It’s no secret that Americans are getting fatter. Nearly one hundred million people in the U.S. are obese, Based on current trends more than half of all adults in U-S will be obese by 2030, and with this increase in obesity comes an uptick in serious health problems including diabetes, heart disease and cancer. The rise in obesity will also put enormous new strains on our health system – and perhaps most especially, Medicare. Join us for a discussion of the health and health care challenges of obesity, new research on weight loss, and why some say government leadership on this issue is essential.

Guests

  • Claire Wang assistant professor, Department of Health Policy & Management, Columbia Mailman School of Public Health
  • Kenneth Thorpe professor and chair, graduate faculty Health Policy and Management Rollins School of Public Health Emory University
  • Kevin Hall senior investigator, National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health
  • Maya Rockeymoore president and CEO, Global Policy Solutions director, Leadership for Healthy Communities, a national program of the Robert Wood Johnson Foundation.

Transcript

  • 10:06:55

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. According to an international public health research team, if trends continue, half of all Americans will be obese by 2030. Without significant changes, we face both declining health outcomes and skyrocketing health care costs.

  • 10:07:22

    MS. DIANE REHMJoining me here in the studio to talk about the obesity epidemic in the U.S.: Kevin Hall -- he's with the National Institutes of Health -- Maya Rockeymoore of Global Policy Solutions. Joining us by phone from the -- joining us by phone from Atlanta -- forgive me -- is Kenneth Thorpe. He's professor at the Rollins School of Public Health at Emory University.

  • 10:07:59

    MS. DIANE REHMAnd, from Columbia University, Claire Wang, she's assistant professor at the Columbia School of Public Health. And throughout the hour, as we talk about current trends in obesity, I'll be interested to hear your comments, questions, 800-433-8850. Send us your email to drshow@wamu.org. Join us on Facebook or Twitter. And good morning to all of you.

  • 10:08:41

    MR. KEVIN HALLGood morning.

  • 10:08:41

    MS. MAYA ROCKEYMOOREGood morning.

  • 10:08:41

    PROF. KENNETH THORPEGood morning.

  • 10:08:42

    PROF. CLAIRE WANGGood morning.

  • 10:08:42

    REHMClaire, I wonder if I could start with you. You led the research on this latest study. Give us the highlights in terms of the trends in obesity.

  • 10:09:00

    WANGSure. It's a pleasure to be here. In our study, we looked at data on the body mass index in the past 20 years in the United States population. What we saw is a rapid rise of the prevalence of obesity. The most current data, the most recent data from 2007 and 2008, one out of three adults in the United States have a body mass index in the obese range, and two out of three adults in the United States are currently overweight.

  • 10:09:41

    WANGWell, we started to see some signs, some early signs of flattening of this trend in the more recent data. However, if these historical trends were to continue, we're projecting in the next 20 years, by 2030, about half of Americans will be obese if we are not doing anything to reverse this trend.

  • 10:10:05

    WANGIf these trends will continue, we're going to see a combination of a population that are older because we are also experiencing an aging of the population in the United States, as many of the baby boomers are reaching retirement age. So we're looking at a population that -- that's more obese and also older as a result.

  • 10:10:30

    REHMTell me about children as well, Maya.

  • 10:10:34

    WANGSure, definitely. I think the childhood obesity epidemic is definitely something that we're paying a lot of attention to. So, currently, 17 percent of our teenagers are already obese. And so we have just started to see the health consequences of childhood obesity started to surface. I mean, in the past, Type 2 diabetes were called adult-onset diabetes because we don't see that in children.

  • 10:11:04

    WANGBut because of the obesity epidemic, they started to show up very early on, and that has huge health and economic consequences. And that put a burden to our society.

  • 10:11:14

    REHMClaire Wang, she is assistant professor in the Department of Health Policy and Management at Columbia University School of Public Health. I wonder if, now to you, Maya, we can talk about the known health consequences of obesity.

  • 10:11:39

    ROCKEYMOOREThe known health consequences are actually quite tragic. Obesity leads to chronic diseases that are quite expensive, everything from Type 2 diabetes to hypertension, to heart disease, to stroke. All of these are obesity-related diseases that cost this country quite a bit. And so they are largely preventable, and they can be prevented if we actually tackle this overweight and obesity problem in our country.

  • 10:12:05

    ROCKEYMOOREWe do know that, currently, obesity cost the nation $147 billion annually. And so Claire's research actually projects forward on that and comes up with an estimate of an increase of approximately $66 billion on top of that annually if we do nothing to attack this. However, the good news is that we're actually moving down the path towards attacking this in a number of ways.

  • 10:12:32

    ROCKEYMOOREYou know, the nation has experienced an imbalance in terms of physical activity and nutrition over the past four decades. In fact, there's been a fourfold increase over the past four decades in childhood obesity alone. And we know that adult obesity rates are continuing to rise tremendously. So, you know, the efforts that are taking place around the country certainly focus on personal health, but they also focus on environmental health.

