Health May 2010

Beating Obesity

By 2015, four out of 10 Americans may be obese. Until last year, the author was one of them. The way he lost one-third of his weight isn’t for everyone. But unless America stops cheering The Biggest Loser and starts getting serious about preventing obesity, the country risks being overwhelmed by chronic disease and ballooning health costs. Will first lady Michelle Obama’s new plan to fight childhood obesity work, or is it just another false start in the country’s long and so far unsuccessful war against fat?
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Left, photo courtesy of the author; right, photo by Stephen Voss

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.

Moreover, living in neighborhoods among obese people makes one more likely to be obese. Social norms in those areas tend to be more accepting of obesity, so the “social costs associated with being obese,” the authors of a University of Colorado study write, might well be reduced. In 2007, researchers who spent 32 years following the weight of more than 12,000 Americans concluded that obesity was contagious—that people who were close friends with obese people had much higher chances of being obese themselves. Fatness, it seems, is viral.

This jumble of circumstances and effects is what Thomas Frieden means when he says that just being an American can naturally lead you to be obese: obesity is an almost inevitable consequence of living with our cultural norms, our history of agricultural production and subsidies, our long-standing socioeconomic inequalities, and the impact of technology on our behavior and bodies. Against this formidable dynamic, America has erected two lines of defense: name-calling, and hectoring about diet and exercise.

For the average fat person, life can be an endless chain of humiliating experiences. On a flight to Denver not too long ago, I watched as a very large woman struggled to settle into her seat. Next to her, a much skinnier man curled his lip in disgust. The woman softly asked a passing flight attendant for a seat-belt extender. The flight attendant didn’t hear her over the roar of the engines, so the woman had to ask again, and this time, everyone looked at her. Grocery shopping, eating at restaurants, going to the movies, having drinks at a crowded bar—for the fat person, these are situations to be negotiated and survived, not enjoyed. The workplace is no different: a television executive once remarked to me that my career as a political analyst would “really take off if [I] would just lose a few pounds.” When I was fat, I avoided meeting people’s eyes. I didn’t want to subject them to my ugliness.

Unfortunately, our culture reinforces this anxiety by turning obesity into pornography. This is not surprising. Obesity has become not just a scientific fad of sorts, generating intense research, curiosity, and public concern, but also a commercial gold mine that draws on the same kind of audiences that used to go to circus carnivals a century ago to peer at freakishly obese men and women. The TLC network, which long ago transcended its “Learning Channel” origins and gave the world Jon and Kate, now features obesity-programming blocks. One recent special followed the progress of an extremely obese teenage boy who struggled through bariatric surgery and its aftermath. Another special chronicled the life of the fattest man in the world. In addition to The Biggest Loser, NBC’s popular weight-loss boot-camp competition, and Fox’s More to Love, a dating show for larger people, the Oxygen network now has a dancing competition called Dance Your Ass Off. Fat people are funny.

The impact of “fat porn” on fat people is counterproductive. It’s true that stigma can restrain obesity rates. Researchers speculate, for example, that black men are less likely than black women to become obese, in part because within the black community they would face a higher stigma. In general, overweight young people tend to be socially marginalized. But there is little evidence that increasing stigma actually reduces obesity rates. And plenty of evidence shows that stigma makes fat people more likely to feel depressed, to experience stress, to receive poorer medical care, to experience discrimination in the workplace, to go on eating binges, and to duck exercise.

Stigma might be more bearable—an unpleasant way station on the path to a thinner, healthier life—if diet and exercise, the most prescribed solutions to obesity, worked. But they don’t. Qualification: if you eat less and exercise more, you’ll lose weight. But the chances that you’ll stick with that regimen are slim, and the chances that you’ll regain the weight, and then some, are quite high. A systematic review of weight-loss programs, by Thomas A. Wadden and Adam Gilden Tsai of the University of Pennsylvania, found that the evidence that commercial and self-help weight-loss programs work is “suboptimal.” People who diet often regain more weight than they lose.

Much of the solid advice society imparts to people who want to lose weight is best suited, intentionally or not, for well-off Americans. As I was Googling obesity earlier this year, an ad for a book by Jillian Michaels, the take-no-prisoners strength coach on The Biggest Loser, popped up: “Weight-loss expert Jillian Michaels has been there too. After years of exercise and painstaking dieting, she figured there had to be an easier and more effective way to become healthy and stay slim. And there is!”

