A Big Fat Crisis

Introduction

I am one of the 97 percent of Americans who find it difficult to routinely eat a healthy diet and get sufficient exercise.¹ I have been fortunate not to have serious weight issues, but according to the US Departments of Agriculture and Health and Human Services’ Dietary Guidelines for Americans, I am still supposed to eat a wide variety of fruits, vegetables, and whole grains; limit my consumption of meat; and drink the equivalent of three cups of milk every day. And because my cholesterol is high, it has to be skim milk. Hypertension runs in my family, so I also need to limit my salt intake.

If you think that maintaining a healthy lifestyle would be easy for me because I am trained as a medical doctor and conduct research on diet and physical activity, you couldn’t be more wrong. Adhering to this kind of healthy diet is neither easy nor fun. You pretty much have to cook everything from scratch, and whether you work outside of the home or are a stay-at-home parent, it’s no picnic finding the ingredients and the time to prepare tasty, balanced meals. In every supermarket I visit, the items are scattered everywhere in no logical pattern that I can understand. I often have to ask for help to locate what I need. Does the store have any low-salt canned beans? Or will I have to buy them dried, soak them overnight, and then boil them for hours?

When I do find the right aisle, I am never sure which item to choose from the dozens of available varieties. Which cereals really have less sugar and more fiber? Should I get the multigrain, whole wheat, or rice flour pasta? What about chips? Are the baked chips or the ones with the flax and sesame seeds really good for me? There are so many products, and I just don’t have the patience to read every label.

It was especially difficult to be a wise consumer when I had to take my kids grocery shopping with me, whether they were four or fourteen. As a mom, I not only had to figure out what to buy for my family but also had to remove more than half of what my kids managed to sneak in the cart before I got to the checkout—chips, sodas, and sugar-frosted cereals. Now that my kids are older and I tend to shop alone, I have a hard time resisting the premium dark chocolate candy bars at the cash register. Yum! Should I get the large bar or the three-pack of small ones?

And my family hates to eat at home all the time. (Boring!) Once in a while I give in and take them out to a restaurant, even though it is next to impossible to find a meal away from home that is both healthy and delicious. Last week we went to a Mexican restaurant called El Torito, conveniently located a few blocks from our house. The menu listed the calorie count next to every entrée, as mandated by a recent California law that requires all restaurants with twenty or more outlets to list calories prominently on menus and menu boards. Although this theoretically should have helped me choose something healthy, I could find hardly any meals under nine hundred calories. And that’s not including the free chips and salsa, the margaritas, or dessert. Forget about trying to find skim milk, fruit, or a low-salt option—it’s just not on the menu.

(El Torito is not an exception, by the way. According to recent research, fewer than 4 percent of restaurant meals meet the latest USDA guidelines for sodium, fat, and saturated fat.²)

What about exercise? That should be easier than finding a healthy meal, because it only involves carving out thirty minutes five days each week. But it somehow doesn’t work out that way. Although I could take more breaks and be more active during the day, or even walk around the block a few times, other things always seem to take priority. Deadlines for completing projects, the needs of my family, and the lure of a good movie after a tiresome day at work keep me in a chair, in a car, and on a couch.

Should I blame myself for my failure to make healthy choices? Should I hold myself responsible for eating too much chocolate? For my untoned, sagging biceps and belly? Should you? When we’re on our own, who else is there to blame?

Because I have many family members and friends who are overweight or obese,* my interest in addressing the epidemic is both personal and professional. Unlike most medical doctors who see patients for a living, I specialize in public health. Rather than helping individuals with their medical problems, I study entire populations, trying to pinpoint why people engage in behaviors that lead to ill health. With board certification in public health and preventive medicine, as well as a master’s degree in epidemiology—the study of the incidence, distribution, and control of disease across a population—I have spent more than twenty-five years studying why people engage in risky, unhealthy behaviors like smoking, drinking too much, having sex without a condom, eating too much, and exercising too little. For the past twelve years, as a scientist at the RAND Corporation, my focus has been on the obesity epidemic and how we can reverse it.

