Obesity, Individual Responsibility, and Public Policy
Tuesday, June 10, 2003

Unedited Transcript

Agenda:

10:45 a.m.	Registration
11:00	Opening Speaker:	Richard A. Epstein, University of Chicago
11:30	Panel I: Epidemiology and Implications of Obesity
	Panelists:	Frank Hu, Harvard School of Public Health
		Glenn Gaesser, University of Virginia and author of Big Fat Lies
	Moderator:	James K. Glassman, AEI
12:30 p.m.	Luncheon Speaker:	Richard H. Carmona, U.S. surgeon general
1:30	Panel II: Why Are We Obese?
	Panelists:	Ruth Kava, American Council of Science and Health
		Tomas Philipson, Food and Drug Administration and University of Chicago
		Sally Satel, AEI
		John E. Calfee, AEI
2:45	Break
3:00	Panel III: Remedies
	Panelists:	Michael S. Greve, AEI
		Kelly Brownell, Yale University
		Greg Critser, author of Fatland
		Rick Berman, Consumer Freedom
4:30	Adjournment

Proceedings:

MR. GLASSMAN: Good morning, everyone. Please be seated.

My name is Jim Glassman. I'm a Resident Fellow at the American Enterprise Institute and host of the web site techcentralstation.com, which deals with issues of technology and public policy, and I welcome all of you today. This is a very large crowd, and we're happy to see so many people for this all-day Conference on Obesity and Public Policy.

There is no doubt that Americans, as well as the French, the Germans, the Italians, and people in most countries, are getting fatter. According to the latest statistics three out of five U.S. adults are overweight, as well as one in seven children and adolescents. Obesity among adults has doubled since 1980, and overweight among adolescents has tripled. Approximately 300,000 deaths a year are associated with obesity and overweight. A study printed in the New England Journal of Medicine on April 24, "documents an association between cancer and the body mass index." The costs of obesity, health-related and otherwise, are estimated at about $100 billion a year in the United States, or at about 1 percent of GDP. This conference will explore the public policy consequences of what has been called an "obesity epidemic."

Americans have been getting fatter for some time now but the issue is only lately reaching public consciousness, perhaps because of some high-profile lawsuits, including one in which several overweight children sued restaurant chains for selling them hamburgers and french fries. Unfortunately, this issue has not been treated with the seriousness or skepticism that it demands. Just before we began Kelly Brownell of Yale said, "there are not enough smart people who have been concentrating on this issue." Well, we seek to remedy that situation today with this conference, which will explore the public policy consequences of rising overweight and obesity.

Since C-SPAN is scheduled to cover part of the conference, we have even more reason to be on time. So let me just give you a brief outline of the schedule today: After Richard Epstein's opening address we will immediately, without a break, proceed to the first panel on the epidemiology and implications of obesity; in other words, on how fat we are and what it means for our health. We will then have a short break, and at about 12:20 we will move very quickly to the other room, over there, for lunch and a speech by the U.S. Surgeon General, Richard Carmona, who will begin his address promptly at 12:30, while you're still eating. The final two panels will take place in the same room as lunch. In the first of the two, four panelists will discuss why people are obese, and in the second four panelists will discuss remedies, and we will adjourn promptly at 4:30.

One housekeeping matter: All of you should have chosen your lunch by now, and you have a choice of our version of the Big Mac, for which I think you receive, like I did, if you want that, a little pink card, a little pink piece of paper. Since this dish was devised by AEI's renowned chef, T.J. Akpeneye, we call these burgers T.J. Macs. Or you can also have a salad with chicken, and keeping with our theme today we are going to take a tally on how many people choose what.

I want to thank Sally Satel, Resident Fellow at AEI, from whom you will hear in the after-lunch panel, for doing most of the R-W, the real work, in organizing this conference, along with her able and talented Research Associate Erin Conroy, and also thank my Research Associate Sharon Utz [ph], and to Lisa Howie and Elizabeth Bowen of AEI.

One of the themes of this conference will be realms. Is obesity, undeniably a problem, a matter that demands a public policy or a public health solution, or is it more appropriately assigned to the realm of personal choice and responsibility. It is a pleasure and an honor to present as our opening speaker, Richard Epstein.

Before I do that, I have a note from Sally asking me to ask if Glenn Gaesser is here. If he is, he should raise his hand. If he's not ... did he raise his hand? Yes. He's there? Could you raise your hand again, Glenn?

VOICE: I don't think he is here.

MR. GLASSMAN: No. He's not here. Okay, fine.

Alright, on with the introduction. Richard Epstein, who will address this broader issue and help frame the conference. Richard Epstein is the James Parker Hall Distinguished Service Professor at the University of Chicago, where he has taught for the past 30 years and is director of the John M. Olin Program in Law and Economics. He is also Peter and Kirstin Senior Fellow at the Hoover Institution. He has written loads of books. We are all extremely jealous, because not only has he written a lot of books, but they are very, very good, and on many different topics, among them his classics, Simple Rules For A Complex World, and the just-published Skepticism And Freedom: A Modern Case For Classical Liberalism. I present Professor Richard Epstein.

PROFESSOR EPSTEIN: I am under strict orders to keep the train moving in accordance with this time, and I actually spoke here last night and I'm not going to give the same talk, but it's certainly on the same theme. And the topic here is one, which involves the interaction between private responsibility and public health. And I got into this problem not as somebody who has any particular interest in obesity. And as I trust I will be able to demonstrate very quickly, any particular knowledge about the subject but rather somebody who has always been concerned with the appropriate scope of state power for regulation.

If one wants to go back to the classic 19th Century formula, which tried to describe what were the kinds of topics for which state regulation was appropriate and which ones were not, the usual formula said that the state may regulate under its police power those things that are concerned with the public health, safety, morals, and general welfare of the public at large. And if you look at this term it seems to be very, very broad, and in some sense what it seems to do, indeed, is to be coterminous with anything that anyone would ever care to regulate to begin with. And so there is a temptation to say that we have this gigantic two-step.

First, what we do is we protect individual liberty and property, and then we turn out to create a police power exception, which is coterminous with the liberty that we protect. So that the Constitution simply says we give with the left hand and take with the right and therefore have done nothing whatsoever to undermine the power of legislative dominance. I got into the area because I became profoundly convinced very early on in my life that the two-step had to be the wrong step. And that the way in which one has to think about this problem is to actually make sure that when you define the areas of public health and safety, you do not define them so broadly as to eviscerate problems of liberty and property on the one hand and the implicit senses of responsibility that work with it.

So the emphasis that I put is not so much on the word health, about which I know relatively little, even about my own I sometimes think, but rather about the word public, to try to figure out what kind of limitations that word places on what's going on. And when you start to think about this what you should do is to think about public health in some sense as dealing with public bad, and you should think about public bad to some extent as though they are the mirror image of public good.

What's the definition of a public good? Well, generally speaking, when we talk about these forms of public good, what we do is we're referring to those kinds of things, which will be under-provided in voluntary transactions. Because the benefits that are created are those, which in effect cannot be excluded from some fraction of the population, which enjoys them. So you have individuals who bear all the costs of producing certain kinds of goods for which others will share, and if you rely solely on voluntary means in order to achieve some production of these things they will be systematically under-produced.

And the only way in which you can effectively stop this particular problem is to find ways to tax the beneficiaries of these programs so as to make sure that the production can be supported to the level that it provides public benefit. And so when you start going through the 19th Century and you worry about the creation of roads and turnpikes and so forth, and sewer systems and the like, all of these things were thought to be public good. And therefore it was appropriate with respect to government financing, even though individual choice is about how one lives and organizes his life was not.

Now, many times when you start dealing with the creation of public good, these are goods, which are designed to counter various forms of public bad. So the original idea with respect to public health in many cases was to try to deal with those sorts of things which in fact were genuine, sell-understood, communicable diseases and epidemics.

One of the things I think that gets people on the wrong track, when you start to deal with the obesity problem, is for people to use the word "epidemic" first in quotation marks and then without quotation marks. As if the kinds of problems that you have to face are more or less identical to the sorts of things that you have to face with respect to infectious or contagious diseases. Where I think everybody understands that the power of the state to intervene in order to protect against their spread is, if not well-neigh absolute, and it should not be well-neigh absolute, is certainly unquestioned with respect to most of its execution in most of the time. And the reason why that turns out to be the case is that the public bad has exactly the inverse quality of the public good.

We have a situation where somebody can internalize all the benefits form certain kinds of conduct, and yet its adverse consequences will spread to other individuals. And unless you can find some way to constrain this particular person other people are going to be hurt. Generally speaking, buying them off will work a little bit, but the problem with purchasing these compliances is that you get other people to engage in bad behavior so they can be bought off, so that sooner or later when it comes to the control of public bad what one has to do is to deal with the situation in which you are prepared to use coercion against those people.

What happens in the debates with respect to obesity, and in the debates about smoking, is there is a rather systematic effort in dealing with these problems is to try to say that the epidemic--and Jim, in fact, used that kind of language when he started--that what we're dealing with is more or less the same sort of problem, whether you're dealing with traditional public health issues on the one hand, for which I think there are undoubted cases for government intervention, and these other kinds of issues which, whatever you want to say about it, obesity, I think we can say with some degree of confidence, is not a communicable disease. And therefore what one has to do is to back off a little bit and to start to ask yourself what are the appropriate ways in which to deal with the issue.

