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HEALTH CARE: Of Carrot Cake and Oreos

Dr. David Kessler, as you've probably heard, is out with a terrific best-seller called "The End of Overeating: Taking Control of the Insatiable American Appetite."

The cover grabs your attention: very pure white glossy background with a carrot cake and carrots.

I don't like carrot cake. But as I told Dr. Kessler, if the cover picture were an Oreo, I wouldn't be able to have his book in my house.

I got to know Kessler while I was covering tobacco back in the late 1990s, but hadn't seen him in quite a few years until he spoke at a conference of health writers I attended last week.

He was the luncheon speaker: the healthiest of the box lunch options, the one I chose, was vegetables -- drenched in salad dressing -- on a white-bread roll, an apple, and two chocolate chip cookies in plastic wrap. I didn't want to eat them until Kessler began talking about how smells triggers cravings and my friend Ivan sitting next to me unwrapped his cookies. But, concentrating intently on the dress I wanted to wear at a college reunion this weekend, I ignored Ivan and the cookies, and listened to Kessler. Luckily, they weren't Oreos.

Anyhow, David happened to be heading to Washington this week, and we ended up having a longer and more provocative conversation about fat, policy, parenting, Oreos and social norms than either of us expected. (I took him to a place where only the tea was supersized.)

Normally I avoid writing about books until I've finished reading them (which is why we have only given a passing shout-out to T.R. Reid's excellent The Healing of America... I will tell you just how excellent it is when I get past page 50... which will probably be after this weekend's college reunion). But while I'm only about halfway through Kessler's book, I wanted to share some of our conversation while it is still fresh in my mind.

"The End of Overeating" is not about health reform or health insurance, or even about how health reform will improve the care and management of obesity-related diseases like diabetes and heart disease (although that will help).  Nor is it just about the social determinants of health or steps like kids getting more exercise at school and healthy school lunches and walkable neighborhoods and all that. The book isn't about government regulation (although better and more useful labeling, he told me, is essential -- and the Froot Loops "Smart Choices" flap may help lead to better public awareness.)

His book is about our bellies. And our brains.  

About how and why our brains tell us to keep putting large quantities of bad food in our bellies. And how we become wired to want more and more of the bad food that gives us a quick fix and still leaves us wanting more. Why I can't have Oreos in my house, and why the top layer of my wedding cake in my mom's freezer "talked" to her so loudly and insistently that she gave it away while I was on my honeymoon. And how and why the social norms in contemporary America have changed.  We used to eat food. Now we eat processed stuff. Stuff engineered by food companies that know exactly what they are doing. A dash of fiber and a bit of fortification buried under layers and layers of sugar, salt and fat.

And it's everywhere. And we eat it all the time. And it's getting worse and worse.

Kessler  writes:

Foods built layer upon layer to stimulate our senses. Foods high in sugar, fat and salt, and the cues that signal them, promote more of everything: more arousal... more thoughts of food... more urge to pursue food... more dopamine-stimulated approach behavior... more consumption... more opioid-driven reward... more overeating to feel better... more delay in feeling full... more loss of control... more preoccupation with food... more habit-driven behavior... and ultimately, more and more weight gain.

We don't just have palatable food. We have hyper-palatable food. We don't have habits, we have conditioned hyper-eating, driven behavior. Conditioned driven behavior isn't exactly the same thing as an addiction to a drug or nicotine... but it's a close cousin.

The result, in his view, is an obesity epidemic so severe that it has emerged as the biggest public health challenge of our lifetimes. This comes from a former FDA commissioner who did about as much as anyone on earth to combat tobacco. And who has also been involved in the fight against HIV/AIDS.

We're already spending $147 billion a year on obesity -- twice what we spent a decade ago. And it's only getting worse. Reversing the obesity epidemic, he told me, is also "harder than anything we've ever done in public health."

I look around and see what he means. Too much. All the time. Everywhere.

Today, at a college snackbar, I saw "macaroni and cheese pizza." (It's just what it sounds like.) Yesterday morning, as I wrote part of this post in an airport departure lounge, I saw a coffee stand at each end of the corridor, but they weren't serving what we used to think of as "coffee." This coffee is loaded with syrups and flavors and chocolates and garnishes and whipped cream. There was a diner at one end of the corridor, (fries, fries fries) and a dubiously greasy-smelling seafood place offering breakfast at another (I didn't dare look). In between, there was no shop for me to pick up a cheap watch to replace the one I dropped rushing out of the house for my plane. But there's a pizza place, an Arby's, a California Tortilla, McDonalds (with really really long lines), a Chinese take-out place, a Quiznos, and yes a place for me to buy a newspaper and a bottle of water -- but the woman in front of me in line was getting a Coke and a candy bar for breakfast. And the bigger-than-it-used-to-be bag of M&Ms on the newsstand counter had a logo about fighting breast cancer.  

So a lot of what David Kessler and I spent an afternoon talking about wasn't so much about the Baucus bill or the Waxman bill, or medical homes or more nurses. It was about social norms, and how to change them. He has some ideas in the book, but much of  that is still a conversation going on in his head. We changed the social norms for smoking, even before the laws he fought for were enacted. And we're going to have to change the social norms for food. Kids used to say, "Daddy please don't smoke," Kessler recalled. How do we get them to say, "Daddy, please don't buy me fast food." Because without significant changes in what we eat, how we eat, when we eat, and why we eat, the costs -- both economic and physical -- to ourselves and our nation will be overwhelming.  Way bigger than any Oreo.