There are plenty of guidelines intended to help people figure out what to eat. The Dietary Guidelines for Americans, a consensus on what people should and shouldn’t eat to stave off obesity and diet-related chronic diseases, haven’t changed much in the past fifteen years. Even if you’ve never read them, you can probably guess what they say: eat your fruits and vegetables and go easy on sweet, salty, and fatty foods. Not very complicated, yet only 3 percent of Americans faithfully adhere to the recommendations.³

Similarly, the recommendation for physical activity has remained constant for nearly twenty years. Adults should get at least 2.5 hours of moderate exercise every week (e.g., thirty minutes five times per week), and children should get sixty minutes every day.⁴ Yet fewer than 5 percent of adults and less than half of all children exercise enough to achieve these modest goals.⁵

As a result of not meeting either the diet or physical activity guidelines, two out of three adults and one out of three children in this country are overweight or obese.⁶ Although in theory we know what to do to optimize our health—eat reasonable portions of nutrient-rich food and exercise regularly—in practice we don’t do it.

This gulf between our knowledge and our actions has long plagued me. As a physician and public health researcher who has studied obesity for more than a decade, I am especially aware of what I should be eating and how much I should be exercising. And I’m especially aware of the consequences of being obese: higher rates of diabetes, heart disease, hypertension, osteoporosis, and even cancer. Still, like most Americans, I find that this understanding only goes so far. It doesn’t dissuade me from eating more sweets than I should, and it doesn’t propel me to go jogging after a long day of work. I want to be healthier and stronger, I want to live longer and continue to lead an active lifestyle for years to come, but I fail to take the necessary steps to make this happen. And so do most Americans.

From a rational perspective, the motivation to eat well is clear. Research suggests that

       •  Being obese doubles one’s risk of dying prematurely.⁷

       •  Eating too many trans fats increases the risk of coronary artery disease by 23 percent.⁸

       •  Eating too little fiber increases the risk of colon cancer by 18 percent.⁹

       •  Drinking one sugar-sweetened beverage every day increases the risk of diabetes by 83 percent in women.¹⁰

       •  Excess dietary salt is believed to be responsible for 62 percent of all strokes.¹¹

The research demonstrating the harms from eating too much food, especially too much sugar, is becoming increasingly clear and graphic. The Pennington Biomedical Research Center in Baton Rouge, Louisiana, whose mission is to tackle nutrition-related problems, recently showed how healthy people can develop risk factors for heart disease and diabetes merely by being fed too much.

To precisely measure what happens to the overfed body, Pennington scientist Alok Gupta recruited fourteen healthy volunteers, with no hypertension, no diabetes, no heart disease, and a normal waist size, and had them eat all their food at Pennington for two months. During this time they were poked, prodded, and observed to see what was going on internally when the calories in their diet were increased.

In the first week the volunteers spent an entire day in a metabolic chamber to have their daily energy requirements assessed. They had biopsies to measure the size of their fat cells and MRIs to measure the volume of all their fat, including the fat in their internal organs as well as the fat stored under the skin and around the waist. After quantifying the volunteers’ total body fat, total body muscle mass, and total body water, Gupta measured the fat in their livers and the fat around their lower legs and in the calf muscles. He measured the baseline functioning of all their organs—the liver, the pancreas, and all the hormones related to eating, like insulin and leptin. He also measured inflammation in the blood and tested how well the blood vessels function by seeing how quickly blood vessels in a single finger recovered after the circulation was cut off for five minutes. And for seven days, while the volunteers wore an accelerometer to record how active they were, their blood pressure was also measured every thirty minutes.

Then, every day for the following seven weeks, the volunteers were served 40 percent more calories than needed to maintain their current weight. As they stuffed themselves, the measurements continued to record what happened to their organs, blood pressure, hormones, fat cells, muscles, and blood vessels.

