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Is there a middle way on obesity?

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As I've now heaped a lot of praise on Marc Ambinder's article on the obesity crisis, let me offer up some criticism, too. In the beginning, Ambinder engages in a bit of unfortunate even-handism. "Each side is held in political check by the other," he says, "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."

But Ambinder's analysis goes on to offer an analysis that, well, lends itself to either punitive, government interventions that are politically impossible or miracle surgical interventions that are expensive and dangerous. In this case, the only answers that even approach the scale of the problem are far more extreme than anyone is comfortable with. But the fact that we're not comfortable with extreme answers doesn't mean more moderate interventions will be effective.

Much of Ambinder's argument can be summarized by something Thomas Frieden, the director of the Centers for Disease Control and Prevention, told him. "If you go with the flow in America today," he said, "you will end up overweight or obese.” Ambinder's list of the economic, structural and biological forces that make up "the flow in America today" is enough to make you give up and eat a Twinkie. Advertisements to children. Bacteria in our guts. Compounds in our plastic bottles. Vending machines in our schools. Desk jobs. Billions of dollars spent on research making foods "hyper-palatable" to the point of addiction. Evolutionary programming urging our bodies to hoard excess calories. How much your mother ate while she was pregnant. The increase in portion sizes. The rise of snacks between meals. So-called "food deserts." The fact that people in obese areas become more comfortable with obesity themselves.

Compared with all this, Ambinder's hope that Michelle Obama's cooperative relationship with food companies will read to a workable strategy seems tinny indeed. He spends a lot of time on the need to end food deserts, for instance. But a USDA study examining whether lack of access to fresh food really was a contributor to obesity concluded, basically, that it wasn't. Other programs in the Obama administration's middle way include "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." All good programs, maybe. But none of them even hint at sufficiency.

Ambinder himself is an example of the difficulty that these gentler strategies will face. "As an upper-middle-class professional," he writes, "I could draw on plenty of resources in my battle against weight." But despite spending "lots of money" -- and presumably lots of time and intellectual energy -- on different fixes, it wasn't until he turned to bariatric surgery that he lost the weight. The flow in America is very strong.

For that reason, I think it's quite possible that a mix of surgeries and pharmaceuticals eventually becomes our society's answer to obesity. The risk of these treatments will go down, their efficacy will go up and their cost will settle into a more affordable range -- particularly compared with the cost of treating the complications of obesity. If we want to go at this without scalpels and pills, the changes will have to be dramatic: No more vending machines in schools and workplaces. No more food advertisements aimed at children. Serious investments in walkable communities. Significant taxes on junk food and sodas and even mega-portion meals at chain restaurants. Significant subsidies for healthier foods.

I'm not really advocating one or the other in this post. Rather, I'm suggesting that the forces behind the obesity problem are many and powerful. If this is something we want to solve, the response will have to be proportionate. Changing a river's direction is no small task.

Photo credit: Lenny Ignelzi/AP.

By Ezra Klein  |  April 16, 2010; 10:40 AM ET
Categories:  Health  
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Comments

Government can make contributions like you mentioned, such as labeling rules (information is good), school lunches, etc., but no comprehensive government solution is available. Any such attempt would not only fail, it would arouse resentment from both left and right, as Americans are not comfortable with making diet a public policy issue. Any solution will be grassroots.

Posted by: jduptonma | April 16, 2010 11:15 AM | Report abuse

Government can make contributions like you mentioned, such as labeling rules (information is good), school lunches, etc., but no comprehensive government solution is available. Any such attempt would not only fail, it would arouse resentment from both left and right, as Americans are not comfortable with making diet a public policy issue. Any solution will be grassroots.

Posted by: jduptonma | April 16, 2010 11:16 AM | Report abuse

True. Weighty problems require weighty solutions.

