The Economist Special Issue
December 15, 2012
Containing Obesity
The Big Picture: The world is getting wider, says Charlotte Howard. What can be done about it?
IT IS LUNCHTIME at Eastside Elementary School in Clinton, Mississippi, the fattest state in the fattest
country in the Western world. Uniformed lunch ladies stand at the ready. Nine-year-olds line up
dutifully, trays in hand. Yes to chocolate milk, yes to breaded chicken sandwiches, yes to baked beans,
yes to orange jelly, no to salad. Bowls of iceberg lettuce and tomatoes sit rim to rim, rejected. Regina
Ducksworth, in charge of Clinton’s lunch menu, sighs. “Broccoli is very popular,” she says, reassuringly.
Persuading children to eat vegetables is hardly a new struggle, nor would it seem to rank high on the list
of global priorities. In an age of plenty, individuals have the luxury of eating what they like. Yet America,
for all its libertarian ethos, is now worrying about how its citizens eat and how much exercise they take.
It has become an issue of national concern.
Two-thirds of American adults are overweight. This is defined as having a body mass index (BMI, a
common measure of obesity) of 25 or more, which for a man standing 175cm (5’9”) tall means a weight
of 77kg (170 pounds) or more. Alarmingly, 36% of adults and 17% of children are not just overweight but
obese, with a BMI of at least 30, meaning they weigh 92kg or more at the same height. If current trends
continue, by 2030 nearly half of American adults could be obese.
Americans may be shocked by these numbers, but for the rest of the world they fit a stereotype.
Hamburgers, sodas and sundaes are considered as American as the Stars and Stripes. Food at state fairs
is American cuisine at its most exuberantly sickening. At the Mississippi fair, a deep-fried Oreo biscuit’s
crispy exterior gives way to soft dough, sweet cream and chocolate goo. It is irresistible.
The rest of the world should not scoff at Americans, because belts in many other places are stretched
too, as shown by new data from Majid Ezzati of Imperial College, London, and Gretchen Stevens of the
World Health Organization (WHO). Some continental Europeans remain relatively slender. Swiss women
are the slimmest, and most French women don’t get fat, as they like to brag (though nearly 15% do). But
in Britain 25% of all women are obese, with men following close behind at 24%. Czech men take the
European biscuit: 30% are obese.
And it is not just the rich world that is too big for its own good. The world’s two main hubs for blub are
the Pacific islands and the Gulf region. Mexican adults are as fat as their northern neighbors. In Brazil
the tall and slender are being superseded by the pudgy, with 53% of adults overweight in 2008. Even in
China, which has seen devastating famine within living memory, one adult in four is overweight or
obese, with higher rates among city-dwellers. In all, according to Dr. Ezzati, in 2008 about 1.5 billion
adults, or roughly one-third of the world’s adult population, were overweight or obese. Obesity rates
were nearly double those in 1980.
Fat of the land
Not long ago the world’s main worry was that people had too little to eat. Malnourishment remains a
serious concern in some regions: some 16% of the world’s children, mainly in sub-Saharan Africa and
South Asia, were underweight in 2010. But 20 years earlier the figure was 24%. In a study of 36
developing countries, based on data from 1992 to 2000, Barry Popkin of the University of North Carolina
found that most of them had more overweight than underweight women.
The clearest explanation of this extraordinary modern phenomenon comes from a doctor who lived in
the 5th century BC. “As a general rule,” Hippocrates wrote, “the constitutions and the habits of a people
follow the nature of the land where they live.” Men and women of all ages and many cultures did not
choose gluttony and sloth over abstemiousness and hard work in the space of just a few decades.
Rather, their surroundings changed dramatically, and with them their behavior.
Much of the shift is due to economic growth. BMI rises in line with GDP up to $5,000 per person per
year, then the correlation ends. Greater wealth means that bicycles are abandoned for motorbikes and
cars, and work in the fields is swapped for sitting at a desk. In rich countries the share of the population
that gets insufficient exercise is more than twice as high as in poor ones.
Very importantly, argues Boyd Swinburn of Deakin University in Melbourne, diets change. Families can
afford to eat more food of all kinds, and particularly those high in fat and sugar. Mothers spend more
time at work and less time cooking. Food companies push their products harder. Richard Wrangham of
Harvard University says that heavily processed food may have helped increase obesity rates. Softer
foods take less energy to break down and finely milled grains can be digested more completely, so the
body absorbs more calories.
These global changes react with local factors to create different problems in different regions. Counterintuitively, in some countries malnutrition is leading to higher obesity rates. Undernourished mothers
produce babies who are predisposed to gaining weight easily, which makes children in fast-developing
countries particularly prone to getting fat.
In Mexico unreliable tap water and savvy marketing have helped make the country the world’s leading
guzzler of Coca-Cola: the average adult consumed 728 servings last year. In America junk-food calories
are often cheaper than healthy ones. Suburban sprawl and the universal availability of food have made
the car the new dining room. In the Middle East, Bedouin traditions of hosting and feasting have
combined with wealth to make over-eating a nightly habit. Any inclination to exercise is discouraged by
heat and cultural restrictions. In Beijing teenagers and office workers cram the fast-food restaurants
along Wangfujing. Even home-cooked Chinese meals contain more meat and oil than they used to.
Doting grandparents shower edible treats on scarce grandchildren.
Together, these disparate changes have caused more and more people to become fat. Many cultures
used to view a large girth with approval, as a sign of prosperity. But obesity has costs. It lowers workers’
productivity and in the longer term raises the risk of myriad ailments, including diabetes, heart disease,
strokes and some cancers; it also affects mental health. In America, obesity-related illness accounted for
one-fifth of total health-care spending in 2005, according to one paper.
A huge new global health study, led by Christopher Murray of the University of Washington, shows that
since 1990 obesity has grown faster than any other cause of disease. For women a high BMI is now the
third-largest driver of illness. At the same time childhood mortality has dropped and the average age of
the world’s population has risen rapidly. In combination these trends may mark a shift in public-health
priorities. Increasingly, early death is less of a worry than decades spent alive and sick.
It is plain that obesity has become a huge problem, that the factors influencing it are fiendishly hard to
untangle and that reversing it will involve difficult choices. Radical moves such as banning junk food
would infringe individuals’ freedom to eat what they like. Instead, some governments are cautiously
prodding their citizens to eat less and exercise more, and food companies are offering at least some
healthier foods.
In a few places obesity rates seem to be leveling, but for now waistlines in most countries continue to
widen unabated. Jiang He and his colleagues at Tulane University have estimated that by 2030 the
global number of overweight and obese people may double to 3.3 billion. That would have huge
implications for individuals, governments, employers, food companies and makers of pharmaceuticals.
The Caveman’s Curse: Why it is easy to get fat and hard to slim down.
OBESITY SEEMS TO have a simple cause. An individual consumes more calories than he uses, so the
surplus is stored as fat. Reversing this would seem to be a matter of choice. Don’t eat that burger; do
use your bicycle. But this basic equation masks lots of questions about why some people get fat and
others don’t, why it is so hard to lose weight, and what damage excess fat does to the body. A legion of
scientists are now looking for answers.
It is widely assumed that people are capable of choosing exactly what they eat, but that is only partly
true, for various reasons. First, they form associations and habits around food at a young age. It is not
for nothing that Proust’s reverie in “Remembrance of Things Past” was inspired by a madeleine cake,
and why some dishes are known as “comfort foods”. Second, the amount of food people consume is
often influenced by external factors, from the size of their plate to the music being played in the
background, as Brian Wansink of Cornell University has documented. The bigger the bowl of soup, the
more of it people will slurp.
People’s bodies are also predisposed, to varying degrees, to gain weight rather than lose it. The body
uses a range of hormones known as homeostatic factors to indicate whether it is hungry or full. For
example, ghrelin, made in the stomach, helps to signal that the body wants food. Leptin, a hormone
secreted by fatty tissue, tells the brain that it is time to stop eating. These signals are meant to help the
body balance energy consumed with energy spent, but they can be overridden by other factors.
