NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington.
Everybody knows that obesity can contribute to an early death, but maybe just as bad, fat people suffer from stigma in life: avoiding eye contact, the air of judgment and now a slew of shows like "The Biggest Loser" that contribute to a kind of fat porn that can be taken to mean that it's okay to laugh at fat people.
You can look up the sobering statistics, but it's beyond argument to conclude that obesity is epidemic, bad before 1980, much worse since then.
In February, first lady Michelle Obama declared an ambitious new campaign against childhood obesity. The goal is to end the epidemic within a generation.
In the May issue of The Atlantic, Marc Ambinder looked closely at this plan and at the many unsuccessful initiatives that preceded it, and he brings personal experience to this story. For much of his adult life, Marc Ambinder was obese.
If this is your story, too, tell us what we don't know about your life and your fight against obesity, 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, Nike scandal and celebrity endorsements, but first Marc Ambinder, politics editor of The Atlantic, joins us from a studio at The Atlantic here in Washington, D.C. Nice to have you on the program today.
Mr. MARC AMBINDER (Politics Editor, The Atlantic): It's good to be here, Neal.
CONAN: And those statistics, it's staggering, but they are, as you point out, only likely to get worse.
Mr. AMBINDER: Without intervention, they're only likely to get worse, and it's quite possible that within a generation, a majority of kids will grow up obese, and if not a majority of white kids, a majority of kids who are African-American or Hispanic, Native American or kids who tend to be poor. And to me, that's a tragedy, and it's a basic social justice issue.
CONAN: You also say that there's a program that we know will address this issue. It's the one you used, bariatric surgery.
Mr. AMBINDER: In terms of a cure for people who already are obese, you know, there's really only one, you could call it a sure-fire cure if you want to. It doesn't mean it's the only intervention that can work, but that would be bariatric surgery, any form of - any number of the different forms of gastric bypass surgery.
If you look at the long-term success rates for this procedure, which is fairly radical, what it essentially does is try to counteract tens of thousands of years or longer of human evolution and press the reset button on how your body and brain regulates caloric intake. But it's a major surgery that involves, in some cases, as mine, separating your stomach from your digestive tract and tying it into your bowels directly so that what remains is a walnut-sized cavity that forms your new stomach.
It's not the only solution. There are people who can be obese as adults and who can work hard and lose weight and maintain it, but there aren't very many people who can do that.
And particularly if you don't have the resources or the access to health care or the access to nutritionists or the time to exercise during the day, the chances that, when you are obese, you can cure obesity are slim to vanishing.
CONAN: And the fact is that as a society, this is not an answer for, well, millions of people are obese.
Mr. AMBINDER: Right.
CONAN: This is beyond calculation, and the fact is there has to be some other kind of policy, and, you know, basically you say we really have to stop telling people that diet and exercise are going to do this for them.
Mr. AMBINDER: And there's absolutely no question. I mean, I'm also, you know, not saying the opposite, that people shouldn't live healthily and, you know, eat well and exercise, but as a solution to obesity, telling someone to exercise or to diet is simply beside the point. I mean, it just doesn't - it's not going to help them, and most likely, it's not going to work because they're just not going to have the resources to do it.
There are so many pressures, physiological, environmental and social, that conspire to keep them obese once they are obese, that, you know, they're essentially set in this condition, which is one reason why, when we conceive of obesity, we should stop thinking of the image you see on television all the time of the headless adults - well, not headless - but adults whose heads are cut off by the top of the screen walking down the side of the street the way that TV footage illustrates any story about obesity and think of kids under five years old.
I mean, throughout the world, there are more than 30 million kids under five years of age, according to the World Health Organization, who are obese, several million in America. Think of obesity by thinking - by starting to think of that young kid who doesn't have the capacity to make choices and is already obese, and then reason your way to solutions.