  • 10:12:58

    ROCKEYMOOREWhat is it about our environments that are creating this obesity in our society? And what can we do to tackle our environments to improve healthy eating and increase active living?

  • 10:13:11

    REHMMaya Rockeymoore, she's president and CEO of Global Policy Solutions. Kevin Hall, you were also part of this research team. Are we really eating that much more?

  • 10:13:29

    HALLWell, it's a good question. And one of things that my laboratory at the NIH is devoted to is trying to quantify the changes of food intake that are responsible for changes of body weight. And we do that by actually making mathematical models of how human metabolism changes as people gain and lose weight.

  • 10:13:47

    HALLSo one of the results from our research was to try to look at the global trends, or actually more specifically the U.S. trends, of average adult body weight over the past 30 years -- it's gone up by about 10 kilograms or about 22 pounds over the past 30 years -- and to try to quantify how much more people would have to be eating in order to give rise to that slow rate of average weight change -- turned out to be a little above 200 calories per person, per day.

  • 10:14:16

    REHMPer day.

  • 10:14:17

    HALLYes.

  • 10:14:17

    REHMTwo hundred calories per person, per day, which doesn't seem like a huge amount, but, apparently, it is.

  • 10:14:27

    HALLWell, that's all that would be required, and that's discounting any changes of physical activity, actually. It would have to less than that if physical activity has decreased substantially since the 1970s, which, you know, there really isn't that great data to suggest that is has.

  • 10:14:41

    HALLCertainly, physical activity changed quite a lot since the turn of the 20th century towards the middle of the 20th century as mechanization has improved. You know, labor conditions and hard labor basically dwindled away over the first part of the 20th century. But since then, where we actually have had the rise of obesity is only since the 1980s or so. Really, food intake seems to be driving most of that.

  • 10:15:06

    REHMKevin Hall, senior investigator at the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, and now, turning to you, Ken Thorpe. Can you tell us what percentage of our health care cost can be attributed to obesity?

  • 10:15:35

    THORPEWell, that's -- it's a good question, Diane. You know, roughly, about 20 percent of our overall spending is linked to obesity. And we know that, over time, that it's a major contributor to the growth in the cost of health insurance. So about 10 to 20 percent of the growth in health insurance premiums over the last 15 years is directly linked to rising rates of obesity.

  • 10:16:02

    REHMNow...

  • 10:16:02

    THORPEIt also plays...

  • 10:16:03

    REHM...what differences do you see around the country?

  • 10:16:10

    THORPEWell, there is enormous variation in these rates. You know, certainly the Southeast tends to have the highest rates. You know, we've done some similar projections looking at state by state numbers. And we projected that, by 2018, that six states -- and they're largely in the Southeast -- would have over half of their adult population considered obese.

  • 10:16:32

    THORPEAnd if you look at those states, they are exactly the same states that have very, very high rates of diabetes, high blood pressure, bad cholesterol, asthma, back problems, pulmonary disease -- a host of chronic illnesses directly linked to obesity. And as a result, the cost of health care in those states is very high as well.

  • 10:16:52

    REHMKenneth Thorpe, he is professor and chair of the graduate faculty at the Health Policy and Management, Rollins School of Public Health at Emory University. Do join us, 800-433-8850. Send us your email to drshow@wamu.org. And, Kevin Hall, I gather even an extra 10 pounds can make a difference.

  • 10:17:26

    HALLRight. It's -- it turns out that relatively modest weight changes, both on the positive side increase risk for diseases like diabetes, especially in cardiovascular disease. But on the downside, in other words, losing a modest amount of weight can actually make a big difference as well. And, of course, very obese people often want to lose a lot more than 10 pounds, but even a small amount of weight loss is beneficial for health.

  • 10:17:52

    REHMAnd where would that show up, that 10 pounds of weight loss?

  • 10:18:00

    HALLWhere would it show up...

  • 10:18:00

    REHMIn terms of disease.

  • 10:18:03

    HALLOh, okay. So, I mean, one of the biggest risk factors that obesity presents is a risk of Type 2 diabetes. And one of the things that's been shown in many studies, including the diabetes prevention program, has been that relatively modest weight loss, which actually does take relatively intensive lifestyle changes to accomplish -- and persistent.

  • 10:18:25

    HALLThat's one of the key issues, is that those lifestyle changes have to be persistent over time -- does dramatically decrease the risk of Type 2 diabetes.

  • 10:18:33

    REHMKevin Hall of the National Institutes of Health. When we come back, we'll talk further, take your calls. I look forward to hearing from you.

