Fat Chance

There’s nothing socially or medically wrong with being fit and fat; you’re doing better than the people out there who are thin and sedentary. But there is something medically wrong with being fat and sick. Especially if you’re suffering metabolically, which 80 percent of obese people are. If you fall into this category, you are costing society money in caring for your metabolic illnesses, reducing productivity, and clogging up (and bringing down) the health care system. Not to mention digging yourself an early grave! The vocal proponents for the political and social rights of the obese, primarily the National Association to Advance Fat Acceptance (NAAFA), say, “Being fat is a badge of honor. Be fit and fat, be fat and proud.” No victimization here. And I agree. But NAAFA is also opposed to academic obesity research where its primary goal is weight loss – because why would you investigate a condition that is totally normal? They don’t think attention should be paid to how much kids weigh. This is puzzling to me. There is something highly paradoxical about enabling your child to be fat and sick. The majority of obese kids will be diabetic and cardiac cripples by the time they’re fifty. The science and research that NAAFA’s policy would seem to exclude are critical to studying this epidemic and determining what we can do about it. It’s my job as a pediatrician to protect these kids from such misguided thinking.

Seat 6: The Commercial Food Industry

The commercial food industry responds to the obesity pandemic with two mantras. First, “Everyone is responsible for what goes into his or her mouth.” Is that true? What goes into our mouths depends on two things: selectivity and access. Second, “Any food can be part of a balanced diet.” True but irrelevant because, thanks to the food industry, we don’t have a balanced diet, and they’re the ones that unbalanced it. They are a major instigator of the obesity pandemic through both their actions and the kind of rhetoric they use to justify those actions. Corporations repeatedly say one thing, yet do another. McDonald’s now advertises a healthier menu, with commercials featuring slim people in exercise clothes eating salads. However, the vast majority of people entering McDonald’s, even if they come in with the idea of eating a salad, instead order a Big Mac and fries. And McDonald’s is well aware of this. Its recent billboard campaign, “Crafted for Your Craving,” says all you need to know. Carl’s Jr.’s promotion of the “Western Bacon Six Dollar Burger,” which has a whopping 1,030 calories and 55 grams of fat, generally depicts fit and attractive people consuming the company’s fare with relish. Do you really think they would continue to be thin if they ate this on a regular basis?

Food has become a commodity (see chapter 21), with foodstuffs that can be stored being traded on the various commodities exchanges. Speculators can corner the market on anything, from pork bellies to orange juice, by betting how much the price will rise and fall. And it’s because individual foods are treated as commodities that the downstream effects of changes in the food supply, and subsequently food prices, are being felt worldwide (see chapter 21). Cheap food means political stability. There is an imperative to keep food highly available and the prices as low as possible. Everyone is for cheap food. The United States spends 7 percent of its gross domestic product (GDP) on food, which allows the populace to buy more DVDs and iPads and take more vacations. But cheaper food, loaded with preservatives for longer shelf life, costs you on the tail end, and way more than all your gadgets and vacations put together (with interest).

Seat 7: The Federal Government

Our government is extraordinarily conflicted about where it should stand on the obesity pandemic. In 2003, former U.S. surgeon general Richard Carmona stated that obesity was an issue of national security, a stance that current surgeon general Regina Benjamin has upheld (despite the fact that she herself is obese) and one to which the U.S. Army has signed on. The public health branches of the government tell us that we eat too much and exercise too little. Mrs. Obama’s Let’s Move! campaign centers on the idea that childhood obesity can be battled by planting school vegetable gardens, encouraging kids to get out and exercise, and remaking the School Nutrition Act. All necessary, but not sufficient.

The U.S. government does everything it can to keep food cheap (see chapter 16). The USDA has chosen not to accept any responsibility for its role in the obesity pandemic, continuing to market our Western diet around the world. The Farm Bill (see chapter 21) maintains food subsidies to keep farmers employed and growing more crops. The growers make their profits on volume. The food processors make big markups and pass them along to the consumer. And the USDA subsidizes food entitlement programs to the poor, such as the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) and the Women, Infants, and Children nutrition program (or WIC, which supplies low-income infants and their mothers with food and health care), to keep them alive and complacent. Until 2007, WIC bowed to the pressure of food lobbyists. The foodstuffs provided were largely unhealthy, and included white bread and high-sugar juices.