Posted by: ostap666 | April 16, 2010 11:27 AM | Report abuse

Transportation and land use is an area where government policies can have a huge impact. Just look at the studies that show lower levels of obesity in areas where there is less dependence on the car--people simply get more exercise in their day to day lives and the result is better health. I was sorry to see that Ambinder's article didn't even mention the Robert Wood Johnson Foundation's program "Better Living by Design" -- a project that encourages healthier urban design and encourages walkable communities. It is a concept that I am so happy to see Secretary LaHood embrace, because the benefits truly do extend beyond liveability and positively impact a community's health and wellbeing.

Posted by: jh-c | April 16, 2010 11:28 AM | Report abuse

The government can do some things that decrease the economic incentives to eat junk, as well as labeling food as jduptonma suggested, but ultimately it comes down to habits.

If you can get into a habit of regular exercise, smaller proportions, and a more diverse and healthier mix of foods, then all other things being equal you'll be healthier and slimmer. The problem, of course, is in forming those habits, which is why people yo-yo on their dieting.

Posted by: guardsmanbass | April 16, 2010 11:29 AM | Report abuse

First observation Ezra, I grew up working in the logging and construction industries and worked very hard during weekends and the summers. My lunches were high calorie to support the activity. Ironically, any lunch I can buy from the major chain restaurants or even the corner pub, just a walk away from my desk job, pack far more calories that I used to consume.

I also agree with 'jduptonma' that obesity is a symptom of an addiction to food. Like any addiction, it depends on the individual making a choice to change their behavior. I have four coworkers who underwent stomach surgeries to 'cure' their obesiety. Two are now within the 'regular' BMI range; one dropped a lot, but has stabilized still in the obese range; and the fourth dropped, but has continued to regain the weight over the last two years. Their issue has been with their behavior.

On the other hand, how many alcoholics or addictive drug users would be told it's all their own fault when they're forced to live in a bar or a pharmacy. Like tobacco, if the only products a company is peddling are high-calorie sugar/fat/salt bombs to line their own profits, then they should shoulder part of the consequence.

Posted by: Jaycal | April 16, 2010 11:32 AM | Report abuse

Poorer people, especially African- and Latin-Americans, do face extra stresses in their lives that contribute to obesity, including cultural and economic factors and especially stress. For others the prevalence of high-fructose corn syrup products, especially sodas and other drinks, is key. And telling people to eschew fats, which are satisfying, leading them to gorge on high carb snacks was a disaster. Remember Snackwells?

But beyond the fact that much of American industry makes money off of obesity, there are still people who are educated, love fruits and especially vegetables, have access to the best food in the country, have time to exercise and cook and still manage to be overweight from too little exercise and too much of that healthy food. I would hate to have to undergo bariatric surgery. But it takes a tremendous amount of effort in meal planning and exercise, and tremendous willpower to lose weight.

Having quit smoking in my thirties and again after a brief lapse in my fifties, food is infinitely harder precisely because one must eat and we are built to enjoy food. It is true that once you acquire all those fat cells, they scream to be fed and are very hard to get rid of. But still, I'd go after the food manufacturers, end the corn and sugar subsidies, and do what can be done to make people's lives less stressful, starting with really repairing the safety net. Beyond that, it is up to each of us.

Posted by: Mimikatz | April 16, 2010 11:33 AM | Report abuse

"For that reason, I think it's quite possible that a mix of surgeries and pharmaceuticals eventually becomes our society's answer to obesity."
"food is infinitely harder precisely because one must eat and we are built to enjoy food. It is true that once you acquire all those fat cells, they scream to be fed and are very hard to get rid of."

i am amazed, really amazed....at the way people eat.
children that i work with over the easter break, are allowed to gorge themselves on the worst snackfoods, with no limit.
so many people i know, in my age group of sixties and older, eat junk, with abandon, and then have to go for knee and hip surgeries because they are carrying so much weight.
and then....they still continue to eat poorly.
and with diabetic conditions, high cholesterol, high blood pressure.
and i happen to live in a retirement community, and there are frequent events for which you choose an entree.
even though they do have vegetarian selections, the choices is almost always between meat and fish.
educated people, with children.....with their own health issues still often take little responsibility for what they eat.
and i see advertised "healthy" servings of fruits in cans, and drinks that have fruits and vegetable in them.....and they cost a lot of money. for heaven sakes, why dont people just eat an apple or a banana instead?
many people do have a good awareness of healthy nutrition, but even among people who know better.....we have a hugely long way to go.
why is self-gratification reaching for junk food?
isnt self-gratification waking up and feeling good because you are eating foods that help your body to work well?
we have gotten all mixed up.

