Abigail Trafford (The Post)

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Having a little trouble with weight control? Look at Fergie, the Duchess of York. Once she was called the Duchess of Pork! Now she's very thin, very active, and a leading spokesperson for Weight Watchers. But managing eating is about more than food. It's about managing your life in an environment that encourages eating and discourages physical activity. Now a new report shows just how unhealthy the obesity epidemic is and the rates have doubled in the past decade.

Being overweight causes more health problems and costs more in medical dollars than smoking or alchohol abuse. It's time for a public health approach to fight this epidemic. That means community action and government leadership to produce a range of public and private incentives that will reverse our over-eating and under-exercising culture. Until then, we're left to struggle to maintain a healthy weight against great odds. Fergie gives us hope. But the country needs a lot more if it's going to trim the national waistline.

To discuss obesity and public health strategies to stem the epidemic is Roland Sturm, Ph.D. of the Rand Corporation.

Sturm is a Senior Economist at RAND and directs the Economic and Policy Program of the UCLA/RAND Managed Care Research Center. His research focuses on the health and cost implications of health risks; the effects of mandated benefit designs on insurance coverage and premiums; the changes of mental health and substance abuse services under managed care; and the effects of the parity legislation for behavioral health care. He has testified on health care issues in Congress and numerous state legislatures. His research on risk contracts in managed care won the National Institute of Health Care Management's 2001 Annual Award for excellence in original and creative health care research.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Hello everybody. Worried about your weight? Want to know why? It's not just about you. It's about our culture. We're going to talk about changing the culture to stop the obesity epidemic. Sending us your questions and comments.

Abigail Trafford: Mr. Sturm. Welcome to Health Talk. Everybody wants to be thin.
But most people are overweight. More people are obese than smoke! Why are we suddenly in an obesity epidemic?

Roland Sturm: Well, it is not quite that sudden, but it is certainly recent. In the US, there have been increases in overweight (including obesity) rates between 1960 and 1980, but they were very minor. However, rates have dramatically increased since then, especially in the obese category, which almost doubled since 1990. Why now? Because the environment has changed, making it costly or at least inconvenient to stay thin. In the past, people were paid for hard physical labor, now they have to spend their own money to exercise in a pleasant environment and take it out of their leisure time.

Abigail Trafford: There are many reasons why people get fat. Some say genes. Others say lack of will power. You say it's the environment. Tell us more what you mean.

Roland Sturm: We need to be careful to distinguish between factors that can explain why a certain individual gains weight and why a population gains weight. Our genes have not changed in the last 10 years, Americans have not suddenly lost all their willpower, nor has there been an epidemic in mental health disorders (if anything, there are far fewer untreated cases than in the past). These factors may explain why certain individuals are affected and others are not, but they are dead-ends as far as large population changes are concerned.

So, what HAS been changing to such an extent? Physical activity is increasingly engineered out of our life. Sedentary jobs have been on the rise, car miles traveled are increasing, and more and more “entertainment” consists out of lounging in front of the TV. Just between 1990 and 1995, the percentage of trips on foot or bicycles dropped from 7% to 5%. That isn’t news, but exhorting people to exercise more, eat healthier (and stop smoking and drink responsibly) is not going to change this. Car-friendly (and bike/pedestrian-hostile) urban developments, desk jobs, television, relatively cheap calorie-dense foods are some of the recent environmental changes that have changed relative prices in favor of less physical activity without a corresponding decreased caloric intake.

Columbia, Md.: How is obesity defined? Are there different "levels" of obesity?

Roland Sturm: Overweight and obesity refer to increased amounts of body fat, commonly assessed by the body-mass index (BMI, calculated as weight in kilograms divided by height in meters squared). The standard categories are: underweight (BMI<18.5), normal (18.5-24.9), overweight (25-29.9), obese (30+). According to these criteria, about 1 in 3 Americans is overweight, but not obese, and an additional 1 in 4 is obese. The primary drawback of the body-mass index is that it cannot distinguish fat mass from lean mass and therefore misclassifies some individuals. So, it wouldn't be the greatest measure to assess people clinically, but it is fine for large studies where large numbers make up for such measurement error. Other methods occasionally used in epidemiologic studies are waist circumference, waist-to-hip ratio, and skinfold thickness.