Inside the profession I think the way I would describe it is as follows: That is, when you talk about public health in the sense of dealing with diseases and epidemics, you put that in opposition to private care. So that the traditional view was, for example, how physicians treated their individual patients, and all the rest of that stuff, was subject, generally speaking, to private contract--maybe to some form of government regulation. But if so on rather different kinds of ground--and that that division, I would argue, is, in fact, the appropriate way in which we want to think about the issue. We don't want to get ourselves into the position where we've privileged the idea of government intervention in dealing with problems of obesity by making the false analogies to those kinds of cases that deal with externality.

How, then, ought we to think about the way in which we look at the obesity question? Now, here, if in fact the consequences of obesity are vivid as force first and foremost, not exclusively but first and foremost, on the individual who actually suffers the bad effects of these things, what one wants to do is to figure out how you organize a social system which internalizes the cost on these particular people and allows them to take some private and voluntary action steps to counteract the problems at hand. That is, my view about obesity is not that the medical litany of all the things that are wrong with it are in fact false. I think that they are in fact for the most part true, but one has to be very careful in how you state it.

For example, to take an example of an inexact formulation, when Jim said that there are 300,000 deaths each year which are attributed in part to obesity, you have to be very careful to see whether. Or not it's going to take somebody who is going to die at 70 if they are healthy and they are dying at 30 because they are not. Or whether it is because somebody in fact is going to die at 69 and 11 months instead of 70 years of age because of obesity. Both of those statements are absolutely consistent with the proposition that there are early deaths by 300,000 from obesity. But the way in which you deal with, either collectively or individually, would be vastly different because the cost under the one formulation, if it's true like with AIDS, is vastly different from the cost associated with the other alteration.

The question, therefore, that you have to face as an analytical matter is how you are going to be able to figure out exactly what the costs of obesity are. If you do this collectively you have to face the problem of the mass of heterogeneity within the population, some individuals being very heavily subject to these risks and others not, such that any system of uniform taxation or regulation is likely to have wildly disparate effects. And so you therefore have to start to think about a way in which you can individualize the treatment with respect to obesity and similar conditions to take advantage of the separate knowledge that individuals have in individual circumstances about themselves.

So let me give you my first modest proposal on the way in which one wants to attack the obesity problem by making it from a public issue into a private issue. And that modest proposal is to make sure that employers, schools, churches, groups of any sort whatsoever, are entitled to fully discriminate with wrath, hatred, vengeance if they so choose, against any person who is obese. That is, I can now exclude you by virtue of being obese from any particular program that I want to keep you out.

Now, you say to yourself, why does anybody wish to have such a lofty form of public ambition as this one. And I think there is a real good explanation for it, which does not make me into the drooling savage, which I tried to portray myself only a moment ago, which is the point about the public health situation. That if individuals find themselves unable to deal with these issues in many circumstances what they have to be able to do is to get some kind of assistance or help in order to enable to respond to the question at hand. One of the ways in which you can incentivize them to get that help into voluntary markets is to impose upon them a cost if they don't comply with certain kinds of requisites.

So if we have a situation in which employers are now entitled to fire anybody who gets too obese with respect to a certain kind of job, two things will happen. One is that individuals who want these jobs will now have a stronger incentive to try to slim down on their own, and if necessary hire some of you, I'm happy to say, in order to help them with that particular problem.

In addition, most of these employers don't wish to fire people as if that's the way you make money. What they wish to do in effect is to have a healthy work force. And the ability to exclude individuals by virtue of the fact that they are obese carries with it a much more important right, which is the ability to organize the behaviors inside the firm so as to help individuals control the kinds of weights that they have.

So there are many businesses, for example, who organize lunches and cafeterias, and the ability to exclude will give you the right to figure out what's going on the menu. And if you decide that the folks of you who are carrying pink slips in your pockets are the kinds of people that you are going to regard as inappropriate, the strong right to control what's going on inside the firm will in fact allow you to substitute the white slips in its place. And, indeed, with many firms what happens is that you start to tell individuals that we're going to give you certain bonuses if you perform at certain kinds of levels, give certain kinds of fitness rooms, exercise rooms, and so forth. So that what happens is the problem with respect to obesity, instead of being handled in the centralized way which cannot deal with the individual variation, can now be handled in a decentralized way in which there will be relatively strong incentive.

The question then is how far will this go. And here, again, the point relates to, I think, the misformulation of the question which is generally put, which is you may be able to tell something about the frequency and the incidence of obesity by looking at the figures. But what one also has to be able to do is to be able to figure out what the consequences of obesity are in the individual case. And to the extent that you get private incentives on this particular problem you will be able to get, on balance, better information about the way in which the issue is going to be solved than if you try to make one sort of single, collective deliberation of what's going on.

So what, then, does this leave--and I have just a couple of more minutes--to the public sector with respect to these sorts of things. And here let me just talk about two forms of intervention that you might want to think about, and I'm not going to reject one. But I am going to reject the other, and the one that I'm not going to reject I regard as largely useless, and the one that I am going to reject I regard as downright dangerous.

The first mechanism that one can try to use with respect to public health is to get more information out there about what it is that kills, what it is that harms, and what it is that maims. And many people have thought that what you need is government in order to achieve that result. I don't believe that that is particularly, in the sense that I have been bombarded with all sorts of statements about my immediate demise--in fact, I think I'm listed as officially obese under the government standards, which itself is another problem. I think they are wrong, not me, in this particular case, so I think there are lots of sources of private sources of information out there. But if somebody wants to create another public source of information, I'm not going to object particularly mildly. Bcause I think it will be read with all the loving care and attention that people give to the back of a can, for the most part, when it comes to deciding what the contents are.

What typically happens is that you don't know the particulars about this, that, or the other ingredient. But you have a general sense that when you eat ice cream you're going to get more fat content than if you have a soy hamburger, and it's the kind of knowledge that you already have that probably is decisive. And the incremental gains or losses that you suffer from more precise labeling requirements I think are going to be relatively unimportant, whether you are talking about transgenic fats or anything else that happens to be there. I think the problem with regulation in this area is that it doesn't change the world overly much because people pretty much know the way in which the situation is already. So I am just not going to fight this particularly hard, but I don't have much use for it.

The taxing situation, in contrast, is a much more complicated issue. And there you do have all sorts of things to worry about. In principle, if you could figure out what the perfect level of tax was so that you were able to impose taxes on individuals such that the cost that they impose on society, say, through collective health plans, could be offset by the tax to reduce consumption, maybe you would do it. But there are several problems here that are extremely difficult. First of all, what happens is what you are worried about is obesity, what you could only tax as the input. The inputs that you tax off would be fairly far down the chain of production, and unless you know exactly how they are combined and how they are metabolized you don't have any really strong sense that the taxes in fact are going to produce the desired results in particular cases.

There is a wonderful paper by Jeff Strunard [ph] which sort of indicates just how complicated it is to figure out whether people need more or less calcium in their diets to deal with various things like osteoporosis. And it turns out that there is no linear relationship between the amount of an ingredient like calcium that is required and the consequences that happen to individuals. A lot of it depends upon protein cases from other sources, exercise level, and lots of other things, and what this suggests is that upstream control can't handle, as I mentioned earlier, the heterogeneity problem. The only thing that's going to be able to solve this thing is downstream operation.

So in conclusion, what I think one ought to do in this situation is to remember that there is no particular advantage that the public health sector has in dealing with the problem of obesity. This is a serious problem for individuals, but like other serious problems, from bankruptcy on the one hand to heartache on the other, there are other ways to do it. So that the better thing in thinking about the obesity problem is like to use dating services to handle the life of the lovelorn, use obesity services to handle these particular problems.

I think that you will discover, regardless of the level of passion that you bring to the subject, the effort to find a collective solution to this issue will elude you. The fundamental difference between public health and communicable diseases on the one hand and individual choice decision is, I think, not only a hallmark of political theory, I also think in effect it is a mark of prudence. You really can do some good with respect to the first area.

In the latter area, every time you try to regulate there will be adaptive responses by individuals, which will beat you down. And so what you have to do is to get voluntary compliance in order to help the situation, and the most important thing that you as a group can do is to figure out how not to subsidize obesity, which takes us right back to the end of this talk, which is the Hippocratic Oath: primum non nocere is the most important piece of advice in public policy. Translated into English it means, "first, do no harm." And if you can come out even after this conference, you are ahead of the game.

Thank you.

[applause]

MR. GLASSMAN: Richard, if you could just stay there for a second, I want to ask a question, and we will have a little bit of time for it.

PROFESSOR EPSTEIN: Sure.

MR. GLASSMAN: As far as internalizing costs is concerned, and you have written a book about health care, Mortal Peril, is there a way to internalize costs through the health insurance system? Or is part of the problem that we have to day the fact that we have sort of semisocialized it? Go ahead.

PROFESSOR EPSTEIN: You are a decent, man, Jim. Yes, I mean, it's exactly [that]. I wrote a book called Mortal Peril: Our Inalienable Rights to Health Care?, in which I argued in part that the scheme of social insurance is exactly the opposite of a scheme of insurance, because insurance essentially says that everybody is going to have to pay a premium which covers its anticipated losses so that there is now an attempt to economize, whereas social insurance means that everybody gets benefits up to the level he needs, so it's a massive system of cross subsidy.

And this, then, creates this very serious modern problem. You have this crazy system of cross-subsidies out there in which healthy people now subsidize fat people, which is the wrong thing, of course, to do. And then the healthy will come back and say, if I'm subsidizing obesity I demand to have some control on the way in which people behave because nobody will write insurance unless you have some conditions on the behavior of the insured.

And everybody says, you are absolutely right. And then you try to figure out what kinds of conditions that you can impose. And it turns out that you are pushing on the end of a very long chain, and that every effort to try to reduce some kind of individual responsibility component into systems of public health care insurance have failed. If you look at Medicare, the level of implicit cross-subsidies, even within the over 65 groups, forgetting about all those that go beyond it, they are just absolutely legion. So that is, in effect, a program, which flunks my last injunction.

