AMA Declare’s Obesity A “Disease” – Good or Bad Idea?

If you haven’t heard the news, last week the American Medical Association reclassified obesity as a “disease” (it was previously known as a “condition).  This decision is largely symbolic, and has been hotly debated over the past few years.  In fact, the AMA’s council on Science and Public Health actually recommended not defining obesity as a disease, due to the many limitations of defining obesity based on BMI (something that we’ve discussed several times in the past).

Last year the Canadian Obesity Network student group at the University of Ottawa hosted a debate with the title “Is Obesity A Disease?”, and given these recent developments I thought it would be a good time to republish a summary and video of the debate.  Arguing that obesity should be considered a disease was Dr Arya Sharma, and arguing that it should not be considered a disease was Dr Jacqui Gingras.

One thing that I found disappointing about the AMA’s decision was that they decided to stick with a definition of obesity based on BMI alone (UPDATE: this isn’t technically the case – see below comment from AMA committee member Ethan Lazarus for details), which many clinicians and reseachers (myself included) think is an extremely problematic measure.  In fact, at the debate last year, Drs Sharma and Gingras agreed emphatically that BMI should not be the sole measure used to determine if a person is considered “obese”.  And if we were to use some other measure which focused on overall health risk rather than just body weight (for example, the Edmonton Obesity Staging System), then I think many of the potential problems with this decision would be minimized.  As it is, I’m hoping that the benefits (improved treatment for those who need it) outweigh the downsides (obesity-related bias, fat shaming, etc).

The video of the debate can be viewed below. For a higher resolution version of the video which is more suitable for lectures, public presentations, etc, feel free to contact me through the comments section below. Also, feel free to distribute/embed/edit the video, as it has a Creative Commons Attribution licence. Thanks to Joseph Abdulnour for doing a fantastic job with the video!  The debate can also I be downloaded by (clicking here), or simply subscribe to the Obesity Panacea podcast in itunes (click here).

The debate was broken into 3 subsections, and moderated by Dr Mark Tremblay:

Section 1: The health impact of obesity – does obesity cause increased health risk, or is it merely an innocent bystander?

Section 2: The medicalization of obesity – how has obesity come to be viewed as a medical condition, and is this a good or bad thing?

Section 3: Concluding statements: Should obesity be viewed as a disease?

Each section also included an opportunity for a brief rebuttal from each of our experts, as well as 10 minutes of Q&A with the audience (which included a fair number of obesity experts as well).

Areas of agreement

One of the first things that the two debaters agreed upon is that BMI is useless as a means of defining obesity.  Instead, Dr Sharma argued that obesity should be defined as “as a condition in which excess body fat threatens or affects health”, and that it is in this sense that obesity should be considered a disease.  Similarly, there was no disagreement whatsoever about the very real harm done by weight bias and discrimination.

Areas of disagreement

As expected, the primary area of disagreement came over whether the medicalization of obesity would be helpful or harmful to people with excess body weight.  Dr Gingras argued that obesity has already been medicalized/pathologized, and that it is this very medicalization that promotes weight bias.  As people are constantly exposed to the message that “fat kills”, they have begun to look down upon people with above average weight as being unhealthy or worse (scroll through the comment thread on any obesity-related mainstream media article to see how individuals with obesity are viewed by the general public).

In contrast Dr Sharma argued that it is precisely because obesity is not viewed as a disease by the medical establishment, it has instead been positioned as a “lifestyle” problem.  From a post on his website the morning after the debate (the entire post is well worth reading):

It is exactly because we do not exclusively leave the diagnosis of obesity (which I define as a condition in which excess body fat threatens or affects health) to trained, licensed, and regulated health professionals, that we have created a ‘free-for-all’ where we continue propagating the myth that everyone with a few extra pounds is unhealthy and needs to lose weight. This is the key downside of not medicalising obesity – if only a trained health professional can tell whether or not your weight is affecting your health then someone without this training, should not be making assumptions about your health simply based on your size – indeed, it will hopefully become common knowledge that only your doctor or nurse can tell whether you have obesity or not.

Dr Sharma also argued that by failing to medicalize obesity, we continue to allow charlatans and snake-oil salesmen to promote their ridiculous (and often harmful) “cures” for obesity, which would not be possible if obesity were viewed as a legitimate disease by the government and medical establishment (as an example, he pointed out that you can’t open up an unregulated “cancer treatment center” in a strip mall, but you certainly can open a weight loss center wherever you please).