The “Food Pyramid,” the federal nutrition guide released in 1974 (see figure 2.2a) and revised every five years, cultimating with “MyPyramid” in 2005, was never based on science. Indeed it was top and bottom heavy – hardly a pyramid. In response to calls for revision from many in the medical community, the Food Pyramid was deep-sixed in 2011. “MyPyramid” has now morphed into “MyPlate” (see figure 2.2b). The most recent guidance from the Dietary Guidelines Advisory Committee (DGAC), released in 2010, says that obesity is a problem (shocker) so we should all eat less fat, sugar, and salt. We’re all supposed to eat more fruits and vegetables, and less of everything else. This is stating the obvious. Don’t we already know this? Eat less? How? If we could eat less, there wouldn’t be an obesity pandemic. But we can’t.

Fig. 2.2a. The Ancient Pyramids. The traditional USDA Food Pyramid, circa 2005, which advised us to eat more grains and less fat and sugar. Alongside it, what Americans actually ate – more like an hourglass than a pyramid.

Fig. 2.2b. The Modern Merry-Go-Round. Under pressure from consumer groups and in response to the emerging science, the Pyramid was relegated to ancient history, and MyPlate was adopted by the USDA in 2011. MyPlate advises us to eat approximately half a plate of vegetables or fruits, one quarter fiber-containing starch such as brown rice, and one quarter protein, preferably low-fat. It’s too early to tell if this change will have any effect on American eating habits.

Each of the stakeholders in the obesity pandemic is singing the same tune: “Your obesity is your personal responsibility, it’s your fault, and you’ve failed.” And all these accusations are a variation on a theme based on one unflappable dogma: a calorie is a calorie.

Calories Don’t Count If…

The clues are all around us as to what’s really happened. It’s time to look at where those extra calories went, because it is in these data that we will find the answer to the obesity dilemma.

There are three problems with “a calorie is a calorie.”

First, there is no way anyone could actually burn off the calories supplied by our current food supply. A chocolate chip cookie has the equivalent calories of twenty minutes of jogging, and working off a Big Mac would require four hours of biking. But, wait! Olympic swimmer Michael Phelps eats 12,000 calories a day and burns them off, right? If this were the case for all of us, diet and exercise should work – you’d burn more than you ate and lose weight (see chapter 13). And diet drugs should work – you take the drug, eat or absorb less, and lose the pounds. Except the meds don’t deliver on their promises. They work for a brief period, and then patients reach a plateau in weight loss (see chapter 4).[9 - R. Padwal et al., “Long-Term Pharmacotherapy for Obesity and Overweight,” Cochrane Database Syst. Rev., Art. No.: CD004094. DOI: 10.1002/14651858 (2004). PMID: 15266516.] Why? Do the patients stop taking the pills? No. So why do the medications stop working? The answer: because the body is smarter than the brain is. Energy expenditure is reduced to meet the decreased energy intake. So a calorie is not really a calorie, because your caloric output is controlled by your body and is dependent on the quantity and the quality of the calories ingested.

Second, if a calorie is a calorie, then all fats would be the same because they’d each release 9.0 calories per gram of energy when burned. But they’re not all the same. There are good fats (which have valuable properties, such as being anti-inflammatory) and bad fats (which can cause heart disease and fatty liver disease; see chapter 10). Likewise, all proteins and amino acids should be the same, since they release 4.1 calories per gram of energy when burned. Except that we have high-quality protein (such as egg protein), which may reduce appetite, and we have low-quality protein (hamburger meat), which is full of branched-chain amino acids (see chapter 9), which has been associated with insulin resistance and metabolic syndrome.[10 - C. B. Newgard et al., “A Branched-Chain Amino Acid-Related Metabolic Signature That Differentiates Obese and Lean Humans and Contributes to Insulin Resistance,” Cell Metab. 9 (2009): 311–26.] Finally, all carbohydrates should be the same, since they also release 4.1 calories per gram of energy when burned. But they’re not. A closer look at the specific breakdown of the carbohydrate data reveals something interesting. There are two classes of carbohydrate: starch and sugar. Starch is made up of glucose only, which is not very sweet and which every cell in the body can use for energy. Although there are several other “sugars” (glucose, galactose, maltose, and lactose), when I talk about sugar here (and in the rest of this book), I am talking about the “sweet” stuff, sucrose and high-fructose corn syrup, which both contain the molecule fructose. Fructose is very sweet and is inevitably metabolized to fat (see chapter 11). It is the primary (although not the sole) villain, the Darth Vader of the Empire, beckoning you to the dark side in this sordid tale.

