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The Big Fat Question

If obesity is America's number-one health problem, why do so many people have to go it alone?
December 1, 2001 |
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Imagine there were a disease that kills as many as 400,000 Americans a year -- more than the number who die from breast, lung, colon and prostate cancers combined. This disease is as insidious as AIDS, claiming its victims after decades of weakening their hearts, blowing holes in their arteries, suffocating their organs and grinding down their joints. You have a 1 in 5 chance of having this disease, and if you do, you will be blamed for developing it and publicly shunned. Now, imagine that your doctor doesn't know how to treat you. Are you worried yet?

The disease is real. It's called obesity, and it's not just a national case of bad eating habits; it's a public health emergency. More than 25 percent of adult Americans are obese. Another 35 percent are overweight and gaining at an escalating rate: Since 1970, the percentage of the American population that is obese has increased 60 percent. "We have an urgent crisis," says James Hill, Ph.D., a leading obesity researcher at the University of Colorado Health Sciences Center in Denver. "This is not a cosmetic issue; this is not a global failure of will or failure of character. It is a medical problem with medical consequences. If obesity were an infectious disease, we'd mobilize the nation."

Instead, we sit back and munch a few more potato chips. From 1989 to 1996, Americans increased their daily caloric intake by 163 calories per day and have gained about 15 pounds since 1980. "We are surrounded by huge portions of calorie-rich foods we don't have to get out of our cars to get -- and they cost practically nothing," says Barbara Rolls, Ph.D., a professor of nutrition at Penn State University in State College. "You couldn't design an environment more conducive to people getting fat."

Most often we blame the individual, yet there are plenty of other culprits. Ten years after public health officials first raised concerns about skyrocketing obesity rates, the institutions most able to affect our health have done little to fight our burgeoning culture of fat -- from insurance companies that make you pay out of pocket for your Weight Watchers visits, to physicians who aren't trained to help patients lose weight, to a government that devotes twice as much money to researching diseases that kill one tenth as many people. What's going on? SELF interviewed government officials, doctors, scientists and overweight Americans about this brushed-under-the-carpet crisis. With their input we created a 10-point plan (opposite) to encourage all Americans to trim back to healthy levels. First up in our line of fire: the medical establishment.

Doctors Don't Do Obesity

Jennifer, a 37-year-old policy analyst in Washington, D.C., is 5 feet 9 inches tall and weighs almost 250 pounds. (She asked that her last name be withheld.) While her cholesterol and blood pressure are normal, Jennifer's body-mass index, a calculation based on height and weight, is 36 -- six points higher than the Centers for Disease Control and Prevention's clinical definition of obesity (a score of 30) and 11 points higher than the maximum score the CDC considers healthy (25). Like millions of other obese Americans, Jennifer is a medical crisis waiting to happen. As she ages, she is roughly twice as likely as a person of a healthy weight to develop type 2 diabetes, at least 50 percent more likely to develop heart disease and 86 percent more likely to get colon cancer. Yet no doctor has ever pressed her to lose weight for health reasons. "My doctors have always told me I am incredibly healthy," she says.

In fact, the majority of doctors don't urge patients to lose weight until those patients already have a related disease -- even though studies have shown time and again that even a small weight loss can prevent someone who's overweight from developing an obesity-related disease. (As many as 10 million Americans could cut their risk of developing diabetes in half simply by losing 10 pounds.) Only 42 percent of obese patients say doctors have advised them to lose weight, and only 34 percent say doctors have told them to exercise, according to two recent studies in the Journal of the American Medical Association. "The medical profession has ignored obesity since forever," says Arthur Frank, M.D., who runs the George Washington University Weight Management Program in Washington, D.C. Like the rest of society, doctors have viewed being overweight as a failure of character, not a medical condition. "They think it's a bad habit," says Dr. Frank, adding that physicians basically take the position, "'It's not a disease. Why should we care about people who just eat too much?'"

Even if your doctor does care, there's little she may feel qualified to do other than prescribe expensive (and controversial) weight loss drugs. Why? The dirty little secret in the medical profession is that doctors don't learn how to help patients lose weight. "Med students get a lot of information -- biochemistry, physiology -- but it's not under the title of nutrition, so they can't apply what they know to patients," says Clifford Lo, M.D., director of the Harvard Human Nutrition Program in Boston, which is working to add nutrition curricula to medical schools nationwide. Currently, only about a third of U.S. medical schools require students to take nutrition classes; even fewer teach students how to help patients lose weight.