We first have done a great deal of help. And you will do better with obesity if you get rid of all of these programs and, as it were, go after the third rail of Washington to figure out how you unravel the Medicare and the Medicaid kinds of programs. And to try and make sure that the insurance system doesn't have the subsidies and the cross-subsidies, and if it doesn't have it then the rest of the market will work.

But this is, I think, in fact and practice the single hardest problem. Do we use second-best solutions by creating one set of controls to offset one set of subsidies? And I think the long history of mankind shows that the counter-strategies never work. You always try to go after the original problem rather than creating a second problem, which in some naive sense is supposed to offset the original one.

MR. GLASSMAN: Question? Stand up. Just tell us who you are.

VOICE: Jacob Sullum, Reason magazine.

MR. GLASSMAN: I know who you are, but not everybody does.

PROFESSOR EPSTEIN: That's right. And for your own good, Jacob, give me whatever applies.

MR. SULLUM: You mentioned that a tax approach, by which you probably had in mind something like a fat tax ...

PROFESSOR EPSTEIN: Yeah, sure.

MR. SULLUM: ... or a junk food tax, wouldn't work because different people are situated differently. I sort of hesitate to suggest this, but what about an annual weigh-in where people are charged for each pound over their ideal weight? Wouldn't that be a more efficient approach?

PROFESSOR EPSTEIN: Oh, I mean ...

VOICE: What about jockeys?

MR. SULLUM: And what would be the problem with that in terms of efficiency?

PROFESSOR EPSTEIN: Oh, I mean ... well, actually, in terms of ridiculous taxes, this is far superior to the fat tax, precisely because it deals with the input as opposed to the output. The question you then have to do is to establish individual baselines. I mean, I'm an ectomorph. I'm six foot, one. If I got to 200 pounds I'd be fat. But you get somebody else who's got a slightly different body build, at six food one he should be 200 pounds and not 185. So you're going to have to have the weighing police come in and establish an ideal baseline for 280 million American individuals. And then impose the tax differential on them, and have to figure out the question if I'm supposed to be at 185 and I'm actually down at 183 do I get a 2-pound bonus going in the opposite direction to offset the tax. I think in the end you can do it, I suppose, at that point, but I think it would be absolutely crazy. That's the first one.

The second problem: Now suppose that I am a little bit overweight, and I say, look, you can't impose the tax on me. I just had a very bad bout of neurological disorders in my stomach and I had to take steroids, and they put 10 pounds on me. And, you know, the truth about the matter is I'd rather be obese without having this incredible gastric pain than being underweight. So I think I'm entitled to a medical exemption from the overweight tax. And again, you've got 280-300 million people, and you're going to go through it one-by-one, figuring out whether or not these exemptions are there. I think the appropriate response is, kill the subsidies and don't worry about the taxes.

The general rule when you have the question of whether to subsidize or to penalize: The right answer in 98 percent of the cases is to do neither. And what you're trying to do is to figure out some very clever way in which we can do both. And I just think in the end, we really don't want to go down that road.

MR. SILVERGLADE: Hi, Bruce Silverglade, Director of Legal Affairs, Center for Science in the Public Interest.

PROFESSOR EPSTEIN: You have a dangerous title.

MR. SILVERGLADE: I really enjoyed your presentation, and you are obviously extremely articulate about this issue. And I was amused by your self-admission that by government statistics you might be a few pounds overweight, and like many of us who enter middle age we might become a few pounds overweight.

I guess the thrust of your presentation, if I take it correctly, is that you are for voluntary action, so I was wondering what are you doing voluntarily to reduce your weight? Because I'm concerned that both through the private and insurance system public health statistics that people of your weight will end up costing us in health care costs, and I'm worried about my insurance premiums and Medicare. Your rates of heart disease and diabetes and cancer are higher than others who weigh a little bit less than you, so what are you doing voluntarily, and what can we do to reduce the health care costs as a result.

PROFESSOR EPSTEIN: What I do voluntarily is I actually play basketball, and so forth, and I burn it off in fat. I do it. One of the things that, thank God, is true, is that the insurance system may be able to insulate you from some of the costs, but it can't insulate you from all of the costs. So there are still some private incentives working. But I, in fact, try to do that. I try to eat carefully, I read these statistics, I am completely persuaded by them, I've never smoked a cigarette in my life and I have defended Philip Morris passionately over the years, and I will still continue to do so, but I don't work for them any more.

But I think the right thing to do is to reexamine the public health system and insurance system and to ask yourself why it is that you tolerate these cross-subsidies which then requires you to use these coercive mechanisms. And I just don't see the case. I mean, it's real difficult to figure out how it is that you individuate when everybody is entitled to join in the program, but that's an argument to say that you have to go back to voluntary markets.

Remember, there is a fundamental tension here: Everybody says that you have to have some kind of universal, open-ended insurance, be cause otherwise there will be adverse selection. Well, if you have this universal system it turns out you now have moral hazard. And the great fundamental truth about all insurance is that you can't run away from one problem unless you embrace others.

And the importance of competitive markets in these circumstances is that instead of having a single monopolistic program, which is sure to get it wrong, what you do is you have multiple competitive programs who have incentives to figure out how much of a risk you can ensure. And at what premium and how much not, and if certain people fall through the cracks let it be an object lesson. Because I think on balance you will probably have lower levels of mortality if, in fact, you require more of individuals than you will if you're always extending safety nets on the one hand and turning around and trying to impose various kinds of serious conditions on others.

And so I think the implicit criticism that I would make of the question is that I think that you're in this camp of we subsidize and penalize simultaneously in the hope that the whole thing is going to cancel out. And I really don't think it's going to work, I think, with respect to obesity.

I don't wish to argue that there aren't third party consequences. They are aggravated by government regulation. But if you remove them, generally speaking, if you put the incentive on the fellow who bears the lion's share of the cost--that is, the individual and his immediate family--you are going to get better health outcomes than if you try and have massive programs of support on the one hand and regulation on the other. So I will stand at the usual position.

I'm going to take one last question before I go.

VOICE: In the last question it seemed to be the key phrase there is costing us. And I think the point that you're making is that the objective is to internalize the cost of being fat. Your fat costs other people something--if you were fat. You're not fat.

PROFESSOR EPSTEIN: But I am, by government figures. I'm probably 15 pounds overweight. But they are nuts if they don't adjust themselves by age. I mean, there are real difficulties with using collective numbers.

MR. BROWNELL: Kelly Brownell from Yale. It seems to me a very important part of this discussion is understanding the cause of the problem. And if you attribute obesity to personal failing and misbehavior, then of course thing that you are talking about perfectly applies. If this is a consequence of a bad environment, then they don't. Then it becomes like a communicable disease. It's not communicable, but nonetheless, out of personal control.

And, of course, it's not one or the other, but it's pretty hard to make the argument that people are less disciplined today than they were a year ago or 2 years ago or 3 years ago, that there is some personal behavior going which really changes the environment. And so the idea of weighing people in once a year or somehow imposing penalties on people with a problem could be seen as taxing people for getting a disease who live by Love Canal.

If the environment is bad enough, you're going to gave an epidemic of obesity. That's exactly what's been created in our country. And so the environment has to change. So I don't know that you're going to get much mileage out of addressing this as a personal issue.

PROFESSOR EPSTEIN: But I think you're using the environment and epidemic language in a dangerous [fashion ?]. Certainly the cost and benefits of the consumption of information have surely changed. Tom Philipson [ph] will speak to this later today. But one of the problems that you have in this particular area, or not a problem, is that if you are obese today. Your ability to control the conditions are probably great than it was 20 years ago, so that the cost of obesity may to some extent go down, which expects that you will get more of it.

Now, that may be wrong, but it may be right. That is, you can take cholesterol judges. You have higher levels of obesity and lower level of cardiac arrest than you had 20 years ago. Somebody has to explain what's going on with respect to the difference.

And the other thing that, of course, is different, is we have many more cross-subsidies built into the systems now than we did before. And if you eliminate those it may be that you start to see a reversion to some of the earlier forms of behavior. So I agree with all of that.

But the important thing is at this point, you are trying to talk not about traditional public health issues. There is a sense in which you get cultural public health imperialism in which every issue having to do with the provision of medical care, the distribution of income in society, the employment relationship, and so forth, becomes a public health issue. And the real lesson here is not that these aren't problems, but if you put them within this particular lens you may get the wrong analytical framework on it.

I see my time is growing neigh. The heavy hand of fate hangs on my left shoulder or my right shoulder, so I shall retreat while the going is still good. Thank you.

[applause]

MR. GLASSMAN: Thank you, Richard. That was terrific. And, by the way, in answer to Kelly's question, we have an entire panel on the subject of why of causes of obesity right after lunch. Thank you again.

Could Frank Hu and Glenn Gaesser come up? Come on up here.

Let me just also remind everyone that when this panel is finished we are going to proceed very quickly to lunch. And unfortunately, we have to finish the panel at 12:20 exactly. And, by the way, the obesity "epidemic," in quotation marks, does not only involve humans. According to a story in USA Today, obesity in pets is on the rise. My colleague, Duane Freese, writes a study by the Purina Pet Institute, apparently examining the ribs of millions of dogs and cats and other pets, although not turtles or fish, found that they were disappearing under layers of fat. So we are not alone.

Frank Hu, M.D., one of at least three M.D.'s we have here today speaking, is an Associate Professor of Nutrition and Epidemiology at the Harvard School of Public Health. He is also an Associate Professor of Medicine at the Harvard Medical School. And he received the American Heart Association's Established Investigator Award in 2002. He will go first.