Later, I flipped through Michaels’s book, and discovered that the real secret is … exercise and painstaking dieting. Michaels’s book argues that our physical environment messes up our hormones, which in turn affect our appetite and energy level. Eat a little of this and some of that, she tells us, but never this and only a smidgen of that. Don’t let stress rule your life. “GO ORGANIC.” “Prepare food to minimize toxins.” You want to know her secrets, but you quickly realize that her day job is her secret; her celebrity status, which lets her see top-flight endocrinologists, is her secret; the freedom her status and position in life give her to follow a diet, that’s her secret. On The Biggest Loser, contestants are plucked out of their environment and social circle, sent to a weight-loss boot camp, and forced to radically change their calorie intake and output for several months. That’s one way to lose weight. But who, besides the very rich, or the very idle, can replicate the show’s setup?

Lest you think I’m advocating the acceptance of obesity, I’m not. As Mark Hoofnagle, a surgeon and a leading crusader against obesity denialism, has put it, just because “modern medicine has largely ameliorated the effects of [being] overweight, that doesn’t mean that being overweight doesn’t put you at risk for a number of problems.” We should care about what we put into our bodies, and we shouldn’t neglect exercise. But we need to recognize the limits of individual agency, especially in the new, “obesogenic” environment that’s been created over the past 30 years, and especially for those in the bottom third of the socioeconomic pyramid. Putting individual solutions and free will up against the increase in portion sizes, massive technological and societal changes, food-company taste-engineering, and the ubiquity of effective television advertisements is like asking Ecuador to conquer China. And yet, that is what public-health campaigns suggest we do.

The government can’t ask someone to pursue a healthier lifestyle—to attain a “normal” BMI, to become a non-stigmatized being—if it isn’t prepared to provide that person with the foundation for health granted to some of us purely by the accident of birth. “Increasing awareness” about healthy lifestyles is not simply gentle paternalism; in the absence of real support, it’s immoral. In that context, stigmatizing young children for being fat is unconscionable; stigmatizing poor adults is only marginally less so; and stigmatizing Mexican American boys and black women and American Indian children of both genders for their weight is both immoral and racist.

There is a way to beat obesity. But it is radical and expensive. No other diet or weight-loss approach is remotely as effective as bariatric surgery. Most people who seek it out have tried everything else. Many of them can pinpoint the moment they concluded that they had no other choice.

Mine came late in the afternoon on June 13, 2008, when I learned that Tim Russert, the Meet the Press host, had died of a sudden heart attack at NBC’s Washington bureau. I didn’t know Russert well, but as I sat at my desk, my tolerance for the status quo ended. I’m 30 years old, I remember thinking. I can’t spend another decade like this. I Googled bariatric surgery Washington D.C.

Nine months later, on a morning in March 2009, Dr. Joseph Afram, the director of the bariatric-surgery program at George Washington University Hospital, picked up his scalpel and went to work, carefully separating my stomach from my digestive pouch and leaving a walnut-size cavity, which he then attached directly to my small intestine. When he was done, my stomach was … no longer. It had very little room for food, and if I ate more than it could hold, I can promise you, my stomach would let me know in a hurry.

In the half century since surgeons began performing bariatric procedures, the surgery’s mortality rate has declined to half of 1 percent, and its long-term success rate—people who keep at least 50 percent of their excess body weight off for several years—has become exceptional. For reasons clinicians still don’t quite understand, the surgery seems to cure diabetes, sometimes instantly. The surgery does not work for everyone: some people who endure it will essentially regrow their stomachs and gain back the weight. Though the rate of minor complications can exceed 30 percent, the incidence of more-severe complications is less than 3 percent. But the procedure is still an equalizing force: for a honeymoon period, about six months to a year after surgery, it allows you to resist the environmental and physical pressures that intensify appetite and food addiction.

I have been lucky. I weigh, as of this writing, 150 pounds—down from 235 pounds when I entered the operating theater, with a BMI of 34. My severe diabetes went away quickly. A few months later, I was able to sleep without an air mask for the first time in four years. My doctor kept watch over me, making sure I got enough protein, and looking for signs that I was channeling any addictive urges in the wrong direction (like alcohol or drugs).

