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By Matthew Rees

Food and Health Fact #142: Washington is MIA on obesity. Why?

Follow me on Twitter: @foodhealthfactsFind all previously published Food and Health Facts hereHappy new year. This week marks the continuation of an experiment: occasionally publishing only once a week and featuring longer commentary pieces, many of which build on short items previously published in Food and Health Facts.

Among the many mysteries of America’s obesity crisis, I’m awestruck by one in particular: the federal government’s failure to do anything about it. With one exception, obesity has never received high-level attention from the White House or from Congress. And even with obese individuals who have tested positive for Covid faring much worse than non-obese individuals, there’s been no concerted effort in Congress or in the Biden Administration to make obesity reduction – or even just healthier eating – a national priority.

A few basic facts about diet, obesity, and health underscore the need for attention.

• The U.S. adult obesity rate (42 percent) is the highest in the world (outside of Kuwait and a few tiny island nations) and has risen from just 12 percent in 1976.

• Three diet-related chronic health conditions — cardiovascular diseases, cancer, and diabetes – account for about 25 percent of the $1.5 trillion in total U.S. health care spending.

• All diet-related chronic health conditions result in nearly 1.5 million U.S. deaths each year. (There have been about 837,000 Covid-related U.S. deaths since March 2020.)

Given all the rhetoric that gets expended about U.S. health care, shouldn’t policymakers be more focused on America’s declining health and what’s causing that decline?

Emblematic of the policy failures is the federal government lacking a coordinated strategy to address diet-related conditions. The coordination breakdown was the focus of a recent report by the non-partisan Government Accountability Office – a congressionally-mandated independent watchdog agency – in which the authors identified 200 federal initiatives related to diet, spread across 21 agencies. “When asked whether the federal government had a strategy for directing diet-related efforts,” wrote the report’s authors, “officials from the 16 agencies we interviewed either said there is not a strategy or were not able to identify one.”

In thinking about Washington being MIA on obesity, I often reflect on another consumable product that had major implications for individual health, and health-care spending, and that did get the attention of the nation’s policymakers: tobacco.

There were many reasons why, but many of them could be traced back to the tobacco companies’ history of deception, manipulating their products to make them addictive, and marketing to children. And then there was the small detail that cigarettes were toxic.

Academic research and interest group activism helped lay the foundation for a crusade against the tobacco companies, and that crusade was eventually picked up by figures such as Henry Waxman, a long-time Democratic congressman, and David Kessler, who was commissioner of the Food and Drug Administration from 1990-97. (Kessler’s memoir of his tobacco-focused work, A Question of Intent: A Great American Battle with a Deadly Industry, is a fascinating read.)

Also fundamental to progress against tobacco were regulatory measures that made smoking both more expensive (through taxes) and less convenient (no smoking on flights, and in offices, restaurants, etc.). The Justice Department upped the ante by suing the tobacco companies in 1999 and holding them liable for increased Medicare costs stemming from smoking-related illnesses.

The campaign had its critics (even I was one of them) but it was extremely successful. Less 14 percent of American adults smoke today – down from a peak of 42 percent in 1964. Also striking is the decline in the youth smoking rate – it’s now less than 9 percent. (See the adult and youth data here.)

The reduction in smoking is probably the greatest U.S. public health victory in the past 50 years, along with developing therapeutics to treat people with AIDS. (Caveat: cigarette sales increased in 2020 – for the first time in two decades.) And while efforts to further reduce smoking rates continues, the more recent crackdown on Juul and other e-cigarette products shows what’s possible when regulators and policymakers decide to target a product that’s deemed unhealthy.

These tobacco campaigns beg the question, where are crusaders like Henry Waxman and David Kessler when it comes to obesity? Why is no one trying to hold the food and beverage companies accountable? With 73.6 percent of American adults overweight or obese in 2017-18 – figures that are sure to be higher once the data is released for 2020-21 – and with obesity affecting people of all incomes, ages, races, ethnicities, and geographies, why haven’t some policymakers seized on the opportunity to advance public health (or just boost their public profile) by taking on the issue?

Two past efforts are worthy of mention. While mayor of New York, Michael Bloomberg proposed banning restaurants from selling sugar-sweetened beverages larger than 16 ounces and posting calorie counts for foods being sold at select food establishments. Alas, the beverage measure was struck down in court and studies show the calorie labeling did not result in reduced calorie consumption. He was more successful with banning smoking in restaurants and bars – something that was controversial at the time but repealing it today would be unthinkable. Even so, the initiatives helped build awareness about the volume and quality of food and beverage consumption.