And then after that, Glenn Gaesser, who is a Professor of Exercise Physiology and Director of the Kinesiology Program at the University of Virginia.

DOCTOR HU: Yes, thank you very much. I want to thank Sally for inviting me to this very interesting conference.

I was asked to talk about obesity and mortality. To me this is the least controversial issue in medical science and public health because the data is so overwhelming. It is more overwhelming, more convincing than tobacco. But now that I am in the conference, I think I will be open-minded about a different point of view.

This is a quote from my colleague, Frank Sachs [ph]: Obesity is defined in terms of the worst effect on health. It is not defined as population realms, because this is very important. When we talk about healthy body weight we are not talking about a movie star, who is 120 pounds, but is more waist circumference. So actually, when we define obesity we're talking about adverse health effects. Since there is a lot of confusion about the definition of obesity, let me just review a little bit about the definition.

Body mass index is the most widely used index. The measure of obesity is very simple. It is weight kilograms divided by height meters squared. And some of you may be wondering why we cannot just use body weight as a measure of obesity. The problem with body weight is that it's highly correlated with height. The taller you are, the heavier you are, so that is the apostolic definition. Everyone has a different baseline. So this, originally, you need to adjust for height when you measure obesity. And so body mass index is minimally correlated with height. So this really is important to use the body mass index as a measure for obesity rather than use body weight.

As you know, the common use cutoff point for overweight is BMI 25, and for obesity is BMI 30. So when you're talking about that you are in the obese category, I don't think that's that clear. Perhaps you are in the overweight category. Of course, those cutoff points are arbitrary because those are defined by scientists who come to conferences and people have different opinions about what is the optimal BMI for different populations. But those cutoff points have been widely accepted by international standards.

There are some problems with BMI as a measure of obesity. BMI is not a perfect measure of obesity because BMI is affected by body frame and muscularity, so if you use BMI for Mark McGwire or Arnold Schwarzenegger, it doesn't make any sense, because they have so much mass in their body. So BMI is not specific for obesity.

On the other hand, the intra-abdominal fat, technically visceral fat, is actually worse than the overall body fat, and is mostly strongly correlated with metabolic syndrome, with diabetes and heart disease, and the practicality is waist circumference, if we commend it as the best practical measure of central obesity. So body weight is not everything. We have to keep in mind that there are different types of obesity: overall obesity and central obesity, and central obesity is probably more problematic than overall obesity.

Here, we have two people exactly the same weight, 175 pounds, and the younger person has more muscle and less fat; the older person has more fat and less muscle, but we have the exact same weight. And this person on the righthand side has more fat in the body. If you use body weight or use BMI you will see that they have the same degree of obesity. But if you measure waist circumference the person on the righthand side is clearly more obese than the other person. So again, body weight is not everything. We have to keep in mind that BMI is not the most optimal measure of obesity.

So for central obesity the cutoff point for a woman is 35 inches of waist circumference is 40 inches of circumference. And this definition actually has been incorporated into the definition of metabolic syndrome. So in defining metabolic syndrome we are not using BMI. We are actually using waist circumference.

Right now we are conducting several large epidemiological studies at Harvard, the Nurses Health Study and the Health Professional Products Study, to track the obesity epidemic to look at the effects of obesity health consequences. The Nurses Health Study was started in 1976 by Frank Spizer [ph], and the Health Professional Products Study started in 1986 by Wilbur Willis [ph], and these two large cohorts included about 170,000 men and women that have been followed for 20 to 30 years. So we use this data to look at the effect of obesity and other life factors on cancer, cardiovascular disease, and diabetes.

This is a summary of numerous publications on this project from these cohorts. As you can see, as BMI increased, the risk of type-two diabetes, gallstone disease, hypertension, and coronary heart disease increased dramatically. And there is no threshold, basically, from BMI 21 to 30. There is a menial relationship between body mass index and the risk of all those chronic diseases for both men and women. The results are remarkably consistent.

In terms of weight change, the evidence is also very consistent. Weight gain during adulthood from age 18 or from age 21 is associated with dramatically increased risk of type-two diabetes, gallstone disease, hypertension, and coronary heart disease. Again, the results are very consistent between men and women. Even for those who gained 5 pounds or 5 kilograms during adulthood there is associated substantial risk of those chronic diseases.

This is a paper, which was published recently in the New England Journal of Medicine looking at BMI and risk of type-two diabetes. As you can see, as BMI increased the risk of type-two diabetes increased dramatically. Those who have BMI 35 or more have 40-fold increase of the risk of diabetes, compared to those who had BMI 23. And clearly, overweight and obesity is the singlemost important risk factor for type-two diabetes. This is the reason we've got a twin epidemic of obesity and type-two diabetes. We estimate that 60 percent of type-two diabetes cases can be explained by overweight and obesity. That means that if we can control the obesity epidemic then we will be able to control the type-two diabetes epidemic.

Waist circumference, as just mentioned, is a good marker of central obesity. It's a strong predictor of type-two diabetes, hypertension, and coronary heart disease, and, as you can see, for women this is more important. Central obesity is associated with a 40-fold increased risk comparing the woman who has central obesity with those who don't have central obesity. And for men, the risk ratio is more, but still you can see the monotonic increase with type-two diabetes with central obesity. The results are very similar for hypertension and heart attack.

Recently there is more evidence relating obesity and cancer. These are from 20 projects, which include several thousand breast cancer patients. You can see there is modest increased risk of breast cancer, postmenopausal breast cancer, with the increasing obesity. The magnitude of association is much smaller than coronary heart disease and diabetes.

When we look at the relationship between body weight and breast cancer, it looks like for those who didn't use hormones, postmenopausal hormones, the increase is more dramatic compared to those who use hormones, because we know that hormones is a risk factor for breast cancer. So there is the interaction between obesity and hormone use. And I think this is a very interesting area for obesity and breast cancer.

Obesity dramatically increased to endometrial cancer. This data is from the Nurses Health Study. Increased risk of pancreatic cancer, kidney cancer, brain cancer, and non-Hodgkin Lymphoma. So at this point the evidence for mobility, obesity and mobility, is very clear. I mean, the evidence is just so overwhelming.

There is still some controversy in terms of mortality, because mortality is more difficult to study, although it is much easier to count dead bodies. But it is a difficult end point, because when we talk about mortality we're talking about both the incidence and survival. So when you find an association, you don't know whether this is due to the incidence or due to the survival.

And also there are several methodological problems with these kinds of studies. They can be confounded by weight loss due to preclinical conditions. For example, people pre-cancer, they can lose weight. Or other chronic abuses. For example, pulmonary disease. If they have COPD and other pulmonary diseases they can lose weight. So ....

[end of side 1]

... and this kind of study can be confounded by smoking because smokers tend to weigh less and they tend to die earlier, and many studies over control for biological intermediate end points like diabetes and hypertension.

BMI is not the best measure of obesity among old people because when people get older they lose weight, actually. The weight loss is primarily due to muscle rather than due to fat. So BMI is not very useful for measuring obesity among old people.

This is data Jara Minson [ph] published several years ago in the New England Journal of Medicine. She looked at the overall cohort of the Nurses Health Study because there a J-shaped type of association. So the risk is increased on the lower end of the BMI and then mortality increased when BMI exceeds 27. So this is a J-shaped relationship which has been observed in many studies.

However, when she stratified on the Nurses by smoker's data, if you look at the level of smokers who had stable weights you can see a menial relationship. So the higher the BMI, the higher the mortality rate. And you can see still the J-shaped or U-shaped relationship among smokers and the former smokers and current smokers. So this suggests compounding by smoking. So when we look at the data we actually have to look at whether the data is related to nonsmokers or smokers.

In the Nurses Health Study, BMI at age 18 also significantly increased, significantly associated with the increases of mortality, especially cardiovascular mortality. So the higher the BMI at age 18 the higher the mortality. So this suggests a very important issue of childhood obesity, because if this association is real it suggests that childhood obesity is very dangerous and can carry excess mortality as adulthood.

The largest study so far that has been published is an American Cancer Society study, which included 1 million men and women. This is the largest study so far. And they look at BMI and mortality in both men and women and in different age groups. As you can see, there is a menial relationship between BMI and the mortality for all the age groups except the oldest age group, 75 to 84. As I just mentioned, BMI is not a very good marker for obesity for this age group.

Some people have argued that if you are physically safe then you don't have to worry about obesity, and the problem with this kind of statement is that it is not supported by scientific data. June Stevens [ph] recently published a paper in the American Journal of Epidemiology looking at this issue of compared fatness and fitness in relation to all sorts of morality in both men and women. And what she found is that both physical fitness and fatness are important for mortality, so they are independent. If you look at the figures among those who are physically fit, obesity is associated with a 30 percent increased risk of mortality.

So this means that being fit doesn't reverse the increased risk of mortality. And the highest risk group is those who are unsafe and also obese. The lowest risk group is those who are physically safe and no longer obese.

This is data from the American Cancer Society looking at obesity and cancer mortality for both men and women. Again, they have 1 million subjects in this study. And basically, there is a menial relationship between BMI and cancer mortality for both men and women, especially for women because of breast cancer.

When they look at the individual cancer point, obesity is associated with almost all the major cancers in both men and women. For men, prostrate cancer, kidney cancer, colon cancer; for women, colon cancer, ovarian cancer, breast cancer. So this data, I think, demonstrates definitely that obesity is a major cause of cancer mortality.