The third problem with “a calorie is a calorie” is illustrated by the U.S. secretary of health and human services Tommy Thompson’s admonishment in 2004 that we’re “eating too damn much,” would suggest that we’re eating more of everything. But we’re not eating more of everything. We’re eating more of some things and less of others. And it is in those “some things” that we will find our answer to the obesity pandemic. The U.S. Department of Agriculture keeps track of nutrient disappearance. These data show that total consumption of protein and fat remained relatively constant as the obesity pandemic accelerated. Yet, due to the “low-fat” directives in the 1980s of the AMA, AHA, and USDA, the intake of fat declined as a percentage of total calories (from 40 percent to 30 percent). Protein intake remained relatively constant at 15 percent. But if total calories increased, yet the total consumption of fat was unchanged, that means something had to go up. Examination of the carbohydrate data provides the answer. As a percentage of total caloric intake, the intake of carbohydrates increased from 40 percent to 55 percent.[11 - P. Chanmugam et al., “Did Fat Intake in the United States Really Decline Between 1989–1991 and 1994–1996?” J. Am. Diet. Assoc. 103 (2003): 867–72.] While it’s true we are eating more of both classes of carbohydrate (starch and sugar), our total starch intake has risen from just 49 to 51 percent of calories. Yet our fructose intake has increased from 8 percent to 12 percent to, in some cases (especially among children), 15 percent of total calories. So it stands to reason that what we’re eating more of is sugar, specifically fructose. Our consumption of fructose has doubled in the past thirty years and has increased sixfold in the last century. The answer to our global dilemma lies in understanding the causes and effects of this change in our diet.

There’s one lesson to conclude from these three contradictions to the current dogma. A calorie is not a calorie. Rather, perhaps the dogma should be restated thus: a calorie burned is a calorie burned, but a calorie eaten is not a calorie eaten. And therein lies the key to understanding the obesity pandemic. The quality of what we eat determines the quantity. It also determines our desire to burn it. And personal responsibility? Just another urban myth to be busted by real science.

Chapter 3

Personal Responsibility versus the Obese Six-Month-Old

Sienna is a one-year-old girl who weighs 44 pounds. She was 10 pounds at birth and was delivered by caesarean section due to her size. Her mother is not obese, but her father is overweight. Her mother tested negative for diabetes during the pregnancy. Since birth, Sienna has had an incredible appetite. Her mother could not breastfeed her because she could not keep up with the baby’s demand for food. An average infant of Sienna’s age will eat one quart of formula per day. Sienna consumed two quarts per day. When Sienna was six months old, we told her mother to start feeding her solid foods. Sienna eats constantly and will scream if her mother does not feed her. She already has high cholesterol and high blood pressure.

Is Sienna obese because of her behavior? Was this learned behavior? When would she have learned this behavior, and from whom? Has she, at age one, learned to control her mother to get what she wants? Should she accept personal responsibility for her actions?

Based on “a calorie is a calorie,” behaviors come first. Personal responsibility implies a choice: that there is a conscious decision leading to a behavior. This behavior is formed because of learned benefits or detriments (e.g., a child placing her hand on a stove and learning it is hot). But does this make sense with regard to obesity? In everyone? In anyone? There are six reasons to doubt “personal responsibility” as the cause of obesity.

1. Obesity Is Not a Choice

The concept of personal responsibility for obesity doesn’t always make sense. In our society today, one has to ask: Are there people who see obesity as a personal advantage? Something to be desired or emulated? Across the board, modern Western societies today value the thin and shun the obese. Obesity frequently comes with many medical complications, and those afflicted are more likely to develop heart problems and type 2 diabetes (see chapter 9). Obese people spend twice as much on health care.[12 - D. Thompson et al., “Lifetime Health and Economic Consequences of Obesity,” Arch. Int. Med. 159 (1999): 2177–83.] Studies show that the obese have more difficulty in dating, marriage, and fertility. The obese tend to be poorer and, even in high-paying jobs, earn less than their peers.[13 - J. Bhattacharya et al., “Who Pays for Obesity?” J. Econ. Perspect. 25 (2011): 139–58.]

