Respond to this Article December 2001

Fixing a Fat Nation

Why diets and gyms won't save us from the obesity epidemic.

By Tom Farley and Deborah Cohen

On a Tuesday evening, in a brightly lit classroom at West Jefferson Medical Center in suburban New Orleans, 10 fat people are gathered for their weekly support meeting under the guidance of a physician, a psychologist, and a dietician. One by one, the participants share their successes and lapses. "I lost one pound since last week," says Robert. The group answers with polite applause. Next, Tiffany: "My weight was the same." Sympathetic nods. "But I bought a new skirt and I went down three skirt sizes." Enthusiastic clapping.

Behavioral-modification programs like this one designed to treat obesity can be found across the United States. But the participants in this case are children, some as young as five. The average participant enters the clinic at an astonishing 69 pounds overweight. These children are far from unusual. As of the early 1990s, the National Center for Health Statistics (NCHS) found that 11 percent of children between six and 17 were overweight, twice the comparable percentage a decade earlier. Today there are 5.4 million overweight American children, and another 7 million considered "at risk" of joining them.

The epidemic of childhood obesity is only the latest grim chapter of a burgeoning American tragedy. The NCHS found that the proportion of obese adults increased by two-thirds in the 30 years from the early 1960s to the early 1990s. Telephone surveys by the Centers for Disease Control (CDC) have shown obesity rates skyrocketing another two-thirds since then.

In 1991, when the epidemic was less intense, researchers from St. Luke's/Roosevelt Hospital in New York estimated that obesity killed 325,000 Americans a year---eight times the number who die of AIDS, and more than the combined deaths from alcohol, drugs, firearms, and motor vehicles. It approaches the 430,000 per year killed by smoking. But while smoking rates are going down, obesity rates are accelerating. Soon---if it hasn't happened already---obesity will become the number-one killer in America. The cost of caring for those sickened with entirely preventable obesity-related illnesses tops $70 billion per year, about half of which is paid by government.

Now, here's the scary part: Everything the medical community has prescribed to fight obesity has failed. Even the best programs, like the kids' clinic in New Orleans, do little more over the long term than keep off a few pounds. Since the 1950s, health experts have been warning Americans to lose weight and telling them how: by eating less and exercising more. Over that time, obesity rates tripled. It's about time we admitted that we are losing the battle against obesity.

This isn't news. Individually, we beat ourselves up for lack of willpower or for choosing a night at a burger joint with the kids over a trip to the gym, dramatizing personal failure even though in today's junk-food-laden society, it's nearly impossible to stay thin. The desk job, the television, the Internet, suburban housing developments and their roads to nowhere all conspire against us. Yet we still view obesity as an individual problem, and so does the government.

But the epidemic is spreading at such an alarming rate that it can no more be viewed as an individual failing than 19th-century cholera epidemics could be blamed on poor personal hygiene. Indeed, given the rate Americans are dying, we'd better start treating obesity like an infectious epidemic. Combating obesity and its many attendant illnesses will not require more cholesterol-lowering drugs or even diet books or workout videos, but rather a retooling of our environment to get us moving again and to put the doughnuts a little farther out of reach.

The dangers of mid-management spread

Obesity is not just an image problem. Those who are overweight are more likely than thin people to die from heart disease. They have higher blood pressure and greater risk of stroke and kidney failure caused by hypertension; colon, breast, and prostate cancer; gallstones and arthritis. To this list, the National Institutes of Health (NIH) adds "complications of pregnancy, menstrual irregularities, hirsutism, stress incontinence, and psychological disorders (depression)."

Overweight people are also much more likely to develop diabetes, an increase in blood sugar derived from the body's resistance to the hormone insulin, which itself increases the risk of heart disease, stroke, and kidney failure. By damaging circulation in blood vessels, diabetes can lead to infections of the extremities, usually the feet, necessitating amputations. It causes blindness. From 1958 to 1998, the percent of American adults diagnosed with diabetes increased sixfold. At least 20 million Americans now have diabetes, including millions who are unaware. Related medical care costs, currently $44 billion a year, are rising fast.

These days, it isn't hard to spot truly gargantuan people. Watching a 300- or 400-pounder lumber down a supermarket aisle or struggle into an airplane seat, it's easy---perhaps even comforting---to decide that our own 20- or 30-pound inner tubes are nothing to worry about. But because there are so many more of us than them, far more of those who die unnecessarily are in our group. The epidemic isn't just a problem of the grossly obese; it's a problem for all of us.