The past 10 years has witnessed the revolution in our understanding of the biology of adipose tissue. In the past, when I was in medical school, the adipose tissue was considered as passive storage for energy, and just fat. Now we realize that adipose tissue is a very active endocrine organ, and is the largest endocrine organ in the body. It secretes a large number of hormones, important hormones and [inaudible], and those hormones and [inaudible] can directly cause metabolic syndrome, diabetes, hypertension, heart disease, and even cancer.

For example, among persons in postmenopausal women, adipose tissue is the primary tissue to create estrogen, and estrogen, we know, is carcinogenic. This is the reason that obese postmenopausal women have much higher breast cancer risks than non-obese women, because adipose tissue creates estrogen. So we know in a sense that body fat is not passive storage room for energy. It's actually a very active endocrine organ.

Current [inaudible] is that if you're not overweight or obese, I think, you should maintain a BMI between 18.5 and 25, minimize weight gain. If you are already overweight and obese, avoid further weight gain and aim for 5 to 10 percent sustainable weight loss. So we're not talking huge future weight loss, we're talking about moderate weight loss. And the benefit of moderate weight loss has been demonstrated by several clinical trials.

The most noticeable one is the DPT, the Diabetes Prevention Trial, I'm sure many of you are familiar. This is funded by NIH, and this study showed that a 7 percent weight loss can reduce type-two diabetes by 58 percent. So moderate weight loss can prevent the majority of type-two diabetes among high-risk populations. And the matter for me is that the entire diabetic has dropped, and it can only prevent 61 percent of type-two diabetes. So this suggests that style interventions, moderate weight loss, can go a long way in preventing type-two diabetes, and I'm sure that this kind of message can have a substantial public health and communicable implications.

So just to conclude, the evidence on the consequences of obesity is overwhelming, although the optimal BMI is yet to be defined. So I'm not talking about 21, less than 23, or 23 versus 25. I think it's very difficult to define the exact optimum BMI. However, obesity, overweight, is clearly associated with an increased mortality.

Being safe does not reverse an increased risk of mortality associated with obesity. I think this is a very important point. Both physical fitness and fatness are important for mortality. This is something we're going to discuss today. From my point of view, public health measures are clearly urgently needed to curb the obesity epidemic.

Thank you, very much.

[applause]

MR. GLASSMAN: Glenn Gaesser is Professor of Exercise Physiology. He's also the author of Big Fat Lies: The Truth About Your Weight And Your Health, and I think he will address some of the exercises described in his new book, correct?

PROFESSOR GAESSER: Yes. In the meantime, let me just ask a question to Professor Hu. Just so we all understand, these studies controlled for behavioral factors, correct? So just looking at overweight, you talked about smoking as one of the behavioral factors that was clearly controlled for, but there are obviously other levels of not even behavioral factors, but demographics, education, and so forth.

DOCTOR HU: Yes. Most of the studies I just mentioned those factors have been controlled for. The most important factor is smoking, because smoking is related to both obesity .... [inaudible], actually, people who smoke tend to be in there .... and mortality. So that's the most important respect.

VOICE: [inaudible]

MR. GLASSMAN: He said, one of the reasons that obesity has increased in the United States is because smoking has decreased.

DOCTOR HU: Yeah, that's an interesting idea.

[laughter]

DOCTOR HU: Actually, I have the data; I don't have time to show it. It actually is from [inaudible], that looked at the obesity trend among level smokers, past smokers, and current smokers. They are all going off in the same direction, and they are basically parallel over time. So I don't think decreased smoking is an explanation for obesity trend.

MR. GLASSMAN: Professor Gaesser.

PROFESSOR GAESSER: Thank you.

You are going to hear something entirely different now. What I want to make clear here is that this issue of obesity and health is anything but an open and shut case. There are a number of epidemiological principles that need to be adhered to when you look at these kinds of observational compare and contrast type studies.

When you look at each and every one of these ten principles, the link between obesity and mortality and morbidity fails on at least one or more of these principles, which means to date we really don't have any clear picture of what impact obesity has directly on mortality. And I'll get back to these principles in a few moments.

The key points I want to leave you with today, though, are that, one, the health threat of overweight and obesity have been exaggerated. This is not to minimize the health implications of obesity. But I do think some scientists, the media, have overestimated the risks associated with being overweight or obese.

Secondly, the health benefits of weight loss have been overstated, and sometimes the risks have been underestimated. Furthermore, the hazards of weight fluctuation or yoyo dieting may be much more significant than generally acknowledged. And most importantly, from my perspective, most so-called weight-related health problems can be improved independently of weight loss. And again, I'll show some evidence in just a few moments.

Far more important, certainly from the perspective of the individuals that are heavier than average or have BMI's in the 25, 30-plus range, it is easier to get them fit and healthy ... and I'm speaking about in terms of physical fitness and metabolic fitness here that I'll describe in just a few moments ... than it is to get fat people thin.

I do want to qualify this. By saying that fat can be fit or that fat can mitigate some of the health risks associated with overweight or obesity is not saying that it's okay to be fat. When Big Fat Lies was published it kind of got labeled as a fat mantra that it's okay to be fat, we don't have to worry about our weight, and that's not the point I was trying to make. But we do need to ask some questions: Is obesity a bona fide disease? Perhaps it's just a natural physiological state. From my perspective, for most of the people that fall into the overweight or obese category it's a proxy for an imprudent lifestyle. So the question then becomes which of these is most relevant, and therefore which do we focus on the most.

Let's take some of these assertions that are floating out there: The notion that obesity kills. This statistic here that obesity kills some 300,000 Americans each year has been cited by the media no less than 1,000 times in the last 3 years, according to a Lexus database search. The sources frequently cited are down here at the bottom, a couple of articles that appeared in JAMA, one about 10 years ago, one a few years ago.

When you look at one of those references you find that there is absolutely no mention of obesity whatsoever. When you look at the second one, by David Allison Colleges published in JAMA 1999, they looked at about six epidemiological studies and from them hand-selected epidemiological studies. They concluded that obesity kills 300,000 Americans each year, give or take a few thousand. But they stated in their conclusion that this assumes that all of the excess mortality amongst obese persons is attributable to their obesity.

Now, let's look at this relationship here. This is kind of a schematic of the kinds of relationships that Dr. Hu just presented just a few moments ago, and you see that the relative risk increases as BMI increases. But if you look at all the epidemiological studies, and when I did my research for Big Fat Lies I must have reviewed more than several dozen studies published here in the United States, everywhere in the world.

From the very first study, the Framingham Epidemiological Study that began in 1948, on down to the current study still going on, and Framingham is as well, and you see a number of different relationships. You see a shallow J-shaped or U-shaped relationship, even flatter still. This is analogous, this quite similar to the one found by the National Health and Nutrition Examination Survey epidemiological followup study. Which, by the way, and this was published a few years back, that if you are an African American, for example, and the weight tables of the BMI charts that Dr. Hu referred to give standards for all Americans. If you are over 25 or 30 or you are overweight or obese, respectively, and that somehow you've got increased risk. Well, our own government, who issued those tables, has data that actually shows that if you're African American, for example, your best chances of avoiding premature death are if you are overweight or obese.

Sometimes you get a flat line. Sometimes you even get a negative relationship, such as an older individual. So it's not all that clear cut. And again, we get back to this epidemiological principle which suggests that we need to make sure that we have not only statistical association, but temporal sequence, consistency in the findings, persistence over time, independence from other factors, dose response, and so forth. And we just don't have that when we look at all of these principles combined.

So let's look at this relationship again. When you see this relationship you see an increased relative risk here. And this is from most of the highly publicized studies that we read about, Nurses Health Study, and so forth, Framingham, the Alumni, and the like. And we have to ask the question: Are there some factors that co-vary with BMI that are not being accounted for here, such as diving in weight fluctuation? And this goes back into the 40's and 50's and 60's when people were on all sorts of whacky diets, starvation diets, liquid protein diets, people were yoyo-ing all over the place. As a matter of fact, the Framingham study published about years ago in the New England Journal of Medicine found that weight fluctuation could account for all of the excess cardiovascular mortality amongst the overweight Framingham participants.

Weight loss drug use also increases as BMI increases. So we have to ask the question might some of the excess mortality we see in overweight or obese people be due, at least in part, to the use of weight loss drugs, either prescription or nonprescription, over the last 40 or 50 years?

And my favorite as an exercise physiologist is physical and activity and low fitness. Now, Dr. Hu mentioned one study published just last fall by Stevenson Colleagues [ph] that looked at both fitness and fatness. Now, that's not the only study that's been published. One study published by Steven Blair [ph] and Colleagues at the Cooper Institute, an ongoing study started by Ken Cooper about 30 years ago, and these data were published in 1999, as you can see here, and there are three important take home messages here.

Basically, these data come from about 25,000 men. They were followed up over a period of about 8-1/2 years on average. Each one was given a body fat test, each one was given a full medical exam, each one was given a full 12-lead electrocardiogram stress test on a motor driven treadmill, to establish fitness level.

Fitness was defined rather generously here. All the men had to do was be in the top 80 percent of their age group. So we're not talking about 10K marathon-type running or the President's physical fitness standards that our children have to achieve to get that gold star. This is a very generous definition of fitness. And what do you see when you look at relative all-cause mortality here, with the lean, fit men as the standard?

There are three take home messages here. Far and away the most important is the obese men who are classified as fit have mortality that is just as low as any of the other men. Certainly, regardless of the fatness level it is important to be fit. And the fat, fit men are actually better off than the lean, fit men.