CONAN: Let's see if we can get some callers in on the conversation. We're talking with Marc Ambinder of The Atlantic about his article in the May issue, "Beating Obesity," 800-989-8255. Email us, email@example.com. And Bill's(ph) on the line from Stockton, California.
BILL (Caller): Hey, good morning, Neal.
CONAN: Good afternoon where we are, but hello.
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BILL: I'm sorry, I'm sorry. I'd just like to point out some interesting things as I was listening to that last segment. I'm 52 years old, and back in the '60s, during my formative years, my mother was a single parent. She had three young children. And as a result, we received an awful lot of assistance from the social agencies, which included a lot of the USDA-supplied foods.
Now, some of this was actually quite good, quite nutritious, and a lot of it, though, seemed to have an awful lot of high fat content, when I look back.
CONAN: Are we talking about government cheese here?
BILL: Government cheese and other commodities of the day. And to that point, you know, I was always a chunky kid. In the fifth grade, my grandmother, you know, kind of said, hey, Bill, why don't you get rid of some of that, and so forth.
When I went through high school, I became a three-season athlete and a good student, but I could still never completely got all of the weight off. I was a swimmer for two seasons, and I wrestled during the winter, very high activity. Somewhere along the way, my body decided it needed to be fat. Through the years, I...
CONAN: Wait a minute, your body decided it needed to be fat?
BILL: My body just decided it needed to be overweight, not fat, not obese, just heavy. When I went through - into the Air Force, I had to starve myself for a full week to get myself just underneath the weight threshold, and for my continued years, it was the same thing.
CONAN: And you're out of the Air Force now, and is this continuing to be a problem?
BILL: No, it continues. The only time in my life that I really, really seem to thin down with any significance was when I was riding on the order of 400 miles a week on a bicycle.
CONAN: Well, that's not something that people, most people who are not riding in the Tour de France can keep up most of the time. But you said something interesting, and this is something that Marc Ambinder wrote about in his piece. But with us here in the studio is Dr. Arthur Frank, who spent three decades working with patients to manage adult obesity. Nice to have you back on the program, Dr. Frank.
Dr. ARTHUR FRANK (Founder, Co-director, George Washington University Weight Management Program): It's nice to be here, thank you.
CONAN: Can people's bodies decide that they want to be fat?
Dr. FRANK: In effect, yes. Because what happens, this is a disease. And we work on the assumption that you manage it, that you can manage it by making choices. And it fails to recognize that the important part of this is your neurochemistry.
Your brain regulates your eating, and it regulates your eating with an astonishing amount of tenacity. Your brain decides how much you should eat, and you can override your brain signals, which is in effect what you have to do by eating less. You can override, superimpose some sort of conscious control on your brain signals. But it's difficult to do that. It's extraordinarily difficult to do it. And I agree with Mr. Ambinder that what you've got to do is, you've got to - it's very difficult to eat less, but it's in effect what you have to do.
Now, what we've got to do in reality, if we're going to deal with this, is we're going to have to manipulate the neurochemistry of the brain, much as we manipulate the chemistry of the body in order to control hypertension or in order to control high cholesterol.
We can do that, and we can do it effectively, and we can do it in a sustaining way. It's very difficult to do it merely by your determination to eat less and exercise more.
CONAN: Bill, thanks very much for the call. It's an interesting point. And Marc Ambinder, going back, what Dr. Frank is talking about, of course, is, well, it can be done with a large number of people but those who have access to the kind of health care that he's talking about. You are talking, though, about a much broader approach where policy can reduce those problems and reduce his patient flow, with any luck.
Mr. AMBINDER: Right. Well, I should say by way of disclosure that I know Dr. Frank and have spent time in his clinic and have seen the people that he has helped and, you know, and so validate the work that he is doing, but ultimately, Dr. Frank would not have to be in practice, and people wouldn't be at the point where they would feel compelled to undertake in.