Animal experiments show that when rodents first consume a sugary food the brain releases dopamine, a
chemical also involved in drug addiction. It signals pleasure and helps drive motivation. The more
scrumptious the food, the more dopamine is produced. The same reaction is found in humans. But over
time a glut of sugary foods seems to change the brain’s circuitry. Obese people become conditioned to
getting excited by the sight of yummy food. Just a glance at a fried Oreo can trigger higher activity in the
frontal cortex (linked to reward and motivation) of a fat person than it would in those of normal weight.
At the same time fat people seem to have fewer dopamine receptors. This is a dangerous combination—
they get more worked up by the prospect of junk food, but also get less pleasure from eating it. This
may drive compulsive overeating. And as an individual gets fatter, levels of leptin, the fullness hormone,
rise so much that the brain seems to stop responding to it. When he starts to lose weight, leptin levels
drop and the brain signals that he is starving, even if he still has plenty of fat to spare.
All this served man well until very recently. Cavemen needed to eat what they could when it was
available, storing any surplus because the next meal could be a long way off. But what was useful in the
savannah is less so in suburbia, home to the 512-calorie 7-Eleven Super Big Gulp Coca-Cola. Man’s
biology is hopelessly out of sync with the modern environment.
“Humans have a biological disposition to a certain size of fat store. If they try to lose weight, the body
will work hard to make sure they regain it.” Yet not everyone is obese. Studies of siblings and twins
show that the propensity for getting fat is largely determined by genes. In the 1980s Rudolph Leibel of
Columbia University and his colleagues were among the first to identify some genes that influence the
way the brain regulates food intake. Since then genetic analyses have revealed many more genes
involved in this process. Genetics does not guarantee that someone will get fat, says Philip James of the
International Association for the Study of Obesity, nor does it explain the dramatic rise in the number of
fat people in recent decades. But genes do help explain why, given similar conditions, some people are
fatter than others.
The mechanisms that help make people obese also prevent them from losing weight easily. Dr. Leibel
argues that humans have a biological disposition to a certain size of fat store. If they try to lose weight,
the body will work hard to make sure they regain it. Leptin levels drop while hunger-signaling ghrelin
levels rise. A recent study by Joseph Proietto and his colleagues at the University of Melbourne showed
that, even a year after individuals had lost weight after dieting, their levels of leptin remained depressed
and those of ghrelin elevated. Dr Leibel and his colleagues examined patients before and after they had
lost 10% of their body weight through a diet, using magnetic resonance imaging to watch their brains
respond to food. Before the weight loss their brains viewed the food with relative equanimity.
Afterwards they signaled great excitement.
Such studies help explain why so many diets fail. It is not just lack of willpower but a biological response
honed over millennia. “The evolutionary process has led to a gene pool that is designed to defend body
weight against falling below a minimum,” Dr Leibel explains, “but not to defend against gain.”
All this biology, however, cannot explain one notable feature of the obesity epidemic. The rich and welleducated have mostly managed to stay slim, or at least have got less fat than the less well off. In
America obesity rates in children with college-educated parents are less than half the rates of children
whose parents lack a high-school degree. Marion Devaux and her colleagues at the OECD, a rich-country
think-tank, found an inverse relationship between education levels and the likelihood of getting fat in
Australia, Canada and England. The picture is slightly different in poor and middle-income countries,
where the more affluent urbanites are usually the first to put on weight. As the economy develops,
however, the poor become obese in disproportionately large numbers.
Among the many explanations put forward for this link is that educated people may be better informed
about health issues. They may also have better access to doctors, gyms, parks and healthy food. The
poor may be under greater stress, making it harder for them to resist food that is cheap, tasty,
convenient and relentlessly advertised. Whatever the cause, a lot of poor and uneducated people are
also fat.
For poor and rich alike, an easy medical solution to obesity would be a great boon. But such treatments
as are available leave much to be desired.
Slim Pickings Medical treatments are unlikely to reverse obesity rates in the near future.
LUBNA ISLAM, HER dark eyes rimmed with turquoise liner, has always struggled with her weight. Born in
the United Arab Emirates, she slimmed down when she was at medical school in Pakistan but quickly
regained weight after returning to Abu Dhabi. “Here all the time you’re sitting in air conditioning, cars
are available,” she explains. “It’s a relaxing lifestyle.” With a BMI of 38, and weighing about 109kg, she
decided to have gastric surgery. After the operation she suffered from nasty side-effects. After a second
procedure she is more comfortable and now weighs 77kg. “I recommend it to my own patients.”
Bariatric surgery is a dramatic intervention in the body’s natural machinery, an extreme response to a
condition that for most patients is preventable. But Al Noor Hospital, where Dr Islam works, has seen a
surge in demand for such operations. The main bariatric surgeon performs an average of seven
operations a week. Most patients are below the age of 35.
Many hospitals the world over offer similar services. In Belo Horizonte, Brazil’s sixth-largest city, nearly
15,000 patients have sought bariatric surgery at Santa Casa hospital since 2008, though fewer than
1,000 got it. Galzuinda Reis, the hospital’s main bariatric surgeon, is happy to offer the operation but
worries that too many people want it. This demand is driven by two factors. First, and most obvious,
people are getting fatter. Second, although pharmaceutical companies excel at treating the diseases
that come with obesity, they have been conspicuously unsuccessful at treating the condition itself.
This is not for a lack of incentives. The average American would much prefer to be thinner. More than
half of America’s adults went on a diet in 2010. A good anti-obesity drug would be a blockbuster. But
regulators have banned more diet drugs than they have approved. Fen-Phen, made by Wyeth, worked
quite well but posed risks to the heart. In 1997 America’s Food and Drug Administration (FDA) asked
Wyeth to withdraw it voluntarily because of its effect on heart valves. Over the following decade drugs
from Sanofi-Aventis and Abbott were dropped for fear of other health risks. Until this year the FDA had
not approved a diet drug since Orlistat in 1999. That one is still sold, with decidedly unglamorous
gastrointestinal effects.
Now a new batch of medicines is coming on the market. The three front-runners are from companies in
California. In September Vivus launched Qsymia in America. The drug combines phentermine, which
suppresses the appetite by boosting leptin, and topiramate, a migraine drug that seems to help patients
feel full. Next year Arena will launch its diet drug, Belviq, which acts on serotonin receptors to make
patients feel more satisfied. Orexigen, the third company, is testing a drug that combines bupropion, an
antidepressant, with naltrexone, which is used in alcoholics to block the brain’s opioid receptors.
Patients who took high doses of Qsymia for a year, combined with diet and exercise, lost 10.9% of their
body weight, whereas a control group taking a placebo lost only 1.6%. Those taking Belviq, combined
with diet and exercise, lost an average of 5.8%, compared with 2.5% for the placebo group. But these
are not magic pills that will put an end to obesity. First, patients still have to go on a diet-and-exercise
regime, and even then the weight loss is fairly modest. Second, there are still some safety concerns. In
October European regulators rejected Qsymia over fears of its effect on the heart and central nervous
system. Third, the drugs are eye-wateringly expensive, and it is not clear that either insurers or
consumers will pay. Qsymia costs $160 a month, or nearly $2,000 a year. Vivus says that just one in five
potential patients has insurance coverage for the drug.
Cut and thrust
Bariatric surgery is a more drastic measure, with more dramatic results. A gastric band is fitted around
the top part of the stomach, reducing the amount of food that patients can take in without feeling
uncomfortable. In the most common version of gastric bypass surgery, still considered the gold
standard, the stomach is divided into a small pouch and a larger one, with the small pouch connected
directly to the middle of the small intestine. The small pouch makes a patient feel full more quickly, and
the intestinal shortcut stops some of the food from being absorbed. In a newer procedure, sleeve
gastrectomy, the surgeon cuts out three-quarters of the stomach and staples the remainder shut. The
new, much smaller stomach remains connected to the small intestine. Risks include malnutrition and
leakage from the new stomach into the abdominal cavity. Dr Islam first tried a gastric band, but pain and
vomiting prompted her to have it removed. In May 2011 she had a sleeve gastrectomy which has left
her being able to eat only a quarter of the food she used to.
