The Making of the Obesity Epidemic

With Americans eating increasing quantities of cheap and abundant food, scientists sounded the alarm. “It is clear that weight control is a major public health problem,” Dr. Lester Breslow, a leading researcher, warned at the annual meeting of the western branch of the American Public Health Association (APHA).¹ At the national meeting of the APHA later that year, experts called obesity “America’s No. 1 health problem.”²

The year was 1952. There was exactly one McDonald’s in all of America, an entire six-pack of Coca-Cola contained fewer ounces of soda than a single Super Big Gulp today, and less than 10 percent of the population was obese.³

In the three decades that followed, the number of McDonald’s restaurants would rise to nearly 8,000 in 32 countries around the world,⁴ sales of soda pop and junk food would explode — and yet, against the fears and predictions of public health experts, obesity in the United States hardly budged. The adult obesity rate was 13.4 percent in 1960.⁵ In 1980, it was 15 percent. If fast food was making us fatter, it wasn’t by very much.

Then, somewhat inexplicably, obesity took off. By 1994, the national obesity rate had hit 23 percent,⁶ and studies connected obesity with rising levels of heart disease, diabetes, and other serious illnesses. By 2005, 34 percent of all adults,⁷ half of all African American women, and 15 percent of all American children were obese.⁸

Today, there is little agreement among scientists as to why obesity rates remained flat for so long, or why they then spiked so dramatically after 1980. While there is broad consensus that increased consumption of calories is behind the rise of obesity, there is no consensus about what drove this consumption.⁹ Just as the causes of America’s declining crime rate remain highly contested, scientists have identified a tangle of bio-psycho-social factors behind the rise in obesity, from cheap corn to the breakdown of traditional eating rituals to the decline of smoking.

And yet, over the past decade, more than a few pundits, philanthropists, and advocates have homed in on the idea that the proliferation of fast, cheap, and unhealthy foods had a significant impact on the rise of obesity; that the industrialization and subsidization of agriculture had made foods artificially inexpensive, and food companies responded by supersizing and vastly expanding snack and beverage options. Like the tobacco industry before it, the food industry­­ was profiting by selling slickly marketed products that were dangerously addictive, particularly for the poor, who lacked grocery stores offering healthier food options. Much of the American public health and medical establishment came to believe that one of the most powerful ways to overcome the epidemic was to radically remake our school and neighborhood food environments­­, reducing­­ access to unhealthy foods and increasing access to healthy ones.

But in their rush to condemn corporate agribusiness, food marketers, and neighborhood food environments, public health advocates have too often allowed their policy and ideological preferences to race ahead of the science. This has fostered a reductive story about obesity that appeals to liberal audiences but doesn’t comport particularly well with much of what we know about why people choose to eat unhealthy foods, what the health consequences of being overweight or obese actually are, or why health outcomes associated with obesity are so much worse among some populations than others.

Against the current popular discourse, obesity is better understood as an unintended consequence of affluence than as a disease epidemic. It is not going to be eradicated like polio but rather managed more or less well. While there is nothing wrong with promoting healthy eating, the dominant framing of the obesity problem has led the public health community to pursue unproven strategies, like the transformation of the American food system, while distracting our attention away from interventions that are proven to benefit the health and life outcomes of those Americans threatened by obesity.

1.

Back in the 1950s, public health experts mostly viewed obesity as a problem of personal responsibility. “The American people have learned that good hygiene does not permit spitting on the floor … but they have hardly begun to appreciate the importance of optimum weight in good hygiene,” Breslow told his colleagues in the APHA in 1952. “Here is clearly a task for public health.” The head of nutrition for New York City’s Department of Health lamented that obese people resisted “blaming [their] obesity upon [their] own gluttony.”

At a meeting at Harvard’s School of Public Health later that year, the director of the Western Psychiatric Institute and Clinic told attendees that “most overweights eat to excess for much the same emotional reasons that drive alcoholics to drink.”¹⁰

But by the mid-1980s, public health experts increasingly described obesity as a disease unto itself, rather than a risk factor for other diseases, like
type II diabetes and hypertension. “We want the average American to know that obesity is a disease … obesity is a killer,” said Dr. Jules Hirsch, who chaired a panel on the subject convened by the National Institutes of Health, at a 1985 press conference.¹¹ “I think it is fair enough to predict that eventually obesity­­ will be seen in the same historical context with what we’ve been through with smoking,” said Dr. Edward Huth, editor of the journal Annals of Internal Medicine.