And Dr. Frank's programs are, you know, as he will - they're very comprehensive. They're very complex, and they're fairly difficult to comply with, and some people do. I tried, and I wasn't able to. But the goal is to obviously prevent people, as much as possible - I mean, there are going to be people for a variety of reasons who have a genetic predetermination to - you know, that allows them to lose weight fairly easily and have genetic predetermination that doesn't.
But the idea that, you know, until we get to the point where there is a pill or a series of relatively non-difficult interventions that one can take to not manage chronic obesity - because it can be managed now by treating its effects, by treating type 2 diabetes - but, you know, by reducing the fat that collects around the body, you know. We have to look at a broader approach that starts with the influences that impinge upon even mothers nursing their kids at a very young age, having that linked directly to rates of childhood obesity.
CONAN: And you're talking about policies that affect things like how much and what kind of advertising various companies can do, what kind of labeling they have to put on their foods, what kind of taxes we impose on various kinds of foods, all these sorts of things, very controversial and difficult to get consensus about.
We're going to talk more about those and continue to take your calls, and let's see if we can put Dr. Frank out of business in the second segment of the program.
(Soundbite of laughter)
CONAN: 800-989-8255. If you're struggling with this obesity issue, give us a call, or you can email us, firstname.lastname@example.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
(Soundbite of music)
CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.
America has a weight problem. Most of us are - more of us are obese and overweight than in any other developed country. The question now - what to do about it. Marc Ambinder laid out the scope of the problem and his own fight against obesity. He also described some possible solutions in the May issue of The Atlantic magazine. We've posted a link to that cover story at npr.org, so just click on TALK OF THE NATION there.
If this is your story too, tell us how you're struggling to overcome it, 800-989-8255. Email us, email@example.com. Marc Ambinder is with us, politics editor at The Atlantic, also Dr. Arthur Frank, co-founder and - founder and co-director of the George Washington University Weight Management Program.
And let's see if we can get another caller in on the line. Let's go to Blair(ph), Blair with us from Virginia Beach.
BLAIR (Caller): Hi, how are you today?
CONAN: Good, thank you.
BLAIR: I really was - I had to actually pull off the road, I was so excited when I heard this. I read Marc's piece in The Atlantic when I first saw it, and it was - it really hit home for me. I had a similar struggle.
I was actually as high as 400 pounds up to about three years ago, and I've lost a little over 210 pounds since I had a gastric bypass. In the time being, I've run two marathons, and you know, just had such an amazing difference in my life, and you know, so much of what he wrote was so spot-on, and the gestalt that I see between the life I lead now and the life I lead then is just an amazing, amazing thing.
CONAN: So the surgery worked out for you?
BLAIR: It worked well, but it - and he points it out. I mean, it is a tool. You know, I've said to others that my body kind of needed some time out to relearn what it needed to do. I mean, the thing about the gastric bypass for me is that now that I'm three years out, I could, if I wanted to, eat enough of bad things that I could probably get myself into the same pickle, or if I hadn't figured out how to incorporate a fitness regime in my life, I could begin to gain the weight.
And I'm sure Marc has seen a lot of people go down that gastric bypass path and end up gaining the weight back and worse off, and I was lucky that I've been able to take advantage of it.
CONAN: And he does write about that in his article. He also mentions there can be some bad outcomes in a very small number of cases and some not-so-pleasant side effects sometimes. But I wonder, Dr. Frank, do you agree with Marc that this is - it's not a broad-scale solution to anything.
Dr. FRANK: No, it's not a broad-scale solution, and I think we have to be very careful about the characterization of it as a cure for the disease or as a way, a sure-fire way of controlling the disease. It is a - it's not a sure-fire way of controlling it; it is a way of controlling it, but it does not cure the disease. It does not reset your regulating system.
It is a way of controlling it, much as we have good medications that can control diabetes, but we don't cure diabetes, and we don't cure hypertension. It's merely because we get it under control. This is something which can get it under control and which can sustain it under control.