For young adults who cross a certain weight threshold, bariatric surgery can be an effective preventive step. Its incidence among all adults doubled over six years, to 220,000 surgeries in 2008. And it seems to be increasingly prevalent among obese teenagers: one study suggests that from 2000 to 2003, the number of teens resorting to the procedure tripled. But it’s major surgery, and specialists aren’t comfortable doing it as a preventive measure. Moreover, many insurance companies (including mine) refuse to pay the $30,000 cost, reasoning that any economic benefit they would recoup is years down the road.

Surgery for, say, 1 million of America’s most obese might cost no less than $30 billion, and probably much more. While the total cost of surgery for everyone who is obese—perhaps as many as four out of 10 Americans by 2015—may well be less than the financial burden of the diseases associated with obesity, surgery still seems inordinately expensive, unwise, and unfeasible as a hypothetical mass solution. But the treatment does inform how we ought to approach the problem. The only way to cure obesity is to radically rewire the relationship between the stomach and the brain. Diet and exercise can’t do that as quickly or as well.

If we can’t easily cure obesity, we’ve got two choices: we rely on medical science to ameliorate its effects, in which case we consign the obese to a miserable life waiting for that one pill or Nature article that solves it all; or we get serious about helping to prevent people, and especially children, from becoming overweight and obese in the first place. (Eighty percent of people who were overweight at ages 10 to 15 are obese at 25.) This is the province of policy makers: state legislatures, school boards, members of Congress, executive-branch members, even corporate boards.

But forging any kind of political consensus on how best to curb obesity has been anything but easy. The tale of the Robert Wood Johnson Foundation, the largest philanthropy dedicated to improving health care in America, is instructive. In 2006, after fielding well-regarded campaigns against teen pregnancy, children’s tobacco use, and alcohol addiction, it decided to rethink its nationwide campaign against childhood obesity and become the “connective tissue of the movement,” as the director of the childhood-obesity project, Dwayne Proctor, told me. But the foundation was having trouble navigating the movement’s internal politics.

So in 2008 it asked Robert Raben, a former assistant attorney general under Bill Clinton, for help. Raben and his team held meetings with the different interests: anti-poverty activists; leaders of the “green products” movement, which works to improve food quality in inner cities; academic health experts; advocates for better urban planning (they’re known as the “Sidewalk people”); advocates for public transportation and bike use (the “Bike and Bus people”); the anti-high-fructose-corn-syrup crowd; the nutrition labelers; and others. Raben got a good discussion going. But he found it difficult to figure out how to fuse this collection of interests into a coherent political movement. Successful advocacy campaigns have a clear agenda. Obesity activists had many different agendas: Reducing suffering? Food security? Health? Anti-poverty? And there were even more-basic questions: Should the foundation increase its cooperation with the food industry? Should it adopt a confrontational stance?

“The problem with advocacy groups often is that they refuse to accept that the best policy solutions are additive,” Raben told me. The American political system makes it hard to displace entrenched interest groups. (Indeed, it took tobacco critics half a century before the relevant committees in Congress had enough anti-tobacco members to pass legislation allowing the FDA to regulate tobacco as a drug.) “The committees with the most jurisdiction over food and nutrition policies are the agricultural committees,” Raben says. “Who tend to want a seat on those committees? Not people who represent the consumers of goods. It’s the people whose constituents grow and refine the corn and the fructose. And the problem with advocacy groups is that they refuse to accept that the solution is not about replacing corn subsidies, it’s about adding tomato subsidies. But they’d rather demonize.”

To describe existing federal policies and regulatory approaches on obesity as a patchwork is an insult to quilts everywhere. At least five federal agencies have put forward some kind of national strategy on obesity. Some regulatory challenges have a familiar financial ring: the Food and Drug Administration, which among other things oversees all nutritional labeling and the appraisal of diet drugs, regulates a trillion dollars’ worth of products a year, and has a budget of only $3.2 billion (which actually reflects a significant increase over the previous year). It has 1,800 investigators to inspect about 160,000 domestic establishments.