You can actually find a table that expresses that in height and weight in a summary of the research at:
http://www.rand.org/publications/RB/RB4549/
A higher BMI, beginning in the upper range of the normal weight category, is associated with increased mortality, and increased risk for coronary heart disease, osteoarthritis, diabetes mellitus, hypertension, and certain types of cancer. [2] Even modest weight reductions can have substantial lifetime health benefits.[3] In the US, there has been only a minor increase in overweight (including obesity) rates between 1960 and 1980, but rates have dramatically increased since then. Moreover, this recent increase was concentrated in the obese category, which between 1991 and 2000 alone grew by 60%. [4] Other industrialized countries, in particular Britain and Germany, have experienced similar growth rates in obesity, but started from lower levels. [5]

Harrisburg, Pa.: There was a claim in the press that obesity costs more in health care costs than tobacco. What is the basis for this claim, and might people misinterpret this into thinking that smoking is fine as long as they are thin?

Roland Sturm: The most recent paper was published in Health Affairs, their website is healthaffairs.org, if you want to read the full detail. A summary is here:
http://www.rand.org/publications/RB/RB4549/

I sure hope that NOBODY thinks smoking is a good idea or preferable.

Fairfax, Va.: What do you think is the most unhealthy habit: overeating, smoking or drinking?

Roland Sturm: Everybody knows that smoking, heavy alcohol consumption, lack of exercise, obesity is bad for you – as are millions of other things. But how can we distinguish the truly major problems from minor ones? As surprising as it may sound, there have not even been comparisons for the “big” issues: smoking, drinking, obesity, and our study set out to compare their effects on health care utilization and chronic conditions. The surprise, even to me, was that obesity had a stronger association with chronic medical problems, worse quality-of-life, and higher health care costs than daily smoking or alcohol abuse.

There are important outcomes outside the scope of this analysis that could provide a different ranking. Smoking may still account for more premature deaths and alcohol abuse is likely to account for more externalities (e.g. drunk driving accidents).

Montreal, Quebec Canada: If Americans,as well as people here in Canada, would only wake up and STOP eating in fast-food places,and at all these doughnut shops,etc.there may be help. Why do so many want to self-distruct?It's beyond my comprehension.

Abigail Trafford: It's not just North America. The obesity epidemic is occurring in Germany and Britain, too. But it's not happening in the Netherlands. Why not? The Dutch can't have more will power than all of us! What is it, Roland?

Roland Sturm: True, this is not just a US problem, the UK, Germany, Brazil have seen similar increases, although they started from much lower levels. On the other hand, Holland or Sweden have not experienced the same increases. Is it really just a fast-food issue? I'm not so sure and I personally think it is more a change in overall physical activity.

Washington, D.C.: Dear Mr. Sturm,

What are your views on using weight alone as a risk assessment tool?

While I agree that obesity is a terrible problem for Americans, I am often the target of judgements concerning my weight. Doctors often concentrate too closely on my weight and neglect the fact that my % of body fat is normal, I exercise regularly, eat right, and actually have lower than normal blood pressure and resting heart rate.

I once had a nutritionist completely ignore the fact that I was there to address food allergy problems because she felt I needed to lose 20 pounds!

Roland Sturm: I'm not a clinician, but just focusing on weight alone is silly. Overall fitness is very important. This is not something the BMI can assess, but any physician would.

Takoma Park, Md.: Problem -- the company cafeteria!
My employer's cafeteria offers many choices, and I can find a healthy lunch if I want to. I usually pick roast chicken, salad, and/or steamed vegetables. BUT, the "lunch specials" are almost always unhealthy -- pepperoni pizza, meatball subs, and fried chicken with french fries (to name a few). It looks like the cafeteria is encouraging people to eat the most unhealthy food, because that's the cheapest lunch available.

