In 1948, Congress doled out $5 billion to Europe in the first installment of the Marshall Plan, the World Health Organization was born, a simian astronaut named Albert I was launched into the atmosphere (he died), and doctors in Framingham, Massachusetts, an American everytown that once was a seat of the abolitionist movement, began a pioneering study of cardiovascular disease. Its initial results helped persuade the American Heart Association, in 1960, to push Americans to smoke fewer cigarettes and, a year later, to cut down on cholesterol. Today, thanks to a long-running public-health campaign, Americans have lower blood pressure and cholesterol, they smoke less, and fewer die from cardiovascular disease. In fact, from 1980 to 2000, the rate of deaths from cardiovascular disease fell by at least half in most developed countries.
Would that we had had similar success battling obesity. In 1960, when President-elect John F. Kennedy fretted about fitness in an essay for Sports Illustrated titled “The Soft American,” roughly 45 percent of adults were considered overweight, including 13 percent who were counted as obese; for younger Americans, ages 6 to 17, the rate was 4 percent. Obesity rates remained relatively stable for the next 20 years, but then, from 1980 to 2000, they doubled. In 2001, the U.S. surgeon general announced that obesity had reached “epidemic” proportions. Seven years later, as the obesity rate continued to rise, 68 percent of American adults were overweight, and 34 percent were obese; roughly one in three children and adolescents was overweight, and nearly one in five was obese. Americans now consume 2,700 calories a day, about 500 calories more than 40 years ago. In 2010, we still rank as the world’s fattest developed nation, with an obesity rate more than double that of many European nations.
Video: Marc Ambinder revisits his decision to have bariatric surgery
For that dubious distinction, we pay a high price. The obese are more likely to be depressed, to miss school or work, to feel suicidal, to earn less, and to find it difficult to marry. And their health care costs a lot. Obese Americans spend about 42 percent more than healthy-weight people on medical care each year. Improper weight and diet strongly correlate with chronic diseases, which account for three-fourths of all health-care spending. Type 2 diabetes is one of the leading drivers of rising costs for Medicare patients, and 60 percent of cases result directly from weight gain. In short, even as the nation is convulsed by a political struggle to “reform” health care, no effort to contain its costs is likely to succeed if we can’t beat obesity.
The good news, if you can call it that, is that the rate of increase in obesity in the United States seems to be slowing. The bad news is that no one knows exactly why. And the debate on how to deal with obesity remains frozen. On one side are the proponents of individual responsibility, who believe that fat people suffer from a surplus of self-indulgence and a shortage of willpower. On the other are people who believe that Americans are getting fatter because of powerful environmental factors like cheap corn, fast food, and unscrupulous advertising. Each side is held in political check by the other, and both have advocated unrealistic solutions: diets and exercise programs and miracle drugs that don’t work versus massive, and in many cases punitive, government interventions that are politically impossible.
I’m intimately acquainted with the struggle against fat. I may have been skinny as a child—my family used to joke about putting meat on my bones—and I played sports in school, but by the time I was bar mitzvahed, I was overweight. In my 20s, I spent hundreds of hours with personal trainers and diet doctors, and tried virtually every popular diet at least once. Lots of money in the pockets of the gurus; no joy for me. Approaching the age of 30, I passed the nebulous but generally accepted clinical threshold separating the merely overweight from the obese: a ratio of weight (in kilograms) to the square of height (in meters) of 30 or more. (A body-mass index, or BMI, of 18.5 to 24.9 is considered “normal”; from 25 to 29.9 is considered “overweight.”) I also developed severe diabetes and sleep apnea. My aching back was the least of my problems.