My thoughts, and one more area of agreement

Both Drs Sharma and Gingras made excellent points, and to be honest it’s tough to decide exactly where I come down on this issue.  It almost seems as though obesity has been medicalized in every way except the one that matters.  It has certainly been medicalized in the eyes of the general public, and on this issue I agree with Dr Gingras that it has had very real negative consequences for people viewed as being too heavy.  However, the fact that the government/medical establishment continue to view obesity (defined using Dr Sharma’s definition, rather than BMI) as a lifestyle problem rather than a genuine disease, has also led to lack of qualified medical support on this issue, as well as evidence-based public health strategies.

In the end Dr Gingras pointed out one other key area where she and Dr Sharma were in agreement, and that was the issue of improved training for healthcare professionals.  Regardless of whether or not you think that obesity is a disease, there is little doubt that healthcare professionals receive inadequate training in how to deal with obesity-related issues, and that this has negative consequences for their patients.

The podcast is released with a creative commons license, so feel free to repost/embed/edit/reuse as you see fit.

Thanks everyone!

A big thanks to the many people and organizations who helped organize the debate.

  • Our presenters (Drs Sharma, Gingras, and Tremblay)
  • Our funders (CIHR through a Cafe Scientifique grant, as well as the Canadian Obesity Network Student and New Professionals organization, and in-kind support from the Healthy Active Living and Obesity Research Group at the Children’s Hospital of Eastern Ontario Research Institute),
  • The organizing committee at the University of Ottawa CONSNP  (Joseph, Zach, Angela, Megan and Richard)
  • The press officers at the Canadian Obesity Network (Brad Hussey), the CHEO RI (Adrienne Vieanneau) and University of Ottawa (Thalie Tremblay)
  • Our hosts at the Richelieu Vanier Community Center
  • Last but not least, all of the individuals who attended the event and contributed to the discussion.


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27 Responses to AMA Declare’s Obesity A “Disease” – Good or Bad Idea?

  1. Lisa says:

    It’s my opinion that obesity is a mental health issue. Gastric bypass will only have lasting results if the person practices healthy eating habits and regular exercise – for LASTING CHANGE, that is, lifestyle changes. In my case, I was only able to do this AFTER I had a healthy self-esteem.
    It’s not enough to have a small stomach. It can be stretched if you try to eat more. Statistics show that 10 years post op, majority of gastric bypass patients gain all or half of the weight back. I recall my surgeon telling me to not worry about the calories, just eat until the first sign of fullness. Well, that worked for the first 5 years. By the next 5 years, I had stretched my stomach just enough to gain an average of 20 pounds per year! Hence, I found that the natural way of expending more calories than you consume to be the best remedy for me. Since, July 1, 2012, I have lost nearly 60 pounds. I need only 40 more to go!! I think gastric bypass to be good for those 200 or more pounds overweight, and not 100 pounds or more, which it is currently to be considered eligible for gastric bypass. If I had the chance to do it all again, I would not have done gastric bypass at only 100 pounds overweight. It is too drastic and shocking to your body. I lost my gall bladder, too, because of the extreme rapid weight loss the first 3 months. The best way is to lose weight over a reasonable time.

    • cowsharky says:

      It can be a mental health issue, but you can’t assume that’s true for everyone who is fat. And if a fat person has an eating disorder it’s not always binging/compulsive overeating. My ED manifests as starving/purging. I didn’t binge, though to my disordered mind it felt like that when I ate normal amounts of food. Sometimes I even purged on an empty stomach; the main purpose of purging was to punish myself for being fat. I’m not sure how the DSM-V would categorize it, but going by IV, it was ED-NOS. I’m doing a lot better now, but I have to count calories to keep myself from going *under* the minimum of 1200.

  2. Jason says:

    I agree with your Lisa, I think the best way is natural weight loss over a reasonable length of time. I do however humbly believe obesity is generally more of a lifestyle problem than a disease.

