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Published On July 23, 2009

POLICY

The Future of Obesity?

A long campaign halved the percentage of U.S. smokers. Could a similar effort succeed against the nation’s obesity epidemic?

YOU CAN STILL SEE IT ON YOUTUBE. In 1968 a heavily medicated William Talman, known to almost everyone as Hamilton Burger, Perry Mason’s foil on the long-running television drama of the same name, spoke in a public service announcement as photos and home movies of his family appeared on the TV screen. He didn’t really mind coming up short in those fictional courtroom battles, Talman said, but now he was in a fight he didn’t want to lose. “I’ve got lung cancer,” he explained. “So take some advice about smoking and losing from someone who has been doing both for years. If you don’t smoke, don’t start. If you do smoke, quit. Don’t be a loser.”

Six weeks later, Talman was dead. But he won his case. The war on tobacco and smoking he helped kick off has been extraordinarily successful. In 1971 the U.S. government prohibited cigarette advertising on television, and the decades since have seen a steady, concerted campaign by public and private health organizations and local, state and federal lawmakers. They have sought to make cigarettes more expensive and inconvenient (through higher taxes and greater restrictions on where smoking is permitted) and to drive home the health risks and hygiene consequences. Once considered the quintessence of cool, lighting up has become a social faux pas, discouraged by withering glances and thank you for not smoking signs. Ashtrays, once a fixture even in nonsmoking households, have all but disappeared. Manufacturers have been subjected to increased, and ever more successful, investigations and lawsuits—with huge monetary awards often used to fund further antismoking efforts.

Smoking, of course, remains a major public health issue, with an estimated one in five American deaths caused by such smoking-related illnesses as lung cancer, obstructive pulmonary disease and coronary heart disease, according to the American Lung Association. Yet per capita consumption of cigarettes dropped from 4,345 in 1963 to 1,691 in 2006. And the percentage of U.S. adults who smoke has fallen by more than half since 1965, to a level of around 20%.

Could a similarly concerted effort by government and health organizations make progress against another kind of epidemic? More than a third of American adults and more than one in six children are obese, according to the Centers for Disease Control and Prevention. They have a body mass index of 30 or higher. (A man six feet tall, weighing 222 pounds, has a BMI of 30; so does a five-foot-five woman weighing 181 pounds.) And their obesity puts them at high risk for an array of serious health problems, from heart disease and diabetes to hypertension, liver disease and many types of cancer.

In some places, the antiobesity effort has already begun. This fall parents of public school children in Massachusetts won’t just learn how their son or daughter is doing in math and social studies; they’ll also find out the child’s BMI. In New York City, restaurant chains have been required since 2008 to post calorie counts for every item they serve. And scores of municipalities have banned junk food from school cafeterias.

Even as such initiatives gain momentum, there are questions about the parallels between smoking and obesity and about whether a campaign against our collective girth makes sense. Whereas tobacco is an addictive but physiologically unnecessary substance, food is, of course, essential to life. You can’t go cold turkey on protein, fats and carbohydrates. And while smoking represents a single substance (tobacco) delivered primarily through one product (cigarettes), food comes in almost infinite varieties, each with its own nutritional values and risks.

Moreover, tobacco presents a component—secondhand smoke—that makes it ripe for legislation. Many of the most aggressive initiatives have been justified because smoking represents a public health hazard to innocent bystanders, including children. Although research by scientists, including Nicholas Christakis of Harvard and James H. Fowler of the University of California, San Diego, suggests that people influence the obesity levels of those in their “social networks,” that’s not as compelling as the notion that kids in smoke-filled public spaces greatly increase their risk of lung cancer.

Could a combination of public health messages, food industry regulation and healthy lifestyle promotion help stem the tide of obesity-related illnesses? Should we even try, or would the effort infringe on personal freedoms? Can we at least find a way to help children and the poor—two demographic groups that are particularly susceptible to the messages of a fast-food culture? Should we make it less socially acceptable to be overweight, just as smokers have been made personae non gratae, or do we need to be more forgiving, to counter the stigma and the discrimination increasingly connected to obesity? Or should we, to paraphrase a recent political catchphrase, sue, baby, sue?

Those are some of the issues addressed by eight experts who are vitally interested in the obesity question.

