Good Health And Wellness For Life

Schools Found Improving on Nutrition and Fitness

ATLANTA, Oct. 19 — Spurred by the growing crisis in child obesity, the nation’s schools have made “considerable improvements” in nutrition, fitness and health over the last six years, according to a new government survey that found that more schools require physical education and fewer sell French fries.

The survey, which is conducted every six years, shows that more schools than six years ago offer salads and vegetables and that fewer permit bake sales. More states and school districts insist that elementary schools schedule recess and that physical education teachers have at least undergraduate training. More states have enacted policies to prohibit smoking at school and to require courses on pregnancy prevention.

Perhaps most striking, 30 percent of school districts have banned junk food from school vending machines, up from 4 percent in 2000. Schools offering fried potatoes in their cafeterias declined, to 19 percent from 40 percent.

The results of the survey by the Centers for Disease Control and Prevention elicited cheers on Friday from public health and education officials, as well as warnings against complacency.

In some instances, the officials pointed out, progress toward healthier living and learning was notable only because so many schools had started from such low points.

The percentage of districts that require elementary schools to teach physical education increased, to 93 percent last year from 83 percent in 2000.

But just 4 percent of elementary schools, 8 percent of middle schools and 2 percent of high schools provided physical education each school day, as is recommended by the disease control agency. One-fifth of schools did not require physical education at all.

Although the researchers found that the proportion of schools selling bottled water grew, to 46 percent from 30 percent, they also said three-fourths of high schools sold soft drinks and that 61 percent sold potato chips and other high-fat snacks.

“What we’re seeing is that the nation’s schools really are making progress in addressing the obesity crisis and teenage tobacco use,” said Howell Wechsler, the director of the division of adolescent and school health at the disease agency and an author of the study. “But large numbers of schools are still not implementing recommended policies. We need all the nation’s schools to have environments that make it easy for children to make healthy choices.”

In some instances, Mr. Wechsler said, states set policies that districts and schools do not immediately embrace, particularly when mandating physical activity.

“It takes a while for the policies to go down,” he said. “Local school districts just haven’t been able to figure out how to make time for physical education in the school day.”

The overall picture, however, suggests a nationwide response by school administrators and elected officials to concerns about children’s weight and inactivity.

A recent national survey determined that 17 percent of children from 2 to 19 could be classified as overweight. The prevalence of overweight children for all age groups is nearly double that of a decade ago.

In 2004, Congress passed a law requiring each school district to develop a “wellness policy” to promote the students’ health by setting goals for nutrition education and physical activity. Those policies are just now taking effect, and some school administrators predict that the next survey will show more marked improvements. Some schools have set out to place health education on a par with academics. In Los Angeles County, Sepulveda Middle School has banned soft drinks and eliminated unhealthy snacks from the school store. Salad, fruit and yogurt are always available in the cafeteria, said Patricia J. Pelletier, the principal.

Nearly an hour of physical education is required daily, the school offers after-hours training in distance running, and it has started a class on healthy cooking for parents.

“If kids are healthy and have healthy lifestyles, they’re going to be better students,” Ms. Pelletier said. “They’re going to be in school, and they’re going to be connected with the teachers in a better way.”

Dr. David K. Appel, director of the Montefiore School Health Program, which provides health services to 15 schools in the Bronx, said the improvements noted in the study “show that we are now in the early stages of a comprehensive societal response to what could be the greatest health challenge the U.S. has ever faced, which is pervasive childhood obesity.”

Dr. Appel said much more needed to be done, particularly in educating families and gaining the support of marketers of fast food and soft drinks.

The survey found that nearly two-thirds of schools prohibited tobacco use in all locations, including at off-campus functions, up from 46 percent in 2000. Another finding was that the proportion of states that require middle schools to teach human sexuality grew, to 59 percent from 46 percent.

The report found a variety of indications of healthier cooking in school cafeterias. Fifty-five percent reported that they had removed the skin from poultry before cooking, up from 40 percent, and 46 percent now use low-fat cheeses, up from 31 percent. But 12 percent of elementary schools, 19 percent of middle schools and 24 percent of high schools offer students brand-name fast food from businesses like Pizza Hut and Taco Bell.