Perhaps my own losing struggle with weight reflects a failure of willpower. That seems more plausible to me than the argument that I was a helpless victim of Arby’s. But most fat people aren’t like me: as an upper-middle-class professional, I could draw on plenty of resources in my battle against weight. The people most vulnerable to obesity, however, do not have access to healthy food, to role models, to solid health-care and community infrastructures, to accurate information, to effective treatments, and even to the time necessary to change their relationship with food. And if that is true for fat adults, it is even more true for fat children, many of whose choices are made for them. Their vulnerability to obesity is much more the result of societal inequalities than of any character flaw. Indeed, for all the attention paid to fat’s economic costs, the epidemic’s toll on children is a stark reminder of its moral dimension. Without some form of intervention, researchers worry, large numbers of black and Hispanic children in the United States will grow up overweight or obese and lead shorter, less fulfilling lives. Is that a legacy we want to live with?
If we are to solve the many problems that obesity is creating for American society, we must first move beyond the stale “willpower versus the food-industrial complex” debate. We need to understand what causes obesity, and what can really address it. And we need to try everything from rezoning fast-food restaurants and restricting food advertising to supporting new treatments and rewriting insurance policies. We won’t summon the collective will to take these steps until we recognize that our attitudes toward obesity are as unhealthy as the condition itself. We don’t want to look at fat people, much less pay for their medical care; we don’t want to be contaminated by them. But if we want fewer fat people in our midst, then we, as a nation, must start by treating them without condescension or contempt, and recognize the real obstacles that stand between them and better health.
It’s fashionable in anti-obesity circles to borrow insights and metaphors from the 50-year battle against smoking. That struggle offers useful lessons, mostly in the sphere of politics, but the story arc of American tobacco is much less complicated: nicotine is a habit-forming drug packaged in a carcinogenic product that the tobacco industry promoted while hiding the truth about its deadly effects. Doctors knew that nicotine was addictive, and they had ways to treat the addiction. Raising the social stigma against smoking helped to curb the practice, as did higher taxes on cigarettes.
Obesity belongs in a different category of social illness. You can’t become a smoker until you decide to start smoking. For all the peer pressure and advertising that helped turn many 20th-century Americans into walking chimneys, you don’t have to smoke to live. “But if you go with the flow in America today, you will end up overweight or obese,” Thomas Frieden, the director of the Centers for Disease Control and Prevention, told me when I met him at an obesity conference in Washington last summer. “This does not absolve individuals of the responsibility of trying to get more exercise and eat healthier. But it suggests a synergy between policy intervention and personal efforts to lose weight.” Frieden’s tenure as New York City’s health commissioner from 2002 to 2009 was intensely productive and attention-getting: under his direction, the city banned trans fats from restaurants. And as anyone in Manhattan who grabs breakfast at Dunkin’ Donuts or other chain establishments knows, caloric content is strategically placed on menus. “I am confident that the problem of obesity can be solved,” Frieden told me. “But whether it will be solved is a different question.”
The rise in obesity is associated with a rogue’s gallery of individual, social, and technological factors. The “Big Two,” as scientists call the leading factors, are reduced exercise and increased food consumption: Americans are ingesting more and more calories than they’re burning. But underlying that simple energy-in, energy-out equation is a complex, and so far inexorable, interplay between powerful physiological and societal forces.
Start with our bodies. Molded by evolution in the Pleistocene era, when grains and meat were not easily acquired, they are hardwired to store as much energy in reserve—fat—as possible. Some scientists think that the brain tries to regulate our caloric intake and metabolism to keep our weight within a range that is heavily influenced by our genes. This “set-point theory” argues that an obese person’s body will actually “defend” an excessive weight. An alternative hypothesis, “settling-point theory,” argues that body weight settles into a range determined not just by genes, but by their interaction with learned behaviors and environmental cues.
External physiological factors also play a part. Start by blaming your mother: recent research suggests that your likelihood of obesity may be shaped by how much she ate during pregnancy (mothers who dieted or overate were more likely to have babies at risk of obesity later in life) and whether she smoked (smoking may suppress appetite, but it correlates with fatter offspring). Obesity is also correlated with lack of sleep, with exposure to certain chemicals (like bisphenol A, used in making plastic bottles), even with the type of bacteria that is found in our intestines. And, of course, we adapt, not necessarily in the most healthful way: a high-fat, high-sugar diet can alter the composition of the bacterial flora to persuade our gut to signal the brain to eat even more.