 

FIGHT THE ABUSE OF FOOD 

Food doesn’t just provide nutrition; it also makes us feel good, so we eat more, storing up energy in case we don’t have enough to eat later. For aeons, that physiological effect was essential to survival. Now it’s making trouble, especially in the case of food that may be addictive. Research by Bart Hoebel of Princeton University has demonstrated that after just a few weeks of bingeing on sugar water, rats develop withdrawal symptoms similar to those observed in alcoholic rodents. And at Brookhaven National Laboratory, our brain-imaging research shows that obese people, like drug addicts, have fewer than normal dopamine D2 receptors, which help regulate behavior. Our hunch is that overeaters may be compensating for a sluggish dopamine system by turning to the one thing that gets their neurons pumping.

We can’t outlaw food, but maybe we can use technology to turn the tables on our own hardwired cravings. Perhaps we could use the same ingenuity that gives us processed foods laden with refined carbohydrates and corn syrup to develop “twenty-first-century foods” that have high nutritional value and can satisfy addictive cravings without being highly caloric. —Gene-Jack Wang is senior medical scientist and chair of the medical department at Brookhaven National Laboratory in Upton, N.Y.

 

START A WAR ON CONSUMPTION

Obesity is mainly the result of having food available everywhere at all times, and the only way to combat it—short of having everyone undergo bariatric surgery—is to have public policy that dissuades consumption. The food industry has trained people to think that snacking between meals is acceptable. Every gas station has a mini-mart, vending machines are ubiquitous, and drive-through windows are open 24 hours.

We could take our cue from countries less beholden to business interests. Sweden, Norway and Greece have enacted laws restricting food marketing, especially to children. We also need to improve access to healthy foods for the poor by shifting agricultural subsidies to favor fruit and vegetables over corn and soy, which feed cows and provide high-fructose sweeteners for fast food.

Other ideas for discouraging obesity?such as charging people with high BMIs more for health insurance, just as smokers must pay higher rates for life insurance—assume that obesity is under personal control and ignore biological and environmental causes. Nobody wants to be overweight. —Kelly D. Brownell is a professor of psychology, epidemiology and public health and director of the Rudd Center for Food Policy and Obesity at Yale University.

 

DON'T TREAD ON THE RIGHT TO BE FAT 

In a free society, the individual has the right to make diet and lifestyle choices—and the responsibility to enjoy or suffer the consequences.

The government should not try to solve the obesity problem by coercing consumer behavior or by restricting the freedom of businesses to advertise their products. Some argue that such controls are justified because people who develop obesity-related illnesses will be treated at taxpayer expense. But the sole legitimate function of government is to protect individual rights, not violate them. Just because government currently violates individual rights by forcing citizens to pay for others’ health care does not justify further violations in the form of telling Americans what we may or may not eat. Two wrongs don’t make a right.

Those who become ill as a result of their poor choices should pay the price themselves or rely on voluntary charity rather than be supported by taxpayer dollars. —Paul Hsieh, a physician in Denver, is a co-founder of Freedom and Individual Rights in Medicine, a nonprofit group that promotes personal liberty and free markets in health care.

 

STOP STIGMATIZING THE VICTIMS 

Consider the public health response to HIV/AIDS. The government has funded research, reduced obstacles to treatment and used public education to combat stigmas. But in fighting obesity, we haven’t put these very effective tools to good use. Employers are free to discriminate on the basis of weight, and the beliefs that obese people have poor moral character and lack impulse control are still widespread.

Though drugs are being developed to modify our genetic predisposition to fat and sweet food, the Food and Drug Administration has such a low risk tolerance for any new medication that manufacturers have grown overcautious. The FDA must encourage research into legitimate medications while regulating opportunists, such as makers of over-the-counter diet products. But none of that can do much good until we view obesity as an epidemic affecting our entire society rather than the fault of individuals who don’t know any better. —Morgan Downey, a former executive director of the American Obesity Association, serves on the board of the Surgical Review Corporation, which certifies bariatric surgery centers of excellence.

 

CHANGE THE WAY THE GROUP THINKS 

At Harvard, research into how social environments influence personal decision-making supports the claim that obesity, like smoking, is a public health problem that requires a public health response. Both are related to choices made by individuals, but there’s also an incredibly strong social component at work. Human beings in a very fundamental sense behave like flocks of geese or herds of wildebeests. They do things in droves, and whether you gain or lose weight, or start or stop smoking, depends very much on what the people around you are doing.