A decade later, public health professionals supersized obesity again, from disease to epidemic. Unhealthy calories were everywhere, and they were too cheap, too plentiful, too palatable, and too deftly marketed to avoid. “Environment is the real cause of obesity. Congress and state legislatures could shift the focus to the environment by taxing foods with little nutritional value,” de­­clared Kelly D. Brownell, now director of the Rudd Center for Food Policy and Obesity at Yale, where he is also a professor of psychology, epidemiology, and public health, in an influential New York Times op-ed in 1994.

By the early aughts, the epidemic came to be viewed by many as caused in large part by profit-seeking corporations. Eric Schlosser’s 2001 Fast Food Nation framed rising obesity as a consequence of America’s car culture and fast food marketing to children. New York University nutritionist Marion Nestle’s 2002 Food Politics described rising obesity rates as the inevitable consequence of a food system where corporations must sell more and more calories to stay profitable. An analysis conducted of the period found that while 1990s media coverage framed rising fatness around individual responsibility, by the early 2000s the framing had shifted to societal factors.¹² And in 2010, David Kessler, the former Food and Drug Administration commissioner who sought to regulate tobacco companies in the 1990s, argued in The End of Overeating that food companies were concocting their products to hit a highly addictive “bliss point” of sugar, fat, and salt. These manipulations, he and others argued, were akin to tobacco companies’ adjusting nicotine and chemical levels to make cigarettes more addictive.

Why did the public health profession transform obesity from a condition resulting largely from issues at the individual level, whether ignorance or personal­­ discipline or socioemotional factors, to an epidemic attributable to corporate malfeasance? Arguably, the half-century effort to reduce cigarette smoking played as much a role as any new medical evidence, profoundly influencing a generation of public health scholars as they turned their attention to the obesity crisis.

Early public health campaigns had mostly focused upon combating contagious diseases and food- and water-borne illnesses. Educating the public about public health risks, advocating new behavioral norms such as hand washing and immunization, and constructing modern sewage systems and other infrastructure had occupied the attention of public health officials during the latter half of the 19th century and first half of the 20th century. Those efforts had succeeded in eliminating a range of public health risks from the prior century in spectacular fashion.¹³

Smoking, however, represented a new kind of public health challenge. Nicotine was physically and psychologically addictive, and unlike, say, inadvertently drinking contaminated water or contracting polio, lighting up a Lucky was an elective behavior, one that many smokers strongly associated with social status and sophistication. In addition, the most serious health consequences related to smoking only occur decades after a smoker takes up the habit. It was one thing to ask Americans to adopt relatively effortless behaviors like hand washing, immunizing their children, and not spitting in service of public health benefits that were almost immediately apparent. It was quite another to try to persuade a subset of the public to give up a deeply ingrained habit that they derived great pleasure from in order to avoid death or serious illness in middle or old age.

And yet by adopting increasingly proactive and proscriptive tactics, antismoking advocates would eventually experience great success too. In 1964, when over 40 percent of all American adults smoked¹⁴ Surgeon General Luther Terry issued a widely publicized government report warning of smoking’s negative health effects.¹⁵ This report, along with a variety of policy measures that followed in its wake, helped initiate a long period of decline in smoking rates. Mandatory warning labels were applied to cigarette packaging.¹⁶ The Public Health Cigarette Smoking Act of 1970 banned cigarette ads on radio and TV. Nonsmoking zones were created on airplanes and other communal spaces to accommodate the growing cadre of Americans who viewed smoking as unhealthy and unpleasant. In the same way that earlier public health efforts had established that not washing one’s hands and not covering one’s mouth were bad manners, so too did antismoking advocates position smoking in public as unacceptable personal behavior.