That's not to say there aren't doctors out there trying to tackle America's epic weight problem. Sharon Hochweiss, M.D., a New York City internist, taught herself nutrition basics through her own personal struggle to fight excess pounds. Now she helps her patients do the same. "I tell patients that avoiding obesity is not the same thing as being thin," she says. "A little bit of weight loss goes a long way toward staying healthy and staying off medication." This message has helped many of her patients drop a few pounds and get back to healthy levels. And studies back up what Dr. Hochweiss says she's learned through trial and error: Patients whose doctors tell them to lose weight have three times the success rate of patients whose doctors don't. "Patients are reluctant to abandon the project if they know someone is checking on them," Dr. Hochweiss says.

But physicians like Dr. Hochweiss are the exception, and not just because of a lack of concern. Helping patients lose weight doesn't pay. Insurance companies will cover the cost of insulin once your obesity has led to diabetes; they'll pay for the drug Zocor to treat your high cholesterol. They'll even pay the $45,000 cost of bypass surgery once your arteries have clogged up. But if you just want help controlling your weight before you develop a more serious disease, you're out of luck. Insurance companies don't cover weight loss or diet plans, support groups and monitoring by your physician because they don't recognize obesity as a legitimate diagnosis.

One reason is the insurance company that pays for weight loss is unlikely to reap the benefit. For example, let's say Insurance Company A picks up the tab for a patient in her 30s to attend a weight loss program. Her success prevents her from developing diabetes by the time she's in her 60s, but by then she's retired and insured by Medicare, which enjoys the double advantage of not having to pay to treat her diabetes and not having paid to help her lose weight. In terms of Company A's bottom line, helping her shed pounds was a losing proposition.

The result is that physicians such as Dr. Frank, whose patients pay up to $600 a month out of pocket for weight loss treatment, have daily battles with insurers. "If a person has hypertension, I put down hypertension. The treatment for hypertension is weight loss," Dr. Frank says. "But then the insurance company comes back and says, well, you're treating the patient's obesity. I say yes, but I'm treating the patient's hypertension." Insurers get away with not paying because federal insurance guidelines back them up. "It's remarkable that all of the federal agencies involved in health policy say obesity is a disease -- the Food and Drug Administration, the Public Health Service, the National Center for Health Statistics. The only [agency] that ignores it is the one that has to pay: Medicare," Dr. Frank says.

No Funds to Fight Fat

If Medicare would start covering obesity treatment, it would in turn nudge the private health insurers that most of us rely on into doing the same. But the chances that Congress will pass legislation directing Medicare to do so are about the same as science declaring doughnuts a health food. One reason is that Congress does not want to expand the Medicare budget. Two years ago, it threw out a provision in a bill that would have devoted federal funds to providing nutritional advice to obese Americans who are too poor to buy private health insurance. The other reason a bill mandating that Medicare pay for obesity treatments would not have much hope of passing is that some of the most powerful interest groups in Washington, D.C. -- such as the health insurance industry -- would be aligned against it. Joseph Luchok, spokesman for the Health Insurance Association of America, says, "We would be opposed to any mandate from Congress or the states saying you have to cover obesity."

The reality in Washington is that health-care priorities are most often set by those groups that have the clout to lobby Congress -- either because they have money (the insurance and food industries) or because they can mobilize large blocs of voters, the way women have for breast cancer. When it comes to obesity, however, there is no such base of supporters clamoring for Congress to fund and create the kinds of programs, research and regulations that could tighten Americans' belts a notch.

One look at the federal budget says it all. The CDC, in Atlanta, spends roughly $16 million annually on programs that would prevent obesity by promoting nutrition and physical activity. By comparison, it spends almost $100 million on tobacco-control programs. "Poor diet and inactivity kill as many people as tobacco," says Margo Wootan, D.Sc., a nutrition scientist at the Center for Science in the Public Interest in Washington, D.C. "The investment in nutrition and physical activity programs pales in comparison to their impact on health."

The slice of budgetary pie is no bigger when it comes to obesity research: The National Institutes of Health (NIH) spends about 1 percent of its budget on obesity research each year. In 2001, it allocated $226 million for obesity study, compared with $2 billion for research on cardiovascular disease and diabetes, diseases for which obesity is the major risk factor. No doubt 77 years of advocacy by the American Heart Association have helped generate the extra dollars for heart disease. On the other hand, America's 50 million obese citizens have been practically nonexistent as a political force on Capitol Hill, according to Morgan Downey, executive director of the American Obesity Association in Washington, D.C., which was founded in 1995 to try to influence research on the issue.