Other challenges are more complex, embedded in long-standing institutional and legal struggles. The Department of Agriculture is charged with both promoting American agriculture and regulating it. The tendency of former USDA officials (notably the former secretary Dan Glickman) to subsequently work on behalf of food giants like Archer Daniels Midland gives you some idea of the extent of what economists call “regulatory capture.” Tom Vilsack, the current secretary of agriculture, may be more willing to take up the fight against obesity: he grew up chubby and has struggled with his weight. But the long-running saga of the USDA’s National School Lunch Program shows the limits of his department’s regulatory powers: started in 1946 in response to the nutritional deficiencies of U.S. military recruits, the program soon became embroiled in serial struggles among food and drink companies, farmers, agribusiness, school administrators, and nutritionists over who could regulate what, where, and when. In 1983, acting on a suit brought by the National Soft Drink Association (now the American Beverage Association), a panel of judges that included Robert Bork ruled that the USDA could regulate drinks only in public-school cafeterias, and only at mealtimes. As long as soft-drink and candy companies had the permission of local school boards and administrators (who often needed fees from these companies to fund school activities), they could sell anything anytime or anyplace else. So the next time you straddle a doorway between a school cafeteria and a hall, know that you’re between two regulatory universes.

For many anti-obesity activists, the holy grail of federal regulation is food marketing. Wide evidence suggests that advertising feeds obesity, triggering what the psychologist Robert Cialdini has called the brain’s “click-whirr” response. Recently, for example, psychologists at Yale University showed a cartoon to two groups of children. One group saw food commercials interlaced between segments; the other viewed the cartoon with commercials, but not for food products. Both groups were given a snack to eat while watching. The children who saw the food ads ate nearly 50 percent more of the snack they were offered. It didn’t seem to matter what the advertised food actually was: “Across diverse populations,” wrote the researchers, “food advertising that promoted snacking, fun, happiness, and excitement (i.e., the majority of children’s food advertisements) directly contributed to increased food intake.”

But the battle-scarred Federal Trade Commission has good reason to move slowly on this front. In 1978, when the public-health bugaboo was not obesity but tooth decay, it took a look at food and drink commercials targeted at kids and concluded that many were unfair. “Unfair” meant that the benefits of the products didn’t outweigh the drawbacks, and that kids did not possess the sophistication to make informed decisions. Emboldened by liberal paternalism and tone-deaf to brewing anti-government sentiment, the FTC went beyond what the science supported and proposed three rules: that all ads aimed at children 6 and younger be banned; that ads for especially unhealthy sugary foods (those that threaten dental health) be banned for children ages 7 to 11; and that ads for less-sugary foods aimed at them include health disclaimers. A Washington Post editorial wondered why the FTC had become the “great national nanny.” What happened next emboldened opponents of regulation for decades: an industry lobbying campaign was so effective that Congress pointedly (though briefly) would not reauthorize the agency’s budget. For the past 30 years, the FTC has been reluctant to test the limits of its authority in this area and has brought cases against food companies only rarely. It is exquisitely sensitive to charges of intervening in the space reserved for families, with a senior official reasoning in 2004 that parents had much more ability, because of technologies like TiVo, to control their kids’ viewing habits than they did in 1978.

Congress has its crusaders seeking to goad federal agencies like the FTC into more-effective action. Chief among them is Democratic Senator Tom Harkin of Iowa, who told me that he became seized with the problem of obesity as a member of the Senate Agriculture Committee: “We were dealing with food, nutrition, and infant formula, and the more I got into that, the more I began to see that while we’ve got food stamps for people and we’ve really conquered hunger in America, all these people on food stamps are obese.”

When Harkin was chairman of the committee, he drafted the USDA’s budget for the federal school-lunch program. Last spring, Harkin introduced a bill that would regulate the snack machines outside cafeterias that are such a prodigious source of calories for kids. For years, he has championed efforts to standardize and make more visible the nutrition content on food labeling. (The evidence that this particular intervention works is scant; in general, people who are already healthy are the ones most likely to read food labels.) In 2004, Harkin asked the FTC to study the potential effects of an advertising ban; in 2008, in a follow-on study that Harkin also pushed for, the agency found that marketing to kids was pervasive and damaging, even as it stated, without irony, that most large companies were beginning to take their “self-regulatory obligations seriously.”

The mash-up of congressional health-care drafts, endorsed by President Obama this February, contains several worthy anti-obesity initiatives. Insurers would now be required to pay for obesity screening and counseling. Medicaid programs would be required to cover obesity counseling. The bill includes billions of dollars for community health centers, and it experiments with so-called Safeway grants for small employers to create employee-wellness programs. Safeway, the grocery giant, says it has reduced its health-care expenses by providing financial incentives that encourage employees to, among other things, shop around for medical care, give up smoking, lose weight, and lower their blood pressure and cholesterol. We don’t yet know whether employees are healthier over the long term, whether the program is fair to poorer employees, or whether, if implemented nationally, this approach would save as much as Safeway’s CEO suggests. Still, it’s an experiment worth funding.