Posted by: jkaren | April 16, 2010 11:45 AM | Report abuse

Our civilization exploits every human weakness as a means to profit. It enfeebles everything it touches by providing an indulgence to soothe (and cultivate) every anxiety, no matter how normal and inevitable a part of life it may be. People who grow up in America cannot stand to be even the slightest bit hungry, ever. And being a little bit hungry most of the time is the only real way to avoid obesity. Have a little pride, people. Stop being a slave.

Posted by: SqueakyRat1 | April 16, 2010 11:47 AM | Report abuse

"and do what can be done to make people's lives less stressful,"


just being alive is stressful....but if people would take responsibility to eat better....it could definitely alleviate some of the stress from having medical conditions that impair your quality of life and cause more stress, cost everyone more money and affect the general health and well-being of our society.
i contend that many, many people know what to do....they just choose not to do it......and "being busy, being stressed" are just excuses.
good nutrition comes down to self-discipline, a desire to be healthy, and a wish not to be a burden to society.

Posted by: jkaren | April 16, 2010 11:51 AM | Report abuse

"If we want to go at this without scalpels and pills, the changes will have to be dramatic: No more vending machines in schools and workplaces. No more food advertisements aimed at children. Serious investments in walkable communities. Significant taxes on junk food and sodas and even mega-portion meals at chain restaurants. Significant subsidies for healthier foods."

Are those changes really all that dramatic? Maybe to our libertarian-bent society. But really, no one complained about cigarette advertising being banned, and, honest, I don't think a soda tax would be that big of a deal (if it weren't for pushback from the soda industry). Once you do these things, people pretty much accept them after the initial grousing. (I remember when seat belt laws were first enacted.)

As I see it, the issue is that we have developed a two-tier society with respect to eating in this country: one side is all super-sized and industrialized food; the other is all local, fresh, and sustainable. Maybe I live in an elistist urban island, but it seems to me the latter is gaining enough cultural steam to influence things, especially with the younger generation. It's not even all that much of a white upper-middle class economically advantaged thing. I sometimes shop at a Whole Foods on the south side of Chicago whose clientele is largely African American. Everybody has cartfuls of leafy green vegetables and fruits. (Though god knows they are woefully overpriced by the WF bandits.) Our downtown farmers markets are full of people of every stripe, from businessmen to new immigrants.

Posted by: JJenkins2 | April 16, 2010 11:52 AM | Report abuse

I strongly urge consideration of 2 important contributors to obesity:
1. government corn subsidies had a major role in our increased use of high fructose corn syrup, as well as the sudden rise in illegal immigrants who were no longer able to farm corn competitively;
2. the huge increase in endocrine-disrupting substances in our environment.

There's a straightforward way for government to address these:
1. stop the subsidy!
2. regulate environmental chemical exposure.

I think even anti-regulation types would agree about the need to reduce environmental endocrine disrupters, if they took a look at the data about the increase in little boys becoming little girls, from frogs and salmon to humans.

Ezra, if you want to change the course of a mighty river, climb a mountain and move a pebble.

Posted by: lroberts1 | April 16, 2010 12:06 PM | Report abuse

No mention of restructuring farm policy? None of those things will make a dent until food is once again priced at cost. That would be a really extreme fix but it would put Coke and every fast food chain out of business so it's never going to happen unfortunately...

