A New Tool to Better Understand Your Food

The food on your plate is the product of a unique supply chain. Sometimes it's complex, other times more intimate between farmer and consumer. Either way, food production is not just a question of ingredients, but also how such ingredients are processed together, and ultimately the composite nutritional value of the food. 

Nothing epitomizes this more then the current debate about GMO (genetically modified organism) labeling on food products. Advocates want to know - and claim it's their right to know - what is precisely in the food they are eating. A number of state legislatures have also considered legislation on the issue. The debate rages regarding the health implications of GMOs, but either way, from a transparency perspective, I'm always in favor of having as much information as is needed to make an informed decision about the things I value.

This is why I was so excited to see a new resource available to help consumers make more informed decisions about food. The Environmental Working Group released a new comprehensive database of 80,000 foods last week, called Food Scores. It scores each food in three primary areas: ingredients, processing, and nutrition. Each individual food receives an overall score, and includes an a very useful summary page with other information about the nutrition facts, ingredients, and how that particular product compares with similar products. 

Here are a few screen shots of the interface.

But of course I'm always skeptical of these types of scoring tools. An index score is only as useful as the underlying assumptions are sound. In the case of Food Scores, I went straight to the nutrition scoring methodology to better understand those nutrients deemed "good" and which fell into the "bad" category.

A few thoughts:

1. Fewer calories prevail. I've written a bit on this, so I won't spend too much time on it. But, calories aren't necessarily something we need to be afraid of, or always cut. More importantly, it's quite easy to reduce calories while at the same time add in more unnatural ingredients and processing. A classic example I like to refer to from Rich Food, Poor Food is in comparing regular Lays potato chips and "Baked Lays," the so-called healthier alternative. Baked Lays has fewer calories, but it also has a bunch more unnatural ingredients. 

2. Saturated fat is still demonized. Though more and more research is supporting the contrary, prevailing opinions continue to claim high saturated fat intake as one of the primary causes of cardiovascular disease. Similar to calories, the Food Scores methodology takes the "less is better" approach.    

3. The methodology seems contradictory when it comes to naturally occurring sugars, such as those in fruit. On the one hand it puts natural sugar in the "negative factors" category, while also having fruit content as a positive factor. All fruit has sugar, some more so then others. By processing fruit, such as with juicing, it's quite easy to create a fairly concentrated source sugar, which if consumed consistently over time, has implications for insulin, cognition, energy levels, and long-term health.

4. Lastly, though some aspects of the underlying methodology can be debated, the database is extremely powerful in supplying different types of information related to a huge number of foods. However, for a usability perspective, going to a website can be a cumbersome process for many consumers. Who has time to search for everything that's going to be included on their grocery list that week? It will be interesting to see if the EWG takes additional steps, such as creating a smartphone app, to try and make the database more accessible and usable.

Take a look at the tool and let me know what you think in the comments.  

Women Make Tough Choices When it Comes to Family and Wellness

Working mothers make difficult trade offs when it comes to career and family. While trying to pursue career aspirations, mothers often try to balance the responsibilities of being a parent.  

Workplace policies aren't always supportive of a healthy balance between the two. Inflexible work arrangements mean mothers make hard choices when it comes to taking care of a sick child or earning a paycheck. 

A recent poll by the Kaiser Family Foundation, a nonpartisan think tank, sheds light on some of these trade offs that working women (now comprising about half of the US workforce) must make.

In the majority of households across the country, women manage health care decisions for the family. Roughly three out of every four women decide on a doctor, take children to appointments, and then execute a health provider's recommendations on care.  

When doing these things though, many women take time off from work. And 60 percent of women who take time off are not compensated.

   
Such inflexibility has a number of ripple effects:

1. Women lose out on valuable pay, which is already not on par with their male counterparts.

2. Seeking health care turns into a last resort. Out of fear of losing pay, women may opt to forgo seeking heath services for a child.

3. Decisions related to health and illness are major sources of stress by themselves. Work challenges and trade offs only add to this stress.

The good news is that more employers are thinking about employee wellness. Organization policies and culture, however, don't always find their way into these conversations. If wellness is indeed a priority, we need to think about the ecosystem of factors that influence our entire physical, mental, emotional and spiritual well-being.     

Should children be using standing desks in schools?