It takes an enormous amount of work for the long term to maintain that. Many people, most people actually, do tend to regain at least some. It is not a cure. It is not a way of solving the problem. It's a way of managing the problem.
CONAN: And that's one of the things that also - that Marc talks about in his article. And would you agree with him that in fact we need to address this on a policy basis, that we have to figure out what we're doing as a nation to get us into this mess in the first place?
Dr. FRANK: There are three parts to the - I'm going to be simplistic for a moment. There are three parts. Number one is we have to change public policy, and this is something which is so vital and so important and which is discussed in the article. We've got to change the way we deal with this as a culture, as a group, as a community. We have to change the way we deal with it.
Number two is we have to understand the neurochemistry of how people eat. We have to get at what are the mechanisms that control, regulate eating, which is very tightly controlled by a very complex series of brain chemistries. Now, we are understanding large parts of that. The difficulty is in managing and manipulating it.
The third part is what we've been dealing with unsuccessfully for the past 50, 75 years, and that is to say eat less. It's personal behavior. It's your own willful misconduct that has caused this, and that's not true. And it's also extremely difficult to change personal behavior in the long term because the brain is so tightly regulated about how it controls eating, because eating is what you need to do in order to survive.
CONAN: Here's an email we have from Adam in Kansas. Given that the solution to obesity has been known for years, namely healthy eating and daily exercise, why does obesity continue to be such a problem in the U.S.? And Marc Ambinder, that gets to the doctor's point and to one you make in the article. It may be on an individual basis that some of the time willful conduct is part of it, but not overall.
Dr. FRANK: Not overall. It's - a large part of the problem is how you behave, how you deal with the problem. You've got to deal with it.
CONAN: And Marc talks about kids who basically don't have a lot of choice here.
Mr. AMBINDER: I think, you know, the objection one hears to, well, why do you have to involve the government in what is fundamentally a personal choice, you know, my response to that was, well, that objection may have been a valid objection 30, 35 years ago, when the nuclear family was more intact than it is, when, you know, both parents in families weren't working, when you didn't have nearly the number of single parents, and the inequality in the health - the inequalities in the health care system weren't such that, you know, that those inequalities can in a sense be a marker for - a marker for obesity.
These parents in vulnerable communities don't know how to deal with their kids' eating habits. They don't have the time to do it while still making sure that they can make money for their kids. And the kids don't know what to do.
So no one essentially is at the level where they're making choices. Therefore to me it doesn't really make sense from a policy or even a moral perspective to talk about this as if it were a choice issue, because you're essentially saying then, well, these poor people, these African-Americans, these Mexican-American boys, these African-American women, Native Americans on reservations, are just making bad choices, worse choices than we upper-middle-class white people are, and I don't think that's correct. I think that's actually a fairly reprehensible way to look at the problem. So - go ahead.
CONAN: I was just going to bring another caller into the conversation. Let's get Randy on the line from Madison, Wisconsin.
RANDY (Caller): Yes, I was very obese about 20 years ago and fortunately found a researcher in Madison that helped me, after I lost well over - about 120 pounds, down into a fairly ideal body weight, and then it was the sustaining it.
But what has happened, I found the motivation that helped me maintain it was not only did I have this help, but I looked at my family and my wife and I knew I could not be a father or a husband to these children and get them raised and into college unless I was able to move around and be a parent.
That helped me, but what's happening now, I'm regaining, exactly as your gentleman is saying, I'm regaining this weight no matter what I do. I'm back. I've got 55 pounds, about, of it back, and so now we have come to the conclusion: I need this ruin why? And as I've gone out there, and God bless you, Marc, God bless you, Mr. Frank, you're wonderful people and - for staying in this fight.
And I have done a - all my effort in behavior and diet, as I've gone out there to try to find a surgeon, I and the doctor who has helped me, a marvelous researcher who has helped me, we cannot find a surgeon. Unless you have a 40 BMI, they don't want to take somebody that's 34, who's gaining his weight back incrementally, who has high blood pressure now and whose blood sugar is back.