  • 10:20:03

    REHMAnd we're dealing with the issue of obesity. A new study projects that, by the year 2030, half of all adult Americans will be in the obese category. And that means -- how do you define obese, Kevin?

  • 10:20:26

    HALLSo obesity, clinically, is defined as a body mass index. That's your mass and kilograms divided by your height and meter squared, not a thing that people are doing on a regular basis.

  • 10:20:35

    REHMYeah, hardly.

  • 10:20:36

    HALLBut it's about 30 and above is considered obese.

  • 10:20:39

    REHMThirty pounds.

  • 10:20:40

    HALLNo, no, 30 kilograms per meter squared.

  • 10:20:42

    REHMOkay. You've got to straighten that out for me. What does that mean in terms of pounds?

  • 10:20:49

    HALLWell, it depends how tall you are. And you have -- I can't do the conversions in my head very well.

  • 10:20:54

    REHMOkay. Claire?

  • 10:20:55

    WANGFor an average height adult male, it's about 30 pounds over the normal range.

  • 10:21:03

    REHMI see. And, Claire, is it also a matter of so much more food being available in this country now than, say, there was even back in 1940?

  • 10:21:22

    WANGThat's absolutely a contributing factor because excess weight gain is a consequence of -- is a result of positive energy balance. So energy in exceeds energy out. So as Kevin was just discussing, there are just more calories available to us, and these -- over the course of the past few decades, they have become cheaper. So we do consume a lot more calories than we can burn off.

  • 10:21:52

    HALLRight. If I could expand on that, just to kind of put some numbers on it, since the 1970s, both the USDA, as well as the Food and Agriculture Organization of the United Nations, have independently assessed the food supply in a variety of nations. And in the U.S., it's gone up by about 900 calories per person, per day.

  • 10:22:09

    HALLAnd as I mentioned before, typically, people have only increased by about 200, or a little bit more than 200 calories, per person, per day. So, in fact, one of the things that we discovered a couple years ago was that that predicts that there's a food waste issue. In other words, we're wasting more and more food every year. And, in fact, that has been independently confirmed by the EPA, who has looked at municipal solid food waste.

  • 10:22:35

    HALLAnd food waste has actually gone up by 50 percent since the 1970s. So we're now wasting about 1,400 calories per person, per day, in the U.S.

  • 10:22:44

    REHMMaya.

  • 10:22:45

    ROCKEYMOORESo add that on top of the fact that, you know, the suburban lifestyle is one that depends on cars. And so Americans aren't getting as much physical activity as they used to. Certainly, kids in schools are not getting as much physical activity as they need. Approximately 90 percent of elementary schools do not have daily physical education classes anymore. And, certainly, we know that both children and adults are watching more television.

  • 10:23:10

    REHMOf course.

  • 10:23:11

    ROCKEYMOOREThey're playing videogames. They're, you know, on the computer. They're not outside getting physical activity.

  • 10:23:17

    REHMKenneth Thorpe, here's a tweet. "What is a bigger problem, tobacco or obesity?"

  • 10:23:27

    THORPEWell, Diane, it's Ken. I think, both in terms of prevalence and cost, it's obesity. I mean, tobacco rates are still too high. We have something like 20 percent of the adult population smoking. That's declined from about 50 percent in the 1960s. The obesity trends are going exactly the opposite direction. They've doubled since the mid-1980s to 34 percent now. So both the trends and the costs are higher.

  • 10:23:54

    THORPEAnd if I may just add, in terms of the age distributions here, this is a problem for the Medicare program and seniors as well. You know, the Congress is going to come back in a couple of weeks and talk about finding ways to slow the growth in entitlement spending. Well, the growth in obesity and associated chronic diseases in the Medicare program are going to add about $450 billion in spending to that program over the next decade.

  • 10:24:19

    THORPESo, I think, you know, really paying attention to interventions that are really addressed to finding ways to change lifestyle, generate weight loss and also engage people who have these chronic diseases, to keep them healthier, I think those two policy avenues really need to be at the top of the agenda when the Congress gets back.

  • 10:24:39

    REHMAnd to you again, Ken, here's an email, this from Joe in Silver Spring, Md., who says, "Isn't that increased health care cost reduced by the shorter lifespan of people who are obese?"

  • 10:25:03

    THORPEWell, actually, that's not true. It is the case for smokers, who tend to die much younger than non-smokers. But the -- if you look at lifetime spending for people at age 65 in Medicare, who are obese versus normal weight, that obese Medicare beneficiary spends about 15 to 35 percent more over their lifetime on health care than the normal weight person.

  • 10:25:30

    THORPEAnd the reason is is that the differences in mortality rates between a normal weight and obese adult may be up to a year or year-and-a-half. There are some estimates that have it basically there's really no difference. But every year that that obese person is living at 65, 66 and 67, they're incurring about 40 percent more in health care spending than the normal weight adult is during that period.