It's discouraging for me and I don't know what to do about it.

Abigail Trafford: I'm with you! Today I got a yogurt. But often the special is pizza or tacos and sour cream. I'm under pressure. I'm working at my desk. Wouldn't it be nice to have some "love food" --food that makes me feel good, that takes my mind off things. Well, that's a recipe for eating the wrong stuff--and it's all available in the company cafeteria! Roland, how can we change this environment? You'd think that company cafeteria would be like school lunches--eager to get people to eat right.

Roland Sturm: We certainly agree. In fact, my colleage Deborah Cohen, is developing workplace intervention studies where healthy meals are an important part. It is hard to avoid the temptation to eat unhealthy food when there are financial incentives (or convenience) that favor it. This is not just an issue of lunch, but how about the candy machines in the aisles? The donuts at meetings?

Laurel, Md.: One of my biggest frustrations in getting a handle on my health is not knowing the nutritional content of foods when I eat out. Now I don't expect every small local eatery to supply this information, but it sure seems like the larger national chains could do so. Fast food places have their nutritional information online, but the sit-down places (Applebees, Outback etc.) don't. Any way to pressure these chains to help us out? Or are they too afraid we won't like what we see? It's hard for the consumer to demand more nutritional offerings when we don't know what we're getting in the first place!

Abigail Trafford: My editor went to the movies, and after editing the column, she asked the food stand in the movie theater why it didn't offer fruit and other healthy food instead of just buttery pop corn, sodas and candy. The guy said: Gee, we never thought of that. Roland, how can consumers make restaurants and food stands think about offering healthy -- or healthier-- fare?

Roland Sturm: That in fact would be one of my policy suggestions. People cannot make informed choice if they don't have the information. Nutritional labeling is a relatively simple - and not overly burdensome - regulation, just like most prepared foods in supermarkets are labeled now.

Washington, D.C.: A recent study in Journal of Women's Health and Gender-Based Medicine (Jan/Feb 2002)reports that fitness levels are lowest lowest in minority groups, particurlary minority women. The most sedatary group and most over weight group is postmenopausal minority women.

What is the most effective program/service design to turn this around?

I'd like to lead an effort initiated out of the community health centers(where these women recieve most of their care).

How do you keep these women interested,engaged and committed to the process of developing a healthy lifestyle?

Roland Sturm: I think the discussion (and questions) is going into a clinical area that I do not have the right expertise.

Treatment is a very important issue, but from a policy perspective, we need to emphasize prevention. Obesity is not very different from smoking, alcohol abuse, illegal drugs in that respect. Prevention is easier than treatment. By then much of the health damage has already been done.

Rockville, Md.: I've recently begun keeping close track of calories, fat, fiber, carbs etc. in the foods that I eat. Cooking at home is easy, and eating out at many restaurants is also getting easier.

However, my biggest obstacles are restaurants that refuse to give out ingredients or any indication of the nutritional make-up of the dish. I do my best trying to read between the lines, i.e. avoiding fried, braised, sauteed items -- but often you just can't tell.

I just this week tried in vain to get this kind of info for ONE dish offered on the menu by Copeland's -- a dish that has been on its menu for years -- and was told that it was unavailable. The approximate total nutritional value for a recipe can literally be calculated in a matter of minutes.

Given the levels of obesity, diabetes, hypertension, and food allergies in the U.S., we ought to have a law requiring this.

Abigail Trafford: What about a law? What about legislation to change eating out!

Roland Sturm: I think we just had a similar question. How can people make informed decisions without the right information? Labeling is a regulation that is not very burdensome and increasinbly important because people eat out more and more often. This is simply one of many reflections of how society is changing - the relative prices of prepared foods (whether in restaurants or at the supermarket) versus cooking at home have changed.

Alexandria, Va.: What is your opinion of the "fat acceptance" special interest groups? It seems to me that, if my tax dollars are being gobbled up by someone whose health problems are caused by their unwillingness to shut their pie holes after ingesting a reasonable number of calories, obesity should be no more socially acceptable than drunk driving or heroin addiction. Compassion, sure -- along with a diet and exercise program and no more french fries. Your thoughts?