When we subject our Pleistocene bodies to our modern era, in which corn is cheap and animals are killed by others and safely prepared, the effect on waistlines might seem predictable. But why did the obesity rate accelerate in the United States beginning in the 1980s, setting us apart from our peers in other developed countries? (Though the Mexicans and the British come close.) Did Ronald Reagan’s declaration that “it’s morning again in America” prompt us all to start eating bigger breakfasts?
Sort of. Over the past two decades, as the U.S. economy shed manufacturing jobs, work has become more sedentary for many people; the decline in the real minimum wage and thus labor costs (which account for one-third of the cost of fast food) has made that Happy Meal even happier; and the pressures and distractions of modern life have driven us away from our hearths and off to T.G.I. Friday’s. The average American spends half of his or her food budget outside the home, and the concept of a “regular” mealtime—which correlates with healthful body weight—has been consigned to the dustbin of Nick at Nite sitcoms. (When a group of Italian economists recently divided the number of calories consumed per day by the amount of time spent preparing food, they found that Americans consumed 42 percent more calories per minute of food-prep time than Europeans.) Portion sizes have increased at restaurants and at home: Brian Wansink of Cornell University and Collin Payne of New Mexico State University reviewed all seven editions of The Joy of Cooking and found that, since 1936, the calorie counts for one serving of 17 out of the 18 recipes that have been continuously published—including macaroni and cheese, beef stroganoff, and apple pie—have increased by 63 percent.
Food companies like to keep us happy, and they’ve figured out which molecular combinations make our mouths water. Cheaply manufactured, energy-dense, sugary and salty snacks now crowd our refrigerators and pantries. David Kessler, a former commissioner of the Food and Drug Administration, has written a book, The End of Overeating, that accuses the food industry of manipulating the levels of sugar, salt, and fats in food in order to create a neurochemical addiction. Over time, these “hyperpalatable” foods change our brain chemistry in ways that make us overeat. Other researchers have discovered that withholding sugar from rats seems to bring on symptoms similar to those produced by drug withdrawal. Food companies have also done their best to turn food into entertainment: we barely blink at fast-food commercials that lure kids by offering free toys with their meals. Even the non-food economy has learned the benefits of having food around: according to researchers at Tulane University, a fifth of furniture stores, for example, serve up candy and other high-calorie snacks. As Kessler puts it, “It’s socially acceptable to eat at any time. That wasn’t the case four or five decades ago.”
Those at the base of the socioeconomic pyramid have been most exposed to these changes and have the fewest resources to resist or counteract them. In fact, obesity has become a marker of sorts for lower socioeconomic status. The lower your educational attainment, the more likely you are to be obese. In the United States and other developed countries, where access to food isn’t usually a problem, poor people tend to be fatter than wealthy people, and Americans living in rural areas tend to be more obese than Americans living in inner cities. (In 2008, the five states with obesity rates of 30 percent or more were Alabama, Mississippi, Oklahoma, South Carolina, and Tennessee.) Black children are more at peril of becoming obese than white children; black women are more than 50 percent more likely to be obese than white women. “At the current rate of increase,” epidemiologists noted in a recent article in Obesity, “it will take less than 30 years for all black women to become overweight or obese.” Obesity rates are above average among Mexican American boys, as they are among Hispanics generally. Obesity rates among young American Indians tend to be nearly twice the national average.
Untangling correlation and causation is difficult, and many of the causes overlap. But obesity researchers increasingly believe that material disadvantages best explain the spread of obesity among poor people. Populations with less access to health care, for example, tend to receive less preventive care like nutritional advice or weight-loss regimens. Many poorer neighborhoods have fewer supermarkets and more fast-food franchises per capita. The food sold at bodegas, small markets, and convenience stores in inner cities is frequently of poor quality and cheap. What’s cheap? Well, as obesity researchers like to point out, over the past several decades, fresh-fruit and vegetable prices have risen significantly while prices for sugary processed foods have dropped.