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?

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.

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Marc Ambinder is The Atlantic’s politics editor.

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