Idea Lab: Criminal Element

Has the Clean Air Act done more to fight crime than any other policy in American history? That is the claim of a new environmental theory of criminal behavior.

In the early 1990s, a surge in the number of teenagers threatened a crime wave of unprecedented proportions. But to the surprise of some experts, crime fell steadily instead. Many explanations have been offered in hindsight, including economic growth, the expansion of police forces, the rise of prison populations and the end of the crack epidemic. But no one knows exactly why crime declined so steeply.

The answer, according to Jessica Wolpaw Reyes, an economist at Amherst College, lies in the cleanup of a toxic chemical that affected nearly everyone in the United States for most of the last century. After moving out of an old townhouse in Boston when her first child was born in 2000, Reyes started looking into the effects of lead poisoning. She learned that even low levels of lead can cause brain damage that makes children less intelligent and, in some cases, more impulsive and aggressive. She also discovered that the main source of lead in the air and water had not been paint but rather leaded gasoline — until it was phased out in the 1970s and ’80s by the Clean Air Act, which took blood levels of lead for all Americans down to a fraction of what they had been. “Putting the two together,” she says, “it seemed that this big change in people’s exposure to lead might have led to some big changes in behavior.”

Reyes found that the rise and fall of lead-exposure rates seemed to match the arc of violent crime, but with a 20-year lag — just long enough for children exposed to the highest levels of lead in 1973 to reach their most violence-prone years in the early ’90s, when crime rates hit their peak.

Such a correlation does not prove that lead had any effect on crime levels. But in an article published this month in the B.E. Journal of Economic Analysis and Policy, Reyes uses small variations in the lead content of gasoline from state to state to strengthen her argument. If other possible sources of crime like beer consumption and unemployment had remained constant, she estimates, the switch to unleaded gas alone would have caused the rate of violent crime to fall by more than half over the 1990s.

If lead poisoning is a factor in the development of criminal behavior, then countries that didn’t switch to unleaded fuel until the 1980s, like Britain and Australia, should soon see a dip in crime as the last lead-damaged children outgrow their most violent years. According to a comparison of nine countries published this year by Rick Nevin in the journal Environmental Research, crime rates around the world are just starting to respond to the removal of lead from gasoline and paint. “It really does sound like a bad science-fiction plot,” says Nevin, a senior adviser to the National Center for Healthy Housing. “The idea that a society could have systematically poisoned its youngest children with the same neurotoxins in two different ways over the same century is almost impossible to believe.”

The magnitude of these claims has been met with a fair amount of skepticism. Jeffrey Miron, a Harvard economist, wonders how lead could have had such a strong effect on violent crime while, according to Reyes, it showed almost no effect on property crimes like theft. He also doubts that the hypothesis could explain the plunge in the U.S. murder rate from the 1930s through the 1950s. “I certainly think it’s a reasonable exercise,” Miron says. “We just have to be appropriately suspicious of how much you can actually show.”

The theory will be put to the test as children grow up in Indonesia, Venezuela and sub-Saharan Africa, where leaded gasoline has just recently been phased out. Meanwhile, the list of countries that still use lead in gas — Afghanistan, Serbia and Iraq, as well as much of North Africa and Central Asia — does not rule out a connection with violence.

No matter how suggestive the economists’ data, it takes a doctor to show that some of the people most damaged by lead are out there breaking the law. Herbert Needleman, the University of Pittsburgh psychiatrist and pediatrician whose work helped persuade the government to ban lead in the 1970s, recently studied a sample of juvenile delinquents in Pittsburgh; the group had significantly more lead in their bones than their peers. And lead may not be the only source of damage. The National Children’s Study will soon begin to track more than 100,000 children to determine the effects of exposure to common pesticides, among other chemicals.

Jascha Hoffman is on the staff of The New York Review of Books.

Big Losers, but Can Viewers Keep the Pace?

