cover_story (2006-26)

Jay and Kathy Kersting dropped nearly 200 lbs between them.

Dr. Michael Zemel

Through much of her adult life, Kathy Kersting was afraid to step on a bathroom scale. “It was like not opening a bill when you get it in the mail,” says Kersting. Now a healthy, vibrant woman in her mid-30s, she’s seated at a Bearden-area Panera bakery, though her table is conspicuously devoid of pastries or frothy cappuccino. “You don’t owe the bill if you don’t see it.”

Like too many Tennesseans nowadays—like too many Americans in any locale, for that matter—Kersting was overweight. And not just a little, either; at 5 feet 6 inches tall and roughly 280 pounds, and with a Body Mass Index over 40, she was what many dieticians classify as morbidly obese.

But while the severity of her condition was unusual, the way she got there was all too familiar. She and her husband, Jay, a radio personality with Knoxville’s Citadel Broadcasting, both came from families who took eating seriously, and for whom weight problems were not uncommon.

“I grew up in Kansas City, where the basic food groups were beef and pork,” says Jay, a big man with a brassy voice. He was no lightweight himself at his peak of 6 feet 4 inches, 312 pounds. “Then we went to Wisconsin, where it was beef, pork and cheese. Then I became an adult, and beer got thrown into the mix.”

Mix in two complicated pregnancies, then the pressures of raising their boys in a busy two-income household, sprinkle liberally with plenty of takeout and quick-fix pasta and fried foods, and you have a sure-fire recipe for what has become the single most significant public health problem in America.

For Kathy, the psychological and physical hazards of obesity eventually forced her to consider another way of life. “I had self-esteem issues,” she says. “I didn’t like how I felt. I didn’t like what I saw in the mirror. I had back problems, couldn’t walk up the stairs without being winded. And I realized I wanted to be around for a while, for my kids.”

When Jay suggested they try a commercial weight loss system being touted on the air at his radio station, she agreed. The couple became a test case for the system, which is mostly predicated on controlling portion sizes and making smarter food choices, and their results have been monitored regularly in a series of radio advertisements.

Since beginning the program, Jay has dropped from 282 pounds to 244, before stabilizing at around 250, close to his weight in high school. Kathy’s results have been dramatic; she’s dropped well over 100 pounds in a year and a half, and she now spends her early morning hours in the gym before taking the stairs up to her office in the University of Tennessee’s McKenzie Lawson Center.

“The doctors told me that Kathy was successful because she knew this would not be a quick process,” Jay says. “It’s a 12, 15, 24-month thing. And it’s a lifestyle change.”

It’s a lifestyle change many of us need to consider. Statistics say that Americans have gotten a whole lot fatter over the last 25 years, and Tennesseans are among the—pardon the pun—biggest offenders. According to the U.S. Health Department, obesity rates have doubled in America since the late ’70s, from around 15 percent to nearly 30 percent as of 2002. To be classified as obese, an adult must have a Body Mass Index, or BMI (a ratio of bodyweight to height) over 30.

The percentage of Americans who qualify as simply overweight (BMI of at least 25), meanwhile, increased from 48 to 65 over the same period.

An oft-cited 2005 study by Trust for America’s Health ( F as in Fat: How Obesity Policies are Failing in America ) found that Tennessee ranked fifth in the United States with an adult obesity rate of 25.6 percent, and seventh in rates of obese and overweight adults combined at 61.9 percent. The average Tennessean, in fact, has BMI of 29.2, only eight-tenths of a point short of obese.

Those numbers quickly give way to other, even more troubling numbers, in the form increasing rates of weight-related illnesses, lives lost and healthcare costs. Obesity is now known to be a risk factor for a veritable rogues’ gallery of life-threatening—or at least highly unpleasant—medical conditions, from multiple cancers to diabetes to cardiovascular disease to sleep apnea, decreased sperm counts, stress incontinence and excessive body hair.

The country spent in the neighborhood of $120 billion on obesity-related health issues in 2003, according to the National Conference of State Legislatures, including roughly $1.8 billion in Tennessee. A study out of Emory University in Atlanta estimates that private health spending attributable to obesity increased tenfold between 1987 and 2002.

What all that means is that today’s generation could be the first one in American history to have a shorter life expectancy than the preceding one—that according to a 2005 analysis of obesity trends in the New England Journal of Medicine. William Dietz of the Centers for Disease Control (CDC) has declared obesity “an epidemic…the likes of which we have not had before in chronic disease.”