States and cities have come up with some of the best structural initiatives. In Pennsylvania, for example, the state has partnered with nonprofits and supermarkets to open high-quality food stores in underserved areas. In Louisville, Kentucky, housing projects, including the one where Cassius Clay grew up, have been redesigned with a focus on health. In one, wide sidewalks ring the perimeter so families and kids can walk in groups with less fear of crime. Near the boxer’s childhood home, the local sanitation department has cleaned the soil of toxins for the creation of a community garden. And there is a farmers’ market at a school across the street every Saturday. With the strong leadership of the mayor, the blue-collar city of Somerville, Massachusetts, lowered the rate of obesity in its elementary schools by promoting exercise in schools, smaller portions in restaurants, health counseling, and biking and walking to school. (The Robert Wood Johnson Foundation supported all three of these initiatives.) Kenneth Warner, the dean of the University of Michigan’s School of Public Health, sees obvious parallels with the war on tobacco: “When you look at the most important development in tobacco control, aside from taxation, it’s the smoke-free laws for workplaces and public spaces: they started out in a few localities, many of them in California,” he told me. When I spoke with him last fall, he was skeptical that the federal government would be a leading force for change.

But that was before Michelle Obama went public on February 9 with her campaign against childhood obesity. Almost a year earlier, she had decided to make fighting obesity her principal cause: working largely in secret, over a period of about six months in 2009, the first lady’s staff and the White House Domestic Policy Council began to draft a truly comprehensive anti-obesity strategy. They enlisted Cabinet secretaries like Vilsack, who, according to several government officials I spoke with, is willing to confront the agriculture giants that the USDA regulates. Obama herself spent dozens of hours in private conversations with virtually all stakeholders. With health-care legislation stalled, the administration decided to unveil the initiative in early February. It is modest and audacious, all at once. The proposals that Raben and his group pondered have a place in the framework: state and local cooperation, nutrition-labeling standards, money to promote programs to bring healthy food to poor communities, and reforms to the school-lunch program. The goal is to end the epidemic of childhood obesity within a generation.

Like other trademark Obama-administration policies, it is cautious and reliant on consensus. Moreover, Obama’s effort is understandably constrained by the reality of the Great Recession: though it targets “food deserts”—places, rural and urban, where low-cost nutritious food is hard to find—it proposes only $400 million to begin to remedy the problem, a process estimated to cost billions.

And where are the ideas of the CDC’s Thomas Frieden, arguably the administration’s most outspoken anti-obesity advocate? In an article that appeared in Health Affairs shortly after the unveiling of the first lady’s strategy, he advocated, among other measures: instituting “a tax of a penny an ounce on sugar-sweetened beverages”; increasing subsidies for fruits and vegetables; using zoning restrictions to keep fast-food restaurants away from schools; “removing unhealthy foods from all schools, child-care and health-care facilities, and government institutions”; and “completely eliminating” children’s exposure to food advertising on television (which he says could reduce childhood obesity by 15 percent). In February, I asked Frieden about the discrepancy between his approach and the White House’s, particularly on the soda tax. He responded quickly: “Price, if we learned from tobacco, is the single most effective way of reducing consumption, and I think there’s strong evidence that a soda tax would be very effective. But a soda tax is also very controversial and very challenging, and, as with tobacco, a lot of the innovation happens at the state and local level. And I would anticipate that some state or other will likely go before any national level in terms of taxing soda.”

A few weeks after Obama announced her plan, I asked Susan Sher, her chief of staff, whether the first lady was trying to encourage cooperation, rather than attacking the industry for, say, advertising. “It is clear that this is just a first step, and for example, the totally voluntary commitment that the beverage industry made is a terrific first step,” Sher told me, referring to a recent agreement that would put calorie counts on the front of soda bottles and cans and on vending machines. “But the FDA may have more-stringent requirements in the future, so I think that everything that’s happened so far shouldn’t be viewed as the end of the game in any respect. We didn’t make demands, and I think that the first lady is very clear that that is not her role, that you have a lot of federal agencies involved in regulations—the FTC will probably have a say about this as well, in terms of advertising. So this was really a lot of industry deciding, at least at some level, ‘We want to be part of the solution, not just part of the problem.’” A few weeks later, the FDA—led by Margaret Hamburg, another New York City veteran with a strong nanny streak—warned 17 food manufacturers that their food labeling made misleading health claims that needed to be corrected. This was the most significant FDA enforcement action on such matters in more than a decade.