Abigail Trafford: This is tough. We don't want to blame the victim. Especially when the culture is at fault for encouraging over eating and the lack of activity. Yet "shaming" smokers and isolating them has had some effect in changing the culture around smoking. Roland, your thoughts?

Roland Sturm: Obesity is just a bit more than just individual responsibility, even if the latter plays an important role. The debate continues about whether obesity should be considered a disease in its own right and there are some arguments in favor of it. Advocacy groups like the American Obesity Association strongly support this goal, which was pioneered successfully by mental health advocates and played an important role in mental health parity legislation. Mental illness, especially depression, was for a long time also considered a question of individual responsibility - until there were effective treatments and science could show how mental illness affects brain chemistry. The disease paradigm has also been promoted, though less successfully, for alcohol and drug abuse, and some researchers also say that applying the disease paradigm to obesity could be interpreted as self-serving advocacy without a sound scientific basis. Still, there is more to it than just telling people to eat less and exercise more.

Now, about that fat acceptance movement. I did get my share of hate mail recently, two particularly nasty ones this morning alone, but crackpots exist everywhere.

Washington, D.C.: I've read many articles that say the success rate for long-term weight loss is not very good. For example I read somewhere that 95% of people regain their lost weight within 5 years. Doesn't it seem like the odds are against a person who loses weight, if they are looking for long-term -permanent- weight loss? What is the best way for a person to get in that elusive 5%?

Roland Sturm: Yes, the prospects for long-run weight loss dont look too good. That is one of my arguments for prevention. Even successful treatment cannot restore health.

In the future, there may be better therapies. Again, mental health was a pretty grim picture, but there have been tremendous advances in treatments. Obesity treatment is not quite there.

Arlington, Va.: It sounds like most of the people on this discussion are blaming everyone but themselves for their weight loss: restaurants don't provide nutritional information, the cafeteria offers fatty foods, the movie theater sells only popcorn and candy.

But no one is forcing you to eat this stuff. I'm overweight for two very simple reasons: I eat too much and don't exercise enough. It's because of my choices and my actions or inactions.

People need to take responsibility and not blame anyone else.

Abigail Trafford: But it's not all or nothing. There are many factors in being overweight. What an individual does is obviously significant--to that individual. But obesity is a cultural problem--it's a public health problem. It can't be solved by relying on individuals to change their behavior--against great odds. That's why it's important to take action to change the enviroment. If we're really serious about reducing obesity, we have to look at system-wide change. That's where culture, advertising, laws all come in. Roland, your thoughts?

Roland Sturm: Overall, I agree. But you make your decisions based on the incentives you face. People drive more if walking is unpleasant and gas is cheap. People eat more unhealthy food if it is cheap or free.

But the opposite also holds: If walking is more pleasant than driving and gets you where you want to, people walk. If softdrinks are more expensive than milk, even school kids will buy more milk. If cigarettes become more expensive, people smoke less.

It is fine for people to make their own decisions, but if it creates a public health problems (which includes financial burdens on others), there are reasons to rethink what incentives the environment offers and whether it wouldn't be prudent to change some of them.

Alexandria, Va.: I appreciated your comments about the problems that bikers, walkers, and runners have when they try to exercise outside. I try to do all three on a regular basis and I swear that vehicle drivers are trying to kill me! They don't pay attention to their surroundings, run red lights and stop squarely in pedestrian crossings. We need to find more ways to get more people to call for safer neighborhoods, maintained sidewalks and bike paths. It's hard to do that when they're glued to their TV's. -My favorite anti-bike path arguement is that the paths will give criminals easy access to homes near the path. When was the last time anyone stole a TV set riding a bike?-

Roland Sturm: Good point and this is definitely high on my list of suggested policy changes. The issue, of course, is how to get there.