Posted by: megankeenan | April 16, 2010 1:56 PM | Report abuse

Ezra - have you been watching jamie oliver's new show? It seems to me that the three basic things could be covered in schools - teaching kids how to read food labels ( I couldn't believe the lenghth of the list of ingredients in the chicken nuggets and the food service woman seemed to think it was fine because chicken was listed as the first ingredient); 2) teach people how to cook - people seem to no longer be taught how to cook at home maybe with the exception of immigrant families; 3) get rid of processed foods on school lunches.
I really hope Michelle Obama is watching this show and I'm willing to bet that the lunch program at sidwell friends is very different from your typical public school.

Posted by: KDID | April 16, 2010 1:56 PM | Report abuse

Ezra - have you been watching jamie oliver's new show? It seems to me that the three basic things could be covered in schools - teaching kids how to read food labels ( I couldn't believe the lenghth of the list of ingredients in the chicken nuggets and the food service woman seemed to think it was fine because chicken was listed as the first ingredient); 2) teach people how to cook - people seem to no longer be taught how to cook at home maybe with the exception of immigrant families; 3) get rid of processed foods on school lunches.
I really hope Michelle Obama is watching this show and I'm willing to bet that the lunch program at sidwell friends is very different from your typical public school.

Posted by: KDID | April 16, 2010 1:56 PM | Report abuse

one significant way to combat obesity is to improve the nation's public transportation infrastructure, especially on the west coast. with cheap and convenient public transit as in many european cities, people would get a 20-30 minute daily amount of exercise walking to and from their tram stop and their destination. since our mass culture is so dependent on driving everywhere, there's no exercise in our day-to-day activities unless we specifically make time for it.

Posted by: goadri | April 16, 2010 2:09 PM | Report abuse

I agree with Marc Ambinder’s essay but there are a number of things that Washington can do to combat the obesity problem. Many of these I detailed in my blog, A Diet for the New Administration (see http://www.downeyobesityreport.com/2009/09/)
The first thing is for the government to stop fueling the problem. Congress has mandated a dozen or so commodity programs whose purpose is increase human consumption. The USDA imposes mandatory dues on producers and gives the money to industry boards who then collaborate with the food industry to expand consumption for their products. These industry boards are private, non-profit entities, basically out of public view. These programs are highly creative and effective…in expanding demand and Americans’ waistlines. At this time of great concern over childhood and adult obesity can any government program to increase American’s food intake be justified?

Posted by: MorganDowney | April 16, 2010 2:21 PM | Report abuse

--"I think it's quite possible that a mix of surgeries and pharmaceuticals eventually becomes our society's answer to obesity."--

That's the stupidest thing I've ever seen you write, Klein. You're not all there, are ya?

Posted by: msoja | April 16, 2010 2:23 PM | Report abuse

--"Government can make contributions like you mentioned"--

Bzzzzzzzzzzt. Government never contributes. It only steals and forces.

Posted by: msoja | April 16, 2010 2:26 PM | Report abuse

--"one significant way to combat obesity is to improve the nation's public transportation infrastructure"--

And, after umpteen billion or trillion dollars, if other people's weight still troubles your mind, then what? Some other whim will occur and you'll happily recommend marching the citizens off in pursuit of it? Ad nauseum?

Other people's weight is like other people's money. Mind your own business.

Posted by: msoja | April 16, 2010 2:36 PM | Report abuse

It'd be funny if it weren't so serious. Considering that it's a span of two generations in which we seem to have forever altered what is reasonable, there may be little hope for human-kind. We walked a mile and a quarter to junior high school and a mile and a quarter back. We walked a mile to high school and a mile back. The car was for important things, not for driving to a friend's house; that's why we had bicycles. There were no hand-held games, no cell phones, and no watching television unless an adult turned it on or approved it's being on.

We played cards, board games, invented in the basement or garage, threw baseball or football, and explored the fields and woods. We went to the park. We lay in the grass and watched the clouds pass. We walked or rode our bikes to the library. Older siblings looked after younger, introduced them to games and play. We read to each other, invented and acted in plays. We did schoolwork. We took gym class twice a week during junior high and high school.