On average, the group gained more than sixteen pounds, their body fat increased by 2 percent, and their waists grew more than three inches. Extra fat was deposited in organs rather than in muscle, especially in the liver. The average fat cell size grew by 54 percent.

Indicators of systemwide inflammation increased by 29–50 percent. Fasting blood sugar (an indicator of diabetes), cholesterol, and insulin resistance all increased. Blood pressure and heart rate went up and blood vessel functioning capacity was reduced by about 21 percent—altogether demonstrating a significant increase in factors associated with heart disease.

At the end of seven weeks, most of the volunteers still felt fine and had measures that remained within the normal range. But it was very clear that continuing the trajectory would have led to serious problems.

Although most people understand that being overweight or obese puts them at a greater risk for all kinds of diseases, especially life-threatening ones, on a day-to-day basis the consequences seem pretty remote. The body changes happen gradually, and without these detailed measures they often go undetected. Moreover, even if we put on two pounds per week, we generally don’t get any obviously recognizable symptoms letting us know that any internal damage is occurring. Most people put on one to two pounds per year, so it would take more than eight years to match what the Pennington volunteers gained in eight weeks.

Although there is no doubt that obesity increases the risk of a wide variety of medical problems, what is less well understood is why people eat too much even though they are aware of the negative consequences.

The conventional wisdom is that obesity is the expression of individual weakness, gluttony, and/or lack of personal responsibility. Some claim that the current epidemic, therefore, indicates that a substantial portion of the population has lost all sense of self-control while the rest are intentionally choosing to become fat.¹² This is where I am extremely skeptical.

The increase in obesity cannot simply be an isolated matter of lack of self-control. Why? If the absolute loss of self-control was responsible for the obesity epidemic, it would mean that people in this country had more willpower thirty years ago, when the rate of obesity was half of what it is today. It would mean that people in countries with lower rates of obesity like Japan, Costa Rica, Sweden, and Finland are more controlled, more responsible, and perhaps even morally superior to Americans. Is that plausible?

The fact is, the majority of people who are overweight appear to have plenty of self-control in most other areas of their lives. They have completed school and earned college or higher degrees; they maintain full- or part-time jobs, arrive at work on time, complete their assignments, raise successful children, vote, volunteer, and contribute to society in many ways. Few get into trouble with the law or are violent, impulsive, or irresponsible in ways that demonstrate low self-control.

Based on my own research, as well as the latest insights from behavioral economics, psychology, cognitive science, and the social sciences, the pages that follow describe the surprising forces behind the obesity epidemic and how we, as a nation, can overcome them.

My conclusions contradict conventional wisdom and widely held expert opinion, and go against our intuitive belief that people are fully in control of what they eat. They suggest that our basic assumptions about human nature and how our DNA is hardwired must be changed. Accepting that humans face limitations that interfere with self-control represents, in short, a paradigm shift in how we approach the problem of obesity—and the solution.

Specifically, A Big Fat Crisis argues that the obesity epidemic is the product of two forces:

       (1)  Immutable aspects of human nature, namely the fundamental limits of self-control, the inflexible decision-making strategy of the brain’s noncognitive system, and the automatic and unconscious way that we are hardwired to eat; and

       (2)  A completely transformed food environment, by which I mean all the food-related elements of our surroundings, including grocery stores, restaurants, prices, portion sizes, availability, marketing, and advertising.

The book focuses in equal measure on human nature, with its irrational and unconscious decision-making process when it comes to eating, and the modern food environment, which puts cheap, high-calorie, low-nutrient foods at our disposal in a way that is unprecedented in human history. Drawing on cutting-edge research from a variety of disciplines, I argue that the current discussion surrounding obesity, with its primary focus on individual responsibility and self-control, demonstrates a fundamental misunderstanding of human nature. We are biologically designed to overeat when presented with the opportunity (that is, to eat more than we need in order to ensure our survival); most of us have a shockingly limited capacity to deliberately and consistently regulate our eating behaviors; our eating behaviors are not a matter of thoughtful, mindful decision-making, but instead happen automatically, without our full awareness.