  3. Mike says:

    There is enough similarity to drug addiction and alcoholism for the AMA’s decision to merit support. Addiction itself is a complicated combination of physical and mental conditions. I could argue the same for obesity. Both are apparent after a point, but you can test for them using a lab test per se. By defining obesity as a disease it will now be possible now to work with insurance carriers and government entities to provide treatment coverages at all steps of the progression of the disease and not just when the affects of obesity become apparent. Agree?

    • Mike says:

      That should have read, you CAN’T test for them using a lab test….

    • Travis Saunders, MSc, CEP says:

      That would certainly be the hope, and it’s certainly plausible. However, some of the downsides outlined above also seem very plausible. I’m hoping that they at least try to track things somehow, to see if this is at least improving the health of people with obesity.

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  6. DiogenesNJ says:

    Obesity is not a “public health” issue. It is a quintessentially private health issue. My obesity does not affect your health in the slightest. It may increase the risk of some diseases, but is not itself a disease.

    What the government pays for, it wants to control. So once the government pays for everything…

    It somehow always seems those most eager to define something into the “public health” arena are also those most likely to advocate government force to change peoples’ behavior. Mayor Bloomberg springs instantly to mind. How long before we are issued ration coupons for salt, sugar and butter based on our age and weight?

    • Travis Saunders, MSc, CEP says:

      If obesity is not a public health issue, then are other non-infectious issues like diabetes, cardiovascular disease, etc? If people are sick, then it affects many things in society other than health – the economy as one big example. Now of course this is assuming that having a BMI greater than 30 does means you’re sick (which is a gross oversimplification), but I’m comfortable treating non-infectious diseases as public health issues.

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  8. cowsharky says:

    The problem with this ruling is that obesity can be a risk factor, symptom of another disease, or a side effect of treating a disease. For example, fat around the midsection is a common symptom of PCOS, but now with obesity being a disease, a doctor could focus only on that while ignoring other PCOS symptoms (like thinning hair on the head or severe acne). If you go to the First Do No Harm blog* , you’ll see that this sort of thing happens already, but the AMA’s ruling is only going to embolden these kind of doctors.

    Also, one can easily gain weight from certain meds, as I’m sure the blog owners know. I gained 50+ lbs when I went on a certain SSRI whose name rhymes with Maxil. For a long time I blamed myself instead of the drug, but a couple of years ago my doc put me on a drug whose name rhymes with Mellbutrin and I’ve been steadily losing weight even though my lifestyle is the same. Yeah, I know the plural of anecdote isn’t data, but I’ve noticed that more and more psych meds officially listing weight gain or loss as side effects.

    *I admit that that blog is far from a random sample, but it still is important to read these stories.

    Why isn’t being underweight a disease, especially since there’s a lot less leeway pounds wise before major health problems arise (a person who’s 50 lbs overweight is at risk for some problems and may even already have some, but a person who’s 50 lbs underweight is most likely dead)?

    Also, this ruling is going to be triggery as hell for people with eating disorders. I know when I read about it I had to fight the urge to starve much harder than normally because of it.

  9. Pingback: Is obesity a disease? | Today Health Channel

  10. Thanks for this great review and comments. I was proud to represent the American Society of Bariatric Physicians as their delegate to the AMA, and participated in the discussions and gave testimony over the two obesity resolutions. I thought I’d clarify a couple of things:

    First, the resolution that passed is 420. The other resolution that involved the BMI argument (CSAPH 3) did not pass. The 420 resolution does not make any mention of BMI. It simply asks the AMA to recognize obesity not only as a disease, but as a chronic disease.

    As an obesity medicine physician for the past 10 years, it is clear that obesity clearly meats all possible definitions of what constitutes a “disease,” and that obesity responds best to a chronic disease management approach. Not recognizing obesity as a disease reinforces weight bias (telling individuals that this is their own fault and if they could simply eat less the obesity would go away) and will encourage American medical schools and residency programs to begin teaching American doctors about obesity – what it is, how to do an assessment and develop a treatment program.

    I hope that this represents the first step towards developing better diagnostic tests, treatment algorithms, and spurs research and development in the areas of both treatment and prevention. But to not recognize this disease is a disservice to millions of Americans, and is like sticking our heads in the sands.