Evidence for the effectiveness of bariatric surgery is growing. In a recent study published in the Journal
of the American Medical Association (JAMA), gastric bypass patients six years after surgery had on
average lost 28% of their body weight, compared with a 0.2% weight gain in a control group that sought
but was not given surgery. The surgery patients were also less likely to suffer from diabetes and high
blood pressure. An even longer-term study of Swedish patients showed that those who had had bariatric
surgery had lower rates of diabetes, heart conditions and cancer than those getting other forms of
treatment.
Edward Livingston, a bariatric surgeon and an editor of JAMA, thinks there is still a need for more and
bigger studies over longer periods before committing many more people to an operation involving a
drastic change in the body’s natural structure. But the eligibility criteria for bariatric patients are being
relaxed in some countries. Last year American regulators authorized gastric bands for patients who are
less than severely obese.
Research on other medical methods to fight the flab continues. Philip Smith, co-director of obesity
research at America’s National Institutes of Health (NIH), points to a new understanding of the
relationship between micro-bacteria and obesity. Some bacteria are correlated with being fat whereas
others are benevolent workers that help digest food. Jeffrey Gordon of Washington University has
already shown that transferring bacteria from fat to skinny mice makes the lean ones chubby. Now
scientists are trying to reverse the trick, transferring stools from skinny to fat subjects. Such
“transposition” would need to improve its branding, but it might be better than radical surgery.
As treatments improve, governments need to decide whether they can afford to pay for them. “If twothirds of your people have this disorder, you can’t possibly pay for treatment for two-thirds of patients,”
says Dr Livingston. In America the number of bariatric operations has leveled off (see chart 1). Insurance
companies are often reluctant to pay.
Drugs and surgery will not reverse the obesity epidemic on their own, so it is worth trying other
methods. One patient in Belo Horizonte, Glaucienne, has been obese since she was a child. Now 35, she
is scared of surgery, so is trying to lose weight at Santa Clara with the help of intensive counseling.
Finding time to exercise is hard, says Glaucienne, so she is concentrating on her diet, cutting out salty
snacks, chocolates and other treats.
The most insidious effect of obesity is the likelihood of contracting chronic diseases. Slimming down
even a little can have quite big effects; for example, breast-cancer survivors who dieted and lost an
average of 3kg saw a 24% drop in the risk of a recurrence. But while lots of people remain fat, the
associated ailments represent big business for the drug companies.
A Heavy Burden: Obesity presents a big challenge for governments and an opportunity for drug
companies.
IN THE DAYS when most people did not have enough to eat, being plump marked you out as wealthy
enough to guzzle your fill. But wealthy probably did not mean healthy even then, and today obesity is
seen as a problem mainly because a wide girth is closely linked with high blood pressure, high bloodsugar levels and an excess of cholesterol and fats in the blood. Scientists group these factors together
under the heading of metabolic syndrome, which raises the risk of diabetes, heart disease and other
ailments. Rising obesity rates pose a challenge not just for the individuals affected but for governments
that help pay for their health care.
The most common measure of obesity, BMI, represents weight in kilos divided by height in meters
squared. It is not perfect. A high BMI in an Olympic weightlifter, for example, is due to dense muscle
rather than fat. Researchers have found that the total amount of fat matters much less than where
exactly the fat is stored. The most harmful place is around the belly, the body type politely called appleshaped. James de Lemos of the University of Texas Southwestern Medical Centre studied 732 adults in
Dallas over seven years and found that their BMI and total body fat were not independently associated
with their propensity to diabetes, but visceral belly fat, packed around the internal organs, was. BMI is a
crude proxy for visceral obesity.
Far from being a passive storage unit, fatty tissue secretes hormones, including molecules that promote
inflammation, explains Dr James of the International Association for the Study of Obesity. Chronically
inflamed organs, in turn, stop working as they should. Overloaded fat tissue also pours out fatty acids
into organs where they don’t belong, particularly the liver. At its most extreme, the build-up of fat and
scarring in the liver can lead to liver failure. Non-alcoholic fatty-liver disease is relatively new; the term
was coined in 1986. Now, according to some estimates, it may affect up to one-third of America’s
population.
The effect of obesity on insulin levels is particularly worrying. Insulin, produced by the pancreas, has
many jobs, including delivering sugar to cells to provide them with energy. But inflammation and
inappropriate fat storage may keep cells from responding properly to the hormone, causing so-called
insulin resistance. This prompts the pancreas to pump out more and more of it. Eventually blood-sugar
levels rise out of control and the patient develops diabetes. High levels of blood sugar can lead to
blindness as blood vessels swell or grow on the retina; kidney disease as the body’s natural filters are
overwhelmed; and loss of limbs because of damage to nerves and blood vessels.
Excess insulin causes harm in other ways, too. People who are obese and diabetic are more likely to
contract certain cancers and die from them. This may be because excess insulin supplies glucose to
cancer cells, helping them replicate. Epidemiological studies confirm the hidden dangers of obesity. In a
series of surveys of more than 200,000 American health workers since the 1970s, those who had gained
5-11kg over the period were up to three times as likely to have diabetes, high blood pressure and heart
disease as those who had kept their weight steadier.
But there is much left to learn. The specific role of sugar and of refined carbohydrates is particularly
contentious. Gary Taubes and Peter Attia, of the new Nutrition Science Initiative in California, argue that
not all calories are created equal. Most problems associated with obesity, they say, are caused by sugary
diets and the follow-on effects of insulin, particularly its role in encouraging fat accumulation.
Whatever the precise mechanisms, there is no doubt that obesity is implicated in a surge of chronic
disease. The World Health Organization (WHO) blames excess fat for 44% of cases of diabetes, 23% of
ischaemic heart disease and over 40% for some types of cancer. This is already testing rich countries’
capacity to provide and pay for care.
Developing countries face even bigger problems. About 80% of deaths from chronic disease occur in
poor and middle-income countries, which are already getting the diseases of the rich before having
conquered those of the poor. And in many of those countries chronic diseases threaten to overwhelm
wobbly health systems, says Ann Keeling of the International Diabetes Federation. Though treatments
are available, it is often difficult to get care to those who need it and find the money to pay for it.
Patients in poor and middle-income countries die younger from chronic disease than their counterparts
in the rich world. In sub-Saharan Africa maternal obesity is linked with higher rates of infant mortality,
find Jenny Cresswell and her colleagues at the London School of Hygiene and Tropical Medicine. In
countries with a high incidence of HIV/AIDS there is an additional complication: some HIV drugs speed
up the development of diabetes.
China has particular problems, not because the incidence of obesity and diabetes is unusually high but
because its population, and thus the absolute number of sufferers, is so large and rates are rising. Some
92m Chinese adults are thought to have diabetes, though only 40% of them are diagnosed. Wenhui Li,
an endocrinologist at Peking Union Medical College Hospital, sees undiagnosed diabetics who already
have the symptoms of advanced stages of the disease. Linong Ji, president of the Chinese Diabetes
Society, worries about a looming wave of patients: “We don’t have a system to identify those individuals
and manage education or interventions in their lifestyles.” Treatment for obesity-related conditions in
China generally remains mediocre, and increasing obesity comes on top of other adverse factors, such as
a rapidly ageing population and a passion for cigarettes.
China’s government has taken some steps to deal with the problem. More than 90% of the population
now has health insurance, though the quality varies. The government is also trying to make treatment
available in more places; at present most patients crowd into big-city hospitals. A new plan for fighting
chronic disease, published in July, aims to get people to take more exercise, reduce obesity rates,
improve the care of patients with diabetes and high blood pressure and get people to eat better. It
sounds more like a wish list than a serious plan of action.