Now ask the same question about children. Did Sienna see obesity as a personal advantage? Did she become obese on purpose? Obese children have a quality of life similar to that of children on cancer chemotherapy.[14 - J. B. Schwimmer et al., “Health-Related Quality of Life of Severely Obese Children and Adolescents,” JAMA 289 (2003): 1813–19.] They are ostracized by their peers and are the targets of bullies. Many obese children suffer from low self-esteem, shame, self-hatred, and loneliness. One study showed children pictures of potential playmates. Each looked different and some had physical handicaps, such as being deformed or in a wheelchair. The researchers asked the children with whom they would rather play. The obese child came in dead last. Clearly, obesity is not something to which people, especially children, aspire.

However, this view of obesity does not necessarily square with the beliefs of obese people themselves. They see themselves as perpetrators, not victims. They often state that they know their behavior is out of control and that this behavior is their own fault. They frequently experience yo-yo dieting. They lose weight for a period of time, and when they gain it back they blame themselves, seeing the gain as a character failing. They often recount binge eating, which suggests that a degree of dietary control is lost. These experiences of losing control make them think they had the control in the first place. Did they?

2. Diet and Exercise Don’t Work

If obesity were only about increased energy intake and decreased energy expenditure, then reducing intake (diet) and increasing expenditure (exercise) would be effective. If obesity were caused by learned behaviors, then changing those behaviors would be effective in reversing the process and promoting weight loss. Specific and notable successes have led to behavior/lifestyle modification as the cornerstone of therapy for obesity.

There are the anecdotal cases of weight loss by celebrities, such as Kirstie Alley or Oprah Winfrey, who publicly endorse their diets as if they were the latest fashionable handbags. They share their stories on TV and convince their viewers that this lifestyle change is possible for them, too, and that, as with adding the newest fall color to their wardrobe, losing weight will make them attractive and happy. There are reality television shows, such as The Biggest Loser, that document the weight loss (along with many a meltdown) of “normal people” through controlled diet and exercise. Publicity, cash prizes, and constant attention are often enough to change one’s diet and exercise response for a short time. In any magazine and many infomercials, peddlers of new weight-loss remedies provide before and after pictures of people who have lost 100 pounds.

Whether this constitutes a true lasting change in behavior is doubtful. After all, Kirstie Alley and Oprah, celebrities who live in the public eye, have gained their weight back several times (until their newest miracle diet began, countless new diet books were sold, new gurus were anointed, millions of dollars were made, and the cycle repeated itself). There have been numerous reports of contestants on The Biggest Loser regaining much of their weight after the show ended. Most notably, Eric Chopin, the Season 3 winner, appeared on Oprah to tell his sorry tale of gaining at least half the weight back after his victory. He wrote in one blog post, “I’m still not back on track totally. I don’t know what it is.” Significant weight regain has been seen in up to one third of patients who have had surgery for weight loss (see chapter 19), because the reason for the obesity is still there. Unless it’s dealt with directly, regaining will be the norm, not the exception.

Strict control of one’s environment through limiting caloric intake and increasing physical activity can result in weight loss. This is true as long as the environment remains regulated. A perfect example is the army recruit who consistently loses weight due to monitored diet and vigorous exercise. This also accounts for the number of “fat schools” and “fat camps” that have sprung up nationwide. Parents send their overweight child away for the summer and are thrilled when he returns thinner, if harboring parental resentment. There are numerous reports of Hollywood stars who bulk up for a role (remember Robert DeNiro in Raging Bull?) and then lose the excess weight after shooting. (Of course, they have the benefit of round-the-clock personal trainers and nutritionists to monitor their food intake.) While such results are dramatic, they usually cannot be sustained. Environmental control is different from behavioral control (see chapters 17 and 18).

The real problem is not in losing the weight but in keeping it off for any meaningful length of time. Numerous sources show that almost every lifestyle intervention works for the first three to six months. But then the weight comes rolling back.[15 - T. A. Wadden et al., “Treatment of Obesity by Very Low Calorie Diet, Behavior Therapy, and Their Combination: A Five-Year Perspective,” Int. J. Obes. 13 (1989): 39–46; M. W. Schwartz et al., “Regulation of Body Adiposity and the Problem of Obesity,” Arterioscler. Thromb. Vasc. Biol. 17 (1997): 233–38.] The number of people who can maintain any meaningful degree of weight loss is extremely small (see figure 3.1). However, because behavior/lifestyle modification is the accepted treatment, the general explanation of weight regain is that it is the individual’s fault. Because he is “choosing” not to live a healthy lifestyle, the doctors and the insurance industry do not feel it their responsibility to intervene.