    • Travis Saunders, MSc, CEP says:

      Thanks for that clarification and info, Ethan. Although I’ve got to assume that if most people (including physicians) are told to treat “obesity”, then they are going to assume that it’s diagnosed based on BMI. I think that all the reasons you’ve listed for viewing obesity as a disease are good ones, and I’m hoping that it has the desired positive impact. I think that may have been a bit more likely if there had been some clarification on what constitutes obesity (e.g. is it just being heavy or is it some other classification like the EOSS), but I’m hopeful nonetheless.

      • Travis –

        I happen to agree with you and actually provided the Reference Committee D testimony on and information on EOSS. I also used EOSS in my testimony to the House of Delegates. Further, I use EOSS in my practice every day.

        However, EOSS really hasn’t been exposed to large enough clinical use in the US really with only 1 or 2 small studies. I don’t think we are at a point where we should be recommending EOSS for use in diagnosis and treatment. However, we should be at a point where we are doing larger scale research trials on EOSS.

        The AMA resolution says nothing about action or desired effects. The resolution is a scientific one – it states that based on what we know about obesity, it should be considered a chronic disease. What we do with this is another story. Will this lead to changes in medical education? Research? Prevention strategies? Payment models? Covered diseases under the affordable care act? Changes in Medicare / Medicaid coverage? Changes in school lunch programs?

        These are all possible as a result of this resolution. Without this resolution, really it leaves obesity out of the medical fold. While there will be lots of press on this, doubtlessly much of it negative, I strongly support this move by the AMA, and remain hopeful that the consequences will benefit individuals who struggle with this incredibly complicated and difficult to treat problem.

        • Travis Saunders, MSc, CEP says:

          Thanks for the detailed response, Ethan. I wish this level of discussion and nuance were possible in regular media articles! I’ve updated the post with a link to your comment to clarify that BMI wasn’t actually included in the resolution.

        • cowsharky says:

          Ethan, what about the concerns I discussed in my posts above? There already is a problem of doctors failing or even refusing to treat other health problems of fat people because they can’t see past their weight. Now that obesity is a disease, it will be easier to justify only focusing on a patient’s weight when they have other problems not necessarily related to their weight. There have been cases of people who had tumors go undiagnosed for years because of fat-hating doctors. How will that get any better now?

          What about when weight gain results from treatment for another condition? As I mentioned before, I gained weight after being put on an antidepressant. When I suggested to my doc that it might be responsible for the weight gain, she dismissed it and offered to put me on Meridia. Fortunately I was smart enough to refuse. But again, I can imagine a doc deciding that a patient’s weight is more important than managing their depression, and seriously messing up their treatment. This kind of thing happens now already, and I’m willing to bet my paltry paycheck it will get worse thanks to this ruling.

          Finally, there’s the problem of ED triggering. Not every fat person overeats. I average around 1200-1500 kcals a day, and it’s a daily struggle to _not_ go way under the 1200 mark. The day I read of the ruling, I was extremely triggered and it took all my strength not to go back to my starving pattern. Fat people with starving-type EDs are probably going to continue to be undiagnosed or even _encouraged_ keep hurting themselves.

          I’m sure you had the best of intentions, but I really think this is going to hurt people.

  11. Cowsharky:

    You raise 1 great point after the next. Let me answer how I feel about these.

    In recent studies, unfortunately, physicians represent one of the most common sources of weight bias (treating patients inappropriately because of their weight). I think there are a lot of reasons for this – medical students and residents aren’t trained in how to properly perform an assessment or develop a treatment plan, treatment options are limited, and if physicians code obesity on the bill, most insurers refuse payment. It is not excusable that physicians blame their patients for this complex problem. Recognizing it as a disease suggests to physicians this is not a problem that will be solved by “eating less,” and that the causes are more than “eating too much and exercising too little.”

    The treatment of obesity is difficult for many reasons, not the least of which is that our medical system has done such a bad job of recognizing this and educating our doctors. I also agree with your other points – having worked with tens of thousands of patients on their weight, commonly treatment of other problems (like depression, as you mentioned) results in significant weight gain.

    Perhaps if doctors could code “obesity” in their diagnosis list at the same time as depression, they would be more likely to choose treatments that don’t cause weight gain. Or, they may be more inclined to monitor for weight gain, and if it occurs, change treatment or do something to offset it.

    Recognition and treatment of these issues requires the way we train and reimburse physicians to change. This is a topic I lecture on in my home state of Colorado and nationally on a regular basis. In my experience, physicians have been very receptive to learning about this.