However unfortunate rising obesity rates may be for those afflicted, they offer a big opportunity for
pharmaceutical companies and makers of medical kit. Standard & Poor’s, a ratings agency, estimates
that the diabetes market, currently worth $35 billion, will reach $58 billion by 2018, a jump of 66%. The
number of patients receiving dialysis to clean their blood after kidney failure may rise by more than 6% a
year between 2011 and 2020, according to Bank of America Merrill Lynch. That means a lot of extra
business for Fresenius Medical Care and DaVita, the world’s two biggest dialysis companies. Similarly,
obesity’s effect on the heart will boost companies like Medtronic, the world’s leader in cardiac gadgets
such as pacemakers, valves and stents.
An ill wind
The health industry has already poured billions into developing treatments for chronic diseases. Statins
such as Lipitor, made by Pfizer, an American drug company, help lower harmful cholesterol. Diabetics
may begin treatment with metformin, an older, off-patent drug that, among other things, is thought to
improve the body’s response to insulin. If that is insufficient, patients may take human insulin or newer
insulin analogues. Novo Nordisk, a Danish company that specializes in diabetes, continues to invest in
treatments that are simpler to use and more effective.
It helps that governments are increasingly getting involved with trying to improve the treatment of such
diseases. France has contracted with Healthways, an American company, to manage care for French
diabetics. In England the National Health Service (NHS) has introduced a program called “Health Checks”
that aims to examine people aged 40-74 and help them ward off chronic disease or improve the
treatment they are already getting. Brazil last year began offering its citizens free drugs for high blood
pressure, diabetes and asthma.
In countries where the demand for care is overwhelming, companies are increasingly prepared to help
meet it. Zhang Zai Xin, a patient at the Guang’anmen South Area Hospital on the outskirts of Beijing, has
been a diabetic for 30 years. The hardest part, he says, is sticking to his diet. “No more mooncake,” he
sighs, “I feast with my eyes alone.” He is being treated by Ma Li, an endocrinologist trained by Project
Hope, a not-for-profit organization partly funded by Eli Lilly, a drug company based in Indianapolis. Dr.
Ma now teaches other doctors in Project Hope’s “train-the-trainer” program.
Off a packed hallway in another hospital in Beijing, a nurse conducts free cholesterol tests with a tool
provided by Pfizer. Patients are screened while they wait for their main appointment, so they can show
the doctor their results immediately. If the doctor prescribes the company’s drug, Lipitor, so much the
better. Wu Xiaobing, Pfizer China’s boss, plans to continue investing in screening programs and training
for doctors.
Perhaps the most active foreign drug company in China is Novo Nordisk. It decided to make the country
a priority early on, starting in 1994. Recently it said it would spend $100m on a new research center in
Beijing. Perhaps most important, it has helped train more than 220,000 doctors in China since 2003. This
has paid off. Novo Nordisk now has 62% of the Chinese market for diabetes drugs. The company is
expanding its training programs deeper into the countryside. There will be plenty to do for the extra
doctors: by 2030 it expects the number of diabetics in China to rise to 130m, up nearly 50% from 2011.
Such training and screening programs are not confined to China. Eli Lilly supports Project Hope in South
Africa and India. Novo Nordisk’s work includes projects elsewhere in Asia and in Africa. Firms say such
arrangements benefit both them and the country concerned, making treatment easier to get for
patients and increasing sales for the companies. Facing declining revenues in the West, where patents
on many blockbuster drugs have expired, firms are looking to emerging markets as a source of growth.
Lipitor, for example, lost its patent in November 2011 yet continues to command a premium in China
because patients are unsure about the quality of its competitors’ products. But drug companies’ training
programs make some health advocates uneasy. They fear that the companies may use them to promote
its drugs even if they cost more than generic alternatives.
Tension over pricing seems bound to grow, particularly for new patented medicines. Developing
countries, only too aware of the growing burden of disease, are naturally keen to bring prices down. At a
United Nations General Assembly on chronic conditions last year, a serious sticking point in the
negotiations was a proposed form of words that might make it harder for developing countries, under
various trade agreements, to reduce prices for medicines.
By and large, the main challenge for governments, particularly in poor countries, is to find the money to
treat obesity-related diseases. Treatments are readily available. But for reversing the underlying cause,
obesity itself, they need the help of a dubious ally: the food companies.
Small, Rich and Overweight: How Abu Dhabi is tackling its obesity problem.
ONE OF THE most ambitious plans to combat chronic diseases is being introduced in Abu Dhabi, the
biggest state in the United Arab Emirates. Nearly one in five of the UAE’s population is diabetic. Abu
Dhabi is small enough and rich enough to tackle the problem comprehensively. A top-down political
system helps.
In 2006 the emirate recruited Oliver Harrison, a psychologist and then a consultant at McKinsey, to its
new health authority to help tackle chronic disease. When the government launched a health-insurance
scheme in 2008, all adult Emiratis were offered a comprehensive health screening. By May 2010 some
92% of them had enrolled in the program. The results were alarming.
Thirty-five per cent of those screened were obese and a further 32% were overweight. These figures
were similar to those in America, but, worryingly, Emiratis were fatter at younger ages. Some 18% of
those screened had diabetes and a further 27% were at high risk of developing it.
Dr Harrison and his colleagues have been working to improve the care offered. Patients are given
scorecards with a number of indicators, including BMI, the risk of diabetes and smoking habits. Abu
Dhabi’s insurer, Daman, has tested program to help keep patients’ conditions under control. From the
insurer’s headquarters Maitha Al Khalifa calls patients all day to check that they are following their
doctors’ instructions on diet and medication.
But even in Abu Dhabi things have not gone quite according to plan. In Daman’s initial experiment less
than half of those who qualified for the diabetes and obesity program signed up for it. Now Dr Harrison
and his colleagues are preparing a more comprehensive scheme. They expect to launch a new mobile
platform next May, with an array of tools to connect patients to their doctors and monitor diet and
exercise. Patients with chronic diseases will be automatically enrolled in a program and given just one
month to opt out. The health authority will pay program managers only if they improve patients’ health.
In time, Dr Harrison hopes, Abu Dhabi’s hands-on approach may serve as a model for other
governments.
Food for Thought: Food companies play an ambivalent part in the fight against flab.
NESTLE, THE WORLD’S biggest food company, has creative ways to reach far-flung corners of the world.
One of them is to work through people like Flavia Medeiros, a micro-distributor in São Paulo. She sells to
Brazilians who might not at first sight have the cash or inclination to buy Nestlé products. Ms.
Medeiros’s stockroom is packed high with Nestlé cereals, yogurts, candies, chocolate milk and infant
formula. Her local recruits sell products door-to-door, often with IOUs provided by the company. In a
sister program the company has a large boat gliding up and down the Amazon, selling packaged food
and ice cream to the people living along its banks. Nestlé is thinking about kitting out a second boat.
Such sales techniques make some health advocates apoplectic.
For food and drinks companies, rising obesity rates present a conundrum. Companies have a duty to
their shareholders to make money. All big food companies are working hard to sell more products to
more of the world. Many unhealthy products are very profitable. But companies do not want to be
vilified for helping to make people fatter. The specter of government regulation looms large. Many firms
are now conflicted, continuing to hawk unhealthy products yet also touting elaborate plans to improve
nutrition. They insist they will help lower obesity rates, not raise them, but there is room for doubt.
Soft drinks are another matter. Coca-Cola and PepsiCo control nearly 40% of the world’s fizzy-drinks
market between them (see chart 4). Sales of soft drinks across the world have more than doubled in the
past decade, to $532 billion; in India, Brazil and China sales of fizzy drinks have more than quadrupled.
This is troubling, given that sugary drinks accounted for at least 20% of America’s weight gain between
1977 and 2007, according to Gail Woodward-Lopez and her colleagues at the University of California,
Berkeley.
These impressive sales figures look set to rise further. Nestlé is buying local companies in China and
adapting its own portfolio for the Chinese market. Many Chinese find coffee too bitter for their liking, so
Nestlé is offering Smoovlatte, a coffee drink that tastes like melted ice cream. Kraft, a food mammoth,
split itself in two in October. Mondelez International, the new company that now makes the hallowed
Oreo biscuit, is pushing for global domination of the snack market. It plans to increase its investment in
emerging markets, which already account for 44% of its revenue.