"Sitting is killing you." It might even be worst for your long-term health then smoking, suggests some research. The headline is a bit sensational (in this case by TIME magazine), but the underlying message isn't. In many respects, movement has been engineered out of our daily lives. Now, I'm not talking about the 30 minute jog in the morning or weight session after work. These are laudable activities. I'm talking about the regular movement involved in our everyday activities - essentially, being on your feet for more then a few minutes. 

One technical fix to move (pun intended) people in the direction of increased activity is a standing workstation. They've been around for quite some time, but have become quite the craze recently. 

What's the point? 

Why should we be standing morel? The answer in many public health circles is less about standing for a long duration of time, but rather getting people out of a seated position because of sitting's link to a variety of long-term health consequences. For example, a number of studies, such as this one, have shown a dose response association between sitting time and death from all-causes and heart disease. The more sitting, the higher the risk. Even more important, these results were found to be independent of leisure time physical activity. In other words, your morning/evening run, cycle, swim, row (insert your activity or workout of choice here) does not make up for the eight hours spent sitting at your desk everyday. A similar study, called the Sax Institute 45 and Up Study, which is the largest ongoing study of healthy aging in the Southern Hemisphere, has found a 40% increased risk of death for adults who sit 11 or more hours per day compared to those who sit fewer than four. 

Armed with the data, many individuals and employers are making changes. Enter: the standing workstation. More offices have them, and more options are available now than ever before. Some, like this one, can easily shift from a standing desk to a regular seated desk. For employers, it's about trying to minimize ill health-related costs and increase productivity.

Schools, on the other hand, are more of an unknown. Standing desks are still not very common, but new research suggests maybe they ought to be. It's a similar rationale with workplaces. Standing desks would help keep kids healthier and boost learning and academic performance. 

Standing Desks for Kids?
 
A new, first-of-its-kind study that tested the use of standing desks in 24 classrooms in three north-Texas elementary schools showed some interesting results, at least from an energy expenditure perspective. Researchers compared energy expenditure (EE) data and daily step counts for 337 students from two different grades within the three schools. Four different classrooms were measured per grade. Below is a picture of the standing desk used by students in the intervention groups (right) alongside the desk used for the control group (left), which were just the normal desks used at the schools before the study. Two control classrooms had to be excluded from the study because they opted to use exercise balls in place of chairs during the school year. As a result, the number of students in the treatment and control groups were not balanced.

The results?  

It's a mixture of good and bad. 

Good news: 
All students, regardless of gender or ethnicity, took more steps and expended more energy if they used a standing desk compared to those using seated desks. The following two graphs illustrate this point. In addition, students who were overweight or obese had a greater EE of 0.24 kcal/min and 0.40 kcal/min respectively compared to students of normal weight range. (One point of clarification: 1 kcal roughly equals 1 calorie). One could then conclude that from a purely EE standpoint (i.e. not considering the limitations of an energy-based way of thinking - in other words, only calories - about weight gain/loss and metabolic dysfunction), a standing desk is more effective then a sitting one, particularly for those children who are already overweight or obese.  

Students who had standing desks also took more steps per minute on average throughout the day. In the fall semester it was 1.61 steps/minute more among standing versus sitting students. This difference essentially disappeared in the spring semester, though, calling into question whether it was the desk per se that caused the increase number of steps, or simply the fact that it was something new. Similar to EE, greater benefits were observed among overweight and obese students.

Graph of average energy expenditure (measured in kilocalories) per minute by each student.


Graph of average steps taken per minute by students.



Bad news: 
A few points of bad news:

1. The overall effect of the intervention was relatively small. If you take the combined average increase in EE for all students using a standing desk compared to sitting, it amounted to a 0.08-0.16 kcal/min increase. Over a four hour period, this only amounts to an increase of 19.2 - 38.4 kcals. For some perspective, a single cup of fresh-pressed orange juice is 112 calories; a single hard-boiled egg is about 70 calories; and a single slice of Nature's Own whole wheat bread has 60 calories. The basic point is that we're not talking about much here. 

2. A 50% smaller increase in EE was observed among students using the standing desk in the spring semester compared to the fall. Basically, the longer students used the desk, the more they adapted to them, expending less energy.