The absence of lobbying pressure also affects what kinds of research projects get funded. At the NIH, the "sexier" fields of genetics and biochemistry are the ones that get backing. Both are more likely to result in high-profile -- and highly lucrative -- new drugs to treat people who are dangerously obese than in programs to help prevent the disease in the first place.

Certainly those who have legitimate genetic problems deserve the benefit of research, but they are in the minority among America's overweight population and getting the lion's share of funds. That's wrongheaded, says Kelly Brownell, Ph.D., a leading obesity researcher and director of the Yale University Center for Eating and Weight Disorders in New Haven, Connecticut. "The problem with focusing so much effort on treatment is that for every person we successfully treat -- at high cost, by the way -- there are hundreds of thousands more entering the obese population," he says.

Brownell would rather see more research address the cultural, psychological and behavioral issues that lead people to reach for second helpings or wallow in front of the TV. The goal should be to influence Americans before they become obese. "Obesity is a crisis out of control," Brownell says. "Far too little money is devoted to the problem, especially in the area of prevention. A few scattered programs aren't going to make a difference."

A Culture of Fat

but antiobesity programs face more than a lack of funds. They are also suffering from a lack of conviction. Physicians and public advocates alike have had little to offer overweight Americans but the same "eat less, exercise more" message we've heard since 1952, when the American Heart Association first published Food for Your Heart, , a pamphlet recommending dietary changes for staying healthy. Since then, practically every health organization and government agency, from the American Cancer Society to the U.S. Department of Agriculture, has issued guidelines for preventing obesity through diet and exercise, to little effect. "There's never been such a high level of concern and awareness in government," insists William Dietz, Ph.D., director of the CDC's Division of Nutrition and Physical Activity, speaking at a recent conference. Still, he concedes, the message is not getting out. "Despite the efforts we've made in terms of talking about this as a medical problem, we [in government] have primarily been talking to ourselves."

The problem is not the message. Eating less and exercising more are indeed the secrets to losing excess pounds, as anybody who has ever managed to lose weight can tell you. "The average person who is obese knows what they are supposed to eat," says Charles Billington, M.D., a leading obesity specialist at the University of Minnesota in Minneapolis. "They can do it conceptually, but they can't do it for real."

The problem is that getting fat is deeply ingrained in American culture. This is a country where fruits and vegetables have had the largest percentage price increase of any food group since 1982; where entire communities are built without sidewalks; and where portion sizes are so out of control that we think a muffin the size of a softball is a snack. Even hospitals are opening their lobbies to fast food joints. In San Diego, St. Louis and Chicago, you can have a triple bypass and then, before you've checked out of the hospital, enjoy a 600-calorie Big Mac. The average child sees 10,000 food advertisements a year (many of them pitched by their favorite movie stars, cartoon characters and athletes) and spends more time in front of the television than on any other activity except sleeping. "We have spent years and years trying to figure out why the individual is overweight and almost no time thinking about why the nation is overweight," Brownell says. His answer: "It's the environment."

Is it Time to Attack the Snack Makers?

Changing that environment is going to take more than a few public health messages. It is going to take the government doing battle with the food industry -- and that's a tall order. For every $1 the federal government spent last year on promoting nutrition and physical activity, food manufacturers spent roughly $8 advertising fast food, snacks and soft drinks. More important, the food industry is a potent force in Washington. In 1999, it spent more than $7 million lobbying members of Congress, according to the Center for Responsive Politics in Washington, D.C. In recent years, food lobbyists have successfully beaten back antiobesity proposals ranging from nutrition labeling at restaurants to taxes on soda.

Just last year, the USDA attempted to revise its official dietary guidelines to advise consumers to limit their consumption of sugar. "Limit" turned out to be a fighting word. Arguing that the new guideline would hurt their business, sugar-industry lobbyists went into high gear, apparently calling in the chits the industry accumulated between 1995 and 2000, when it poured more than $10 million into political campaign coffers. The industry persuaded 30 senators to sign a letter to the USDA protesting the change and threatened to sue the agency on the basis that science has yet to prove that sugar contributes to the rising rates of obesity. (The tactic is reminiscent of the tobacco industry's claims that science hadn't proven cigarettes cause cancer.) "Limit" never made it into the guidelines.