Americans know that fat is bad for us. We've been hearing it for a half a century, from American Heart Association warnings in the 1950s to pamphlets distributed by the President's Council on Physical Fitness under Lyndon Johnson in the 1960s, to grave CDC warnings about the deepening problem in the 1990s. For a time, in the 1970s, it appeared as though the nation might overcome its fat problem. After Frank Shorter took the gold medal in the marathon in the 1972 Munich Olympics, road races sprouted up everywhere, some with tens of thousands of runners. Sports like tennis and golf also boomed. By 1978, U.S. News & World Report was trumpeting a "fitness mania." "We believe that America is going through a physical-fitness renaissance that can make a real dent in degenerative diseases," Richard Keelor of the President's Council on Physical Fitness said at the time. But it was about this time that already rising obesity rates started to skyrocket.

A Coke a day makes the fat genes play

Why are we so much fatter than our parents 30 years ago? After all, while dietary surveys over the last 20 years show inconsistent results, none show big increases in the number of calories American adults eat per day. Sports clubs, gyms, and road races seem to be springing up on every corner, at least providing the illusion that some people are working out more than they used to.

NIH researchers are spending tens of millions studying the biology behind this conundrum. They've unearthed some interesting facts: Some people are more prone to become obese than others, and to some extent this bad luck is in their genes. The recently discovered hormone leptin helps regulate appetite and physical activity; a handful of people become obese for lack of an adequate supply. But human genes and metabolism don't trump the basic laws of metabolics: We gain weight when we eat more fuel than we burn. If we eat 2,200 calories a day and burn 2,000, our bodies---programmed for the near-starvation conditions of our hunter-gatherer days---store fat for the next famine. We tend to eat a fairly consistent amount of food no matter how many calories we need, so high-fat calorie-dense foods make us fat.

Laboratory rats switched from rat chow to a "supermarket diet" similar to the high-fat diets of modern Americans quickly grow obese. And, when we're not hungry, we can still be tempted by foods or drinks that meet our biologic cravings for sweet or high-fat foods.

It doesn't take much caloric imbalance to make people obese, only consistency. For instance, if a person drives instead of walks for only 20 minutes every day for a year he will store about 26,000 calories, thus gaining about five pounds. Researchers at the University of Minnesota estimated that over a year, those who spend only five minutes each workday sending e-mails to coworkers instead of visiting their offices will gain an extra pound. Drinking a single can of Coke every other day will contribute enough calories to add about four pounds. Most of us gain weight this way, a few grams a day, a few pounds a year---but enough to shorten our lives.

Fat Failures

As a nation, what have we done to respond to this epidemic that kills 325,000 people a year?

Well, we've spent heavily on medical treatment. But it's a near complete failure. Most drugs tested as obesity cures have been so dangerous that the FDA has kept them off the market or withdrawn them after approval (most notably Fen-Phen). The effectiveness of weight-loss drugs is, in the NIH's cautious word, "modest"; they may cut five or 10 pounds. Intestinal bypass (or "bariatric") surgery can cause fat to melt away, but it's so radical and dangerous that doctors reserve it only for the 300-pound-and-above crowd.

Diets and exercise programs aren't much better. An expert panel at NIH concluded that people who follow strict low-calorie diets can lower their weight by about 8 percent over six months. The trouble is, they gain half of it back within the next two to three years. On average, obese people on a prescribed exercise program only lose 2.5 percent of their weight. And these slim successes are people in intensive programs constantly monitored, educated, and encouraged. Sad as it is to say, we ought to consider obesity, like most other chronic health conditions, as pretty much permanent damage.

If fat people and their doctors can't cure obesity, as a nation we ought to prevent it. Health experts have been trying to prevent obesity for decades. But careful large-scale community trials have proven education programs to prevent obesity to be a complete flop; intervention groups gain as much weight as "control" groups. School-based education programs to prevent obesity do no better (unless they include a supervised exercise component).

We shouldn't be surprised that in the United States as a whole, the call, however urgent, to "eat less, exercise more" has failed. There are limits to the summonable willpower of those immersed in an environment that promotes overeating and laziness. The instinct to seek calories and stockpile them for lean times ahead is hard-wired in our genes. (In fact, the few people who truly overcome their body's natural desire to eat have a psychiatric disorder: anorexia nervosa). It may clear our collective conscience to say that obese people can control their habits in eating and exercise, but it won't touch the epidemic.

A key problem is that health experts usually promote dieting and exercise for obese people rather than healthy eating and physical activity for all of us. Obese people are not likely to lose weight through dieting and exercising, but we all would gain less from healthy eating and physical activity.