That same day, however, Sam Kass, an assistant White House chef who works with the first lady on food policy, told representatives from the National Restaurant Association in a conference call that the administration did not intend to “demonize” them or “demonize cheeseburgers and soft drinks,” according to a person who attended. (Through a spokesperson, Kass subsequently denied having said this.) Is there a subtle good-cop, bad-cop routine playing out? Yes, a senior administration official told me. “The goal is to use the threat of regulation to prevent us from having to make regulations, which would take more time anyway,” he said.

Even the ever-cautious FTC is poking its head out of its foxhole. At the request of Congress, the agency plans to submit a proposal (with the CDC and other agencies) for new “voluntary” advertising guidelines by July. What happens next will be up to Congress.

The food industry is anxious, in this new regulatory environment, to cooperate prophylactically. Food giants like PepsiCo, Kellogg, ConAgra, and more than two dozen others have created the Healthy Weight Commitment Foundation to promote better diets and more exercise in schools and the workplace, an effort that the Robert Wood Johnson Foundation, among others, has agreed to evaluate. (The way to promote healthy eating, said Kellogg President David Mackay at the launch event, is “to educate, not legislate.”) The American Beverage Association announced in March that its members have reduced the calories in the drinks they send to schools by 88 percent over six years. Major food-service companies have agreed to double the amount of fruits and vegetables they offer on school menus, a deal brokered by the National Restaurant Association. “There is a creative tension here, and the conversations can be difficult,” said the association’s president, Dawn Sweeney, of its negotiations with the administration. “Having said that, we have to have real things to offer, because if regulation is in the offing at some point down the road, we want to be out in front of it.”

Developments like these make the former FDA commissioner David Kessler, a kindly curmudgeon, optimistic. That’s a big change from how he felt a year ago, shortly after his book was released, when we first spoke about obesity. Then, he told me that he wanted to adopt a strategy similar to the demonization of the tobacco industry that culminated in the early 1990s: when consumers learned that the tobacco industry was spiking the levels of nicotine in cigarettes, they began to confront their own addictions with a clearer sense of purpose—and they had a foil. “Everybody knew [smoking] was bad,” Kessler told me. “But until you saw this industry was manipulating the product like it really was a drug, people didn’t do anything about it.”

Now, for the first time since he left government, he senses that the nation’s political leadership seems determined not only to take obesity seriously, but to do something meaningful. And food-industry firms, he believes, are starting to get nervous—a sure sign that they will offer concessions. Momentum, he told me, is finally building in the right direction. The Obama administration, he said, is “pitch-perfect. Everyone knows that this is the first lady’s priority. Everyone knows that it has the attention of the president’s senior staff. And she is the best spokesperson, and the best kind of spokesperson, to help change people’s minds.”

And minds need changing, not only about the causes of obesity, but about the obese themselves—who they are (and aren’t), and what they represent. That message has to come from the bulliest of pulpits: a hugely popular political figure who can help redirect the stigma that brutally accompanies obesity, away from those who don’t deserve it, and toward those who do—like food marketers who deploy psychological deception, or grocers who put sugary cereals where kids are most likely to see them. Those are the people who should feel ashamed. Cooperation and self-regulation are fine places to start, but the success of Michelle Obama’s campaign will ultimately rest on her willingness to name names.

I hope she’s got what it takes. As I write this, it’s one year to the day since I had my surgery. Walking by my office, a colleague calls me a ghost of my former self. So far, at least, that’s still true. But I was very privileged, and very lucky. I had the resources to conquer obesity and all its attendant miseries with major surgery—a choice that we, collectively, should ensure that the adults of tomorrow don’t have to make.

Marc Ambinder is The Atlantic’s politics editor.
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Marc Ambinder is an Atlantic contributing editor. He is also a senior contributor at Defense One, a contributing editor at GQ, and a regular contributor at The Week.

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