Nevertheless, we assume that most people are rational and that we ourselves are even more rational than others. We see ourselves as powerful agents who decide what we will or will not do on a daily basis, particularly when it comes to our basic preferences, like how we spend our time and what we consume. We believe that we all have the capacity to control what and how much we eat. Although researchers in behavioral economics, cognitive science, and psychology have begun to poke holes in the rational-actor theory of human behavior, most of us still cling to this notion of omnipotence when it comes to food. If you’re being honest, I bet you blame yourself when you are unable to resist temptation—and probably hold overweight individuals accountable for their size.

If the limitations of human nature explain why we are prone to make unhealthy choices, the modern food environment practically assaults us wherever we go. The number of restaurants in America has more than doubled since 1977, and is still growing.¹³ The number of vending machines has also increased exponentially. When I was a child, vending machines were a rarity, and they usually sold either gumballs or cigarettes. Today, vending machines are in practically every office building, gas station, and public venue in the country. Advertising, too, has become increasingly sophisticated and insidious, so much so that we might not even recognize it as advertising: movie scenes feature actors eating name-brand foods, and the judges on American Idol sip Cokes as they dole out their scores. A Big Fat Crisis argues that the modern food environment is the largest determinant of our behavior—and what we need to focus on if we are going to end the obesity epidemic.

Finally, the last section of the book offers concrete solutions, arguing that the most important and modifiable steps in the chain of events that leads to obesity are at the point of purchase and the point of consumption—the supply side of the problem. I contend that we need regulations standardizing portion sizes in restaurants and laws prohibiting the sale of candy at all cash registers. We must demand that restaurants offer balanced meals as alternatives to the standard fare that increases our risk of chronic disease. We have to apply to unhealthy foods the kinds of regulations that have been successful in limiting alcohol consumption—a prohibition on “two for one” specials, for example, and limitations on “all you can eat” promotions.

Because some of my ideas may come across as overly intrusive or inordinately dismissive of the importance of personal responsibility, I describe several historical examples of even larger public health initiatives that were initially derided but eventually embraced. Two hundred years ago, for example, societies throughout the world had no regulations governing environmental conditions. The result was recurrent epidemics of infectious disease, including cholera, typhoid, tuberculosis, and gastroenteritis. At that time, prohibiting people from tossing garbage and human waste out the window and mandating indoor plumbing seemed like an invasion of privacy and an attack on individual rights. Prohibiting butchers from dumping animal carcasses and their entrails on the public streets was considered undue interference with private business. Implementing regulatory controls required long, contentious political battles. Now, because we recognize that integrated sewer systems and restrictions on dumping protect us from infectious disease and exposure to toxic chemicals, we find it hard to sympathize with those who resist these kinds of environmental regulations.

Like cholera and typhoid in the nineteenth century, obesity is the twenty-first century’s public health crisis. Our major approach of exhorting individuals to be more responsible is just not working. Ending obesity requires solutions that transcend individual behavior.

In the 2012 US presidential campaign, Bill Clinton summarized two perspectives on governance. He juxtaposed one philosophy, “We’re all in this together,” a view that indicates that as a society we must take steps to care for one another, with the diametrically opposite view, “You’re on your own,” which suggests that each person has to make his or her own way in the world, without any special help or protections from an unfettered marketplace.

In my view, the reason we have the obesity epidemic is because we’ve been on our own for way too long. Change begins with a fresh perspective and a clearer vision of what we need to do. Let me take you on a journey through the obesity epidemic and show you how we can end it.

* To meet the technical definition of “overweight,” the ratio of one’s weight to the square of one’s height (kilograms/meters²) must be equal to or greater than twenty-five but less than thirty. One is obese when the ratio is equal to or greater than thirty. For example, a five-foot-eight person who weighs more than 164 pounds is overweight; if that person weighed 197 pounds or greater, he would be classified as obese.