The only way most Americans are going to get moving is by making activity a daily routine. There may seem to be a lot of joggers out in parks these days, and private workout spas may be booming, but the percentage of Americans that are deliberately exercising seems doomed always to be small. Only about 15 percent of people tell interviewers in national surveys that they work out regularly, a number unchanged since the mid-1980s.

The same generalization applies to diet. Americans try valiantly to lose weight by dieting, but almost no one keeps on a diet for long. The temptations of easily accessible food are too great. We don't need another diet.  We need a way to make healthy eating unavoidable.

Snacks Attack

After 3 p.m. on weekdays in New Orleans, teenagers wearing plaid school uniforms of Warren Easton High School drift into the Burger King on Canal Street just off campus to order drinks or fries, or just to hang out. Whoppers cost $1.99. A "Value Meal," which includes a Coke and fries, is just $3.39, while packing 1,190 calories, more than half a day's requirement for teenage girls. If you choose to "King Size" your Value Meal (more fries, bigger drink) for 80 cents, you can boost the calories to 1,570.

Next to the Burger King is a McDonald's. And around the corner stands Rally's, another low-cost burger chain. The kids milling around all three make up the restaurant's largest group of customers.

America is larded with high-fat, calorie-dense junk food. Supermarkets devote more shelf space to snacks than to produce. Vending machines sprout up everywhere (including schools). As a New Orleans gas station recently, we discovered Coke vending machines on every pump island so that drivers didn't even have to walk to the cashier for 140 calories of dissolved sugar. The Coca-Cola company admits its goal is to put a Coke within arm's reach of as many people in the world as possible.

Besides in-your-face availability, these forces include saturation advertising. According to Advertising Age, food industry ad spending runs about $10 billion per year. McDonald's alone spends more than $1 billion and Coke more $800 million. These investments pay off, overwhelming healthy messages like the national 5-A-Day fruit-and-vegetable campaign, funded annually at a paltry $2 million.

The promotion and availability of junk food is cutting down on meals eaten at home (which tend to be relatively healthy) and replacing them with constant snacking away from home. Between 1970 and 1995, the percentage of Americans' total meal dollars spent this way nearly doubled to 40 percent. Between 1977 and 1995, the percentage of meals eaten at fast-food restaurants tripled. Vending-machine snack sales jumped 85 percent in the last three decades after adjustment for inflation. As of 1996, teenagers got 25 percent of their calories from snacks. From the late 1970s to the mid-1990s, consumption of soft drinks increased 131 percent. Americans now guzzle an average of 44 gallons of soft drinks per year---well over one 12-oz can a day for every American, easily enough to add a few pounds to each of us every year.

Fat City, USA

Last year, Physicians Weekly dubbed Atlanta "Fat City USA," after its citizens logged a staggering 100-percent increase in aggregate fatness over the previous seven years. Southern food has always clung to the waistline, but it can't account for all of the gain. Other environmental factors had to be at work. Atlanta, of course, embodies all of the worst elements of American sprawl, such as strip malls of big-box warehouse stores with acres of parking lots, six-lane roadways impossible to cross on foot, an absence of efficient public transportation---all of which make for sedentary living. But much of what ails Atlanta can be found in practically every American community.

Americans don't walk any more. If we want to move, we drive. Neighborhoods are segregated from commercial and industrial areas, and sidewalks and crosswalks have disappeared, making it impossible for most of us to walk to a store or to work. In 1995, the National Personal Transportation Survey showed that people traveled on foot or on bicycles for a pitiful 5 percent of trips, down from 7 percent in 1990 and 9 percent in 1983.

Nor are cars the only culprit. Nielsen surveys now show Americans watching an average of four hours of television a day. When we watch television, our bodies downshift into semi-comatose mode, heart rate and muscle activity dropping virtually to sleeping levels. (Thanks to remote control, we don't even get the tiny boost of getting off the couch.)

Even simply sitting and talking with friends burns about 35 calories more per hour than watching TV. Just three hours of TV a day can increase an average couch potato's weight by as much as seven pounds a year. Television-watching has even been the subject of the gold standard of medical evaluations: the randomized controlled trial. Over just six months, growing elementary-school children who kept their TVs gained significantly more weight than children who were asked to give them up.

Schools used to make up for these problems at home by forcing kids to exercise in physical education classes. But of the children in the New Orleans obesity clinic, only two said they had PE classes more than one day per week. National surveys showed that the percentage of high schoolers who attended PE classes five days a week decreased from 42 percent in 1991 to 15 percent in 1996; in any given week 79 percent of adolescents do not get PE at all.