Arlington, Va.: I recall reading in the Post about a successful exercise program at the DOT in which employees were encouraged to come down to the gym, in street clothes, and walk on a treadmill for 10 minutes. Apparently the participation rate was really high. The way it is now, even if you work for a business with access to a gym, you have to organize your life and make time to exercise. Add in two-income households and small children, and you have increasingly less time to exercise (and more incentive to grab a fast food meal). What we need is some kind of change in business culture that rewards folks for getting moving every now and then.

Abigail Trafford: How do we change corporate culture? How do we make employers see that if they encourage us to exercise daily, they will save on health care costs down the line. Meanwhile, they'll get more energetic employees. Roland, what about a fitness break in the workplace the way we have a lunch break?

Roland Sturm: This is exactly the type of intervention we plan to pilot in employers. The goal is to allow exercise periods during the regular work time (by using break times and shortened lunch periods), plus healthy meal choices (yes,labeled and with nutritional facts). If your employer is interested, please contact my colleage Deborah Cohen at RAND. Is it going to be successful? Nobody knows, we'll let you know in a few years....

Anchorage, AK: I am a pediatric nurse practitioner and share many of your concerns. When I arrived back in the US after living overseas for 4 years I was sure there was a conference for obese people in Chicago, why else would so many obese people be in the airport? But they aren't just in the airport, they are everywhere. While we work to encourage fundamental changes in our communities that support healthy eating and reduce obesity, what is the current research on how people shift their thinking to make the changes they need to make to be healthy? What motivates them, what sustains them when it isn't fun or new anymore? Is that a place we can start?

Roland Sturm: I don't think it is the right place to start. You are again thinking in terms of individual attitudes that need to change, but, as I said before, achieving lasting health behavior change is difficult and rarely achieved by exhorting individuals to exercise more, eat healthier, stop smoking, or drink responsibly. The environmental incentives are important - and this is probably what changed more in the last decade than people's thinking about eating and exercise.

Olney, Md.: Is obesity really that bad for you? My friends seem to drink and smoke a lot, and they are all thin. Smoking and drinking seem to be appetite suppresants, and it works for them. They are thin and happy. I'm the only fat one. It's funny how smoking and drinking don't carry as much of a stigma as being overweight. If you're fat, you're villified and made to feel like you're an alien or inferior. If you drink or smoke too much, you're "cool" or in with the "in" crowd.

Personally I'd rather be fat than smoke or drink.

Thoughts?

Roland Sturm: Your friends sure are not exactly into healthy lifestyles. I'm sorry to hear that there are subcultures where smoking and excessive alcohol consumption are "cool" - but, fortunately, these are small minorities.

Washington, D.C.: Hello. I have a question for you. I'm 28 and overweight. I am male, 5'6" and 220 lbs. I am "cuddly." But, I am very active. I work out at the gym three times a week (spinning class) and try to eat well. I also play on a soccer team. My blood pressure is even fine.

Is it that my genes are saying this is the ideal weight for me? Losing weight doesn't work (I usually lose 10 and gain it back in 3 months), but my lifestyle has given me good health.

Thanks!

Abigail Trafford: Here's a radical thought: Do we suddenly have an obesity epidemic because we're redefining what is overweight? Have we lowered the weight/bmi for what's considered ideal? Do we now include many people who would not have been classified as fat before?

Roland Sturm: No, we did not redefine obesity. All the calculations were using exactly the same standards. However, what is true is that there has been a change in the standard where one should be concerned about weight (overweight is now defined as BMI over 25 rather than over 27). But regardless of which measure you use, the increase is because all Americans got heavier, not because the cutpoint changed.

Rosslyn, Va.: hi,

obesity runs in my family. my mother is obese; my sister is morbidly obese. i am thin, but i work VERY hard to stay thin. i exercise regularly, eat healthfully, and walk to as many places as i can. as a healthy, fit person, i'm really beginning to resent obese people. they have become a burden to our healthcare system and an represent to me what is wrong with this country (over-indulgence and sloth). i don't want to be resentful, but i can't help thinking that all obese people can do the same things thinner people do. eat less. exercise. stop blaming everyone and everything else. accept responsibility for your lifestyle. is this so wrong?