  • 10:25:56

    THORPESo there is a little difference in mortality rates, but it certainly doesn't offset the accumulated lifetime spending in Medicare for somebody who's obese.

  • 10:26:05

    REHMClaire.

  • 10:26:07

    WANGYes. I just want to echo Ken's point, who's really the expert in this area. Aside from the health care spending, there are a lot of chronic conditions that's associated with being obese. And a lot of these conditions were occurring during the productive life of Americans.

  • 10:26:25

    WANGSo what we're seeing is, aside from health care spending, there's also a huge cost, an economic cost for society when there is less productivity that we're contributing because of obese -- obesity-related diseases.

  • 10:26:40

    REHMAnd Maya.

  • 10:26:41

    ROCKEYMOOREIn fact, that amount is approximated at $73 billion annually in lost productivity and worker absenteeism. So it's quite costly.

  • 10:26:49

    REHMHere's an email from David, who's in Bethesda. He says, "I've read nearly $1 billion a year is spent at the federal level on obesity research. I understand there is some small segment of the population that cannot lose weight easily due to disease." He doesn't understand why it's necessary to spend all this money, especially in tight fiscal times. There seems to exist some national assumption that the causes of obesity are inscrutable. Kevin.

  • 10:27:36

    HALLThat's a interesting figure. I don't know if it's an accurate figure. I'm on the intramural program side of DNA, so I don't really know how much is spent on obesity research. But if you look at the cost that obesity is costing the nation, as our other guests have pointed out very clearly, it seems that some sort of research about what are the causes of obesity, what is the magnitude of the change required to address obesity, both at a policy level and population level, as well as at an individual level.

  • 10:28:08

    HALLAnd those are some of the resources that our taxpayers who are listening are devoting to my lab's research, to actually better understand, what would be the expected weight change if somebody was to go on a particular diet or a particular exercise program? And it turns out that past guidelines by the NIH and by other organizations around the world turn out to be quite wrong, actually.

  • 10:28:31

    HALLSo there was this notion that if you cut 500 calories per day from your diet over the course of the week, you would generate a deficit of about 3,500 calories. And that would lead to a pound of weight loss, and that would continue...

  • 10:28:43

    REHMA week.

  • 10:28:44

    HALLA week, yes.

  • 10:28:45

    REHMRight.

  • 10:28:45

    HALLAnd that would just continue on. It turns out that when you actually account for how even a normal person's metabolism slows as a result of that diet, that's a very optimistic assessment about how much weight would be lost. In fact, it's about 100 percent off after a year, and it just gets worse after that.

  • 10:29:03

    HALLSo one of the things that my lab is researching is to try to understand, how does human metabolism change when people try to make lifestyle changes in terms of their diet and their exercise program? And we've actually come up with better tools that will allow physicians, as well as people who are interested in doing research on this topic, able to make actual simulations online about how a diet or a physical activity program would lead to weight change in a given person.

  • 10:29:31

    REHMGive me some of the things that you're putting up online.

  • 10:29:36

    HALLSo there's actually a simulator at bwsimulator.niddk.nih.gov. That's BW, as in Body Weight Simulator.

  • 10:29:45

    REHMWow.

  • 10:29:46

    HALLAnd people can enter in their initial age, their height, their gender, their initial weight, as well as some assessment about how much physical activity they do at work and in their leisure time. And then they can enter in a goal weight and then a goal period of time.

  • 10:30:01

    HALLAnd using these new mathematical methods that count for changes of metabolism over time, the simulator will spit back some numbers about what they would have to do to their calories or their physical activity, their exercise program to reach their goal, and then, even more importantly, what they'd have to do permanently to maintain that goal weight.

  • 10:30:20

    HALLAnd so this is replacing some of these old rules, this 3,500 calorie per pound rule that dietitians and physicians have used for about 50 years or so. And we now know it's clearly wrong. And this is -- I hope will allow people to get better expectations about what the rate of weight loss should be and tailor it to their specific body type.

  • 10:30:41

    REHMSo, give me an example. For a man who, say, is 5'10" and weighs 200 pounds, give me sort of an outline of what he would have to do in a given week to lose a single pound.

  • 10:31:04

    HALLRight. So, one of the things accounting for these slowing of metabolism -- we've actually come up with a general rule of thumb, which doesn't apply to everybody, but it's probably pretty good. I would suggest that people actually use the real simulator to get the real numbers.

  • 10:31:18

    HALLBut a good rule of thumb, using our average sort of model, would be that, for every pound somebody wants to eventually lose, they should cut their calories by about 10 calories per day.

  • 10:31:30

    REHMTen calories.