Now, this is more compelling than the data that Dr. Hu just presented. I don't know where the answer lies here. We've got two studies so far published to date that have looked satisfactorily at fitness and fatness at the same time. One shows a complete mitigation of the effects of overweight and obesity. The other shows a modest mitigation of some of those adverse health effects. We need more studies that measure both fitness and fatness to become a little bit clearer on this issue. And this led Dr. Blair and his colleagues to conclude that healthy bodies come in all shapes, and we need to stop hounding people about their weight and encourage them to eat a healthful diet and exercise.

And now I want to talk a little bit about this health at every size, which again is not saying that it's okay to be fat, but rather it may be easier and perhaps more prudent to focus on things that people actually have some control over. So let's take a look at some epidemiological studies and at some intervention studies.

There have been probably a half-dozen or more studies that have looked at the inference of either a change in physical fitness or a change in physical activity in study participants, and looked at that effect over time with regard to its effect on mortality. These studies in general show that when individuals either increase their fitness or increase their physical activity level, they generally show, in comparison to those that were equally overweight or unfit and inactive to begin with, who don't change their activity or fitness level, generally about a 20 to 70 percent reduction in all-cause mortality. This, I might add, is relatively independent of changes in body weight.

If we take a look at the studies that have been done on intentional weight loss, so this more or less rules out any possibility for unintentional weight loss due to subclinical disease at the time that the study begin. This looks at overweight people, men and women, who told the researcher they actually intentionally weight and how much they loss and over what period of time. There are about a half dozen studies that have been published to date. Absolutely none show any benefit of weight loss in terms of intentional weight loss for reducing mortality risks in people who are already healthy. In other words, they have no reported health problems associated with weight.

The two studies that show a modest effect, in terms of an effect of intentional weight loss on mortality risks, both of these studies published by the American Cancer Society, indicate there is no dose-response relationship whatsoever. In other words, the men or women that lost anywhere from 1 to 19 pounds are just as well off as those that lost 20 pounds or more.

And the most recent study published to date on this is even more beguiling. This study followed men and women from 1989 to 1997. Compared to overweight men and women who were not trying to lose weight at the time and did not change their weight, subjects who lost weight, intentionally lost weight, experienced about a 20 to 30 percent reduction in their mortality weight. Those that tried to lose weight but were unsuccessful in doing so enjoyed about the same reduction in mortality, which led the researchers to conclude maybe just trying is good enough.

But even more puzzling is overweight subjects who were not trying to lose weight at the time, and indeed gained weight, actually had the greatest reduction in mortality risk. So you go figure this. It just doesn't make sense.

Now, I will admit that last group was a very small segment, only 3.7 percent of the total population, so I'm not sure what to make of that. But the data on intentional weight loss are very equivocal. The data on changing physical activity or fitness levels are unequivocal.

Again, most weight-related health problems can be improved independently of weight loss. So if you ask a doctor why would you want someone to lose weight, typically it's, well, it's to improve blood pressure, to improve the blood lipid profile, improve glucose tolerance, insulin action, these kinds of things. Most of these can be improved or totally ameliorated independently of weight loss.

You take individuals .... give me 100 that have type-two diabetes and are on either insulin or some oral hypoglycemic medication. In one month I'll have half of them off medication and at glucose normal. They won't lose much weight, but they've got to exercise and they've got to change their diet.

Correlations between weight changes and health markers are usually quite low, indicating that most of the health improvements come about with changes in activity, changes in diet, and aren't necessarily linked directly to weight loss. Its easier to move more than less, in my opinion.

One example of this that might serve as a template for those individuals that have had trouble with dieting and keeping weight off, is one published by Linda Bacon [ph] and Colleagues just a year ago. And I know this woman, I've served on her doctoral committee at the University of California Davis, along with Judy Stern [ph] and others, and what she did was took obese women who had a history of dieting and divided them into two groups. One was a typical behavioral-type approach that focused on weight loss.

So you can see that one focused on caloric research and one did not. Both included physical activity. Only one, the nondiet group, focused on body acceptance and internal regulation of hunger--or not of hunger, but internal hunger cues for the regulation of food intake. Both were counselor facilitated. It lasted 6 months of direct intervention, with about a 6 month followup thereafter.

What they found was that, as you might expect, a considerable weight change in the diet group, but absolutely none in the nondiet group. But when you look at changes in some of the physical health markers such as cholesterol, LdL cholesterol, triglycerides and blood pressure, you see comparable improvements in all of these factors, which suggests that it was probably due to the behavior changes and not the weight loss directly. Most compelling is that the dropout rate was considerably lower in the individuals that focused on body acceptance and just focused on eating healthfully, but not necessarily weight change.

And again, to sum up on this move more, eat less, in two relatively recent studies both diabetes prevention studies, and Dr. Hu talked about one, the Diabetes Prevention Program Study, a large-scale study that was published a couple of years ago .... actually about a year and a half ago .... in the New England Journal of Medicine, as well as the Finnish Diabetes Prevention Study.

Both of these had lifestyle intervention. And although Dr. Hu mentioned that weight loss could lead to a significant reduction in diabetes risk, these were glucose-intolerant people that were followed for a number of years and it looked like lifestyle was able to prevent a significant number of people who were glucose-intolerant from developing full-fledged diabetes.

The researchers are not sure that weight loss was indeed the critical variable. In fact, they don't know whether it was physical activity or whether it was diet or the weight loss. They have not teased that out yet. But they do know that approximately twice as many of the subjects in both studies were able to achieve the physical activity goal, as were those who were able to achieve the weight loss goal. So to me this suggests that it might be better to focus on behavior than rather than a specific weight loss goal.

So is overweight a bona fide disease? I think yes, the answer to that is yes, but only in people who I would call are at extreme or dangerous ways. Those are at the very far end of that extreme. And I'm not sure where to draw that line. Whether it's a BMI of 30, 35, 40, I'm not sure. I would be much more inclined to go with an individual who is heavy but physically active, eats a healthy diet, and has no overt risk factors such as heart disease or diabetes, than I would someone who is thinner but not necessarily very active.

Thin people do not have a monopoly on health and fitness. It might be a natural physiological state for people, and there are some people who distribute body fat differently than others. If it's centrally deposited, that might be a significant health risk. If it's more peripherally deposited, particularly on the hops and thighs, it might not be. As a matter of fact, there are at least a half-dozen studies published in the last 10 years that show that hip and thigh fat correlate directly with HdL cholesterol levels than inversely with triglyceride levels. In other words, the fatter the thighs the better off you are from cardiovascular risk perspective. And that's a pretty consistent finding.

But I think for the most part, it could be used as a proxy for an imprudent lifestyle. Those individuals that have BMI's above 25, and let's face it, the gene pool has not changed significantly in the last several decades, but our body weights in general have, that's lifestyle. For most people I think the imprudent lifestyle leads to a gain in body mass, largely fat. It also leads to the increased risk of diabetes, glucose intolerance, insulin resistance, blood pressure problems, lipid problems, and so forth. And I think the lifestyle is far more important, and we should focus on those.

And so to summarize, finally, if you look at the last two points here, these are the summary of the key points here. I do think there is compelling evidence that suggests that weight-related health problems can be improved independently of weight loss. And it might be better to focus on those because it might be easier to get people fit, both physically and metabolically, than it would be to get fat people thin.

And again, to quote from a very well known obesity researcher who was quoted in the New York Times just a little over a year ago, we need to be very careful when thinking about obesity and health.

Thank you.

[applause]

MR. GLASSMAN: I don't even think we have time for one question. Let me just make one point about fit and fat: My colleague Duane Freese calculated--I think he did the calculations, it's in his piece, a piece about professional baseball players--only 38 out of more than 300 are actually at the optimal BMI of between 19 and 24; 294 are over weight, with BMI's of 25 to 30; and 38 were obese, which is over a BMI of 30.

Alright, one question, but it has to be really quick. And then, in keeping with the idea of moving, which Glenn talked about, we're all going to have to move very quickly over to the next room.

Who has a question? Yes, wait for the microphone, and identify yourself.

MS. HIDEN: I'm Barbara Hiden with the National Soft Drink Association. I have a quick question about physical activity. We hear 30 minutes daily or most days of the week. We also hear 60 minutes. Do you have a recommendation specifically?

PROFESSOR GAESSER: Well, I think Dr. Hu and his research colleagues at Harvard have demonstrated from an epidemiological perspective that moderate intensity activity is very effective at reducing the risk of certain diseases, and particularly cardiovascular disease and diabetes, as are a number of other epidemiological studies.

From the standpoint of just direct intervention studies, moderate intensity exercise works. My own personal recommendation is that individuals who stand to benefit the most are those that are most sedentary. And it really doesn't matter how you do the activity, whether it's all at one time or accumulate bouts of activity throughout the day--10 minute walks, and so forth--it all counts.

So because most individuals claim that the number one reason they don't exercise is lack of time, I think moderate intensity activity might be the best alternative for most people. Because they don't have to change their cloths, you don't have to break a sweat, you don't have to go to the gym to do these kinds of activities that would benefit one. So I think in general the Surgeon General's recommendation, that report that was issued in 1996, is a good thing to follow.

The Institute of Medicine's report last September that said it's 60 minutes we now need, if you read that report carefully it actually states that all activity above sleeping actually counts.

[laughter]

Now, I'm not exaggerating here. It says in the Executive Summary that all activity counts, which means that just in the minute or two it takes us to get from this room to the next room, those two minutes might count. So it's very generous in terms of what counts for activity. And if you want to go a more vigorous route, that's not saying that that's not necessary, or it would be necessary for individuals to give up that for moderate. The more vigorous activity is certainly beneficial. And there are some studies that show that more vigorous activity might imp;rove fitness to a greater extent, and fitness might be a little more important than activity. But both are, I think, very effective.