All these factors, bad enough for the middle class, turn toxic for the poor and minorities. In poor neighborhoods in New Orleans it is hard to avoid corner stores selling doughnuts, potato chips, or fried chicken, while genuine grocery stores are lacking. And in poor neighborhoods, responsible mothers worried about the dangers of the streets corral their children indoors, tethering them to television sets and video games. In a Yankelovich Partners survey, nearly one-third of Americans with incomes below $15,000 per year said they did not walk or jog in their neighborhood for fear of crime, double the proportion of those making $25,000. As a result, today, more than half of poor black women are classified as obese.

The Twinkie Tax

Given the overwhelming forces working to undermine our fat consciousness, we might conclude that obesity is inevitable. But there are plenty of things we can do to blunt the epidemic.

First, on the intake side: We can't ban junk food, but we can regulate it. Michael Jacobson of the Center for Science in the Public Interest and Kelly Brownell of Yale University have proposed slapping a tax on soft drinks and junk food. Such a "Twinkie Tax" may at first seem crazy, but even cigarette sales go down when they are taxed, and tobacco is an addictive drug for which its addicts have few alternatives.

A portion of the revenue of such a tax could be used to advertise healthy food or for counter-advertising junk food. One survey found that 45 percent of adults would support junk-food taxes if the revenues went to health education programs. Jacobson and Brownell estimate that even so tiny a tax as 1 cent per can of soft drink would generate $1.5 billion per year. If only one-third of this were used for counter-advertising, it would still only be 5 percent of the $10 billion spent on advertising by the U.S. food industry. But counter advertising works. When Congress's "Fairness Doctrine" gave us heavy counter-advertising against smoking in the 1960s, cigarette sales fell so quickly that the tobacco companies agreed to eliminate their TV advertising just to get the other ads off the air.

Some of the Twinkie-Tax proceeds could be used to subsidize such healthy foods as fruits and vegetables. Researchers at the University of Minnesota found that cutting the price of low-fat foods in vending machines by 10 percent increased sales by nine percent; bigger discounts correlated with even greater relative sales increases.

We also ought to think about regulating food industry advertising itself. At the very least, we should ban advertising of junk foods to kids, particularly during peak hours of children's television programming. (Parents would likely be eternally grateful to any politician who made this happen.)

Besides taxing junk food and banning its advertising to kids, we can limit the places in which it is available. No one will tell Burger King that it can't run its business, but in the middle of a killer epidemic is it really a good idea to have three fast-food joints within a half a block of a high school? There is no reason we can't, through zoning and planning, regulate the location, density, or hours of junk-food outlets, especially around schools. We also ought to put limits on the location and number of snack-food and soft-drink vending machines.

We should strengthen and enforce the USDA regulation of foods sold in schools. Since the 1940s, federal law has required that lunches and other foods sold in school be nutritious, but the junk food industry has eroded the law and its enforcement over the years. Soft-drink companies are now signing contracts that guarantee schools multimillion-dollar payments in return for putting in vending machines. We should act at the federal, state, and local levels to eliminate such contracts, banning sales of soft drinks in schools all together.

Changes in our modern environment can also increase physical activity, particularly walking and bicycling. For starters, we can require that all neighborhoods have sidewalks and bike paths. A little progress has been made here. When new transportation laws allowed federal highway funds to pay for bicycle paths and sidewalks, federal expenditures for bicycling and walking projects grew in the 1990s from almost nothing to nearly $300 million per year. Still, this represents less than 1 percent of federal highway dollars.

Building recreational bikeways and walking paths makes it easier for people to exercise, but if we really want to make physical activity routine, those paths and trails need to go somewhere useful---such as a store, school, or workplace. That means creating more densely built mixed-use neighborhoods which integrate residential and commercial real estate.

The benefits of this kind of design are already well documented. Studies show that people living in the suburbs, whose neighborhoods are typically less dense than urban areas, drive twice as far and walk and cycle one-third as often as their city counterparts. In 1994, a San Francisco study found that residents of traditional neighborhoods which had a mix of residential and commercial uses made 16 percent of their journeys by bike or on foot, whereas people who lived in the suburbs walked or biked only 10 percent thereof. A Seattle study found that the activity breakdown could even be tied to the age of one's neighborhood. People who lived in neighborhoods built before 1947 went out on foot or bike more than three times every two days. People in developments created after 1977 (just about the time the obesity epidemic took off) dispensed with their cars just one-third as often.