The same is true for children. Due to some notable and individual successes, behavior/lifestyle modification is the cornerstone of therapy. However, this is not a winning strategy for most obese children. Research shows that dietary interventions don’t often work. Exercise interventions are even less successful. And unfortunately for children like Sienna, at one year of age they are unable to run on a treadmill. Also, the effects of altering lifestyle for obesity prevention are underwhelming and show minimal effect on behavior and essentially no effect on BMI.

Fig. 3.1. The “Biggest Loser”—Not You. Percentage of obese individuals who were able to maintain their weight loss over nine years.

3. The Obesity Epidemic Is Now a Pandemic

If obesity were just an American phenomenon it would be an epidemic, an outbreak of illness specific to a certain area. One might then blame our American culture for promoting it. Due to our slippage in education and technological superiority, we’re labeled as “fat and lazy” or “gluttons and sloths.” Yet obesity is now a pandemic, a worldwide problem.

The United Kingdom, Australia, and Canada are right behind us. Also, in the past ten years, obese children have increased in France from 5 to 10 percent, in Japan from 6 to 12 percent, and in South Korea from 7 to 18 percent.[16 - S. Yoo et al., “Obesity in Korean Pre-Adolescent School Children: Comparison of Various Anthropometric Measurements Based on Bioelectrical Impedance Analysis,” Int. J. Obes. 30 (2006): 1086–90.] In fact, obesity and chronic metabolic diseases are occurring in underdeveloped countries that have never had such problems before.[17 - N. Gupta et al., “Childhood Obesity in Developing Countries: Epidemiology, Determinants, and Prevention,” Endocr. Rev. 33 (2012): 48–70.] Previously, poorer countries such as Malaysia had problems with malnutrition. Now Malaysia has the highest prevalence of type 2 diabetes on the planet. China has an epidemic of childhood obesity, at 8 percent in urban areas. Brazil’s rate of increase in obesity is predicted to reach that of the United States by 2020. Even India, which continues to have an enormous problem with malnutrition, is not immune – since 2004, the number of overweight children increased from 17 percent to 27 percent. Sienna is not a rarity; her obese peers are being born everywhere. The areas experiencing the greatest rise in obesity and type 2 diabetes include Asia (especially the Pacific Rim) and Africa, which are not wealthy areas.[18 - A. Ramachandran et al., “Diabetes in Asia,” Lancet 375 (2010): 408–18.] No corner of the globe is spared.

This is not an American problem, an Australian problem, a British problem, or a Japanese problem. This is a global problem. Could each of these countries be experiencing the same cultural shifts toward gluttony and sloth that we are? Childhood obesity knows no intellect, class, or continent.

What change in the last thirty years ties all the countries of the world together? As I mentioned in the introduction, the “American diet” has morphed into the “industrial global diet.” Despite people in other countries disapproving of our fast food and TV culture, our diet has invaded virtually every other country. Our fast food culture is now global due to taste, shelf life, cost, shipping ease, and the “cool” factor (a result of effective marketing). Its acceptance is also a response to the contaminated water supplies in these areas: soft drinks are often safer, cheaper, and more available than potable water.[19 - B. M. Popkin, “Global Nutrition Dynamics: The World Is Shifting Rapidly Toward a Diet Linked with Noncommunicable Diseases,” Am. J. Clin. Nutr. 84 (2006): 289–98.] They are also cheaper and certainly more available than milk.

4. Even Animals Raised in Captivity Are Getting Fat

A recent report documented that, in the past twenty years, animals raised in captivity exhibit increasing body weights. The study examined the records of 22,000 animals of 8 different species, from rats to orangutans.[20 - Y. C. Klimentidis et al., “Canaries in the Coal Mine: A Cross-Species Analysis of the Plurality of Obesity Epidemics,” Proc. Biol. Sci. 278 (2011): 1626–32.] These animals were housed in multiple human-built colonies around the world, including labs and zoos. They don’t eat our commercial food. However, their food is still processed and composed of the same general ingredients as our own. Also, these animals drink the same water and breathe the same air that we do. We don’t yet know why this is happening, but the fact that even animals are showing signs of weight gain argues both against personal responsibility and in favor of some sort of environmental insult to which all life on the planet is now exposed (see chapter 15).