  • 10:31:31

    HALLTen. Now, it's going to take a long time to get there. So you only start to plateau at that new 1-pound weight. So if you want to lose 10 pounds, it's 100 calories per day you would have to cut. You'll eventually plateau at that 10-pound weight loss. But it'll take...

  • 10:31:46

    REHMBecause of the metabolism.

  • 10:31:47

    HALLBecause of the slow -- exactly. But it'll take a long time to get there. It'll take about three years to get 95 percent of the way there. And you'll get about halfway there after a year. So the old rule of thumb would predict that you would just keep going down forever because it doesn't account for the changes of metabolism. And so this new rule of thumb that we're calling the 10-calorie-per-day-per-pound rule really does a capture.

  • 10:32:09

    HALLWhere would you actually end up if you were to make that change today and wait for three years? Where would you end up?

  • 10:32:15

    REHMMaya.

  • 10:32:15

    ROCKEYMOORESo, Kevin, once you plateau, is there something that individuals can do to jumpstart the weight loss period again?

  • 10:32:22

    HALLWell, they'd have to do something else, right? So this sort of rule is giving an idea of what would they have to do permanently to kind of maintain that period. And one the things that our simulator does is it allows you to put multiple stages in, so that if you want to lose weight over a particular period of time, how would you get there, and then what would you have to do thereafter.

  • 10:32:41

    REHMKevin Hall of the National Institutes of Health. And you're listening to "The Diane Rehm Show." Claire, I know you want to add to that.

  • 10:32:53

    WANGSure. I think that rule Kevin has developed is extremely helpful for clinicians, for parents to really tell someone who is really, you know, interested in losing weight and maintain healthy weight to make behavioral changes.

  • 10:33:08

    WANGAnd we started to use that tool to look at some of the environmental and policy changes as well to come up with some concrete goals to reach, you know, whatever -- how many calories that we need to cut out from our energy balance. For example, for kids, the research has shown that every additional hour of screen time spent on watching TV and other activities in front of a monitor is associated with 106 calories a day energy intake.

  • 10:33:37

    WANGSo when we are starting to see a lot of the school districts started to restrict on the screen time and also tell parents to restrict the TV-watching time, there are going to be implications on the caloric balance. And each can of soda -- each, you know, can of soda is associated with 150 calories of intake. So where do we cut back on our usual diet in our lifestyle? And how do we connect that to the caloric evidence that we know?

  • 10:34:11

    WANGAnd how do energy balance associated with our weight change is going to all help us develop better tools and strategies to reverse this epidemic.

  • 10:34:22

    REHMMaya.

  • 10:34:23

    ROCKEYMOORESo, what Claire and Kevin are talking about -- come at it from a personal responsibility perspective. However, we have to recognize that environment plays an incredibly important role in this. So the prime example is that we send our children off to school every day, and they spend most of their day, you know, basically a prisoner to whatever's...

  • 10:34:45

    REHMServing.

  • 10:34:46

    ROCKEYMOOREYeah, whatever's offered in the lunch line or whatever is in the vending machine, et cetera. So, you know, school officials and public officials in the community actually have a responsibility to make sure what they're offering in the lunch lines, what's in the vending machines, et cetera, are nutritious and healthy options so that young people can get good nutrition while they're in school, and the same thing in the communities.

  • 10:35:09

    ROCKEYMOOREYou know, food access is a major issue. Healthy food access is an incredibly big challenge. And so, you know, are there full-service supermarkets? Is there a high density of fast-food restaurants in certain locations? How do we tackle that as a society and as a community? And that's what we're doing at Leadership for Healthy Communities, a program that's addressing this by working with state and local officials.

  • 10:35:32

    REHMAnd is, in fact, First Lady Michelle Obama involved in that process?

  • 10:35:40

    ROCKEYMOOREFirst Lady Michelle Obama has her own initiative called Let's Move, and she's also doing a number of very important things nationally. She recently announced a supermarket initiative, where they're seeking to stimulate new supermarkets in food deserts across the country so that people in low-income areas can have access to healthy fruits and vegetables as well.

  • 10:36:01

    REHMAnd, Kenneth Thorpe, how do you see the government getting actively involved in this kind of effort?

  • 10:36:11

    THORPEWell, one way that they can get involved -- and they have -- is by funding research showing what types of tools and interventions can work that really help people lose weight. So they -- about a decade ago, a very important study was done looking at the diabetes prevention program, which is a very intensive lifestyle modification program that deals with diet, exercise, nutrition.

  • 10:36:36

    THORPEWe need to deal with them all. It's designed to push for about 150 minutes of moderate physical activity a week. There's a lot of nutritional education involved. And that particular study found that if -- you know, participants who are enrolled in that program over an 18-month period lost about 7 percent of their weight.

  • 10:37:00

    THORPESo for an obese person who's 6' tall, that's about 16 pounds. That 16-pound weight loss translated into about a 58 percent reduction in the number of new cases of diabetes, so...