AS if all the thin people on television weren’t bad enough, now dieters must contend with the jealously inspired by contestants on “The Biggest Loser,” the hit NBC reality series. The 18 obese Americans lucky enough to have been picked are sequestered on the show’s campus, work out with a trainer up to five hours a day, vote people off their teams and participate in challenges like who can run faster than a kindergartner.

Such stunts may be embarrassing, but the 24-7 focus on weight loss leads to major reductions, which are tallied when contestants step on an enormous scale. And that’s when the show may inspire a bout of self-loathing for viewers trying to lose weight at home: Jerry Lisenby, 62, from Peoria, Ill., dropped 31 pounds in his first week on “The Biggest Loser.” Erik Chopin, 37, from West Islip, N.Y., was the winner last season, losing 213 pounds, dropping to 194 from 407 in eight months.

“I find myself in the beginning of every season raring to go,” said Renee Peters, 35, a serial dieter and computer programmer in Atlanta, who is the host of the online weight-loss forum the Fatfighters. “But then they’ve lost 70 pounds and I’ve only lost 5 in the same time frame, and I find myself eating ice cream.”

The show, in its fourth season, has attracted seven million viewers this fall. “The Biggest Loser” has also built a multimillion-dollar franchise selling goods and services to viewers hoping to lose weight. The show’s first two books were best sellers, as were two workout DVDs.

Ms. Peters is not alone in finding the show’s weight-loss formula undermining, or worse. Some former contestants have cautioned home dieters to stop comparing themselves to what they see. Kai Hibbard, 29, from Eagle River, Alaska, lost 118 pounds last season. She recently wrote on a blog that in the two weeks before the finale she severely dehydrated herself using asparagus (a diuretic), colonics and six-hour stretches of hopping in and out of a sauna. She lost 19 pounds, which as she joked, rebounded to her rear end “almost immediately.”

Rob Cooper, 39, from Edmonton, Alberta, who dropped to 187 pounds from 475 pounds on his own, said that the show can be counterproductive. According to his logic, if you’re losing two pounds a week and you’re watching “The Biggest Loser,” you probably think your diet is going horribly. If you lose two pounds a week and you’re not watching the show, you probably think your diet is going great.

Mr. Cooper, who is now a motivational coach, lost his weight over three years, first by introducing whole foods to his diet, then adding exercise. In his view, drastic weight loss depends on a deep motivation to take care of oneself, plus a sense of accomplishment as the pounds slip off.

The television show “can actually depress a lot of people,” Mr. Cooper said, especially when their steady weight loss cannot compare to the double-digit zingers on the screen. “That’s the opposite of what you want,” he said.

In that case, Ms. Hibbard’s recent advice to fans should delight dieters. “You should only be losing half a pound to a pound a week,” she wrote on MySpace. “If so, you are doing an amazing job.”

Most medical professionals say dieters should lose weight slowly. Not only are they more likely to keep it off that way, but shedding more than 10 pounds weekly, as some contestants routinely do, is dangerous.

“Whether it’s gallbladder disease, hair falling out, skin getting dry,” said Karen Kovach, the chief scientific officer at Weight Watchers, “the more rapid the weight loss, the greater the risk.” She added: “You get above a kilogram a week, the risk really shoots up.”

“The Biggest Loser” takes precautions to be safe: The show promotes weight loss through exercise and healthy eating, and employs four doctors, including a psychiatrist.

But a responsible viewer who wanted to engage in a weight-loss blitz under medical supervision would be hard pressed to find a doctor willing to sign on. “What would I advise someone who wants to engage in a program associated with increased risks of gallstones, cardiac arrhythmias and electrolyte abnormalities, and that has been shown to be less likely to lead to long-term success in maintenance of a reduced body weight than losing weight more slowly?” asks Dr. Michael Rosenbaum, a doctor at Columbia University who has spent over 20 years studying the physiology of weight loss. “I would advise them not to do it.”