“It’s a social issue as well as a health issue,” says Russell Moore, a senior legislative research analyst for the state, and author of a recent report Weighing the Costs of Obesity in Tennessee , “because the costs are borne by all of us.”

But while it makes sense to us that we might be less fit than our great-great-grandparents, salt-of-the-earth people who did real manual labor and who probably regarded the first automobiles with bemused suspicion, it seems hard to believe we’re really that much chubbier than we were 20 or 30 years ago. The statistics beg all sorts of questions. How did we get this way? And why is the problem so egregious here in Tennessee?

At the simplest level, weight management is merely a matter of physiological bookkeeping: calories in versus calories out. But the complexities of life in the 21st century tend to fill the ledger with inputs that skew the bottom line.

“Why are we fat? There is no simple answer,” says Dr. Michael Zemel, professor of nutrition and medicine and director of The Nutrition Institute at UT. A hale, muscular fellow in early middle age, Zemel is also a co-founder of Tennessee on the Move, a non-profit organization devoted to promoting weight management through incremental lifestyle changes.

“Everyone wants to find a villain, but I think that’s a huge mistake,” he continues. “We got where we are through multiple, smaller routes. Weight gains happen in small incremental amounts. And we’re not going to change it by going back to 1950. This is a problem for a modern technological society. We can’t hit people over the heads to do things the way we used to.”

Indeed, when one looks at statistical trends relevant to weight management—everything from time spent in front of computers to fast-food consumption to pedestrian amenities and urban sprawl—it almost seems that our lifestyle patterns were custom-engineered to make us fat.

On the calories-in side of the ledger, the U.S. Department of Agriculture says Americans are eating more calories per day than we did in 1970—about 170 more among men, and some 330 more among women. Much of that owes to the fact that, relatively speaking, food is cheaper than it’s ever been before. Zemel points to labor- and cost-saving technologies in agriculture and food processing, and also to the policies of former U.S. Agriculture Secretary Earl Butts, the Richard Nixon appointee who made food supplies—especially meat—more abundant in the United States.

But while food is relatively inexpensive across the board, the foods that are least expensive and most abundant are the ones that are probably the worst for us. “Sugar and fat are cheap,” observes Jay Kersting, who notes that budget considerations were one of the things that used to dictate his family’s eating habits.

“We could feed our family on processed food for $50 a week—just go to the grocery store, get some spaghetti, and ‘It’ll be good,’” says Kathy Kersting. “We used to eat a ton of pasta, because it was quick and cheap. And lots of McDonald’s—Supersized, of course, because you got more for your money that way.”

The abundance of fattening foods—in other parts of world besides the United States, too—has created some interesting statistical anomalies. Nowadays, obesity rates are higher among poorer Americans than among their wealthier counterparts (though upper-income Americans have seen sharp upward trends as well). Globally, some statisticians claim there are more overnourished people than undernourished—truly a historical first.

It doesn’t take a scientific study to see how and where many of these high-calorie foods are being sold; visit the Burger King on Chapman Highway, for instance, and you will likely be confronted with multiple giant poster-sized advertisements on the windows for Triple-Whoppers, extra-large fries, and a “Meat-normous” breakfast sandwich. Across the street, an Arby’s roast beef house seems little better, with signs posted advertising a roast beef sandwich of some astounding proportion, laden with hyperbolic descriptors, and a picture of an over-loaded baked potato the size of a bean-bag chair.

Unquestionably, we are eating out, especially at fast food restaurants, more than ever before. In Moore’s report, he cites statistics that show dollars spent on fast food in the United States increased 18-fold between 1970 and 2000. A recent Children’s Hospital Boston study says that kids now are eating five times as much fast food as youngsters in 1970.

“The family that ate out once a month is an anachronism,” says Zemel. “It didn’t matter so much that you ate take-out hamburgers when you only did it once a month. But when you do it five times a week, it matters.”

Compounding the problem is the fact that portion sizes at high-calorie havens like McDonald’s, Burger King, et al., have reached gluttonous extremes. A report on “The Heavy Cost of Fat” in the August, 2004 issue of National Geographic notes that supersized servings of french fries and soda are often two to five times larger today than when they were first introduced.

The magazine also includes a graphic illustrating, among other things, the standard 2.8-oz. Burger King hamburger from 1954 (202 calories) versus its 4.3-oz version today (310 calories), and the meager 2.4-oz. McDonald’s serving of french fries of 1955 held up against its 7-oz. counterpart (610 calories) from 2004. Those, of course, are just so-called regular servings; one could well imagine the chaos that would ensue from a time traveler toting a Triple Whopper (1,200-some-odd calories) back to 1954.