  • 10:37:13

    REHMKenneth Thorpe of Emory University. Before we take our break, Kevin, give us that Web address again.

  • 10:37:23

    HALLSure. It's bwsimulator.niddk.nih.gov.

  • 10:37:29

    REHMAnd we shall have that on our website, drshow.org. We'll be right back.

  • 10:40:03

    REHMAnd we have an email on the emotional aspects of gaining weight. Jessie, who has been a practicing psychotherapist for 30 years, says that, "Women generally eat their mad, sad feelings. Men often buy or drink to satiate their deeper yearnings for relationships." Claire, can you speak to that, or Kenneth Thorpe?

  • 10:40:40

    WANGSure. Especially for women, I think the -- when we're talking about excess body weight and obesity issues, let's just remind ourselves that it's not just about the size issue. And, of course, we care so much about how we look. At the same time, maintaining healthy weight, an active lifestyle, eating healthy is really taking care of ourselves. It's good for our health. And that's the most important thing.

  • 10:41:09

    WANGWe wanted to live a productive life, healthy life, so we can enjoy all the activities we enjoy doing and enrich our lives. So -- but at the same time, I think it's really important to remember that when -- prevention of weight gain is much more easier than losing weight, once we already put on 10, 20 pounds.

  • 10:41:34

    REHMTrue.

  • 10:41:34

    WANGSo, based on our model and a lot of the research has told us, maintaining a healthy lifestyle, which means we try to, you know, pick the best food for ourselves and be active, exercise, is really going to help us maintain healthy weight. Even if we put on two or three pounds -- we all do that -- and we'll be able to come back to our baseline much more easily than after we realize we're 20 pounds or 30 pounds overweight.

  • 10:42:04

    REHMAnd here's an email from Henry, who says, "We know there are certain races at higher risk associated with obesity -- Native Americans, African-Americans." Could you please comment on increases across different races, Maya?

  • 10:42:26

    ROCKEYMOOREYeah, actually, the -- in the adult population, African-Americans and Latinos have a disproportionately higher rate of overweight and obesity than do white Americans. And the same is true for childhood obesity. We're seeing that African-American and Mexican American youth and children have higher rates, as well as Native American children and some population groups within the Asians, Southeast Asian island, Pacific Islander population as well.

  • 10:42:54

    ROCKEYMOOREAnd so that is disturbing because we know that these are the same populations that are increasing in terms of their growth in the overall population. In the next 20 to 40 years, we're going to see that these populations will be the majority of the U.S. census.

  • 10:43:13

    REHMAll right. We're going to open the phones now. First to Huntsville, Ala. Good morning, Gary.

  • 10:43:23

    GARYGood morning. Can you hear me okay?

  • 10:43:24

    REHMSure can.

  • 10:43:26

    GARYOkay. Great. Well, my question is the -- isn't it the responsibility of the individual for their obesity more than environmental and also social concerns? Because people say it's the environment, but I was raised by a single mother. She was divorced six times. I was in three foster homes. We lived on food stamps. But I know it's my responsibility to keep myself fit.

  • 10:43:50

    GARYAnd, with that said, I think people focus more on weight loss than fitness and being healthy because weight loss is actually a function of fitness. If you're a fit individual, if you exercise on a regular basis, you eat the right foods with, you know, not the -- with good healthy calories and not the negative calories, that I call them, I think that it would be actually more something to think about that fitness is actually the key and not necessarily weight loss. Thank you.

  • 10:44:23

    REHMMaya.

  • 10:44:24

    ROCKEYMOORESo, actually, the food consumption and physical activity is also a function of what's available in your environment. So what you actually consume is -- your choices are only as good as the choices you have available to you in your environment. So, as I mentioned earlier, if you're in a school that has no access to healthy foods in the school and you're spending most of your time there, then you are a prisoner to what's being offered on the lunch line.

  • 10:44:51

    ROCKEYMOOREIf your school does not have PE, then you are a prisoner, and you're basically -- your environment has structured what your opportunities for health are. The same thing in communities, some communities have -- don't have access to green space that's safe for people to play. They don't have access to walking trails or biking lanes so that people can be safe as they get physical activity.

  • 10:45:13

    ROCKEYMOOREAnd, certainly, I mentioned earlier, some communities don't have access to grocery stores where they can get access to healthy foods. So what we have here is a conundrum. Certainly, personal responsibility is an aspect, but as a function of what's available to you in your environment.

  • 10:45:30

    REHMClaire.

  • 10:45:32

    WANGAbsolutely. And we don't want to tell parents how to feed their children, how to raise their children. But at the same time, I think the government's responsibility is to make sure that the environment is supportive of their healthy choices. Ultimately, we're hoping that the best choices are also the easiest choices.