They want you to be next to death's door, and if you've been responsible and have worked hard, been terribly obese once, they want you to gain all this weight back first.
CONAN: Marc, you were about to say something?
Mr. AMBINDER: Yeah, this is actually a question that I faced myself, because technically I wasn't above the 40 BMI threshold, which is the standard threshold that the Professional Society for Bariatric Surgeons uses as its general guideline. It's also the guideline that Medicare and Medicaid have adopted for paying for this type of surgery.
But there are many doctors now who will conduct the surgery if your BMI is over 35 and you have conditions. Like I had sleep apnea and severe diabetes. But it is, in some ways, for someone - you are unfortunately in a - in terms of the surgery, and there may be other options, but in terms of getting the surgery, you seem to be, you know, in an area that doesn't, you know, fall onto any of the accepted landing platforms. And the one thing - go ahead, yes.
CONAN: And I was just going to say, Marc, even with yours, your insurance didn't cover it.
Mr. AMBINDER: You know, my insurance refused to cover it, even though I had, you know, I had a history of attempting other medical weight loss programs like Dr. Frank's and numerous diets and could document them. And I was lucky because I could afford it.
One thing I do find that's interesting about this surgery, and I don't want to re-litigate this with Dr. Frank, because he is is the expert in this field and I'm just a, you know, I'm a - I have the zeal of a convert to one particular solution, although I recognize that there are numerous solutions.
But one of the problems that I would worry about if too many people reverted to this type of surgery is that you would have surgeons who aren't well-trained in it doing it, and then the complications rates - complication rates would rise. On the other hand, you're starting to see the surgery now used as a way of - in a sense, I'll use the word cure, type 2 diabetes among thinner people who have very severe type 2 diabetes and who have tried other interventions and it hasn't worked.
I feel very - I mean, I feel the frustration of the caller and, you know, I -it's really, really hard because you've spent your life struggling with this. You know that this will - that this - you know, you have the resources once you go through with the surgery to, you know, to maintain - to do what's necessary, but you're just not finding a surgeon to do it.
Mr. AMBINDER: And my heart goes out to you.
CONAN: And, Randy, we wish you the best of luck.
RANDY: Well, thank you and God bless you guys for staying in the fight and helping. If I get this done, it'll be because people like you have gone before, and you are a great example, Marc. Thank you for the work you've done. I'm not going to give up.
CONAN: Good for you, Randy.
RANDY: I'll keep working. Yeah. So thank you.
CONAN: All right. Thanks very much for the call. Dr. Frank?
Dr. FRANK: As far as I'm concerned, when you calculate the BMI for someone like Randy, you've got to calculate his maximum BMI, not his current BMI. The fact that he's got it in control does not mean - right now, well he's got it something of a control - does not mean that his - essentially his BMI was well over 40 and that's what I would use if I were the surgeon who are - who is going to do this procedure.
But it really gets at the whole very important issue, the public policy issue around, for example - one of the issues is the monstrosity of the health insurance system. The health insurance refuses to pay for the treatment of this medical problem. This is a disease. This is a complicated disease. It ought to be treated as a disease. Health insurance companies won't pay benefits for the treatment of obesity.
And so, we get the awful problem of people who are dealing with surgery, an enormous bill of 30, $40,000 or people who want to deal with it with nonsurgical procedures and the insurance companies refuse to pay for it. It's a disease like diabetes is a disease and we've got to deal with it. We can't cure it. We can't - but we have ways of managing it.
CONAN: Even in his - even though in his article in The Atlantic, "Beating Obesity," Marc Ambinder notes, the insurance companies would probably save some money down the road due to the reduced health problems. Anyway, we're talking with Marc Ambinder about his article. And also with us, you just heard him, Dr. Arthur Frank. You're listening to TALK OF THE NATION from NPR News.