Adding to the frustration for viewers, much of the radical weight loss seen on “The Biggest Loser” is a natural consequence of the contestants’ conditions; many start out morbidly obese. The sheer size of their bodies increases the number of calories required each day, so restricting their calorie intake has a more pronounced effect.

“The bigger you are, the greater your energy expenditure,” said Dr. Stephen O’Rahilly, an obesity researcher at the University of Cambridge.

A pound of fat is roughly equal to 3,500 calories, Dr. O’Rahilly said. So if obese people have an energy requirement of 4,000 calories a day, and they go on a 1,000-calorie-a-day diet, they “will have to burn over a pound a day to make up for that energy gap.”

Not so for the modestly overweight. If they require 2,500 calories a day, and they eat a mere 1,000 calories, you’ll “only lose a pound every two or three days,” he said.

Finally, and perhaps most unfortunately for viewers tuning in to the show for inspiration as they pursue their own diets, the most significant factor in the contestants’ big weight losses is probably the fact of participating on a reality show. The losers are all living in what one of the show’s producers, J. D. Roth, calls “a biodome” — a hothouse of emotional and physical intensity with no children to pick up at school, or bosses to please, or houses to clean. The only obligation, besides getting to hair and makeup, is losing weight.

What’s more, contestants on “The Biggest Loser” who work to shed pounds at home after being voted off the show, have an advantage over the viewer. Former contestants receive regular checkups from the show’s doctors and trainers and are also kept in check when strangers buttonhole them about their weight. Plus, stepping on that scale for “the live finale in front of millions keeps motivation strong,” Mr. Roth said.

For those still living on the show’s campus, female team members eat 1,100 to 1,500 calories a day, and male contestants eat 1,500 to 2,300 calories a day, with meals like salmon and wild rice. And everybody spends an hour or two on weight or resistance training, an hour on a high-intensity cardiovascular exercise, and up to three hours walking on the treadmill, using the elliptical trainer or riding a stationary bike. The low-intensity cardio exercise is left out when each diet week is edited to fit a 90-minute segment.

“Most of what goes on while a person is losing weight is incredibly boring,” Mr. Roth said. “It’s like watching paint dry.”

Yet contestants and trainers say it’s those dull hours of low-intensity activity that make the difference. For this season, 250,000 obese Americans sent audition tapes; only 18 made the show. “You watch it because you want to know the secret,” said Ms. Peters, who writes a blog about her attempt to drop 70 pounds. “But the reality is, you can’t. So why bother? Everybody in the real world seems to have the same consensus: nobody has that much time to dedicate to losing weight.”

Paula Schwartz contributed reporting.

Skin Deep: Why Should Kids Have All the Acne?

AT meetings of 12-step recovery programs, people offer gripping testimonials about their struggles, and rarely fail to mention how long they’ve been clean. In commercials for Proactiv Solution, the popular acne treatment, celebrities and average joes on the three-step skin-care program tell their tales of woe and often gush about how long their skin has been clear.

The Proactiv sob sell has galvanized even people who rarely have blemishes to become, well, proactive about their skin.

Rebecca Powell, a graduate student in microbiology at New York University, ordered Proactiv three years ago after seeing an infomercial, although she only occasionally gets a pimple.

Ms. Powell said the products dried out her skin, and she stopped using them. But earlier this month, Ms. Powell, 24, purchased a Proactiv sulfur face mask designed to reduce inflamed pimples. “You see the infomercials and you become more aware of body image stuff and it makes you care more, so you buy it,” she said.

Founded in 1995 by two dermatologists, Proactiv has become a phenomenon by transforming the way consumers think about pimples. The brand captured public attention by hiring stars for its infomercials like Vanessa Williams, Jessica Simpson and Sean Combs to lay bare their valiant struggles to attain flawless skin, effectively turning acne into a celebrity malady. But the company’s real innovation was repositioning mild breakouts from a routine annoyance that a dab of Clearasil might fix to a preventable condition, like cavities, requiring vigilant daily upkeep.

“Ten years ago, we covered it up, but their message is ‘you don’t have to have bad skin,’” said Karen Young, the chief executive of the Young Group, a consulting firm to beauty companies. “They have shifted the consumer psyche.”