And there were few snacks and no soft drinks unless there was a picnic or some other celebratory event. We weren't "cut", but we were largely healthy young people, and the heaviest kid would look like a lightweight today. I look in other people's shopping carts and I'm pretty amazed at what supposed adults are buying for their households. I'm amazed sometimes at what I buy! But I know what's appropriate and I know that control is mine to have or not. As I'm past 60 and can walk, run, bike, swing a tennis racquet, and swim pretty well still I think I'm doing the right things.

But really, we have to admit, fat's not good and really, it's not pretty.

Posted by: Jazzman7 | April 16, 2010 4:22 PM | Report abuse

i feel that this entire argument is moot. having looked at the proposals and read the hearings on childhood obesity there is almost no reference to any pharmaceutical or surgical solutions. the emphasis is on affordable healthy foods, the availability of healthy whole foods in our schools, the re-establishment of physical education and recess, the safety of and number of parks that children can play in, walkable neighborhoods and more education about health. talking about extremes muddies the issues and takes away from all of the helpful solutions offered by the surgeon general. the more natural approach that the actual policies seem to embrace don't have any of the side effects of the extreme measures mentioned and are the ones that most doctors agree are the most beneficial. they are also economically more efficient. all thats being asked is to make government more supportive of and sensitive to long term solutions to our obesity problems that we are sure will work by recreating some of the things that we were doing right in the past.

Posted by: superodalisque | April 16, 2010 5:30 PM | Report abuse

--"I think it's quite possible that a mix of surgeries and pharmaceuticals eventually becomes our society's answer to obesity."--

I'm calling that the Josef Mengele Doctrine. Hail to Klein's vision. We shall literally reshape America with government mandated surgeries! The wise and caring bureaucracy can bring back Fen-Phen after the FDA weighs the risks "with the cost of treating the complications of obesity", and makes the smart choice FOR EVERYONE!

And if you don't like your bariatric surgery, why, you can try to vote for majority control of the government in just a few short years, and hope your representative will work to have it all undone! It's the beauty of the democratic process!

Until then, do your duty citizen. Turn yourself in to the nearest fat reduction center, and look forward to a life of Thai-inspired asparagus salad with fried lemon (which will be a HUGE hit in the government school cafeterias.)

Posted by: msoja | April 16, 2010 6:56 PM | Report abuse

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Posted by: faecloudy | April 17, 2010 6:06 AM | Report abuse

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Posted by: faecloudy | April 17, 2010 6:16 AM | Report abuse

Drugs and surgery are a "middle way?" I reduced my weight through diet and exercise (100 lbs), but it took a long time. And maybe that's o.k. Ultimately, it made it easier to keep it off, since the lifestyle changes were now part of my regular life, and I didn't go back to "normal," which was the root of the problem. It is indeed hard to swim against the tide. Americans want fairy tales like The Biggest Loser. People are repelled when I tell them that I still have to restrict food and exercise. But it's the reality.

Posted by: ciocia1 | April 17, 2010 6:24 PM | Report abuse

As long as our government subsidies the manufactures of High Fructose Corn Syrup with tax dollars and the FDA, EPA are bribed by these companies to allow this poison to be place in all process food people will always be obese, uncontrolled diabetes, cancer and many health problems. I beg people to read the food label and do not buy any product with High Fructose Corn Syrup listed. Of course the leaders of this so call farce to stop the Obese problem is a part of the program. For if they really get real, that will lose the corrupt kickback money that is going on now. So this Obama thing is just what it is, A Farce and lip service which will not accomplish a thing. Being retired Chef, I teach free classes on preparing and eating healthy food by I wonder sometimes if I will be arrested by the corrupt FDA, EPA, FCC, FTC for teaching a better way of life and remove from office all the corrupt officials.

Posted by: ChefRobert | April 21, 2010 11:08 AM | Report abuse

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