MR. GLASSMAN: I think what we're going to do is we may have to squeeze in a little time for Q and A. I'm sure Dr. Hu [ph] wants to respond to what Dr. Gaesser said, and vice versa. But we're not going to be able to do it now. Now we're going to move more, eat less, right? Or you can eat more, I don't care. But on into the other room, please.

[end of side 2, tape 1; begin tape 2 of 3]

MR. GLASSMAN: ... luncheon part of the program. I'm Jim Glassman from the American Enterprise Institute, still, even after my half of a T.J. Macs hamburger. And, by the way, we have the tally: Approximately 80 percent of you chose the salad with chicken as your entree, and 20 percent of you chose the more fattening and deadly hamburger.

Actually, we have not done a calorie count. If we lived in Maine, according to legislation that is now working its way through the legislature, we might have to post that up here.

[Tape 2 of 3]

MR. GLASSMAN: ... luncheon part of the program. I'm Jim Glassman from the American Enterprise Institute, still, even after my half of a T.J. Macs hamburger. And, by the way, we have the tally: Approximately 80 percent of you chose the salad with chicken as your entree, and 20 percent of you chose the more fattening and deadly hamburger.

Actually, we have not done a calorie count. If we lived in Maine, according to legislation that is now working its way through the legislature, we might have to post that up here.

But anyway, most of you chose the salad and the chicken, and the question is whether you would have done this otherwise, if you had known that you were not eating in public and would have been counted. So we can't tell.

This morning we heard from Richard Epstein of the University of Chicago. It helped us to frame the issue that we're discussing today, which is obesity, which is certainly a health problem. Is it a public policy issue, or is it a private matter, or is it a combination of both?

And then, just before lunch, we heard from Frank Hu of Harvard and Glenn Gaesser of the University of Virginia discussing the epidemiology of overweight and obesity. And we heard two strongly divergent viewpoints about how important overweight is, especially as opposed to fitness, and unfortunately we didn't have enough time to have the kind of questioning that we'd like to have, so we may do that later this afternoon.

This afternoon, after the talk that you will hear from the Surgeon General, we will examine why Americans are obese from several angles. We will look at questions of addiction, nutrition, and advertising with Ruth Kava of the American Council of Science and Health; with Tomas Philipson of the Food and Drug Administration, from the University of Chicago; and Sally Satel and Jack Calfee from AEI.

And then, in the second postprandial panel we will address remedies with Kelly Brownell of Yale, Richard Berman of the Employment Policies Institute and Consumer Freedom, and Michael Greve of AEI, and I think I forgot somebody. Someone else is on that panel, someone important--Greg Critser, of course, the author of Fatland, one of my favorite books, which I'm going to quote in a second. So this panel will address the lawsuits, among other things, that are starting to blossom seeking restitution from restaurants, and perhaps soon from food manufacturers for making people unhealthily fat.

Times have changed. In August of 2000 the parody newspaper, which I recommend to you all if you haven't read it, The Onion, headlined "Hersheys Ordered To Pay Obese Americans $135 Billion". The company, said The Onion, knowingly and wilfully marketed to children rich, fatty candy bars containing chocolate and other ingredients of negligible nutritional value, while spiking them with peanuts, crisp rice, and caramel to increase consumer appeal.

Around the same time, in a parody in the Wall Street Journal, Mark Bernstein wrote that food sellers will be next on the list of lawsuits after cigarette makers, as well as Wisconsin cheese lords for clogging arteries, and makers of exciting movies for encouraging a sedentary lifestyle. Bernstein concluded, "It is too hot to exercise, dieting demands willpower, and why bother if you're just a victim. Come on, America, get off that couch and sue."

[laughter]

No longer are these parodies very funny. They have been mugged by reality. It is time to get serious about a public, or is it a private issue? As Greg Critser writes in his book, "the challenge of obesity may be one of the most difficult that modern society has ever faced. After all, overconsumption is an intuitive, rational act." Remember that, those of you who ordered salads. At least on its face, we like to eat. In fact, we are hard-wired to eat. Throughout history, the food problem faced by vast majority of humans was that they didn't have enough of it.

And this issue is so serious that we are very pleased today to have with us the 17th Surgeon General of the United States, Richard H. Carmona, who was sworn in about a year ago. Dr. Carmona has had a very interesting career. He dropped out of high school and enlisted in the U.S. Army 1967. He joined the Special Forces and served with distinction in combat in Vietnam. He then became a paramedic, a registered nurse, and a physician. He completed a surgical residency at the University of California at San Francisco and a Fellowship in Trauma, Burns, and Critical Care at NIH. He has served as a hospital CEO, a public health officer, chief executive of the Pima County, Arizona, health care system, and as a medical director of police and fire departments.

Last week he was asked at a House Energy and Commerce Subcommittee hearing whether he would, quote, support abolition of all tobacco products, end quote. And he answered, I would, at this point, yes. The Washington Post reported while Surgeons General have been increasingly aggressive at advocating efforts to control tobacco use, none made the kind of comments that Carmona did yesterday. Now, our topic today is obesity, but some, including lawyers, see strong similarities between the two issues.

Obesity is a major health concern for the Surgeon General, as his web site attests. What, precisely, is the role of his office and of public policy, in general? We will soon learn. We are honored to have the Surgeon General speak to us today and answer questions. I present Surgeon General Richard Carmona.

[applause]

SURGEON GENERAL CARMONA: Well, I guess the timing was just perfect. Thank you. I heard your remarks as I was coming in. I apologize for being a few minutes late, but all the elevators were not working when we got downstairs, and we had to get in line with about 100 other people to make that transition.

Well, thank you again. Susan Blumenthal, how are you? Nice to see you.

I've been in the job about 10 months now since I've been sworn in as Surgeon General, and my life has been quite a whirlwind. I feel like I'm aging in dog years. I'm quite sure I am. I've crisscrossed the country many, many times. I've gotten more frequent flyer miles in the last 10 months than I've gotten inn my whole life prior to this. I've represented the United States at meetings in South America, as well as the World Health Organization in Geneva. So it's just an unbelievable experience, quite a surrealistic experience.

On a daily basis, the enormity of this job and the responsibility I have weighed very heavily on me. I now sit at the table with those I used to read about in the newspapers. They ask me for advice to address some of our nation's most important issues and pressing problems. So that tremendous responsibility is a recurring theme that I have now, because I recognize that just about everything I say or everything I do, or everything I don't say and don't do also, can be a matter of public discussion, as well as end up being public policy.

President Bush and Secretary Thompson asked me to focus on three priorities as Surgeon General. I'll outline those for you today. And I'll be 100 percent honest about my agenda, because I'm here to enlist your support in most of what I do. Because I realize although I get to occupy this bully pulpit once in a while, the fact is without community support and leadership support such as yours we can't move the agenda forward. And that agenda is one of health and wellness for this country.

Because I don't know many of you I think I'll spend a couple of minutes just to let you know who I am and what my ....

[momentary loss of audio]

SURGEON GENERAL CARMONA: .... okay, here we go. Alright, thanks. That's great, thank you.

Anyway, I was about to say let me tell you a little about myself and my values and what drives me and what's important in my life. As you've heard, I've had somewhat of a nontraditional trajectory here to be Surgeon General. Being the youngest of four children from a Latino family, I grew up in Harlem in New York City, dropped out of high school at an early age, ran the streets. Probably I owe my salvation to somebody who reached out to me at a young age when I was one of those three kids and showed me the error of my ways and encouraged me to go back to high school. But I felt that I was too old at that time, because I had been out for many years and had not done any college preparatory work, nor had I done SAT's or PSAT's or anything like that.

So the same gentleman encouraged me to join the Army. To make a long story short, I did, and it probably was the best decision I've made in my life because it was the first real job I had, and there weren't too many organizations willing to take a risk on a high school dropout at 17 years old. But they taught me about leadership, accountability, responsibility, having a purpose in life, loyalty, dedication, mission, focus, all of those things that are important to success. And little did I realize at that time that I was really building a platform for success for the rest of my life.

I returned, after the service, after Vietnam, and I was going to stay in Special Forces the rest of my life, because for the first time I found some stability. I found a roof over my head, and three squares a day, not always of my choosing, but health care and so on, as so I was pretty happy with this surrogate family. But many of my colleagues encouraged me to go to school, and so I decided to go to school. And I thought I'd like to be a doctor.

Unfortunately, I wasn't prepared to do so, and it was very difficult to get into college, but fortunately for me at the Bronx Community College in New York City they had an open enrollment program for Vietnam veterans. And I was able to get into school and matriculate the first year, after the first year, once I was able to prove myself.

But many of the experiences that I've had in life and would shape my values today and have me understand the importance of health care really come from being a poor child. And lessons I learned from my grandmother, my abuelita who spoke no English, who was an immigrant to this country with 27 children, who came here for improvement in the life of her children and appreciated the American dream that many of your ancestors did also. And so unfortunately for me, I broke that dream that my grandparents worked so hard for for a while, but I got back on track because somebody was nice enough to try and help me.

But I also learned many things about culture and about the values that are important in life from my family. And so today when we speak of health disparities I understand them at a firsthand basis because I was one of those statistics, a child who couldn't get health care, a child who went to school hungry. So I know what that's like. I know what it's like to have a toothache and not be able to go to the dentist because there is no access because there is no money. So I understand all of those issues first hand.

I also understand the importance of culture, in that when I first returned home and I made the announcement to the seniors in my family after my grandmother had died that I thought I wanted to go to medical school. And I was challenged that my uncle, who is still alive and in his 90's, but at the time was more or less the patriarch of the family and wanted me to get into a labor job in the Electrical Union that they had gotten for me. I challenged them and said, I wanted to go to college and medical school. And I was told, well, our people don't do those kind of things. You need to get married and get a job. You need to be like us. They had gone further in their life than anybody had expected. And they never thought of such grandiose things as going to college or going to medical school.