  • 10:45:53

    WANGSo if healthy food are available in the community, and also they are affordable, even for food stamp recipients, then that is a supportive environment for a healthy lifestyle.

  • 10:46:07

    REHMKen Thorpe, can anyone -- can you correlate the rise in obesity to the availability of fast food?

  • 10:46:21

    THORPEWell, there have certainly been several studies looking at the role of both fast foods and the relative price of fast foods versus healthy foods over the last couple decades. And, I think, the consensus is, is that there is an association. Unfortunately, as we are just hearing, less healthy processed foods are much cheaper than healthier options that oftentimes are not available.

  • 10:46:49

    THORPESo, certainly, as processed foods, relatively inexpensive foods that are fast to get and fast to eat have proliferated over time, you know, there has been an association of rising rates of obesity.

  • 10:47:03

    REHMMaya.

  • 10:47:04

    ROCKEYMOOREAnd, certainly, in some communities, you can actually map what the chronic disease rates are in those communities based on what they have access to in their community. So I mentioned earlier food deserts. Food deserts are deserts in terms of having access to healthy foods. But many times, they have an overabundance of fast foods available to them -- restaurants, up and down the strip -- and that's all they have access to.

  • 10:47:27

    ROCKEYMOOREIf you actually look at a city and look at where that -- where those -- the density of those restaurants are and where the absence of available fresh fruits and vegetables are, you almost see a 1-to-1 overlap, higher chronic diseases in those communities that have less access and lower chronic diseases in those communities that have full access.

  • 10:47:49

    REHMAll right. To Larry in -- I guess, it's Jacksonville, Ark. Good morning. You're on the air.

  • 10:48:00

    LARRYGood morning. I have a comment. It seems to me like this obesity might be a little bit systematic of our culture nowadays. It doesn't matter what it is. It seems to be an overindulging society. We buy more houses than we need. We drive bigger cars than we need. We eat too much, drink too much, drugs, even sex, and that's the message that we get from the media.

  • 10:48:26

    LARRYYou deserve a break today and grab all the best that you can. We're just kind of becoming society of over-indulgers.

  • 10:48:35

    REHMWhat do you think about that, Ken Thorpe?

  • 10:48:39

    THORPEWell, you know, that's a tough -- it's certainly a tough one to address. I think that there is sort of a certain set of expectations that we've developed as we get rising income over time and a broader range of products available, whether it's electronics or whether it's different types and forms of TVs and computers and so on.

  • 10:48:59

    THORPECertainly, products that -- proliferation increases the demand for those services, and we do have a, it seems, an insatiable demand for new products and different products. So it very well could be part of the overall culture. And, certainly, you know, there have been a variety of political commentators who have raised enough points about different types of excesses, whether it's quick money in the housing market or quick money in financial market, and so on.

  • 10:49:28

    REHMKevin.

  • 10:49:29

    HALLOne thing that we haven't raised here in and which has, perhaps, caused a lot of these changes in the food environment has been that, in the '70s, there was pretty dramatic changes in U.S. agricultural policy that really -- what we've been talking about has been what we've called the push effect.

  • 10:49:45

    HALLWe've really put all the economic incentives in place to produce, at the farm level, the maximum number of calories and the minimum amount of land, really putting the economic incentives in place so that farmers produce as much as possible.

  • 10:49:59

    HALLAnd people become extraordinarily ingenious at making those raw materials, like corn and soy, into all sorts of processed foods, as well as figuring how to feed them to livestock, where, normally, livestock would not eat corn or soy. Now, they can. And we've really, in some sense, been extraordinarily successful at providing a plentiful food supply for the nation.

  • 10:50:20

    HALLAnd in some sense, the obesity epidemic might be a side effect of this push of cheap calories into the food supply and ingenious engineering of methods of making those foods palatable to humans.

  • 10:50:33

    REHMAnd to Louisville, Ky., on that very subject. Good morning, Ron.

  • 10:50:39

    RONGood morning. The gentleman just made my point. I was going to talk about how agricultural subsidies are meant to satisfy big corporations like Monsanto. And it makes a lot of things cheap and easy that wouldn't necessarily be that way. And I think bringing us closer to something more of a -- resembles a free market more in agriculture would help cut down. It's like he mentioned. Corn is not meant to be fed to livestock.

  • 10:51:06

    RONAnd because the fast-food industry needs a huge supply of it, we fast -- we fatten up cattle very quickly to satisfy this need, and its much lower quality beef, although we have more of it. And in this, people, they eat more meat, which is also not healthy.

  • 10:51:22

    RONAnd all these sugary things with a lot of high-fructose corn syrup, all these corn subsidies and sugar subsidies, a lot of these very cheap -- breakfast cereals and all this kind of thing would become a lot more expensive if we didn't pay for them upfront. They're not cheap. We're just paying for them with our taxes upfront.