A few Unanswered Questions

Two significant areas went untouched in this study.

1. Alignment: Standing in an anatomically aligned position requires significant postural muscle strength in the legs, glutes, abdominals and lower back. When these muscles cannot sufficiently support the body in a functional way, bad habits form, impacting overall body alignment. For a crash course on alignment, read Katy Bowman's blog or book titled, Alignment Matters. One specific area she discusses at length, and warrants highlighting, is the role of footwear. A straight line should be able to be drawn from the top of the head, down to the heals, perpendicular to the floor or ground. When one introduces a healed shoe (in other words, the large majority of commercially available footwear today), this changes the angle by which this imaginary line intersects with the ground. The result? Muscles unnaturally shorten, like those in the calf, hamstring and lower back, changing the entire alignment of the posterior muscle chain as a result. Ever have tightness, soreness or pain in your lower back? Tight calves and/or hamstrings could be the cause.

2. Productivity and/or education outcomes: The link between physical activity and improved brain functioning is well established. For more on this, read the book Spark: The Revolutionary New Science of Exercise and the Brain. Exercise essentially turns on parts of the brain associated with learning, creativity, and other executive functions. This is the basic argument for retaining (and even increasing) the amount of physical activity opportunities offered to students during the school day. Though lower impact and less cardiovascularly taxing then say running, standing still has its benefits. Really, anything other then sitting is preferable. Unfortunately, none of these non-health benefits were examined in the study, though the discussion section of the paper says otherwise. Despite the fact that the study did NOT measure any education-related variables, the authors still concluded, "the results of this study and previous pilot studies have established that activity-permissive classrooms...improve behavioral engagement." Popular media outlets picked up on this assertion and expanded upon it, such as Fast Company who ran a story on September 26th about the study with the headline "Standing Desks Are Coming to Schools, To Cure Obesity and Increase Attention Spans." This despite the fact that the study did NOT actually measure attention span or "behavioral engagement."

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I've used a standing workstation for several years now, whether commercially bought or one I rigged up using various office supplies. But, is this something that should be standard practice in schools in the US? Should children be forced to use standing workstations? Should they be given the option? Are standing workstations simply overrated? I'd love to hear your thoughts.

Is it time to rethink nutrition's public enemies 1 and 2, saturated fat and salt? (Part 1)

Few nutrients are viewed in a more negative light than salt and saturated fat. The infamous "Seven Country Study" by Ancel Keys from the 1950's brought about a crusade to rid the American diet of fat. Since, more is now known about the differing physiological effects of different types of fatty acids (saturated, trans, monounsaturated, and polyunsaturated). Though some fat sources are now generally considered "healthy," like those associated with a "Mediterranean Diet" such as olive oil, nuts, and fish, conventional guidance still puts saturated fat in the "less is better" category. We often continue to hear how it's best to substitute saturated fat with polyunsaturated fats (see a previous blog I did on this topic) Similarly, salt (actually sodium, which is one mineral found in naturally occurring salt) receives a pretty bad rap because of its link with blood pressure. With greater numbers of people experiencing hypertension (high blood pressure), sodium became the primary target. Cut the sodium, reduce the high blood pressure. (If you haven't, take a look at the recently published book by Michael Moss, Salt Sugar Fat: How the Food Giants Hooked Us, which argues fat and salt form two parts of nutrition's current three-headed monster.) 

The current "Dietary Guidelines for Americans," which the U.S. Government updates and releases every five years puts both saturated fat and sodium in the "foods and foods components to reduce" category. It states, 

• "Reduce daily sodium intake to less than 2,300 milligrams (mg) and further reduce intake to 1,500 mg among persons who are 51 and older and those any age who are African American or have hypertension, diabetes, or chronic kidney disease. The 1,500 mg recommendation applies to about half of the U.S. population, including children, and the majority of adults.

• Consume less than 10 percent of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids."

Other nutrition guidelines are slightly more stringent in some respects. The American Heart Association advises to:

• "…reduce saturated fat to no more than 5 to 6 percent of total calories. (Just to put this into perspective, if a person is eating 2,000 calories a day, this amounts to a little more than 1 tablespoon of butter per day or 2 large fried eggs.)

• Choose and prepare foods with little or no salt…aim to eat no more than 2,400 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further."