Fast-food chains, too, have spread far into developing markets. McDonald’s is now in 119 countries (see
box at the end of this section). Yum! Brands, owner of KFC, Taco Bell and Pizza Hut, derives 60% of its
profit from the developing world, and there is plenty of growth potential left. Yum!’s chief executive,
David Novak, explains that the company has 58 restaurants for every 1m Americans, compared with just
two restaurants for every 1m people in emerging markets.
But even as they are expanding, food companies are keen to show that they take the obesity problem
seriously. The International Food and Beverage Alliance (IFBA), a trade group of ten giants including
Coca-Cola, Mondelez and Nestlé, has given global promises to make healthier products, advertise food
responsibly and promote exercise. More specific pledges are being made in rich countries, where
obesity rates are higher and scrutiny is more thorough. In England 21 companies have struck a
“Responsibility Deal” with the Department of Health which commits them to helping people consume
fewer calories. In America, the biggest and most closely watched market, 16 companies have promised
to cut 1.5 trillion calories from their offerings by 2015 (an amount based on a rough calculation of how
much the average American should cut from his or her diet to be healthy). And virtually every company
has a plan of its own to improve nutrition, some more robust than others.
There are three general approaches: cut out bad ingredients, add good ones or introduce new products.
Kraft says it has come up with 5,000 healthier products since 2005, either by improving the recipe for
those already on the market or launching new ones. Coca-Cola has reduced the average number of
calories in its drinks by 9% since 2000 and continues to study new types of low-calorie sweeteners in
addition to those it is already using. Jonathan Blum, who was appointed Yum! Brands’ chief nutrition
officer in March, says he is systematically reviewing the company’s restaurant offerings for what he calls
its three pillars: choice, transparency and nutritional content. Nestlé, in particular, wants to be seen as a
company that makes healthy food. “It is a core business strategy,” explains Janet Voûte, Nestlé’s global
head of public affairs, who used to work at the WHO. The company has set up a new institute to
combine nutritional and biomedical research, in the hope of creating foods that provide a medicinal
benefit. Nestlé is examining its entire portfolio to make sure its products are healthier and tastier than
those of its direct competitors.
The effort to offer healthier products is constrained by two main factors. First, there is little agreement
on how to define healthy and junky food respectively. A carrot is clearly healthy and a sweet fizzy drink
is not, but the distinction is not always as obvious as that. A company may reduce the sugar content of a
biscuit, but that does not make it healthy. A hamburger may be “energy dense”, as nutritionists put it,
with a lot of calories packed in, but it has some nutritional value. Even a deep-fried Oreo, a cannonball
of fat and sugar, will not doom the consumer to obesity if eaten only occasionally.
The uncertainty over which foods are healthy and which are junky makes it difficult to gauge how much
progress the industry has achieved. Nestlé has a detailed “nutritional profiling” system to determine
whether a product is an appropriate part of a healthy diet, and boasts that 74% of its offerings meet the
test. A small Kit-Kat chocolate bar qualifies.
Make me virtuous, but not yet
The food industry’s second problem is one of timing. Public companies may say they want to offer
healthier foods in the long term, but they have a responsibility to their shareholders to boost profits in
the short term. Even as companies develop nutritious products, they will keep marketing fizzy drinks and
crisps until consumers stop buying them. Sales of “better-for-you” products—which Euromonitor
defines as foods that have been tweaked to contain less sugar, fat or salt than similar products—have
more than doubled in the past decade. Even so, they accounted for just 7% of drink and packaged-food
sales last year. Yum!’s Mr. Blum cautions against making too many changes too quickly. “This is not a
sprint,” he says. “Consumers say they want to eat healthy, but their behavior tends to be slightly
different.” He adds: “We have pride in fried, we’re a fan of the pan.”
PepsiCo has seen the industry’s most tumultuous experiment. Indra Nooyi, who became chief of the
fizzy-drinks-and-crisps company in 2006, set out to sell healthier products. She hired Derek Yach, who
had worked on tobacco and diet at the WHO, and set bold targets to reduce salt, saturated fat and
added sugar in the company’s products. In 2010 PepsiCo declined to advertise its sugary drinks during
America’s Super Bowl, launching a marketing campaign for social causes instead. Shareholders began to
revolt. They wanted PepsiCo to give its full support to money-making products, healthy or not.
So Ms. Nooyi has had to backtrack. In February PepsiCo will not just advertise at the Super Bowl; it is
sponsoring the Super Bowl half-time show. Appearing on CNBC, an American business network, in
September, Ms. Nooyi cast herself as a football enthusiast. “You can’t watch a game in a mancave
without doing Doritos, Pepsi and Lay’s,” she said.
Dr. Yach left PepsiCo in October to lead a new think-tank at the Vitality Group, which runs healthincentive programs. Speaking a few weeks after his departure, he said that both investors and health
advocates will have to show more patience. For decades food research centered on taste, not nutrition,
so “we’re talking about pretty radical changes.” For investments in healthy foods to succeed, executives
need to give them ample time and marketing support.
Some want to see quicker progress and stronger regulation. Kelly Brownell of Yale University reckons
that food companies will continue to push junky foods. They are under pressure to sell as much food as
possible, and Yale’s research shows that children are more likely to gorge on sugary foods than on
wholesome ones. Marion Nestle of New York University (no connection with Nestlé) thinks that food
companies will not change unless governments require them to. “Their hands are tied. They can only do
this in a very limited way because of concern over short-term shareholder value.” Dr. Brownell argues
that the food industry has followed the script of the tobacco companies, emphasizing personal
responsibility and funding health research. So far, promises to make products healthier and limit
advertising have helped fend off legislation, but not everyone is happy about that. “No place in the
world have we had self-regulation shown to be successful at solving the issue,” says Barry Popkin of the
University of North Carolina.
Boyd Swinburn of Melbourne’s Deakin University is particularly troubled by the prominent role that food
companies are playing in shaping politicians’ plans for fighting obesity. Several government agencies in
America were mulling voluntary guidelines to limit marketing of unhealthy foods to children, but strong
lobbying has caused the idea to stall. Food companies are among those that present their views to the
WHO, which advises countries on nutrition and food policy, through the WHO’s “public dialogue”
process. For example, companies encouraged the WHO to present a menu of possible policies on food
marketing, rather than a single prescription. Food companies have also given money to the WHO’s
American branch, which unlike its equivalents in other parts of the world has no rules against such
donations.
This makes some at the WHO’s Geneva headquarters shudder. But Nestlé’s Ms. Voûte thinks most food
companies are acting appropriately. Health advocates want diets to change and big companies can help.
“We do respect that there are areas where there are conflicts of interest,” she says, “but there are also
areas where there is a convergence of interest.” In April Nestlé and the International Diabetes
Federation (IDF) announced they would co-operate on diabetes education and prevention. “This
approach is a recipe for more business as usual, more obesity and more diabetes,” trumpeted Dr
Swinburn and 14 other leading academics in the Lancet, a British medical journal. “It’s not tobacco,”
retorts Ann Keeling of the IDF. “This is something we did with a lot of consideration.”
The big question for the food industry is whether it can continue to make money even as it cuts calories.
The first progress report on the food firms’ pledge to remove 1.5 trillion calories from America’s diet is
due next year. The evaluator, appointed by an independent foundation, is Dr. Popkin. He will judge
which products have been made healthier, by how much, and whether consumers have simply switched
from the more nutritious products to less healthy ones. But “their definition of healthy is not my
definition of healthy,” he says.
Dr. Popkin is also concerned that the industry may change its practices in rich countries but not in
poorer ones. Diet sodas make up 22% of Coca-Cola’s sales by volume in Europe and nearly one-third in
North America but just 6% in Latin America. Another report due next year may shed some light on this.
The Welcome Trust and the Gates Foundation are sponsoring a study of food companies’ role in fighting
over- and under-nutrition in both rich and poor countries. If the companies turn out to have been slow
to act, governments will have all the more incentive to take matters into their own hands.
The Big Mac Index: The burger company may be a barometer for the industry.