  • 10:51:43

    RONAnd, also, our more sedentary society, where people drive everywhere and don't really walk to a tram stop, like they might in Europe, that kind of thing, it makes us a lot unhealthier. And so that's basically my point.

  • 10:52:02

    REHMGood points, Ron. Thanks for calling. Claire.

  • 10:52:07

    WANGYes. And then this point is right on target. So we're currently talking about, is government needed in this situation? And I think one of the consideration is whether or not we should be looking at solutions at least to correct for the wrong incentives that's put in place in the past.

  • 10:52:26

    WANGSo, as this gentleman mentioned, we're currently -- essentially, our taxpayers are subsidizing these cheap calories in many ways -- from the farm subsidy point of view, the production of cheap corn and all these unhealthy calories into the system -- and then we're also allowing the companies to commercialize these products, these calories.

  • 10:52:49

    WANGAt the same time, when they're advertising these products, sweetened -- very sugary cereals to our children, they can deduct those advertising costs as business expense. So, therefore, these are not taxed on. And as our research shown, when an obesity -- the obesity epidemic is causing health problems, we are also paying for their health care.

  • 10:53:13

    REHMClaire Wang, she is at Columbia School of Public Health. And you're listening to "The Diane Rehm Show." Maya.

  • 10:53:23

    ROCKEYMOORESo Claire is touching on something that we work on at Leadership for Healthy Communities. We work with state and local leaders across the country, whether they be state legislators, mayors, city council members. And we're seeing trends in the opposite direction.

  • 10:53:35

    ROCKEYMOOREMany policymakers across the country are recognizing their responsibility in this area and are making moves in order to change the physical environment to support healthier kids and healthier communities.

  • 10:53:46

    REHMHowever, you've got strong lobbyists here in Washington, D.C., that are continuing to push not only for the subsidies but for the availability of exactly the wrong kinds of foods.

  • 10:54:04

    ROCKEYMOOREI'm not saying that's not the case.

  • 10:54:06

    REHMYeah.

  • 10:54:06

    ROCKEYMOORECertainly, the food and beverage industry are very strong lobbies. And they have a financial stake, you know, in this. However, the country has a financial stake in this. We're talking about our deficits and our debt. And everybody agrees that health care costs are driving it, and the expensive chronic diseases that are obesity-related are at the leading edge of that.

  • 10:54:27

    ROCKEYMOOREWe have to do something on a societal level to combat this epidemic, and this is key.

  • 10:54:32

    REHMAll right. And, finally, to Fredericksburg, Va., good morning, Bill.

  • 10:54:39

    BILLOh, good morning. I just have a quick comment. I just don't -- it's any of our business how we tell people how to live their lives. If they want to live an obese, sedentary lifestyle, let them. But they should pay the financial burden for it. Somehow I think we should create a program where they're held financially responsible. If there is a financial impact that they're putting on society, we should find a way to make them pay for it.

  • 10:55:04

    BILLAnd also, on the converse side, if someone is leading a lifestyle that promotes -- that's healthy, they should be given a financial incentive to do that through insurance premiums or somehow a financial credit.

  • 10:55:20

    REHMAll right. Ken, do you want to comment?

  • 10:55:23

    THORPEWell, sure. That's a very good point. We do that for smoking. So as part of the Affordable Care Act, the premiums that people buy through the health insurance exchanges will be higher for people who smoke. Also, a part of the act allows employers to vary the cost of health insurance premiums by 30, 40 percent to encourage individuals to participate in workplace wellness programs.

  • 10:55:53

    THORPESo that's more of a carrot rather than a stick. But I think that employers are finding, at the workplace, that well-designed workplace health promotion programs that are voluntary, that if you provide a good structured program with the appropriate financial incentives, that it not only saves health care cost, but, as had been mentioned before, it actually increases the productivity of people in the workplace. (unintelligible)

  • 10:56:18

    REHMAll right. And last word from you, Kevin.

  • 10:56:21

    HALLOne thing that we haven't talked about so far is the fact that obesity is highly heritable. So genetics does play a very large role in determining who becomes obese and who does not become obese. And so I think that, while it's definitely clear that the environment has changed dramatically over the past 30 years, which has given rise to the obesity epidemic, one of the real questions is, why some people and not others?

  • 10:56:45

    HALLAnd why is it that this variation in body weight is still explained by genetics?

  • 10:56:50

    REHMKevin Hall of NIH, Maya Rockeymoore of Global Policy Solutions, Kenneth Thorpe of Emory University, Claire Wang of Columbia University, thank you all so much. Good to have you on. Thanks for listening. I'm Diane Rehm.

  • 10:57:13

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Sarah Ashworth, Lisa Dunn and Nikki Jecks. The engineer is Tobey Schreiner. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information.

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