However, research is continuing to show that nutritional guidance related to both saturated fat and sodium may require a more nuanced approach (as many things in nutrition often do). Before going even further, though, I want to point out the delicate balance that must be struck between public health guidance (like those cited above) and individual nutrition and health outcomes. This is particularly challenging in nutrition. No two individuals are exactly alike and thus have slightly different biologies. As a result, my physiological response to say a high-carbohydrate meal might be slightly different than yours. Genetics plays a role in this. For example, fascinating research presented by Chris Masterjohn at the 2012 Ancestral Health Symposium on salivary amylase (one of the first enzymes your body uses to digest starches/carbohydrates in the mouth) has shown that the ability to digest starches varies from population to population. In other words, some populations, such as those in east Asia, whose diets contain a fair amount of carbohydrate (think white rice), have evolved to produce more amylase then say the Inuits. These important distinctions across populations means general guidelines may not be applicable (or worse, even harmful) for all.

The basic message: public health guidance tends to be extremely broad, focused on what's generally best for groups of people. Metabolism, however, is extremely individualized, often requiring a more nuanced approached. 

Okay, back to fat and sodium.

Some interesting new research published in the past few weeks provides more evidence for why current mainstream guidance may need to be adjusted (coincidentally, the next version of the Dietary Guidelines for Americans are being discussed and are set to be released in 2015). 

Fat

One of the biggest challenges with current guidance on fat is it often overlooks complexity. As I've said before, not all fats are the same (just as not all calories are equal, see this previous post), each having different metabolic and health effects. Because of this, I think it's much more useful to think of food as "information" rather then exclusively "energy." As I've written before, 100 calories of soda tells the body to react in a very different way (think insulin release) then 100 calories of butter. Foods are also not all exclusively "saturated fat" or "unsaturated fat," but rather a mixture. The predominant type of fat usually is the one used to categorize a food as saturated, poly-unsaturated, mono-unsaturated, etc. 

Saturated fat has been public enemy number one, particularly with heart disease on the rise in the United States and globally. But, more research is showing this might be misguided. A 2010 meta-analysis (which included one of the foremost experts on heart disease and cholesterol, Ronald Krauss as an author) found "no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD [coronary heart disease] or CVD [cardiovascular disease]." 

A recent study published in The Lancet attempts to shed some light as to why we hear these conflicting messages: sometimes saturated fat is okay, other times it's not (see the evolution of Time Magazine covers below as an example). One explanation is that it has to do with the length of the carbon chain comprising the fatty acid "tail." (Warning: biochemistry ahead). As there are different types of fats (unsaturated has one or more double bonds connecting two carbon atoms, while saturated fats don't have any), fatty acids can also have varying lengths of fatty acid chains. Short-chain fatty acids, such as butyric acid, have fewer than 6 carbons, while long-chain fatty acids can have 22 carbons or more.

The study used a sub-set of 16,154 people from eight European countries from the EPIC-Interact study to investigate the association between saturated fatty acids and type 2 diabetes. Researchers used a pretty sophisticated procedure of converting the fatty acids into a more volatile state and separating them using gas chromatography. They looked at 37 different fatty acids. 

What did they find? Even-chain fatty acids had the greatest contribution to type 2 diabetes risk. "Older adults, those with higher BMI, and men had higher relative concentrations of even-chain SFAs, whereas we noted the opposite for longer-chain SFAs. Relative concentrations of odd-chain SFAs were higher in people with a lower BMI and in women."

Researchers also conducted an analysis of SFA type and self-reported food intake. They found that "even-chain SFAs (these were the ones with a higher risk of developing type 2 diabetes) were positively associated with alcohol, soft drinks, margarine, and potatoes, and negatively associated with fruit and vegetables, and both olive oil and vegetable oil. By contrast, odd-chain SFAs generally showed positive associations with dairy products, cakes and cookies, nuts and seeds, and fruits and vegetables." This important distinction, thus, sheds some light as to why some saturated fat could actually be a good thing.

Dairy is a good example. There was a recent review article from 2012 on the influence of dairy product and milk fat consumption on heart disease and found "no association and in some cases an inverse relationship between the intake of milk fat containing dairy products and the risk of CVD, CHD, and stroke."