MCDONALD’S GOLDEN ARCHES may have marched into 119 countries, but the quintessentially American
company still resides in a quintessentially American suburb. At its headquarters in Oak Brook, Illinois,
low brick buildings are linked by bucolic trails. In Hamburger University managers learn McDonald’s lore
and way of doing business.
Hallways are named after items on the menu; you may find yourself in McNugget Aisle 2. Even French
masterpieces have been Mac-ified. In a reproduction of Georges Seurat’s “Grande Jatte”, the woman in
the foreground holds not just a parasol but a McDonald’s take-away bag.
No company has so embodied the shift in America’s diet as McDonald’s, and no company has been more
vilified by health advocates, yet until recently no fast-food company has done better. Last year
McDonald’s was America’s leading fast-food restaurant, with sales of $34.2 billion—more than those of
Subway, Starbucks and Wendy’s combined.
But in November the company reported the first dip in monthly sales for nine years, and soon
afterwards it announced it was replacing its American president. The new boss, Jeff Stratton, has a
delicate task ahead.
McDonald’s is used to being attacked. In 2004 “Super Size Me”, a documentary, recorded the sickening
result of eating solely at McDonald’s for a month. (McDonald’s has since scrapped its super-sized fries
and sodas.) In January the company said it had stopped using ammonia-treated beef, also known as
“pink slime”. It has been the target of a number of lawsuits.
Most it recently it was sued over the seductive use of toys in Happy Meals, the McDonald’s meal pack
for children. A judge dismissed the suit in April. Yet despite the hoo-ha 25m Americans visit a
McDonald’s each day.
Even so, the company has made a big push to give itself a healthier image. It has cut levels of sodium in
its offerings by 11% since last year. In March it announced that it would offer apples and smaller fries in
its Happy Meals. It has also introduced other healthy items, such as its Fruit & Maple Oatmeal.
Cindy Goody, the company’s nutritionist, boasts that this accounts for two servings of whole grains (the
government recommends at least three a day). In September the company said it would begin posting
calorie counts on its menus, earlier than required by a new law introduced by Barack Obama.
But will consumers buy the healthier meals they claim to want? There is the cautionary tale of the
McLean Deluxe, a less fatty burger that tested well in the 1990s but failed miserably in the market.
“They said they wanted it, we gave it to them and they didn’t eat it,” says Greg Watson, McDonald’s
vice-president for menu innovation. Consumers still love the core McDonald’s menu. When executives
went on a listening tour earlier this year to hear consumers’ thoughts, many mothers asked McDonald’s
to improve nutrition but also told the company not to change the recipes for favorite foods such as Big
Macs or French fries. “Some items just need to be left alone,” says Mr. Watson.
Today McDonald’s introduces new items cautiously, trying them in just a few restaurants or markets for
a limited period. An experiment to add blueberries to its oatmeal will not be repeated next year. Dan
Coudreaut, the head chef, is more optimistic about an egg-white sandwich on a wholegrain bun.
One benefit of healthier items, explains M.r Watson, is that they make customers feel better about the
McDonald’s brand. Some of them will order the healthier food and some will still order their favorite
burger but be happier about it, in the knowledge that the company also does salads.
Other changes are being introduced, slowly. Ms. Goody says the company may reduce the size of its
biggest soda from 32 ounces to 30 ounces. In the past year Mr. Coudreaut’s kitchen tested a newer,
better veggie burger.
“It was delicious,” says Mr. Watson, “but there is no way our customer would order that today.” The
burger never made it out of the test kitchen.
At the McDonald’s staff restaurant, the head chef proudly points to a new burger being launched in the
American market. The Cheddar Bacon Onion Angus Third Pounder weighs in at 41g of fat, or 62% of an
adult’s recommended daily fat intake.
The Nanny State’s Biggest Test: Should governments make their citizens exercise more and eat less?
NEW YORK has been at the forefront of the battle of the bulge. Its mayor, Michael Bloomberg, thinks he
knows best, and he is rich enough not to care if others disagree. He did encounter vocal opposition
when he proposed last summer to ban the sale of giant containers of sugary drinks. In a hearing
conducted by New York City’s Board of Health, Marty Markowitz, the borough president of Brooklyn,
testified against Mr. Bloomberg’s plan. “I’m overweight not because I drink Big Gulp sodas, but frankly
because I eat too much pasta, pastrami sandwiches, pizza, bagels with cream cheese and lox, red velvet
cake and cheesecake, don’t exercise as much as I should, and my genes are working against me. I was an
overweight kid and I’m an overweight adult.”
He proceeded to supply an update to John Stuart Mill, a 19th-century philosopher who wrote about the
limits of state intervention. Government, said Mr. Markowitz, “can educate, inform, advocate and
inspire, but should not be the final decision-maker when it comes down to what is best for me.” There
was uproar, but the Board of Health approved Mr. Bloomberg’s ban. It will take effect in March unless
the courts stop it.
Politicians around the world are faced with the same questions as Mr. Bloomberg. How can
governments get citizens to take in fewer calories and exercise more? Should they even try? In the past
governments have concentrated mainly on treating diseases rather than preventing them. But as the
world grows older and rounder, chronic disease has attracted new attention. Ageing may be inevitable
but obesity can be prevented, and changes in behavior can make older people healthier. Last year the
United Nations devoted an entire meeting of its General Assembly to chronic disease, including those
brought on by obesity. But there was confusion over what the state can or should do. The WHO has
since set a target to reduce deaths from chronic disease by 25% by 2025. Governments now have to find
ways of meeting that goal.
“The approach politicians favor is to nudge citizens into healthy behavior by making it easier than the
alternative.” Some think that governments have no business telling people what to eat and how to
move. Those who overeat, like Mr. Markowitz, take pleasure from it. According to Mill, “over himself,
over his body and mind, the individual is sovereign.” But Mill allowed for state intervention when an
individual’s actions might harm others. The more each person eats, particularly meat, the greater the
pressure on food supplies. And as overweight children turn into fat adults, military strategists already
worry about the health of future soldiers and employers gripe about productivity.
The biggest costs fall on health care. Estimates vary widely, but America’s Institute of Medicine reckons
that Americans spend between $150 billion and $190 billion a year on obesity-related illnesses. Healthcare costs for obese patients are about 40% higher than for those of normal weight. That has made
many governments more inclined to act. But what can they do?
The obvious model is the battle against smoking, which at least in rich countries has been wildly
successful. The campaign started in the 1960s, mostly with efforts to educate people about the dangers.
In the 1970s the argument for stopping was strengthened by evidence that cigarettes might harm
bystanders. Stronger measures followed, including bans on cigarette advertising, tax hikes and
restrictions on where smokers can light up. Where such policies have been adopted, smoking rates have
dived.
But obesity is much harder to fight than smoking, and the food industry finds it easier to resist
regulation. It is three times the size of the tobacco industry. A cigarette has no place in a healthy
lifestyle, but junk food, enjoyed in moderation, can still play a part in a varied diet.
Perhaps most important, stopping smoking requires individuals to do only one thing: resist lighting up.
Yet someone who wants to slim down must change a broader set of habits, including doing more
exercise, eating less and choosing different foods. Someone who has quit smoking need never pick up a
cigarette again, but someone who is trying to lose weight will be tempted to overeat at each meal. “The
difference with the obesity epidemic”, says Dr Swinburn of Deakin University, “is there is no single policy
recommendation that can tell me how I should behave.”
So governments are trying various tactics. One is to punish the obese for their excessive girth. In an
attempt to bring down health-care costs, Japanese employers, for example, must provide waist
measurements for all 40-74-year-olds. If they do not reduce the number of fat workers on their payroll,
they may get fined. Only in a skinny country could such a scheme become law. But American companies
are already adopting measures that point in the same direction, and the government is encouraging
them. For example, Safeway, a big grocery company, gives employees who are not overweight a
discount on their health insurance.