Proactiv has become a blockbuster by motivating consumers to trade up from a $4.99 drugstore product like Clearasil, made with the antibacterial agent benzoyl peroxide, to a 60-day, three-part regimen, also made with benzoyl peroxide, that costs $39.95 for ongoing subscribers.

The brand now has more than five million active customers and annual worldwide sales of about $850 million, 70 percent of which are in the United States. By contrast, sales of acne products in American drugstores were about $155 million for the year that ended July 15, according to Information Resources Inc., a market research firm.

“Right now, we own acne,” said Greg Renker, a chief executive of Guthy-Renker, the direct-response television company that sells Proactiv. The company spends about $125 million a year buying time for its infomercials on channels like VH1 and MTV as well as Web sites like Facebook, he said. “We are the fastest-growing acne brand in the world.”

The Proactiv story may be just as much about the promotion of acne as a serious disease as it is about the marketing of products to fight it.

“You can get the same amount of benzoyl peroxide at a drug store at a fraction of the cost and it will work as well, provided that you use it,” said Dr. Hilary E. Baldwin, the vice chairwoman of the dermatology department at the State University of New York Downstate Medical Center in Brooklyn. Patients with serious acne who tried Proactiv, in her experience, were unhappy with the results and sought prescription treatments, she said.

People typically get acne after hormones cause oil to build up in the hair follicles, trapping bacteria and triggering superficial pimples as well as deep, painful lumps. The most severe forms of acne can be disfiguring and emotionally devastating and are often treated with prescription drugs. But until recently, adults with less serious facial blemishes did not necessarily view themselves as having acne, which they considered a teenage problem.

The founders of Proactiv, Dr. Katie P. Rodan and Dr. Kathy A. Fields, dermatologists in the Bay Area of California, developed the brand for this adult market, especially for women who get flare-ups every month before their periods. And in the process they rebranded the word “acne,” making it acceptable to grown-ups.

“Women did not identify with acne; they were using euphemisms like ‘stress bumps’ or ‘monthly breakouts’ to describe their problems because they thought acne was an ugly four-letter word or they thought acne was just for teenagers,” Dr. Rodan said. She and Dr. Fields receive royalties on Proactiv sales. “What the infomercial did was give us half an hour to explain that those breakouts you are suffering on a monthly basis are really acne and it is not a curable problem, but it is treatable and manageable,” Dr. Rodan said.

There are no definitive statistics on the prevalence of acne. Nearly 17 million Americans have acne, according to the Web site of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, www.niams.gov, a division of the National Institutes of Health. Meanwhile, the American Academy of Dermatology, which received several million dollars last year from pharmaceutical companies, said 40 million to 50 million Americans have acne; a spokeswoman said that figure is based on a paper, published in the academy’s medical journal, that applied estimates of acne incidence to census data.

But pimples are such a lucrative business that the skin industry is starting to promote acne as if it were a menace on par with heart disease.

Earlier this month, the American Acne and Rosacea Society held a news conference in Manhattan at which one dermatologist described acne as being “at nearly epidemic levels” and another doctor said the group’s purpose was “to defend acne’s status as a legitimate disease”; last year, the society received $285,000 from companies that make acne drugs. Meanwhile, the International Dermal Institute, which trains aestheticians and has just introduced its own acne product line, put out a news release titled “Adult Acne — A Growing Epidemic.”

“We don’t know whether acne is a real epidemic or whether more patients are being driven into dermatologists’ offices thanks to infomercials,” said Dr. Baldwin, who is the president of the American Acne and Rosacea Society; she said she is a paid speaker for nine companies that make acne drugs.

Spotless skin has always had aesthetic value. The zoologist Desmond Morris wrote in his book “Naked Woman” that a smooth, unblemished cheek suggests that a woman is youthful and healthy. Harvard psychologist Nancy Etcoff goes further in her book, “Survival of the Prettiest,” in which she argues that the stigma of pimples has its roots in evolutionary biology. Because acne can be caused by increased androgen levels, potential mates may unconsciously view a woman with blotchy skin as less fertile than someone with clear skin, she wrote.

