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what's the fix?

Here, Dan Glickman, former secretary of agriculture, and nutritionists Marion Nestle, Walter Willett, Aviva Must and James Hill offer their suggestions on how to confront America's worsening obesity epidemic.

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Dan glickman
Secretary of Agriculture, 1995-2001

The fundamental issue here, quite frankly, is that diet, nutrition, and obesity have not been viewed as a major public health issue in this country until fairly recently. Cigarette smoking was. AIDS has been. But overall, what people eat has been viewed to be surplus or extraneous to what the health problems are in this country, and so USDA was part of that. The food producers were part of it, but so was everybody. Nobody challenged the system. …

But now, as a public health issue, it's on the agenda?

Yes. …

... What's the most important thing that the government could do to deal with a crisis in obesity?

Research, to make sure that we know what [in] fact you need to consume or you don't need to consume, so that the public is not inundated by inconsistent information. That means that we've got to research diets and got to do a lot more work on specific foods. That's a big part of it. Second part of it is that in the government programs in the schools and the other food assistance programs, they need to be made consistent with modern science, and we need to do a lot more educating in the schools as to what is good for you and what is productive in terms of diet. Third is exercise, which has to be a part of certainly American society.

And fourth, the medical community must become actively engaged in this issue like they are engaged with catastrophic disease. When you go to a doctor and you're very sick, we can really treat people very well. But prevention has never been, at heart and soul, part of the American medical system, at least with respect to the providers of healthcare.

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marion nestle
Chair, Nutrition Dep't., New York University; author Food Politics: How the Food Industry Influences Nutrition and Health

Characterize the obesity problem as a public health problem. Compared to 20 years ago, is this a worsening problem?

The issue of obesity became prominent just within the last 15 years. This is very recent. It's too recent for a genetic change, and so we have to look at societal changes that have taken place. So what are the main societal changes that have taken place? One, the number of calories in the food supply has gone up. Two, food marketing has increased and become more aggressive. Three, portion sizes have increased. Four, pressure -- it has become more acceptable in society for people to eat more times during the day, and in different locations where food was never seen before.

The result of this is very clear. We're seeing type 2 diabetes, which used to be called "adult-onset diabetes," in very young children. This was never seen before, or hardly ever seen before, and this will be a lifelong problem to manage, and something that will be very expensive to the country, to the people themselves, and to the healthcare system. We're seeing an epidemic of overweight that is occurring so rapidly that the Centers for Disease Control can track it from year to year, and does so on those beautiful maps on its Web site.

Does this now exceed smoking as a public health issue?

My understanding is that the problem of overweight is equivalent to the problem of smoking.

What will be the main drivers for us to change?

Well, I think we're already seeing a major society shift. We're seeing a backlash. We're seeing schools looking at the marketing practices in the schools and throwing them out. We're hearing more and more talk about regulation of advertising on children's television. We're hearing talk about tax strategies, legal strategies, elimination of farm subsidies. The lawsuits have gotten everyone's attention. But I think probably the biggest driver comes from the investment analyses that have come out, looking at the vulnerability of food companies to loss of sales if they don't change their market practices and their product mix.

How would they lose sales?

The investment analyses -- and there have now been three of them that I'm aware of: one from UBS Warburg, and J.P. Morgan in Great Britain, and another from Morgan Stanley in the United States -- all three of them say the same thing, that if people start losing weight, they're going to have to be eating less. Eating less is going to be bad for business, and it's going to be much worse for some businesses than others, so that if these food companies don't fix their product mixes to make healthier food products, and market them in a way that emphasizes the healthfulness of food products, especially those that are lower in calories, they're going to be left behind in this mass movement towards more healthful eating.

But eating less: If the average American eats 1,600 pounds [of food] a year, and they're competing for a share of this stomach, what can they do?

I don't have a very happy message for the food industry. I think they've been given a free ride in marketing for a long time now, and that free ride is now over and it should be over, particularly the marketing to children, which I think crosses an ethical line. They can't all grow in a competitive marketplace. They have argued for years that this is a matter of consumer choice. Well, consumer choice is going to come back and bite them, and that's just how the system works. If they're going to be participants in the system and they're in an over-inflated, over-abundant food marketplace in which there is far too much food for anybody to eat healthfully, some companies are going to lose and some companies are going to win. The winners are going to be the ones that can take advantage of the trends towards more healthful eating, and the losers are going to be the ones that are still marketing junk food.

But what drives us as consumers to eat less?

I'd like to see an education campaign that really tells the truth about diet and health. We never had one. Let's have one that's free of political influence, and says "eat less" when it means "eat less." That would be worth trying.

As consumers, we have our own health to worry about. We make individual choices. People need to be aware, for example, that larger portions have more calories. That may seem obvious, but it is not.