So I had this dream, and I went ahead and did it, and for a while I disappointed them because they thought that this wasn't really out of the box thinking, they thought that I had some type of head injury while I was in Vietnam. But fortunately, I was successful, and fortunately my 92-year-old uncle is still alive to have seen that success. Unfortunately, my parents did not because they suffered their whole life with their own demons, alcohol and others, and succumbed much earlier than they should have because of those problems.

So I understand a lot of the challenges I have today not only from the academic or the theoretical discussion, but having lived them and understanding the impact of poverty, the economy, and all of those tangential factors that come to bear on good health in this country.

In my life I've been a paramedic, I've been a registered nurse, I've been a physician's assistant, I've been a police officer, and ultimately ending up as the CEO of a health system and a professor at a university and teacher. Little did I know that all of those positions would have a great deal of bearing on the selecting of the 17th Surgeon General of the United States. Because prior to nine-eleven, although I have public health background and have a masters in public health policy and administration as well as a doctorate, and so on, there are a lot of my peers that have that, too.

But the fact is that I have very strong connections with the military, with the Department of Defense, with law enforcement, with EMS, with the paramedic community. All of a sudden those things became very important after nine-eleven when we were trying to become a more knowledgeable and prepared society because of the challenges thrust upon us at nine-eleven and the events thereafter.

So where I would like to say that I planned my whole life to become Surgeon General of the United States, the fact is there have been a series of fortuitous events that have gotten me here. And many of the things that I did throughout my life because they were in my heart and I really desired to serve the public, all of a sudden came to the forefront and became very desirable characteristics for a Surgeon General. So I'm thrilled, though, that I have this opportunity.

I am still amazed that I was selected because there were so many wonderful, qualified people who were looking for this job, and many that were competing. And so as I went through the process of becoming Surgeon General, I can tell you, till the day that the President called me to the Oval Office on March 26 and made the public announcement I still thought there must be another Rich Carmona in this country. That they had called the wrong one, because there was just no reason for me to be selected, and that things like that don't happen to somebody like me.

And as immense as this responsibility is and the wonderful opportunity that's been afforded me by President Bush and Secretary Thompson, you give up a great deal to be Surgeon General. You go overnight from a position of relative anonymity, toiling in a community just like many of my peers do, to one of being what they call a public figure, which, when you read it on paper or hear it, it doesn't mean much. But when you live being a public figure, as many of you know, it's a whole different ball game. And overnight you are transformed and propelled into the public eye. And just as when you go through the process of vetting where it's very intrusive, at times malicious, I came to understand that process as I moved toward Senate confirmation as a Darwinian process. And that as I entered that pipeline you get beat up pretty bad, and as I said, it's always intrusive, sometimes malicious, very painful at times, but if you come out the other end and you still have pulse or vital signs, then you are entitled to the job. And so I did okay with that. I had vital signs at the other end.

But I recognized very shortly after taking the job that I gave up a great deal. Because I could no longer be the regular person I thought I was and that I was, and that you don't see your family or friends any more, somebody else controls your schedule, and you really become part of somebody else's world. My wife was amazed at all of this, and she's a very private person. But one time caught off guard by a reporter who asked what it was like, and she said, well, I guess the best way I could sum it up is the country has gained a Surgeon General and my family has lost a husband and a dad. And that's exactly what happens. So it's a wonderful opportunity to serve at the highest level, and I'm always .... indebted isn't quite the right word, but just nevertheless indebted to the President and the Secretary for allowing me this wonderful opportunity.

But as I moved into the job after my first month and I went back home to Arizona to see my kids and their friends, and I was just in a T-shirt and running shorts, and I recognized right away when we went into the fast food restaurant that they asked me to stop at for lunch, that I wasn't the guy that left that town a month before. Because as I walked in, the restaurant was much more crowded than this, and everybody was looking at me. And I felt very unprofessional in T-shirt and running shorts as the U.S. Surgeon General, and trying to do the professional wave as people were waving at me. I sat down and tried to get real low in my seat. And the kids went and got their food and they came back with their friends. And so my son is sitting across from me, and instinctively he pushes his french fries in front of me and said, here, dad, go ahead and have one. And I reach across and I go to pick it up, and I look up, everybody in the restaurant is watching me.

[laughter]

SURGEON GENERAL CARMONA: So, of course, I dropped the french fry, and I told my son dad's got a new job. We have to do this covertly now.

[laughter]

SURGEON GENERAL CARMONA: And I recognized through subsequent conversations with my friends that being very close with the fire and EMS and law enforcement and military community, at times they had known me from my infancy, if you will, when I was one of them. And so I would joke when they would give me things I didn't want to eat and things I didn't like, and often take something and I'd say, oh, I'm not going to eat that. That causes cancer. Well, if I say that, that's a real headline now. No more jokes. You're always on. But again, it's a wonderful opportunity.

The priorities I mentioned: President Bush and Secretary Thompson asked me to concentrate on three issues, and I'm very happy they did because they are evidence-based issues and issues that I fully agree with, and in my discussions with them would have come up independently with those three. So clearly, they had done their homework, and I'm fortunate to be able to work for two leaders who understand the benefits of evidence and science and generating an agenda that is supported by evidence and science.

The first one is prevention. Obviously, the reason for prevention is in many of my lives, including being a trauma surgeon and a trauma director before I was a recovering surgeon as I am now, the fact is that most of what I cared for on a given day or a given night was preventable .... gunshot wounds, driving while intoxicated, domestic violence, all sorts of crimes. Maybe two or three out of every four admissions to the Trauma Center were preventable. It's one of the things that drove me into public health, after a career as an acute care doctor that really what I was caring for was a lot of people who had made bad decisions on that day or a series of bad decisions that came before us. So prevention was very important to me.

Public health preparedness is new to Surgeon Generals. Being the 17th Surgeon General, none of my predecessors had to deal with the threats upon us today of terrorism and the tools of the terrorist, which are weapons of mass destruction. But that fits within the more global all-hazards, in that we still have to care for this country in response to all hazards ... hurricanes, tornadoes, natural and otherwise disasters, and terrorism statistically may be a small part, but it's a new part of what we have to deal with.

And the last, which is something, which is very important to me that the President and the Secretary spoke passionately to me about were health care disparities. They said, "Richard, you need to do something about this." It is intolerable in this country, with the wealth we have, that we have people that can't get care. We have disparate outcomes, we have disparate access, and, as you know, the term disparity is very broad. But it was elating for me because having come from that background as a poor kid, having studied it as an academician and a public health officer and a CEO, that it was something that I equally embraced because of my personal experience, as well as the academics behind it. It was good to know that I have two bosses that understand the need to drive that as part of the agenda.

I'm very pleased that the American Enterprise Institute is turning its attention to the problem of obesity. Secretary Thompson, President Bush, have been pioneering in getting prevention into the American mindset. For example, from October to December of '99, before Secretary Thompson became Secretary, there were fewer than 50 articles in the American press about obesity and overweight. Contrast that with three years later, October to December of 2002, where there were more than 1,200 articles about obesity and overweight in the same sample of American magazines and newspapers, a real important change.

Awareness of obesity is growing, and as the coverage becomes more and more high profile, including the covers of Time, Newsweek, USA Today and numerous other broadcast reports, this coverage is important because Americans need to understand that overweight, obesity, and many related co-morbidities are absolutely preventable.

Prevention is still a radical concept to most Americans. We are a treatment-oriented society, and I am the perfect example, having been a trauma surgeon, made a very good living. Taking care of society's indiscretions, largely, is what I did and my colleagues did, things that could have been prevented that cost a lot of money to care for after those bad decisions were made.

Pervading habits and inactivity erode our quality of life, shorten our life span, and burden our health care system, which is already stretched too thin. In 2000, the total annual cost of obesity in the United States was $117 billion. Obesity is the fastest growing cause of disease and death in America today.

Obesity has reached epidemic proportions. Nearly two out of three Americans are overweight or obese. That's a 50 percent increase from just a decade ago. More than 300,000 Americans die every year from obesity related problems. That's nearly 1,000 people a day, one every 90 seconds. Obesity is creeping into our children's lives. More than 15 percent of Americans age 6 to 17 are overweight or obese. That's more than 8 million young people.

A direct result of the obesity epidemic is that type-two diabetes, previously unheard of in the young, is now rising rapidly. Left unchecked, it leads to serious illness and possible death, as you all know. Worse yet, minorities are faring worse than overall populations. Twenty-three percent of Hispanic Americans are obese, and 30 percent of African Americans are obese, with those attendant co-morbidities. Obesity causes many of the diseases affecting men.

At least 17 million Americans have type-two diabetes. That's about one out of every twenty people. At least 16 million more have pre-diabetes. Each year diabetes costs America $132 billion. It also accounts for thousands of deaths, thousands of hospital stays, and immeasurable grief and sadness for families across the nation who have to care for their loved ones. At least a third of all cancers are caused by poor nutrition, overweight, and simply being inactive. And hypertension, which is aggravated by obesity, contributes to the number one cause of death in this country, heart disease.

The good news is that this health crisis is almost entirely preventable through proper diet and exercise. Everything I do as Surgeon General will focus on prevention first. As we look at the big picture of health care, even beyond obesity, there are perverse incentives in our health care system. We are ready for people to get sick, and then we spend billions of dollars every year trying to make them healthy again. I am grateful for the treatments generated by biomedical research, but we shouldn't have to rely on good science to undo many years of bad habits.

We are