The Soda Connection

Marion Nestle, Ph.D., a nutrition professor at New York University and a member of the 1995 USDA advisory panel, was not surprised by the sugar lobby's success. "The government can't offend the food industry. The Department of Agriculture cannot be in the position of telling Americans to eat fewer American products. Its job is to promote the American food industry," she says. (The USDA oversees many programs, including such well-known campaigns as "Pork, the other white meat.") Part of the problem, Nestle adds, is that targeting the food industry is difficult. Unlike cigarettes in the fight against tobacco, "there's not one food that's demonstrably dangerous," Nestle says. "McDonald's french fries are not poison."

But antiobesity forces may finally have found their wedge: soft drinks. In the past decade, cash-strapped schools have cut physical education at record rates and welcomed soft drink bottlers that offer "pouring rights": exclusive contracts that give schools as much as $100,000 a year in exchange for opening their cafeterias and hallways to soda machines. At the same time, obesity rates among children under age 19 have doubled since 1980. Soft drinks are not entirely to blame, Nestle notes. But, she says, "you can show that children who drink soft drinks tend to take in higher levels of calories than children who don't."

Just as tobacco advertising to children finally swayed Congress to increase regulation of that industry, children's health has started to mobilize members of Congress to pay attention to America's excess adipose tissue. At least one bill has been introduced in Congress that would permit the USDA to impose restrictions on so-called junk food in schools. Several states are considering bans on vending machines in schools. Support for such legislation might get additional heft when the U.S. surgeon general's office releases its expected report on obesity, which will include an action plan for improving the American diet. (At press time, the exact release date had not been determined.)

Primed for this growing fast food backlash, the sugar, food and soft drink companies have contributed to a new organization, called Be Active America! The goal? To promote healthfulness through more exercise -- but not less sugar. "You can pretty much eat whatever you like as long as you're active enough," proclaims Sean McBride, communications director for the National Soft Drink Association.

Baloney, say obesity experts. The campaign looks like an effort to deflect blame rather than help Americans slim down. "It isn't in the interest of any food company to sell less food," says NYU's Nestle. What's more, though promoting exercise is well and good, it's a known truth that it's a lot harder to burn off calories than it is to eat fewer of them in the first place, says Penn State's Barbara Rolls. "We've got to get the food industry to give us healthy food that tastes good and doesn't cost a fortune. That's an attainable goal," she says.

Losing a Ton at a Time

Food manufacturers aren't likely to voluntarily improve their products anytime soon, but that doesn't mean government can't make a difference. Philadelphia Mayor John Street proved last year that it's possible for politicians to influence public health. After enduring one too many cracks about Philly's unhealthy cheese-steak-eating population, he appointed a "fat czar" and dared residents to lose a collective 76 tons. (The city's basketball team is the 76ers.) The city got businesses to institute exercise programs and chefs to create healthy restaurant meals. The mayor himself exercised in public and served fruits and veggies at meetings. Almost 25,000 Philly residents have participated in the program thus far. "We have hundreds of people who brag about their pounds lost and whose doctors have been able to decrease their medication," says Gwen Foster, the city's health and fitness czar. "Every day people stop me on the street to thank me, saying it's the first time they've lost weight."

In Maine, it was a group of committed doctors who changed the tide of obesity in their town. Three decades ago, the residents of Farmington and surrounding Franklin County faced the same obstacles to healthy living as much of rural America: They needed their cars to get around and the cheapest restaurants in town served the fattiest food -- all of which was taking a toll on their health. Franklin County's rates of high blood pressure, heart disease and diabetes were higher than those in much of the rest of the state. Yet today, Franklin County enjoys one of the lowest death rates of any county in Maine, and the second lowest rate of overweight and obese residents.

What transformed the town? The efforts of a group of medical professionals who decided they wanted to prevent disease instead of treat it. Volunteers for the group they formed, Rural Health Associates, showed up at grocery stores to test shoppers' blood pressure and cholesterol and offer one-on-one nutrition advice. Soon they had schools inviting adults to exercise by pacing their halls. They persuaded the local university to permit all townspeople to use its gym. Still thriving today under the auspices of the Healthy Community Coalition, the program involves business leaders, politicians, hospital administrators and 400 local residents who work together to keep dreaming up more healthy-living ideas, such as Stride Into Summer, a community walking program.

Not every town has Farmington's dedicated physicians or Philadelphia's political will, but both places are examples of what a committed government, medical establishment and community can achieve. "There's something important that happened here," says Burgess Record, M.D., one of the Farmington program's early participants. "We've learned something that we can teach the nation." Now, if only the nation is ready to listen.

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