The basic Proactiv kit includes an antibacterial cleanser with 2.5 percent benzoyl peroxide, a toner with witch hazel to reduce oil, and a treatment lotion with 2.5 percent benzoyl peroxide.

“When you work on prevention, you don’t have to worry anymore that you will wake up and your day will be ruined because you look in the mirror and you have a 50-pound honker on your nose,” Dr. Rodan said.

The doctors took their product formulas to Guthy-Renker, which had already found success marketing self-help guru Tony Robbins. The company developed half-hour Proactiv infomercials using ordinary people to recount their transformations from reticent loners with spotty skin into pimple-free social butterflies. The brand keeps customers coming back with an automatic replenishment system that sends products to people, and charges their credit cards every 60 days.

“Proactiv is automatically replenished, it comes to your own door and it works,” said Karen Grant, the senior beauty analyst at NPD Beauty, a market research firm. “What more could you want?”

Indeed, some people with moderate acne who follow the regimen said that it has worked.

“There used to be some new pimple flaring up on my face every day,” said Tammy Lewis, 28, a nurse in Queens, who has been using Proactiv daily for four years. “Now I only get a few minor red spots and it is manageable.”

But Proactiv may not be for everyone.

“One piddling little zit is not going to hurt you, it is not contagious and you might not need to do anything to treat it,” said Dr. Jodi E. Ganz, a dermatologist in Atlanta. “At the same time, you do worry about people with severe acne who might waste a year and hundreds of dollars trying something that is not going to work for them.”

She credited Proactiv’s popularity to a larger phenomenon: society’s increasingly intense pursuit of physical perfection.

“I don’t think people should be obsessed with one pimple,” Dr. Ganz said. “But now that everything from lasers to plastic surgery is so available, we as a society are becoming less tolerant. Any little imperfection, whether it is a blemish or an age spot, has turned into a big deal.”

Op-Ed Contributor: A Test of Bad Health

IF Congress overrides President Bush’s veto of the State Children’s Health Insurance Program, a little-known provision of the original House bill could be revived.

As written, the provision would allocate $300 million to create a Center for Comparative Effectiveness that would test whether newer, more expensive drugs work better than their older and cheaper counterparts. Medicare would use the center’s findings to help decide which drugs to cover. If the center found that a newer, pricier pill was no more effective than the older, cheaper version, Medicare would probably refuse to pay for it.

This sounds reasonable. But it will most likely result in Medicare covering fewer breakthrough medicines, which would, in turn, force doctors to prescribe only the drugs that Medicare will pay for — not the ones that are best for the patient.

Why? Drugs must be tested on large, representative populations that must be monitored for years. Because conducting these studies is so tricky, their findings are regularly overturned or modified by further research. In fact, some are so off the mark that doctors ignore them.

But if Medicare starts using flawed studies like these to determine its list of covered drugs, doctors will have to give them respect they probably don’t deserve. There’s also an inherent conflict of interest when the government conducts comparative-effectiveness studies and then uses those studies to determine which pills are worth buying. The more drugs the government classifies as “wasteful,” the more money it saves.

Look what happened in Britain. In 2001, contrary to expert findings by licensing authorities around the world, the British comparative-effectiveness agency cited “insufficient evidence” for recommending the use of Gleevec in both early- and late-phase chronic leukemia patients.

In 2002, the United States approved Gleevec for another purpose: to treat a rare stomach cancer. It wasn’t until 21 months later that Britain approved the use of Gleevec for victims of the disease.

What aside from cost concerns could explain such restrictions? And what could stop something like this from happening here? The center’s supporters say it will be financed through an independent “trust fund.” But this won’t solve the problem. The center would still be part of the government — and still get in the way of medical innovation.

Peter Pitts is president of the Center for Medicine in the Public Interest, a nonprofit organization that receives financing from the pharmaceutical industry.