    Dr. Sharma’s 5 A’s are invaluable in my talks – most physicians have not received training on which questions to ask, how to perform an assessment, or on recommended treatment options. So, they offer a medication or a diet book – inexcusable in my opinion.

    We have a long road ahead, but it begins by reducing weight bias. Recognizing obesity as a disease will benefits millions of individuals. There may be some people whom it does not benefit or whom it even harms. We need to be very careful with ED patients, as you suggest. But, proper treatment of weight does not cause ED. And we can’t stay where we are – with Americans spending 40 billion dollars a year on useless weight loss supplements and unable to get a good recommendation from their primary care doctor due to the PCP’s ignorance and a lack of incentive for them to receive proper training on this complicated problem.

    Where we are is unacceptable. I find it hard to believe that properly educating physicians will make the problem worse. But, we have a long road ahead of us to improve care, reduce bias, and find better treatment and prevention strategies. Without this pivotal step, though, it keeps obesity outside of the medical realm and the next steps won’t happen.

    Finally, it was not myself who introduced or who passed this policy. The policy was introduced by a consortium of 10 specialty societies including: endocrinologists, surgeons, anesthesiologists and Ob-Gyn’s. It received support from Family Physicians and Pediatricians. The doctors of the AMA voted and collectively agreed that this is a problem worth recognizing. What happens next? I will be eager to see where these types of comments are in 10 and 20 years.

    20 Years ago, depression was a highly stigmatized diagnosis. It was hard to treat and poorly reimbursed. Today, depression is better understood and less stigmatized. Most physicians have a basic understanding of different treatment options ranging from medications to therapy. And most insurers reimburse similar to other diagnoses (mental health parity is a part of the ACA). Recognizing depression as a chronic condition did not lead to an increase in bias or a drop in quality of care. Rather, all physicians now receive training in what depression is and different treatment approaches. We are at the very beginning of a similar path I hope we take for prevention and treatment of obesity.

  12. cowsharky says:

    Ethan, thank you for your thoughtful reply. I’m glad that the BMI resolution didn’t pass because it’s such a blunt measurement. The Edmunton Obesity Staging System makes a lot of sense and I hope it’s adopted widely (unintentional pun). I’m going to try to be cautiously hopeful about this.

  13. Ideally this would result in more research of how fat bodies work, why weight loss so often fails, and other real information. In the meantime, though, I’m afraid this will results in more shaming and insistence that weight loss will treat any problem a fat person has (strep throat, asthma, anemia, etc).

  14. Campbell Keenan says:

    Obesity is now declared a disease! If so, it is a disease of affluence and most people afflicted by it, are obsessed about the difficulty of losing weight, whereas I believe the solution is quite simple. As a kid I grew up in New Zealand during the 2nd world war, when food was scarce and rationed. I remember only 2 kids at primary school who were overweight. One lived on a farm and ate dairy and other foods which were obviously not rationed or at least, were hard to ration by the authorities. The other had no interest in physical activity, but loved eating, particularly fatty fried food. Overweight adults were a rarity, as they are still in poorer societies.

    Today, in the 1st World, the majority of adults are overweight, many grossly and hideously obese. During my frequent business trips to the USA in the nineties, I was taken once to dinner by an obese company representative to Ur Cooks in Houston, Texas, where we selected our own steaks, cooked them and added cooked vegetables. The concept was ideal for feeding yourself a healthy nutritious meal. My host selected an enormous steak about 2 inches thick, covering most of his plate, cooked it and added copious vegetables that almost fell off his plate. I selected the smallest steak available – still large in my view, added vegetables, ate my meal, feeling I probably could have eaten more, but pleasantly satisfied.

    The answer to obesity is common sense. If you are overweight, don’t be so greedy, but select nutritious food of a quantity that doesn’t make you feel (and look like) like a stuffed pig.

    Most obese people blame everyone but themselves – they have tried everything, they say – their genes are wrong (if so, you are lucky, you have an efficient metabolism and don’t need much food to remain functioning and healthy – would have been great in the ‘hunter/gatherer’ days) – they love sweet things – fast food is so tasty (lots of salt and fat!).