So just like people became smart about not smoking, we can solve this problem through education?

I think education is a big part of it. I think changing the environment is a big part of it. I'd like to see us try to find ways to change the environment to make it easier for people to eat more healthfully, in the same way as the environment had to change before people would stop smoking. …

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Walter willett
Chair, Nutrition Dep't., Harvard School of Public Health; author Eat, Drink, and Be Healthy

[What's] the amount of disease that could be prevented through modifying one's diet?

The potential impact of healthy diet, when you combine it with not smoking and regular physical activity, is enormous. For example, our studies have shown that we could prevent about 82 percent of heart attacks, about 70 percent of strokes, over 90 percent of type 2 diabetes, and over 70 percent of colon cancer, with the right dietary choices as part of a health lifestyle. The best drugs can reduce heart attacks by about 20 or 30 percent, yet we put almost all of our resources into promoting drugs rather than healthy lifestyle and nutrition.

Do you think the government agrees with you about what's at stake?

I think the government has under-funded research in diet and nutrition. In some ways we blame the abstract government for it, but in some sense it's also the scientific community that's partly to blame for it, because we often tend to fund the novel, exciting science, the new gene discoveries, the new mechanisms of drugs, for example. Often diet and nutrition and lifestyle are perceived to be sort of passé or too simple, and yet they are very important topics. There is interesting science behind it, but because it's not regarded as so novel and new, it's often neglected in scientific funding. …

When you think about solutions, how can we proceed?

The causes of obesity are very complex, and therefore any response is going to have to be complicated and multi-faceted as well. There is no single solution to this, but we have to do many things to really solve this problem.

We've actually looked at this in a very detailed manner over the past two years in the New England states, and identified eight different areas that we have to really modify. For example, schools have to change what's served, what's promoted in schools. The healthcare providers -- physicians, nurses -- have to be providing much better and effective advice to their patients about controlling their weight. Work sites have to change. The whole food environment and what we promote to children has to be somehow modified, and we do have to protect children from these aggressive advertisements. We have to change the physical environment to make it more conducive, more attractive to bicycle to work, to destinations, not just drive places. Many other things need to be done if we're going to solve this problem, and it's time we really began.

The national obesity crisis, I mean, it's really severe. And to hear you talk about it, it sounds like it's hopeless to overcome it.

The crisis we're facing is severe, and it's getting worse. Interestingly, the full consequences won't be seen for another 30 or 40 years, because it takes that long a time for the risk of diabetes and the complication of diabetes to play out. But it's not hopeless, and I think that's the good news. There are places, if we look around the world, where people have been controlling their weight. For example, in Japan and in Sweden, women have really not been gaining weight as they've gone through midlife and gotten older, so we do need to learn more about how they're doing it.

Also in the U.S. there are many people who are controlling their weight successfully. Not everybody is going to be as successful, even if they do the same diet and do the same amount of physical activity, but many people are doing pretty well. And one piece of evidence we have is that upper-income groups actually only have about half the rate of obesity compared to lower-education groups. So it's not hopeless, but we are going to have to devote many more resources to doing this if, as a whole country, we're going to be successful. ...

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aviva must
Associate Professor, Tufts University School of Medicine

I think we need as a society to start thinking about the environment and the extent to which it promotes obesity, and thinking about everything from neighborhood design to the design of buildings to the food supply to vending machines in schools, any number of things one could tick off that really speak to the food environment and the activity environment that surrounds daily living.

This isn't likely to be achieved with market mechanisms?

No. I think that we probably need what we would consider sort of a public health response, and I think the government is going to have to be very much involved in coming up with policy approaches to dealing with the obesity epidemic.

Are they ready to do this? I can't imagine why anyone would be optimistic, given the history.

Well, I have to be optimistic because it's basically my nature to be optimistic, and I think that there is a tremendous amount of focus and interest on this problem that I would never have imagined a couple of years ago. The government is certainly throwing increasingly larger amounts of money at it, probably nothing like they need to....

I'm not sure yet that we know how to make the market encourage the kinds of changes that we need to see, and the extent to which we're just going to have to use regulation. I'm not sure what that balance is. I do think there will be a balance. I do think that the food companies understand that they're going to have to be sincere participants in dealing with this problem. I'm not naive enough to think that they're going to do it on their own without a strong prod from the government and from regulatory agencies.

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james hill
Director, Center for Human Nutrition, University of Colorado Health Sciences Center

One of the things that we have to look at as a society is: What's our strategy going to be for dealing with the obesity epidemic? We have 65 percent of adults that are overweight or obese, and somewhere between 15 and 25 percent kids. So what are we going to do? Are we going to take all those people that are overweight or obese, have them lose weight, keep it off, and that's the way we solve the problem? We don't know how to do that. I don't know how to do that. Yes, we can help people. We can produce some weight loss. I think that's not the way we're going to get out of the epidemic.