However, Kevin Volpp of the University of Pennsylvania advises caution. A crudely designed penalty will
do little to change behavior. What works best is frequent prompts, not once-a-year punishment. And
strict penalties assume that obesity is due to lack of willpower, when research suggests it has as much to
do with biology and socio-economic conditions.
The approach politicians favor is to nudge citizens into healthy behavior by making it easier than the
alternative. “Soft paternalism” is increasingly in vogue in all areas of government. Barack Obama’s
regulatory tsar in his first term, Cass Sunstein, wrote a book about it (“Nudge”, with Richard Thaler).
Britain’s prime minister, David Cameron, has set up a “Behavioral Insight Team” or “nudge unit” to
suggest strategies for tackling social problems. Nudging holds particular promise for fighting obesity. The
idea is to provide small impulses so that health becomes the obvious choice. Some companies are
already trying to do this (see box at the end of this section). Governments have to find policies that are
strong enough to work well but subtle enough not to get up people’s noses.
Encouraging exercise is one of them. For example, Abu Dhabi, as part of a broader push for better
health, has introduced new urban-planning rules to slow traffic and make pavements more appealing for
pedestrians. Britain launched a series of exercise programs tied to the Olympics. The world’s most
ambitious plan to boost exercise is under way in Brazil. On any given morning in Belo Horizonte a group
of women run around a basketball court and lift makeshift sets of weights in a “health academy”. By
2015 such free exercise classes will be available in 4,000 sites across the country.
For Ronilda Cristina De Jesus, aged 41, the health academy in Belo Horizonte has had a dramatic impact.
Still catching her breath from class, she says she has always been heavy. Her blood pressure got very
high and her glucose levels were out of control. “My doctor said, ‘if you don’t do anything, you’ll die’.”
So she started taking proper medication, trying to eat smaller portions and coming to the health
academy three times a week. She is still severely overweight but has lost 17.5kg. “I know I have a long
way to go,” she says proudly, “but I feel like it’s a victory.”
Physical activity helps to lower the risk of a wide range of ailments, including heart disease, diabetes,
breast cancer and depression. But academics remain skeptical that exercise alone can reverse obesity
trends, despite some success stories, because the calories thus spent are often replenished by a bigger
meal later, as suggested by the phrase “work up an appetite”. Exercise was once thought to speed up
the metabolism, causing more calories to be burned all round. Sadly research suggests that it does no
such thing. Most experts now agree that a change in diet is the single most effective way to lose weight.
What do you know?
Again, governments are trying all kinds of things to persuade people to eat more healthily. Providing
them with more information, as was done with smoking, would seem to be a good start. New York was
the first city in America to require chain restaurants to list the number of calories per serving. Mr.
Obama’s new health law will extend this rule across the country. But evidence on the effect of menu
labeling is mixed. One study in the British Medical Journal found that only 15% of customers used New
York’s calorie information in making their choice, though those who did went for meals that contained,
on average, 106 fewer calories than the rest.
Another study, in the American Journal of Preventive Medicine, compared purchases at Taco Time
restaurants where calorie information was mandatory and where it was not. The menu law seemed to
have no significant effect. In general, if you want to change behavior, “information does not work, and it
certainly does not work quickly,” explains Daniel Kahneman, a Nobel prize-winner and the world’s
foremost expert on the subject.
Rules on marketing may not work either. In 2007 Britain became the first country to impose strict
regulations on marketing junk food to children, but it did not seem to do much good. A recent paper in
PLoS One, a scientific journal, found that the population’s exposure to junk-food advertising has
increased.
Changing the food served up in school cafeterias is more promising and not too difficult to do. In Brazil
at least 70% of school food has to be fresh or minimally processed. America introduced new rules for its
school lunches in 2010, with detailed guidance on the amount of fat, whole grains, fruit and vegetables
they should contain. Mexico has asked schools to reduce portions, cut down on fried foods and salt and
eliminate sugary drinks. But schools do not always comply, says Juan Rivera of Mexico’s National
Institute of Public Health.
America has the opposite problem, with strict implementation of the rules producing nonsensical
results. The school nutritionist in Clinton, Mississippi, says that because of limits on fat she sometimes
adds a cookie to meet the minimum calorie content for the day. Students in Kansas protested against
the lunch law by making a video called “We are hungry.” Its star wears a T-shirt that reads “I Love Beef.”
Michelle Obama, the American president’s wife, is the world’s most prominent crusader against obesity.
She supported the school-lunch law along with new dietary guidelines. But her “Let’s Move!” campaign
has generally had a light touch, trying to persuade rather than regulate. Eventually her work may drive
demand for healthier food. Other governments are taking a similar approach, some setting voluntary
targets.
Mr Bloomberg, however, wants to move much faster. New York has brought in scores of changes to
promote health. Fruit carts dot the city. New bicycle lanes have encouraged a much wider range of
people to take up cycling. All this may do some good, says Thomas Farley, the city’s health
commissioner; but what would make a real difference is for the government to bring down the
consumption of junk food.
A stronger hand
New York’s subway riders are presented with ads that show fizzy drinks turning to lard, which may
dissuade some of them from buying the next can. But the simplest—and most contentious—way to
lower consumption of junk is to make it more expensive. Removing corn subsidies is a much-touted
solution. However, a paper by Bradley Rickard of Cornell University argues that removing America’s
subsidies for corn and soyabeans would have produced only a small dip in calorie consumption.
A more effective way to raise prices would be through a tax. France taxes sugary drinks and is
considering a levy on palm oil. Hungary’s exchequer penalizes not only fizzy drinks but also sugary, fatty
foods. But so far such measures have been ill-conceived or too timid. To have much effect, taxes of this
kind must be levied at 20% or higher, according to a paper in the British Medical Journal. And Denmark
recently announced that it would scrap a one-year-old tax on saturated fat and a planned tax on sugar.
The fat tax had resulted in corporate grumbles and fatty shopping sprees abroad.
Mr. Bloomberg tried to introduce a heavy tax on soda, but it failed in New York’s state legislature. Since
then he has become the first politician to try to limit the size of sugary drinks on sale. He argues that
people who want more than 16 fluid ounces (473 milliliters) of soda can simply buy two bottles. Not
surprisingly, the fast-food chains are not happy. “I think that is the absolutely wrong approach,” says
Yum!’s Mr. Blum, whose KFC, Pizza Hut and Taco Bell restaurants would have to scrap their bigger
drinks. “It says you’re not smart enough to put in your body what you should eat.” America’s drinks
lobby spent more than $2.5m crushing a soda tax in a small city in California.
It would be easier to advocate big changes if it were clear which ones are effective. In one small study,
Cornell’s Dr. Wansink and his colleagues examined the impact of a soda tax in Utica, New York, and
found that households used to buying beer simply bought more of that. America’s NIH is funding new
studies to gauge the effect of different policies. But for now politicians will continue to experiment to
see what works.
Nudge, Nudge: New tools to encourage sensible behavior.
THE CHOICE TO eat a brownie is really no choice at all. The fudgy square presents an immediate reward,
compared with an amorphous, uncertain threat of extra kilos some time in the future and possible
disease even later. Besides, the brownie was included in the price of your sandwich. This type of
decision is part of what David Kirchhoff, chief executive of Weight Watchers, calls “the intention versus
action gap”. His is one of many companies hoping to fill it.
As the number of people gaining weight continues to grow, so does the number trying to lose it.
America’s $4 billion weight-loss market is the world’s biggest, according to Bank of America Merrill
Lynch. The overall diet industry is thought to be worth about $65 billion. The average American dieter
attempts to lose weight four times a year. Diets are not so much a science as a cultural obsession, a
craze that allows exercise studios to charge $35 or more for an hour’s workout. Moreover, the mania is
going global. “The Biggest Loser”, an American television series that shows contestants enduring
grueling workouts and diets, has spawned copycats from Germany to Brunei. Yet obesity statistics
suggest that none of this has had much effect on helping people lose weight. A few companies are
hoping to change that.
Weight Watchers’ members have for years tracked what they eat and met weekly to be given coaching
and support from a Weight Watchers “leader” and other members. This seems to work reasonably well.