    Has old fashioned, self discipline just gone out the window? For goodness sake, stop putting it in your mouth! You don’t need a fad diet. In the blog on my site, ‘Lose Weight’, I specify how to live a life that will banish obesity – you will live longer and enjoy the years much more – simply resolve yourself NOW – only you can do it and it is simple.

    • cowsharky says:

      “grossly and hideously obese” “stuffed pig”

      Such compassion! So much empathy! If I didn’t know better I’d think you were the Will Graham character from the show “Hannibal”.

      Sarcasm aside, comments like this are the reason why I battle an eating disorder daily (and before you assume I overeat, my disorder involves starving–so far today I’ve subsisted on 180 kcals and it’s 4:30 pm where I am). If you read some of my other comments here you might find there’s a bit more nuance than you think.

    • Travis Saunders, MSc, CEP says:

      The answer to obesity is common sense. If you are overweight, don’t be so greedy, but select nutritious food of a quantity that doesn’t make you feel (and look like) like a stuffed pig.

      If only obese people had common sense like skinny people… seriously? Moralizing about obesity helps no one, nor do simplistic messages like “make a decision to lose weight”. The obesity epidemic didn’t begin with a general loss of will-power among advanced nations – it happened when our collective lifestyles and food/social environments changed to promote increased food intake and reduced physical activity, among other things. And if permanent weight loss were as easy as simply eating less and moving more, we’d probably be aware of that by now.

      Here’s an overview of the likely factors that have contributed to current childhood obesity rates (adult contributors are pretty much identical). There is simply no evidence that self discipline or willpower are to blame, and no reason to think that increasing these things will fix the problem.

  15. Campbell Keenan says:

    cowsharky – I have read your comments and sincerely, I do have empathy for you as it appears you are working hard to beat it. The point I was making is that there were no fat people in those horrendous concentration or POW camps of the second world war. I hope you may be interested in my views – see I find exercise the greatest mood elevator and essentital as part of a weight loss program. Also after it, I feel I can take onthe world.

    Best of luck in your endeavours.

    • cowsharky says:

      Just a bit of advice–people who’ve been on the internet for a very long time will tell you that if you cite the Nazis/Holocaust/Hitler in an argument, you’re invoking what’s called Godwin’s Law. A corollary to this law is that whoever mentions Nazis/Holocaust/Hitler automatically loses the argument. For future reference, avoid doing that.

      Your comment did pique my interest and I did some researching. Apparently prisoners in the camps averaged between 1300-1700 depending on how much forced labor they did:
      Of course, when you average things out any very high or very low numbers will skew the results, so it’s hard to determine what the daily number really was, though it’s certainly likely that it went well below the 1200 threshold near the end of the war. Add in the forced labor and rampant disease (typhus, dysentery, etc.) anyone could lose weight. However, I hope you’re not suggesting that introducing concentration camp-like conditions is a reasonable way to lose weight. And if that’s the only way a person could lose weight, I would think that at the very least the stress of such conditions would counteract any good gained from getting thinner.

      I won’t check out your forum. It’s nothing personal; I’m well-versed on exercise and diet and I avoid such forums because they can really trigger my ED. This site is an exception because the blog owners aren’t like the typical Jillian Michaels type when it comes to this topic.

  16. “If only obese people had common sense like skinny people… seriously? Moralizing about obesity helps no one, nor do simplistic messages like “make a decision to lose weight”. The obesity epidemic didn’t begin with a general loss of will-power among advanced nations – it happened when our collective lifestyles and food/social environments changed to promote increased food intake and reduced physical activity, among other things. And if permanent weight loss were as easy as simply eating less and moving more, we’d probably be aware of that by now.”

    Well, we are aware that simply eating less and moving more will almost certainly help to lose weight and if done continually, weight loss will be permanent. However it appears most humans are incapable of this or don’t want to discipline themselves that way, so what can be done about it?

    If obesity is now a disease, I believe governments and educators must get involved, first in teaching children as part of their curriculum at school, about healthy life styles, exercise and good nutrition. Secondly, discouraging the promotion of the ‘all you can eat’ philosophy and sale of known unhealthy foods. This is not easy, but it worked with smoking, certainly in Australia.

    More and more studies show that exercise, especially a sport that a child enjoys, is complementary to good nutrition and importantly, it helps children’s cognitive development, – they think more clearly, achieve better grades at school and grow into more balanced, self confident and happier adults.