Now let's look at a different strategy. A different strategy would be to say: Let's take all adults, no more weight gain. If you're overweight, obese, no more weight gain. Let's take kids and say: No more abnormal weight gain. It's a little tougher with kids because they're growing anyway, but let's look at a trajectory which is a healthy trajectory. What you would do there, that could be achieved with small changes, and what it does is, over time, you essentially grow out of the obesity epidemic. So the next generation will be less obese than this one; the one after will be less obese than that one.

I think personally this is the only way we're going to succeed. I think it's going to take us two or three generations to solve the problem, and I think the way we do it is to start implementing small changes now, so we accept we aren't going to solve the obesity problem in our generation. Our kids hopefully can be a little less, their kids a little less. But if we're going in the right direction with small changes, in two or three generations maybe we get populations that are actually able to achieve and maintain a healthy body weight.

Let's talk about some places where you could have interventions, where you could start to implement. Let's start with the schools.

Well, everybody starts with the schools, because that's where kids spend a lot of time. So that's a great place to start. In America we love to play the blame game. Who's to blame for obesity? So schools are certainly one place that's blamed.

They're blamed because there's no P.E. anymore, so very few kids have mandatory P.E. They're blamed because the school lunches aren't the greatest. They have to be self-sufficient, and they're not so healthy. They're blamed because they get money from vending machines. Somebody has to pay for the band uniforms and so forth, and the vendors can pay for that. So they're blamed for creating an unhealthy physical activity environment and an unhealthy food environment.

Here again, I think we could apply our idea of small changes. One idea is: Let's go in and totally uproot everything. Let's change the curriculum, put in P.E. Let's get healthy food in the lunchroom. Let's get vending machines out. I don't see that happening. I think that's going to be hard to do. But I do think what we could do is start doing small changes over time.

We're in schools trying to get kids to be more active, maybe even during the curriculum. A lot of information now suggests these kids can do active learning. They don't have to sit in a class, in a seat, and learn all the time. They can be up and about. You can find activity breaks, 10 minutes here and there, for the kids. You could look at how you can begin to make small changes in the cafeteria, how you can put better products in the vending machines. I think the whole idea of small changes would work well in schools, and I think schools are willing to do that. I think it would be tough to just tear everything out: whole new food in schools, whole new physical activity curriculum. Yeah, maybe we need to get to that over time, but we've been talking about that for a while and it hasn't happened. So maybe we ought to try the small change approach. ...

That's kids. What about the workplace? Can you see any initiatives there?

The workplace is actually one of the better ones. And what we're finding now is the economic data coming out, showing the healthcare costs of obese employees have now led employers to get interested in this. Now, if employers are interested, and they see that their employees being more healthy can save money, then there're lots of things they can do. So we have America on the Move work site programs where we encourage the employers to provide incentives. You get step counters, you get step goals, you achieve that step goal, you might get an incentive. That incentive literally ranges from hats and T-shirts to days off.

Same way on the food side. If you provide incentives for employers to be healthy, and if you provide them a place to do that -- so if you're asking them to eat better, and to be physically active, they have to have A), the opportunities to do that, and B), a reason to do it. Now that the employers have a reason to provide incentives to the employees, because their healthcare costs are so high, it works beautifully in a work site. …

We talk a lot about education these days, and the old trend of just passing a kid along to the next grade, whether he or she had learned to read or do arithmetic or not. In a way, it's kind of the same thing with the seriously overweight kid. You know, everyone looks the other way. You don't want to offend the kid's parents, get a lawsuit, trouble. It's a hassle for the teacher. But basically, when you're not dealing with this problem when they're young, you're harming the kid.

And this is the issue. Whose problem is it? Schools have traditionally said, "Well, that's the parents' job to teach about nutrition and health and so forth." The parents have said, "Hey, we're too busy. Why isn't the kid getting it in school?" People are looking toward the government. People are looking toward private industry.

At some point, all these places are going to have to take some personal responsibility. Schools are going to have to say, "You know what? The health of the kid is important. Because now we know health relates to learning. The kids that are overweight and unhealthy and inactive aren't learning as well." So it's the school's problem, but at the same time, I don't think we can put it off and say, "Well, let's let the school take care of that."

The parents need to learn how to be role models. Part of the problem is, the parents are overweight and inactive and unhealthy themselves. How do we get into there? What can the government do? This is the issues that we as a society have to struggle with.

But what we can't do is to let any sector off scot-free, saying "It isn't my problem." Because you know what? It's all our problem, and it's only if we do programs in schools, it's only if we do programs at home, in the grocery store, in the hardware store, in the parks, that's the only hope we have of doing it. I don't give anybody a free pass. If you say "It isn't my issue," it's wrong. ...

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posted april 8, 2004

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