Roland Sturm: Congratulations on your success. But maybe not everybody can be as successful even with the same effort

Ft Belvoir, VA: My physician agrees that BMI alone is silly. I weighed 30 lbs above my ideal BMI calculation for large bones and 5 foot 10 height...but I bench press almost 100 lbs more than my own body weight...My physician told me that I had no body fat in my upper body...above my stomach...and nothing terribly excessive even in my belly area...

He pointed out that by BMI Index alone...most of our Football players and Olympic Weightlifters are terribly terribly obese...

Clearly the BMI makes No distinction between muscle and fat...and my physician thinks this is Wrong...

Abigail Trafford: We've gotten several questions on this: what is the best way to determine weight? BMI doesn't work for everyone.

Roland Sturm: Again, see my earlier message about the potential misclassification. That is particularly true for men because the BMI doesn't distinguish lean mucle tissue (good) from fat (bad). That's why the BMI is too limited for clinical decisions - but no doctor would do that.

But in large surveys, these occasional errors don't matter much. In fact, the only thing they do is to UNDERSTATE the association between obesity (defined by BMI) and health problems because some muscular, lean individuals are mistakenly classified as obese. Fortunately, that doesn't happen to often - it would be scary if the real associations were much larger than we estimated.

Kingstowne, Va.: Have you read Eric Schlossel's book "Fast Food Nation"? He argues that the the prevalance of fast food (mostly McDonalds) has led to obesity. I agree with you that it's mostly environmental. I remember growing up (I'm 34) that gas stations just sold gas and maybe had a machine that sold 12-ounce sodas. Now you'd be hard-pressed to find a gas station that doesn't have a full-fledged mini-mart inside! Are we that susceptible to temptation that we cannot resist environmental stimuli? Does that doom all of us to an inevitable future of mass obesity? Yikes!

Roland Sturm: We probably can resist most temptations most of the time. But even small caloric imbalances can have huge effects over time. A small bit of a candy bar in excess of your energy expenditure a day (say a 1/10 of a bar?) and you'll have an additional 20 pounds in a decade.

Alexandria, VA: Abigail-I can't believe you just said "We don't want to blame the victim" when society is at fault.

I'm a 5'7" woman, and I weight about 215 pounds. Why? Not because of "culture" or "society", but because I eat too much Ben and Jerry's ice cream and don't exercise on a regular basis. I caused my problem, not society.

Why are you encouraging people not to take responsibility for their own actions, and instead blaming every problem on "society"? It's ridiculous.

Abigail Trafford: Woah.... It's your body and you have responsibility for it. Each of us has personal responsibility for our health and appearance. But that's not the whole story! Each of us is affected by the culture in which we live. We respond to incentives. We're getting signals from the culture to over-eat and not exercise. That's why it's important to change the culture. You're still reponsible for what you do -- or don't do--to manage your weight. Roland, your thoughts?

Roland Sturm: As usual, the truth is in the middle. There is a role for personal responsibility, but it it not everything

Washington D.C.: Perhaps an obvious point, but isn't natural aging processes partly to blame. I mean, the baby boomers are in their 50's now. In their twenties they were into jogging, in their 30's aerobics, and in their 40's and 50's into investing at home and driving around the suburbs. A larger number of people are heavier just because a larger number of people are older. Plus their habits have always set the tone for what the rest of the age cohorts are doing.

I know I for one am heavier than I was last decade!

Abigail Trafford: Is it "natural" to get heavier with age--is there some biological advantage to gaining a little bit of weight as you get older?

Roland Sturm: It is true that most people gain weight as they got older, but that does not make it an unavoidable trend. This may be just a symptom of the general environmental problem in the US rather than an aging effect. Gaining weight during adulthood is not the norm in some other countries.

A minor point, but the increase in obesity rates we have seen in the last decade is not caused by the overall aging of the US population.

Abigail Trafford: We're out of time. Sorry not to get to all your questions. Thank you Roland Sturm. Thank you all for participating. This is a subject that won't go away. We'll return to it. Meanwhile , join me next week for a Health Talk on marriage.

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