So, yes, there are nuances. This recent study puts forth an interesting hypothesis and supporting evidence for some of the conflicting messages around saturated fat as of late. Most importantly, however, I think it reinforces the need to understand and embrace nutrition's complexity. Food and nutrients are information for the body, with different types sending different messages. Nutrition advice and guidance should embrace these nuances, not cover them up.

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Stay tuned for Part 2 where I will highlight some of the latest research on salt that challenges conventional thinking.

IRONMAN and Little Debbie Join to Market Junk Food to Kids

Big news came out of Tennessee yesterday that I absolutely had to post about -- IRONMAN was "proud to announce" Little Debbie as the title sponsor of IRONMAN Chattanooga through 2016.

Yes, I understand the partnership from a purely business perspective, since McKee Foods, the parent company of Little Debbie, is headquartered in Tennessee. My issues relate to public health, and what this partnership says about where health falls on the spectrum of priorities.

The biggest disappointment, in my opinion, is that race weekend festivities include a IRONKIDS Fun Run. As described on the IRONMAN website, the race "offers young athletes the unique opportunity to feel the excitement of competition while enjoying the outdoors and promoting healthy living."

Here's my big question. How does a race promote healthy living when its title sponsor is a company that manufactures products that contain substances known to HARM health, such a partially hydrogenated vegetable oil (i.e. trans fat) and artificial flavors. Here are the nutrition facts and ingredients from the Little Debbies Fudge Brownies:

Ingredients: Enriched bleached flour (wheat flour, niacin, reduced iron, thiamine mononitrate [vitamin B1], riboflavin [vitamin B2], folic acid), corn syrup, partially hydrogenated soybean and cottonseed oil with TBHQ to preserve flavor, sugar, dextrose, water, cocoa, walnuts, high fructose corn syrup, whey (milk), eggs, soy lecithin (emulsifier), corn starch, salt, leavening (sodium aluminum phosphate, baking soda), colors (caramel color, red 40), natural and artificial flavors, egg whites, citric acid, sorbic acid (to retain freshness), almonds.

What's more, a number of major food and beverage companies have voluntarily committed to stop marketing unhealthy food and drinks to kids under the age of 12. And yes, sponsorships are a form of food marketing (just ask big tobacco). Unfortunately, McKee Foods, is not one of the 17 companies to make this marketing pledge. IRONKIDS events are open to kids as young as 3 years old and up to 15.

Regardless, food marketing to children is deceptive and, unfortunately, ubiquitous. It's well-known how this type of marketing influences children's behavior and preferences. My biggest issue is for the World Triathlon Corporation, which owns the IRONMAN brand, to say it's trying to promote healthy living while at the same time partnering with companies whose products clearly don't align with that goal.

The other ironic twist to this partnership is that IRONMAN Chattanooga is also "benefiting the Crohn's & Colitis Foundation of America." This certainly sounds admirable, but let's dig a bit into the science. Crohn's disease and ulcerative colitis are inflammatory bowel diseases. According to the Mayo Clinic, Crohn's disease "causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea and even malnutrition." One of the most pro-inflammatory foods overly consumed in the average American diet today are vegetable oils (partly because of their extremely high omega-6 fatty acid content). However, the biggest problem comes when vegetable oils are hydrogenated. Enter, trans fats, which research has shown to be associated with the development of ulcerative colitis.

One study, in particular, published in 2013 in the journal Gut, tracked more 170,805 women enrolled in the Nurses' Health Study over 26 years and found that "long-term intake of total fat, saturated fats, unsaturated fats (mono or polyunsaturated) were not associated with risk of CD (Crohn's disease) or UC (ulcerative colitis)." Now, before we exonerate all fat, there was one important exception to this conclusion. They found a "trend towards increased risk of UC (ulcerative colitis) associated with high intake of trans-unsaturated fatty acids."

The takeaway from this: long-term intake of trans fat is associated with the development of inflammatory bowel diseases such as ulcerative colitis. So, doesn't it seem ironic that the race is promoting a product that contributes to the same health conditions it's also trying to prevent indirectly through its partnership with the Crohn's and Colitis Foundation of America?

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IRONMAN has done a lot to grow the sport of triathlon, and I'm thankful for that. In fact, I'm registered to race in IRONMAN events this year. Triathlon is a sport I love and will continue to compete in. Just don't expect to see me at the start line in Chattanooga in the foreseeable future.