In terms of public policy, this can work in both positive and negative ways. Take the government’s subsidy of corn syrup, which makes high-calorie foods cheap. As we eat more of these foods, we get bigger; those in our social networks change their perceptions about what “big” means—and we get bigger still. On the flip side, because social networks are so important to us, interventions may be especially cost-effective. Suppose you get just one person to quit smoking. Then that person’s friend quits, and then a friend of that friend. The same might happen with weight-loss programs. Public perceptions about tobacco have changed during our lifetime, and it’s possible that perceptions about acceptable levels of obesity, given the right push by government policy, will change as well. —Nicholas Christakis is a professor of health care policy at Harvard Medical School and a co- author of Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives.

 

INTERVENE NOW OR PAY LATER 

You don’t need a doctoral degree to understand why so many kids are obese. Yet if we don’t address the problems—massive advertising of high-calorie products, a desperately underfunded school lunch program that is a dumping ground for excess USDA commodities, dwindling physical education—childhood obesity could ultimately bankrupt the health care system. Already, complications from diabetes that once struck people in their fifties or sixties are now appearing in adolescents and young adults; we may soon also see heart attack become a disease of young adulthood.

Public service campaigns encouraging healthier lifestyles are fine. But what we really need is comprehensive regulations—for example, a federal ban on junk-food advertising to children, consistent with the recommendations of the American Academy of Pediatrics and the American Psychological Association. Those in the food industry prefer an approach that relies on personal responsibility—mainly because that takes the onus off them. —David Ludwig is director of the Optimal Weight for Life Program at Children’s Hospital Boston and a co-author of Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/Fake Food World.

 

TAKE THE FIGHT TO MANUFACTURERS 

It took 30 years from the time the first antitobacco lawsuit was filed until a plaintiff finally prevailed in court. But in only a decade of fighting obesity, we’ve had 10 successful lawsuits aimed at fast-food manufacturers, and progress toward the sale of healthier foods has followed in their wake. Texas has ordered mandatory reporting on obesity and fitness for students in kindergarten through grade 12; California, New York City and other jurisdictions have demanded calorie counts on menus; and we’ve seen bans on trans fats.

With tobacco there are just a few major culprits—the largest cigarette manufacturers—and one product. In contrast, the number of fast-food chains and junk-food producers seems infinite. But like the campaign against cigarettes, this one will succeed or fail depending on whether it really can change public perceptions. For a long time, people had trouble seeing that there was anybody but the smoker to blame, but at last they realized that the company making the product also bore responsibility—particularly if it had misrepresented the facts. Now people are looking at obesity and starting to make the same connections. —John F. Banzhaf III, a public interest law professor at George Washington University, has litigated many times against tobacco and fast-food companies.

 

FIX A TOXIC ENVIRONMENT 

Every person has a different “set point”—a weight range of 20 to 30 pounds that his or her body considers appropriate. Healthy eating and exercise can get you to the low end of that range, but try to go further, and the body rebels by conserving energy and increasing the desire to eat. That’s why more than 95% of people who lose dramatic amounts of weight eventually put the pounds back on. Still, our public health policies continue to be guided by the notion that, with willpower and discipline, people with obesity can be thin.

While it’s not yet clear which combination of genetics and conditioning creates a set point, we do know that modern life—with its abundant food, reduced need for physical activity, high stress and irregular sleep patterns—has caused set points to rise sharply for much of the population. We’ve created a toxic environment, and this is how our bodies have responded.

Obesity should be considered a disease, and treatments—whether by a physician, a psychologist or a nutritionist&mdsh;should be reimbursed. To the extent that set points can be modified, the younger the better. We need more research about preventing obesity in the very early stages of life—perhaps even in utero, by encouraging changes in a mother’s behavior. —Lee M. Kaplan is director of the Weight Center at Massachusetts General Hospital and chairman of the board of the Campaign to End Obesity, a national nonprofit organization.

 

DOSSIER

1. The End of Overeating: Taking Control of the Insatiable American Appetite, by David Kessler [Rodale Books, April 2009]. Kessler, a pediatrician and FDA commissioner under Presidents George H. W. Bush and Bill Clinton, explains the science behind appetite and food cravings, noting that highly palatable foods containing sugar, fat and salt activate the brain’s reward center and trigger overeating. He argues that changing one’s behavior is the key to reversing the obesity epidemic.

2. F as in Fat: How Obesity Policies Are Failing in America, by S. Vinter et al. [Trust for America’s Health, August 2008]. This fifth annual report documents the fact that the rate of obesity has increased in 37 states and recommends that federal policymakers join with state and local governments, businesses and schools to craft a national strategy aimed at combating the trend.

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