5. The Poor Pay More

As stated earlier, personal responsibility implies a choice, usually a conscious choice. Can one exercise personal responsibility if one doesn’t have a choice? It is well known that the poor have much higher rates of obesity and chronic disease than do the rich. There are many reasons for this difference, and it is difficult to pinpoint one factor that is responsible. In the United States the poor exhibit two separate traits that argue against personal responsibility.

First, there are possible genetic issues. It is well known that African Americans and Latinos in the United States are more economically disadvantaged than their Caucasian peers. These demographic groups have higher rates of obesity than Caucasians—40 percent of Latinos and 50 percent of African Americans are obese – and are more likely to have associated medical problems, such as metabolic syndrome.[21 - W. Park et al., “The Metabolic Syndrome: Prevalence and Associated Risk Factor Findings in the US Population from the Third National Health and Nutrition Examination Survey, 1988–1994,” Arch. Intern. Med. 163 (2003): 427–36.] Certain genetic variations are more common in specific minority groups. These differences in DNA may, in part, explain the higher rates of obesity and certain metabolic diseases, such as fatty liver (see chapters 7 and 19). Genetic makeup is certainly not a choice.

Second, there are issues of access. There is a difference between the “healthy” diet of the affluent, who can purchase fresh, unprocessed foods that are high in fiber and nutrients and low in sugar, but at high prices, and, the unhealthy diet of the poor, which consists mainly of low-cost processed foods and drinks that do not need refrigeration and maintain a long shelf life. But access does not refer only to what people can afford to buy. Many poor neighborhoods throughout America lack farmers’ markets, supermarkets, and grocery stores where “healthy” foods can be purchased.[22 - C. Gordon et al., “Measuring Food Deserts in New York City’s Low-Income Neighborhoods,” Health Place 17 (2011): 696–700.] Many supermarkets have pulled out of poor neighborhoods, mainly because of financial decisions based on revenue and fear of crime. The national supermarket chain Kroger, which is headquartered in Cincinati, in 2007 purchased twenty former Farmer Jack stores in the suburbs of Detroit, Michigan, but none within the Detroit city limits. The nearest branch is in Dearborn, eight miles away from downtown. Many who live in low-income areas also have limited access to transportation. Lower-class urban areas throughout America have been labeled “food deserts” because they are unable to sustain a healthy lifestyle. If the only place you can shop is a corner store for processed food, is what you eat really a choice? In wealthier areas of San Francisco, nearly every block has an organic food store, while in the city’s poorer areas, each corner is dotted with a fast food franchise.

Even when all foods are available at low cost, the poor may not have access to refrigerators or even kitchens. Many SROs (single-room occupancy) hotels have only hot plates and no space for keeping or cooking healthy meals. Further, there is the issue of time. Many poor families are led by parents who work multiple jobs and are unable to come home and prepare healthy meals for their children, instead relying on fast food or pizza.

Lastly, the poor suffer from issues of food insecurity. People experience massive amounts of stress when they don’t know where their next meal is coming from (see chapter 6). They eat what is available, when they can – usually processed food. That level of stress is incompatible with the concept of choice. Stressed people can’t make a rational choice, particularly one in which short-term objectives (e.g., sating their hunger) are pitted against longer-term objectives (e.g., ensuring good health).

6. The Greatest Rate of Increase in Obesity Is in the Youngest Patients

When you look at U.S. trends in childhood obesity over the past forty years, you see that every age group is affected. However, the age group that shows the greatest rate of increase in the last decade is the two- to five-year-olds.[23 - M. de Onis et al., “Global Prevalence and Trends of Overweight and Obesity Among Preschool Children,” Am. J. Clin. Nutr. 92 (2010): 1257–64.] It is impossible to ascribe personal responsibility or free choice to this age group. Toddlers don’t decide when, what, or how much to eat. They do not shop for or cook their own food. However, as all parents know, they do have lungs and they do make their preferences known in the supermarket. Research has shown that children are not able to tell the difference between a TV show and a commercial until they are eight years old. Children in the United States watch an average of three to four hours of TV per day. The programs are interspersed with commercials that target these young viewers and convince them of what they need.[24 - Kaiser Family Foundation, “Food for Thought: Television Food Advertising to Children in the United States” (2007), www.kff.org/entmedia/upload/7618.pdf.] If you can’t discern what’s marketing and what’s not, how can you defend yourself against it?