Michelle Obama, while First Lady, led the other obesity effort. Her focus was childhood obesity – a vital health issue, given the long-term health implications as children grow older, and given that the United States has the highest such obesity rate in the world. Her primary achievement was spearheading passage of the Healthy, Hunger-Free Kids Act, which strengthened nutrition standards in the federal school lunch program.

A study by Harvard researchers found that in the absence of legislation, obesity prevalence among children in poverty would have been 47 percent higher in 2018. But the researchers – one of whom worked on the Obama effort – also acknowledged that, “We found no significant association between the legislation and childhood obesity trends overall.” (And childhood obesity has only risen during Covid.) A related shortcoming was shifting the focus of her efforts toward exercise (thus the moniker, “Let’s Move”) and away from food, which is far and away the biggest driver of obesity.

The school lunch legislation passed more than a decade ago and since then there have been no serious federal efforts to tackle obesity (and the school lunch regulations were relaxed by the Trump Administration). Some of it is just managerial failures, which is what the GAO report identified. But that’s only part of the story – and not, I think, the most important part.

As I noted in last week’s column, it’s always useful to follow the money, and that’s true here as well. Food and beverage companies are very generous when it comes to spreading around campaign contributions. In 2020, they gave a collective $52 million to federal candidates (House, Senate, President), political parties, and outside groups – with 55 percent of that total going to Republicans and 44 percent to Democrats.

Suffice to say, that money buys them friends in Congress, particularly on the House and Senate Agriculture Committees (where they are particularly generous) While I have no insights as to what drives their campaign giving, I suspect the giving levels would be higher – much higher – if these companies had any reason to be worried about the passage of nutrition-centered policies that could adversely affect them. But as noted in an excellent Politico article on diet's absence from the federal agenda, "Food and beverage companies have been closely following whether marketing crackdowns, warning labels or other more aggressive measures could spread. So far, there isn’t much on the agenda in the U.S." In the absence of any looming threats, why give more than necessary?

The campaign contributions is one theory as to why members of both parties are silent. But there are also factors specific to the ideology governing members of both parties that makes them disinclined to act.

Among Republicans, two fundamental principles are a focus on individual responsibility and resistance to regulation and taxation. The Republican attitude – and I’m oversimplifying here – is that if you want to eat yourself into obesity, you have every right to do so and the federal government shouldn’t do anything to make obesogenic foods and beverages more expensive or more difficult to obtain.

Thus any government crackdown on food and beverage companies would trigger strong GOP opposition (and the predictable cries of “nanny state”), even though people who fit the profile of a growing segment of the Republican Party – rural and lacking a college degree – have obesity rates even higher than the national average. I’m not optimistic that this dynamic will change anytime soon, though the recent 90 pound weight loss by Mike Pompeo, Secretary of State in the Trump Administration and a potential presidential candidate in 2024, could help give the issue some visibility.

Among Democrats, I see obesity as another element of the party’s focus on identity politics. As the party pursues woke policies that aim to be highly inclusive, as well as deferential to the panoply of groups identified as key constituencies, there’s going to be a reluctance to pursue measures that some would inevitably construe as “fat shaming” (a charge that’s the quickest way to shut down constructive debate on the issue).

Add to this toxic stew the fact that blacks and Hispanics (“Latinx” is no more) have higher obesity rates than the national average (see data here), coupled with media outlets like Cosmopolitan publishing cover stories with headlines saying obesity is “healthy,” and you have a recipe for inaction. Left unsaid is that blacks and Hispanics pay the highest price for this inaction, while companies selling sugar-sweetened beverages and highly-processed food – which flood these groups with advertising (particularly children) – see their sales grow and grow.

There's one high-profile Democrat who could shake up the status quo: Eric Adams, the new mayor of New York. Having struggled with his weight in the past (and been diagnosed with type 2 diabetes as recently as 2016), he's now a vocal advocate for healthier eating. In 2020, he even wrote a book about how a plant-based diet can reverse diabetes and other chronic diseases. And he's forthright in addressing uncomfortable topics: "We’ve attached the black experience to the food that colonizers forced on the ancestors during slavery. . . . We culturized the food that was poison for us. And it’s leading to the devastation and the health care crisis that we’re facing."

The causes of obesity are complex and intersect with a range of biological, social, and economic issues (though not necessarily "food deserts" -- see here and here). And public policy is far from the only remedy. For-profit investing in entirely new food products that are healthy and affordable will also be critical, as firms like The March Fund and S2G Ventures are doing.

But dramatically changing eating habits and consumption patterns is destined to be a slow process. Given that, and given that diet-related chronic health conditions account for more than half of all deaths each year in the United States, shouldn’t the federal government be doing more to curtail consumption of the products that are contributing to those deaths?