A paper published last year in the Lancet found that those who took part in Weight Watchers sessions
lost twice as much weight as those who were given counseling by their doctors.
Now Mr. Kirchhoff is trying to put lessons from behavioral economics to work. In a new program
launched earlier this month members will record their meals and exercise as usual, but Weight
Watchers is also offering new tools to ensure that healthy decisions become the default.
First, members will be asked to use the company’s app to track three healthy routines, such as having
fruit and vegetables as snacks. Weight Watchers will send automatic messages of encouragement.
Second, and more tricky, Weight Watchers will try to help members create a healthy environment. Put
cookies on the upper shelf not the counter, for example, or use Weight Watchers’ app to find a hotel
with room service offering healthy food.
Something similar is already being championed by Discovery, South Africa’s biggest health insurer. The
company launched its Vitality program in 1998, in the hope of keeping patients from getting sick. Vitality
members win air-mile-style points for everything from screening for high blood sugar to going to the
gym. Weight Watchers membership is offered at a discount. At Pick‘n’Pay, a co-operating supermarket,
a nutritious grocery cart earns still more points at the checkout, and shoppers also get a discount on the
food. Vitality members can use their points to buy electronics, jewelry or air tickets. According to a study
published in the American Journal of Health Promotion, those who participated in the Vitality program
spent less time in hospital and were cheaper to treat.
Last year Discovery Vitality announced a partnership with Humana, an American insurer. It also has
ventures in Britain and China. The newest recruit is Derek Yach, formerly of the WHO and PepsiCo. He
will lead a new “Vitality Institute”, a think-tank on health and behavior change. “This is not about
imposing anything on anybody,” he says. “It’s about making the healthy choice the easy choice.”
The Last Course: What will it take to make the world less round?
MICHELLE OBAMA WOULD probably be happy if every child were like Precious Moore of Clinton,
Mississippi. Precious has just turned nine and her favorite food is the hamburger. But she likes fruit, too.
She and her mother take a quick walk together every day. “We always exercise, since I was four years
old,” she explains proudly. Her seven-year-old sister often asks to go to McDonald’s, but Precious
disapproves. “I don’t really like their food at all,” she says, scrunching her nose.
Precious and her ilk may be one reason why obesity rates in Mississippi are dipping from their towering
heights. In 2005 some 44% of schoolchildren aged 5-18 were overweight or obese; last year the figure
was down to 41%. Across America, obesity rates in 2010 among both children and adults seemed to be
leveling out. It is unclear why. Recent anti-obesity initiatives may have helped. Dr. Leibel of Columbia
University thinks that Americans may be reaching their biological limit for obesity in an environment
where food is cheap and exercise discretionary: those predisposed to obesity may have become fat
already.
Whatever the explanation for the minor improvement, the broader problem is hardly wasting away. In
Mississippi white children are slimming down but black children are as round as ever. American boys
and men are still getting bigger, as are black and Mexican-American women. And in most of the rest of
the world people still seem to be getting fatter faster.
According to Dr Stevens of the WHO and Dr. Ezzati of Imperial College, London, obesity rates worldwide
nearly doubled from 1980 to 2008, to 12%. Half of the increase was concentrated in just eight years,
from 2000 to 2008. The fastest rise for women was in Oceania and parts of Latin America and for men in
North America and Australasia. Even if obesity rates were to remain at their current levels, which seems
too much to hope for, the consequences would still remain grave not just for the individuals concerned
but also for world food supplies, productivity and government finances. This demands action.
In addition to those quoted, the author is particularly grateful for their help with this report to Sandi
Beason, Thomas Beck, Thomas Bollyky, Geraldine Carroll, Jack Chen, Christine Clayton, Bill Dietz, Christy
Feig, Virginia Ferguson, Paul French, Alfons Grabosch, Michael Haddin, Cindy Hamil, Marc Harrison, Suha
Hazboun, William Heisel, Mauricio Hernández-Ávila, Ken Inchausti, MacKay Jimeson, Sam Kass, Jamie
Love, Alan Moses, Cecilia Muñoz, Alexandre Padilha, James Pope, Danya Proud, Cindy Resman, Peter
Tam, Isabel Tarrisse and Robin Tickle.
Sources
-------------------------------------------------------------------------------The Big Picture
“National, regional, and global trends in adult overweight and obesity prevalences”, by Majid Ezzati and
Gretchen Stevens, Population Health Metrics, 2012
“The global burden of disease study 2010”, by Christopher Murray, the Lancet, 2012
“Overweight exceeds underweight among women in most developing countries”, by Barry Popkin,
American Journal of Clinical Nutrition, 2005
“The global obesity pandemic: shaped by global drivers and local environments”, by Boyd Swinburn, the
Lancet, 2011
“The medical care costs of obesity”, by John Cawley and Chad Meyerhoefer, Journal of Health
Economics, 2012
“Annual medical spending attributable to obesity”, by Eric Finkelstein, Health Affairs, 2009
“Global burden of obesity in 2005 and projections to 2030”, by Jiang He, International Journal of
Obesity, 2008
“Fat China”, Paul French
The Caveman’s Curse
“Mindless eating”, by Brian Wansink
“Long-term persistence of hormonal adaptations to weight loss”, by New England Journal of Medicine,
2011
“Food and drug reward: overlapping circuits in human obesity and addiction”, by Nina Volkow, Current
Topics in Behavioural Neurosciences, 2012
“Food and addiction”, Kelly Brownell and Mark Gold
“Education and obesity in four OECD countries”, by Marion Devaux, OECD
“Income specific trends in obesity in Brazil: 1975-2003”, by Carlos Monteiro, American Journal of Public
Health, 2007
International Association for the Study of Obesity
Slim Pickings
“Health benefits of gastric surgery after six years”, by Ted Adams, Journal of the American Medical
Association, 2012
The Gordon Lab, Washington University in St. Louis
A Heavy Burden
“Dysfunctional adiposity and the risk of prediabetes and type 2 diabetes in obesity adults”, by James de
Lemos, the Journal of the American Medical Association, 2012
“Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US
men”, by Eric Rimm, American Journal of Epidemiology, 1995
"Weight, weight change, and coronary heart disease in women”, by Walter Willett, Journal of the
American Medical Association, 1995
“Weight gain as a risk factor for clinical diabetes mellitus in women,” by Graham Colditz, Annals of
Internal Medicine, 1995
Nutrition Science Initiative
“Globesity-the global fight against obesity”, Bank of America Merrill Lynch, 2012
Food for Thought
“McDonald’s USA nutrition journey: a 2012 progress report”
“To what extent have sweetened beverages contributed to the obesity epidemic?”, by Gail WoodwardLopez, Public Health Nutrition, 2010
Healthy Weight Commitment Foundation
The Nanny State’s Biggest Test
“Accelerating progress in obesity prevention”, Institute of Medicine, 2012
“Taxing unhealthy food and drinks to improve health”, British Medical Journal, 2012
“Changes in energy content of lunchtime purchases from fast food restaurants after introduction of
calorie labelling”, by Tumara Dumanovsky, British Medical Journal, 2011
“Mandatory menu labeling in one fast-food chain in King County, Washington”, by Eric Finkelstein,
American Journal of Preventive Medicine, 2011
“Effects of restrictions on television food advertising to children on exposure to advertisements for ‘less
healthy’ foods”, by Jean Adams, PLoS One, 2012
“How have agricultural policies influenced caloric consumption in the United States?”, by Bradley
Rickard, Health Economics, 2012
Nudge, Nudge
“Primary care referral to a commercial provider for weight loss treatment versus standard care”, by
Susan Jebb, the Lancet, 2011
“The association between medical costs and participation in the Vitality health promotion program”, by
Deepak Patel, American Journal of Health Promotion, 2010
The Last Course
“F as in Fat: how obesity threatens America’s future 2012”, Robert Wood Johnson Foundation, 2012
“Obesity and the economics of prevention: fit not fat”, by Franco Sassi, OECD
http://www.economist.com/news/special-report/21568065-world-getting-wider-says-charlottehoward-what-can-be-done-about-it-big