And here's another email, this from Dave(ph). In my state, Kansas, the legislature is now considering a tax of a penny on each teaspoon of sugar in soft drinks. Does your guest consider this a step in the right direction? Marc Ambinder?
Mr. AMBINDER: I have mixed feelings about excise taxes on soda and sugar. There really haven't been, in this country, which has a very specific culture and way of responding to these types of things, these large-scale behavioral economics experiments to decide to - you know, to see whether these will reduce obesity rates. I'm a little skeptical. I'm skeptical because I worry that the issue isn't one of people choosing to consume a particular type of calorie.
It's simply - you know, they will find other ways because their brain is essentially - I use the word advisedly - addicted to eating a certain level per day in order - so that they feel physiologically and psychologically satiated, they'll transfer it over.
And I'm also quite - frankly, I don't like these taxes that will put the disproportionate burden on people who can least afford it. Even though food is cheap, again, the people for whom this is the largest problem tend to be poor and we - the message the tax sends is not a message I like. If it works, then I may have to revise my preconceptions, but I haven't seen the type of large-scale experiments in terms of public policy to know whether this would work. I'm personally skeptical. I don't know.
CONAN: It's sort of based on the tobacco model. If you drive up...
Mr. AMBINDER: Right.
CONAN: ...the price of cigarettes, you can convince people - at least on an economic argument - maybe I'll try quitting.
Mr. AMBINDER: Right. And that is the basis. And there are similarities between the tobacco intervention model and the obesity intervention model, but there are also massive differences.
CONAN: And here's a tweet that we have from WitchChild(ph). Why are your guests not talking about the role of quality of food in obesity, like overprocessed junk which fills markets? Believe me, a lot of that is in Marc Ambinder's piece. We just haven't had time to get to it, not that it isn't an important part of the conversation.
But I wanted to get back to you, Dr. Frank, and this idea - I know you've Michelle Obama's approach that she's come out to fight against childhood obesity. Is this something that gives you encouragement?
Dr. FRANK: It gives me encouragement, but it - I think it's really, in the net, long-term insufficient. We've got to have - we got to have more resources for the kind of sophisticated research that needs to be done so that we can understand the mechanisms by which the body controls eating behavior.
The body controls lots of things. The body controls sleep. We can override our sleep mechanisms. The body controls eating. We can override our eating mechanisms. It's very difficult to do that. We've got to understand that in a more sophisticated way. What I'd like to do is take that one penny per ounce...
CONAN: Of soda.
Dr. FRANK: ...of soda and I would like to spend that money on doing the kinds of things that we need to do to understand the mechanisms, to understand how the body regulates this. And then we can control it in a much more sophisticated way.
CONAN: And Marc Ambinder, again, there's a lot in your piece that we have not had time to get to. But you do come to the conclusion at the end that there is cause for optimism here.
Mr. AMBINDER: I do. Cautious optimism but optimism, in part because we haven't had the type of political leadership on this issue, this particular issue ever. We haven't had someone who literally has the president's ear. We haven't had a president of the United States make what I consider to be fairly sophisticated remarks about the problem which suggests a level of understanding. And we haven't had government coordination, which we're starting to see now, trying to figure out whether we can make regulations in this area more efficient and non-overlapping. So it's a necessary start.
One other thing that makes me optimistic is that industry is starting to act prophylactically, worried that if they don't act, the government is going to regulate.
CONAN: Can we - there is - we mentioned a lot we didn't get to. Can we have you both get back to us in a month or so, we can go over more of this?
Mr. AMBINDER: I'd love to.
Dr. FRANK: I'd love to.
CONAN: All right. There we go. We'll have you come back.
Dr. FRANK: Great.
CONAN: Appreciate it. We'll arrange a date for both of you and then we'll talk on the radio, too. When we come back - our guests were Dr. Arthur Frank, founder and co-director of the George Washington University Weight Management Program. And Mark Ambinder, his article "Beating Obesity" in the May issue of the Atlantic.
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