But there’s yet another factor on the calories-in side of the ledger—another reason why we spend so much time barking our dinner requests into an intercom system mounted on a pair of golden arches. Moore cites the National Bureau of Economic Research in positing that real income levels have stagnated or declined for many Americans over the last 30 years, especially among those of lower socioeconomic status. Families responded by working more hours—increasing substantially the number of two-income households—in order to maintain their standard of living.

“The increase in time devoted to employment reduced the time available for meal planning and preparation,” Moore concludes in his report. “The rising premium on free time, in turn, made convenience food more attractive.”

Says Kathy Kersting, “When you consider the fast pace of most families, chicken wings and french fries start to look pretty good.”

But while our caloric intake has increased since, say, 1950, Zemel notes it has actually decreased since 1900—a fact that hearkens to the calories-out side of the ledger. As Moore puts it, “If you’re spending all your time in front of the television or a computer screen, but eating the breakfast of someone who worked on a farm in the 1870s, you’re going to have an imbalance in calories.”

In an episode of The Jetsons , the old Hanna Barbera cartoon about a family of four living in the distant future, when miniature flying saucers have supplanted cars as the standard mode of transport, there’s a scene where George Jetson is stuck working with a cleanup crew instead of his usual corporate desk job.

All the crewmen are required to do is press buttons, then sit back and relax while a team of goofily anthropomorphic robots armed with brooms and tools emerge from their robo-hovels and perform all of the actual work. Nonetheless, George and his friends can’t stop bellyaching about how difficult their jobs are, even as they lay against the wall, watching the automatons scurry about, their heads resting on folded hands.

The scene is funny, but it’s also prescient. How often nowadays do we grumble and fume because our PCs take an extra minute to download several pages of information—material we might have spent hours searching out in a library only 15 years ago? Or else curse the name of our service providers when our cell phones lose reception for a few minutes on a rugged and sparsely populated stretch of highway?

Pulling the cell phone off his belt while seated in his office in UT’s Jesse Harris Building, Zemel explains how he calculated that by switching to a cell phone from a pager—thus no longer having to seek out a land line whenever it beeped—he would have gained 3.5 pounds per year without a concomitant change in exercise or eating habits.

“Or consider going to the fast-food drive-through,” Zemel says. “You touch a button to roll down the window, because physically rolling it down or even holding down a button is too difficult; you mutter something into the clown’s mouth; and then you roll up to a window where they hand you, on average, a bag full of 500-800 calories per person. And you expended one calorie, maybe two, in the entire process.”

A Maryville-based bariatric surgeon who performs gastric bypasses on extremely obese patients (BMI over 35), Dr. Mark Colquitt puts it more succinctly when he observes that, “Because of technology, we now inevitably have a choice as to whether or not we want to exert ourselves.”

It seems almost paradoxical that while our technology has improved—thus affording us fewer opportunities to expend calories—our grasp of things like planning and urban design has failed to keep pace, the result being that our potential calorie expenditures are diminished yet again. By and large, our cities are less walkable, less bicycle-friendly, and afflicted with more sprawl than those of any other western nation. Moore’s report takes note of this, pointing out that “the lack of sidewalks and recreational greenspace (in U.S. cities) has contributed to the rise in physical inactivity,”

A 1995 article in the American Journal of Public Health rated the United States dead last among a group that included Canada and nine western European countries in a survey of walking and bicycling trips made in urban areas. According to the survey, American city dwellers walk or bicycle (as opposed to driving or using mass transit) only about seven percent of the time. By comparison, urban residents of the Netherlands were prone to walk or ride some 47 percent of the time, putting them only a little ahead of city dwellers in Denmark, Sweden and Austria.

(A former Michigander, Zemel tells of his first coming to Tennessee in 1990, and his attempts to bicycle to the UT campus from his home in Cedar Bluff: “That was suicidal,” he says. “Traffic doesn’t pay attention to people not in cars, and we haven’t created any functional alternatives.”)

Of course, one solution to our calories-out dilemma is to increase our levels of regimented, or so-called non-utilitarian exercise—activities like jogging or swimming or working out at a gym. But as most anyone who has ever awakened on Jan. 1 with a brand new health club membership and a New Year’s resolution will attest, that’s easier said than done. Studies show that the same time constraints that tend to encourage our fast-food fixations tend to discourage us from spending more jogging through the park or lifting weights. “We tend to make grand gestures, then we are unable to sustain them,” says Zemel. “Life gets in the way.”