PART I

Human Nature and Food

1

It’s Not Your Fault

    “After 6 months of diet success, I can’t control how much I eat. I am a 6’2” tall 19-year-old man. Since May 2008, I lost 50 lbs. from 210 lb to 160 lb. Now, in the last two weeks, I just can’t control how much I eat. Some days, it’s ~2000 calories and other days 4000. Because of that, I put on 10 lbs in two weeks. I am pretty much in depression right now. I can’t think about anything else. What is wrong with me?”¹

    “I feel so out of control. I think I am doing good and then the cheetos call my name or a burger and fries from McDonald’s. I do not need this kind of food. I need healthy food, but there are days that I cannot help myself. Mostly when I am away from my family like when I am at work. I think of different things I can eat and it does not help that I work at a grocery store where I have access to all kinds of junk food and things. But you would think I would eat fruit or veggies at the store, but no not me I get in this kinda trance like state, thinking I am hungry and on the hunt for something that tastes good. I cannot seem to stop this.”²

    “I eat. A lot more than I should. I’ll just finish eating a meal, and suddenly, I want more, but I don’t want just any food. I crave junk food. I know that I should start to eat less and exercise more, but I can’t find the motivation. When I think about how unhealthy this is for my body, I just eat more. It’s gotten to the point where it’s hard for me to control. Please help.”³

Struggling with obesity is not a rare, personal story—it is the problem of our time. More than 150 million Americans are overweight or obese, and across the globe an estimated 1.5 billion are affected.⁴ One-quarter to one-third of all cancers can be attributed to obesity.⁵ Being overweight and/or obese is also a strong risk factor for type 2 diabetes, heart disease, hypertension, joint and back pain, and a host of other medical problems.⁶ The diseases associated with obesity cost our medical system an estimated $147 billion per year.⁷

Even beyond the physical toll of obesity, the emotional pain makes this condition difficult to bear. Not only are overweight and obese people stigmatized by others, but those who struggle with their weight often stigmatize themselves—they feel inferior, ashamed, unhappy, and even depressed. One obese colleague told me that she felt like a blob; mortified by her condition, she started to withdraw from others. She and others like her believe their lack of self-control is an inherent character flaw they may never be able to overcome.

The perceived link between lack of self-discipline and obesity has become so strong that overweight or obese people are often judged as less competent than their thinner peers. US Surgeon General Regina Benjamin was initially criticized for being overweight. What credibility would a health expert have if she couldn’t practice a healthy lifestyle? When New Jersey Governor Chris Christie first began exploring a run for the presidency, his ample girth led many to question his fitness for office. To defuse the charge, he joked about his size by eating a doughnut on the Late Show with David Letterman. However, more recently, he admitted to getting LapBand surgery to help control his weight.

Yet the stereotypical view of obesity—that it is a marker of low self-control, deep character flaws, or serious psychopathology—is plain wrong. Yes, dozens of studies—some of which I will explore in the next chapter—show that overweight and obese adults have much more trouble resisting food than their thinner peers. Obese adults have more problems with self-regulation, they are more impulsive, they have higher levels of urgency, they lack perseverance, and they are more sensitive to rewards.⁸ This is neither novel nor particularly helpful to the two-thirds of American adults who are already overweight or obese.

What is needed is an entirely new way to think about and frame the obesity epidemic. We must recognize that an individual’s ability to resist overeating is limited when excess food is constantly available. Why else would so many people have trouble controlling their weight? If it was so easy to maintain a normal weight and everyone had the capacity, then logically, many more people would have a normal weight. Why suffer the stigma of being overweight? Why rack up chronic diseases that make us feel miserable and force us to take medications if we didn’t need to?

Everyone wants to believe that we all can accomplish whatever we want, if only we try hard enough. Unfortunately, no matter how hard many of us try, we cannot always achieve our goals. Most of us will never be movie stars, rock stars, prima ballerinas, astronauts, the president, or even president of our local parent-teacher organization.