children individually, but we also need to advocate for them on a system wide basis. So it’s something that is very much a part of the feeling at the American Academy that we are in this for kids of all types and of all socioeconomic status.

CHAKRABARTI: So, Dr. Mona, we’ve got a couple of minutes left. I’m going to give you the last word here. So first of all, I mean, what do you think of my assertion there that some of the major factors, for the reasons why you’re seeing obese children walk into your clinic today actually have nothing to do with them, but to do with decisions made in Washington, you know, 40 years ago, 40 plus years ago. And if so, what should we do about it?

HANNA-ATTISHA: It’s been said that pediatricians are the ultimate witnesses to failed social policies. You know, it’s in our exam rooms where we see the consequences of often kind of political inaction for the best interests of our children. We put our kids on a pedestal. We talk, you know, we tell ourselves are the future. But we don’t often put policies in place that respect the science of really, truly what kids need.

So, you know, I would love for that all-out war against the agro business, against these subsidies. You know, we often just have to follow the money to see, you know, what’s happening. And really often that’s not in the best interests of public health and often not in the best interests of children’s health.

This article was originally published on WBUR.org.

Copyright 2023 NPR. To see more, visit https://www.npr.org.

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