Consider also the design of our buildings.How often have you, entering a building for the first time, been unable to find a stairway, or if you found it, avoided it because it was dark, dirty, or behind forbidding doors? Stair-climbing is a great way to burn calories: Kelly Brownell at Yale has estimated that walking up and down two flights of stairs just once a day for a year will keep off six pounds. Studies have shown that making stairs more accessible or more attractive increase use. At a Philadelphia train station, researchers put up a sign encouraging people to take the stairs rather than the elevator because it's "better for your heart": The number of stair-users tripled. (This no doubt also increased the critical "shame factor," a powerful motivator in changing behavior, as those who didn't really want to walk up may have felt pressured into it anyway by the sight of all those who did.)

Beyond physically redesigning our environment, we can put in place other structures to keep us active. In the middle of an epidemic of this size, we simply must require that kids in school get PE five days per week. Extending the school day until 5 or 6 p.m. would also go a long way to keeping kids out of fast-food joints until their parents come home from work.

Let Them Eat Cake

None of these ideas is new. Some health experts have been calling for environmental changes like these for over a quarter of a century. So why haven't we done anything yet? The government agency which ought to take the lead in responding to a public health crisis is the Department of Health and Human Services, but it has delegated the problem to NIH and CDC. NIH is still working on medical approaches: A review of their research grants on obesity showed that 75 percent were for genetic and metabolic studies, and less than one percent was for studies on environmental causes. CDC has done an excellent job tracking the epidemic and publicizing it, but it is not a regulatory agency and can't change government policy.

The federal government's lead agency for nutrition is the U.S. Department of Agriculture, whose primary mission of promoting agriculture often conflicts directly with health goals of reducing food consumption.

Then there's our cherished individual freedom. Some of our fierce individualism spills over into a vague feeling among eminently reasonable Americans that the government shouldn't be telling its people where they can or can't put a vending machine, and also translates into the sense that health is an individual responsibility. But history has shown that in dealing with epidemics of all sorts, ultimately collective, not individual, action radically improves public health.

About 150 years ago, Americans were dying from old-fashioned infectious-disease epidemics. Between 1813 and 1850 in Boston, Philadelphia, New York, and New Orleans, death rates increased by 42 percent thanks to such burdens of newly industrializing cities as crowding, dirty water, and open sewers. Cholera epidemics killed people by the tens of thousands.

The age's medical experts didn't actually know much about the causes of such diseases or how to fight epidemics. But noticing that poor immigrants in the filthy slums of port cities like Boston and New York were particularly likely to get sick and die, they concluded that their eating and drinking habits were "intemperate"; that, as public health historian John Duffy writes, "the basic problem with the poor lay in their lack of moral fiber." The poor had no one but themselves to blame for their diseases. They needed to be taught a combination of personal hygiene and resistance to sin.

It was a nice idea---not so different from today's health gurus' admonitions to lay off the French fries. Of course, like our current crop of self-help dieting books, the personal-hygiene lectures didn't do anything to stop the spread of disease. Then in 1842, a British reformer named Edwin Chadwick published The Sanitary Conditions of the Labouring Population, which argued that miserable working and living

conditions made the poor sick. They were no different from the rich, he argued, except in their environment. He called for local governments to take responsibility for fixing these problems, ensuring clean water, building sanitary sewers, removing animal carcasses, and providing decent housing.

Chadwick's ideas soon crossed the Atlantic and combined with citizen demands for clean water to create a "sanitary revolution" in the U.S. in the latter half of the 18th century, which forced cities to build water and sewage systems and brought about improvements in housing and working conditions. The revolution virtually eliminated infectious disease epidemics; between 1850 and 1915, death rates fell by 55 percent. This improvement---sudden and dramatic by historical standards---happened before doctors had any successful treatments for infectious diseases or even understood what caused them.

Afterward, the lesson was clear: Society could save lives not by teaching the dangers of filthy water or personal hygiene, but by improving living conditions so that people---educated or not---would drink clean water. Or as British preventive-medicine specialist Geoffrey Rose put it, "The great public health reforms of the 19th century which led to such dramatic improvements were undertaken for people, rather than by people."

If we really care about ending the biggest epidemic of our era and about saving some of those 325,000 lives lost each year to obesity, we'll have to try the same approach.

Tom Farley is a Professor at the Tulane University School of Public Health and Tropical Medicine. Deborah Cohen is a Senior Natural Scientist at the RAND Corporation.


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