Are we really heading in the right direction with childhood obesity? (and a fun lesson in epidemiology)

I saw some very encouraging headlines last week about childhood obesity, not the least of which came in the NY Times:

"Obesity Rate for Young Children Plummets 43% in a Decade"

I've also come across graphs like this one, which support the narrative (Note this graph is for obesity only, i.e. 95th BMI percentile - More on the distinctions later).

 

Whenever I see headlines like this though, my first instinct is to immediately go to the actual study, which in this case was published in the Journal of the American Medical Association (or JAMA). After looking at all the data, the story is often MUCH more nuanced than gets spun in the media. This study was no different. More on this in a second.

The other thing that generally happens around these type of epidemiological studies is that speculation abounds about what CAUSED the particular change. These type of prevalence studies essentially take a static picture of a particular health concern (in this case elevated body mass index - the common marker used to assess overweight and obesity) within a given population (a nationally representative sample of children in the US ages 2-19 for this study). If the methods are consistent over time, you can then compare what today's picture looks like compared to the picture, say five years ago. But that's all you can do - compare the pictures. What often happens, of course, is commentators begin to offer different theories as to what caused the changes in the pictures, like in this Washington Post blog. It's important to remember these are just speculations. These studies were never designed to actually assess this question of causation.

We also see the unfortunate occurrence of over-generalization. This is when the findings of a particular population are extrapolated to other populations (this is a big no-no in epidemiology), like in this article that references "youth-related" obesity, but cites the decline found in 2-5 year olds (i.e. children not youth). 

Ok, let's get to the data.

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The following are a series of graphs I put together using the same NHANES data published in the most recent JAMA article, but instead disaggregated by race. These charts tell a much more nuanced story, particularly as there is a significant race/ethnicity component to obesity in the US. Another modification I made was to look back to 1999-2002 to provide additional context on trends (instead of 2003, which the above graph used). The reference point for trends provides a lot of valuable information and shapes how the results are framed.

Let me show you why.

These are prevalence data for overweight and obesity (measured as a BMI of greater than or equal to the 85th percentile and 95th percentile respectively) for several different age groups disaggregated by race/ethnicity.

Overweight and Obesity (85th percentile), 2-5 years old

Obesity (95th percentile), 2-5 years old

*You'll notice from this second graph that an interesting story emerges, one that is masked when only looking at aggregated data. Though there are some significant declines among certain populations (most notably non-Hispanic whites), there is a steep upward trend for Hispanics.

Overweight and Obesity (85th percentile), 6-11 years old

Obesity (95th percentile), 6-11 years old

*Here, I think it's important to think about the reference point, especially in the first graph for overweight and obesity among 6-11 year olds. Though a little progress here and there, all categories have a higher prevalence in 2011-12 than in 1999-2002. The graph would tell a different story if the reference was 2003-04, as in the first graph in the article. We also see another age group where prevalence of overweight and obesity increased most recently among Hispanics (in addition to non-Hispanic whites).

Overweight and Obesity (85th percentile), 12-19 years old

Obesity (95th percentile), 12-19 years old

*Again, we see a similar story to the 6-11 age group. There is considerable variation when looking across race. In fact, we see an overall increase from 1999-2002 to 2011-12 when looking at all races within this age category.

Take Home Message

My take of the data is that it's a much more nuanced story than what's being portrayed. Yes, there are some positive trends. But these are within specific age groups and looking at specific markers (i.e. 85th percentile of BMI vs. 95th percentile). Looking at what happens later in childhood and into adolescence, the trends in obesity aren't as favorable. In a sense, gains early in life (2-5 years old) could be offset by what's occurring in some of the older age groups. And, just because a national-level trend is positive (all kids of a particular age), doesn't mean it's positive for all the different sub-groups (in this case broken down by ethnicity) that make up the national average.

References

All data in the blog were produced using the following:

Hedley AA, et al. Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002. JAMA. 2004;291(23):2847-2850.

Ogden CL, et al. Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA. 2010;303(3):242-249.

Ogden CL. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.


Disclaimer: The views in this article are my own and don't necessarily reflect those of my employer or my employer's clients.