So why are all of these calorie input/output issues more pronounced in Tennessee than in 45 other states? There are many reasons, it would seem, most of them related to regional or cultural factors. “It’s really the region, not the state,” says Zemel, noting that seven of the 10 states rated highest in obesity rates were in the southeastern portion of the United States he refers to as “the stroke belt.”

Statistics bear out that sprawl, inactivity, and the socioeconomic factors that correlate with obesity are all prevalent here, not to mention the batter-dipped phenomenon of traditional southern cooking. “Like most kids growing up in the South,” says Arkansas Gov. Mike Huckabee in 2005’s Quit Digging Your Grave with a Knife and Fork , “I was raised to believe that the preferred way of cooking anything is to first roll it in cornmeal or flour and then fry the ever-loving nutrition out of it in a pan of gurgling hot grease.”

Zemel believes the regional distinctions are mostly counterproductive, however. “The whole country is fat,” he says. “To scratch our heads wondering why we’re a little more fat than Montana is beside the point.”

But resolving the health crisis presented by obesity is even more difficult than understanding the complicated stew of cultural, technological and economic factors that created it. Weight management is a very personal issue, yet the consequences of widespread obesity affect all of us in one way or another.

Many feel a good start would be to make obesity the focal point of a campaign similar to those waged against drunk driving and cigarettes. “We need to have the same type of societal attention on this issue that we gave to smoking 20 years ago,” says Emory University Professor Kenneth Thorpe in a recent study published in Health Affairs .

Moore concurs; the backbone of his recommendations to state legislators is a call for a strategic plan at the state level for dealing with obesity.

“We don’t have clear, specific goals for how we can reduce obesity,” he says, noting that the lack of such a plan may have prevented Tennessee from getting CDC grant monies for weight management programs in 2004. “We need a cohesive vision.”

It certainly seems that, for the moment, we’re more prone to talking about the problem than taking any substantive action. Moore points to at least 10 pieces of obesity-related legislation introduced in the state Legislature between 2002 and 2005 as evidence that we’re making headway. Yet the most substantive of those bills—all of which are laid out on page six of Moore’s “Weighing the Costs” report—were defeated or at least delayed, including measures to prohibit the sale of vending machine goodies in Tennessee high schools, and to require health insurers to offer bariatric surgery coverage to certain patients.

But there was some progress made, including a the passage of a bill that will at least require the sale of healthy vending machine snacks and a la carte items in elementary and middle school cafeterias. The new rules take effect when public schools reconvene in August.

Nan Allison, a part-time lobbyist for the Tennessee Dieticians Association (as well as a dietician herself), says high school administrators jealously guard the revenues produced by vending machines in high schools. But establishing guidelines at the lower grade levels is a start.

“We’ll target lower grades first because they’re forming food habits,” she says. “We can create new expectations about what’s in vending machines. Then maybe in a couple of years we can take another look at high schools.”

But even with awareness campaigns, prudent legislation, and better urban planning, the fact remains that, ultimately, no one can force us to make healthier food choices, or get the exercise we need. No one understands that better than Zemel, who has structured the Tennessee on the Move program on a foundation of gentle persuasion rather than coercion and regimentation. His method begins with two very attainable goals—subtracting 100 calories from one’s daily caloric intake, while increasing (with the help of a small, inexpensive pedometer) one’s average daily number of steps by 2,000. Tennessee on the Move literature offers dozens of suggestions for reaching both of those goals, from pouring skim instead of whole milk on your morning cereal to setting aside 10 minutes out of your lunch break for an afternoon walk.

“We want people to reframe the way they think, to learn that small, sustainable changes can produce big results,” Zemel says. “Our premise is setting a low bar for people to step over.”

The wisdom of Zemel’s system lies in the fact that small changes can produce significant results over time, and that success breeds more success. Though Kathy Kersting didn’t subscribe to Tennessee on the Move, she learned the same lessons while following her commercial diet plan.

She says the first 70 pounds of her weight loss came despite the absence of a significant exercise regimen, merely by adhering to the program’s menu of food suggestions and apportionments. The program even allows for fast food and sweets, she notes, albeit in moderate portion sizes.

Her husband remembers the day the program clicked—really clicked—during a vacation cruise to the Bahamas, when Kathy came out of her shell transformed as the fit, active woman who now sits beside him, eschewing bagels and latte, in the middle of an aromatically tempting Panera bakery. “Suddenly, we’re on this cruise, and she gets me up every day at 6 a.m. to go work out,” Jay laughs. Kathy’s resolve was that of a woman who knew she would never be afraid to step on a bathroom scale again.