In the 1990s, however, the decline in smoking rates slowed, and the rate of smoking among high school students spiked, from 28 percent in 1991 to 36 percent in 1997.¹⁷ In response to those trends, public health advocates began to deploy more-targeted interventions. One new strategy involved the concept of secondhand smoke, which shifted smoking from an individual choice that only harmed the smoker to a dangerous behavior that threatened the health of others. Antismoking advocates portrayed tobacco companies as predators targeting children with cartoon mascots like Joe Camel and sponsorship of rock concerts. They turned nonsmoking zones into more-comprehensive bans and levied increasingly high cigarette taxes. By the late 1990s, youth smoking rates once again started to decline.

The tobacco wars of the 1980s and 1990s would set the template for the antiobesity campaigns that the public health community would launch over the past decade. “In many cases,” wrote the public health advocacy experts Lori Dorfman and Larry Wallack in a 2004 analysis commissioned by the California Endowment and the Robert Wood Johnson Foundation for their antiobesity efforts, “it was appropriate to exact more responsibility from [the tobacco] industry because the industry, through its aggressive marketing and deceptive practices, was responsible for creating much of the problem and benefited from its continued existence.”¹⁸

But in focusing on the antismoking tactics used between 1980 and 2000, public health leaders drew misleading conclusions about what had worked to dramatically reduce smoking rates among the American public. From 1965 to 1990, the US smoking rate dropped by nearly 20 percentage points, from 42 percent to 26 percent,¹⁹ thanks to fairly straightforward public education efforts, alongside modest restrictions on advertising and public smoking, which reinforced new social norms about smoking and health. By contrast, more recent efforts to “exact more responsibility from [the tobacco] industry” achieved much more modest results. Between 1990 and 2010, the smoking rate dropped only a further 6 percentage points. The later efforts were not unimportant — if only because they continued to drive home the message that smoking harms health. But the lessons that the public health community would draw from the antitobacco campaigns of the 1980s and 1990s would weigh heavily as it turned its attention to obesity.

Determined to cast the food industry in the role of big tobacco, influential public health scholars set about defining the causes of obesity in ways that they believed would predispose the public to support societal action to bring the industry to account. “The more an issue is framed in terms of involuntary risk, universal risk, environmental risk, and knowingly created risk,” wrote Regina Lawrence in the 2004 issue of the Harvard International Journal of Press/Politics, “the more likely the opinion environment is to be conducive to public policy solutions that burden powerful groups” (emphasis in original).²⁰

2.

Public health scholars attempted to universalize obesity risk by increasingly referring to it as an epidemic. But for that, obesity needed a body count. After all, the word epidemic had typically been reserved for extremely deadly infectious diseases. The AIDS epidemic, for example, has claimed more than 600,000 lives in the United States alone since 1985.²¹ The 1918 flu epidemic killed more than 675,000 citizens in a single year.²² Cigarette smoking still kills more than 400,000 Americans annually.²³

Obesity, a team of Centers for Disease Control and Prevention (CDC) researchers would conclude in 2005, was nearly as lethal. They estimated that obesity and overweight were causing 350,000 premature deaths a year by the year 2000, a figure that immediately established them as the second leading cause of death in the United States.²⁴ In 2005, a different team of CDC researchers using a different methodology determined that obesity caused only 111,909 deaths — about one-quarter the number of deaths from smoking.²⁵

Part of the reason epidemiologists have had so much trouble quantifying the actual health impacts of rising obesity rates is that the relationship between high body weight and poor health outcomes is not clear-cut. Public health advocates and media reporting routinely conflate being overweight with being obese — the obesity epidemic is often said to affect upwards of 60 percent of the US population. But so far there is scant evidence that being moderately overweight has serious health consequences. In fact, in some cases, extra weight appears to be beneficial. For example, men who are lean and unfit appear to have higher mortality than men who are obese and fit.²⁶ For both men and women over 60, being physically active is a better predictor than body mass index of longer life spans.²⁷

Unlike smoking, which has a direct causal relationship with lung cancer, most forms of obesity do not have a similar relationship with the ailments with which they are associated. The strongest clinical evidence tying excess weight to ill health effects is driven by cases of morbid obesity. For the 4 to 6 percent of Americans who are morbidly obese, severely heavy weight creates physio­logical derangements of the cardiovascular system, lung functioning, liver health, and endocrine functions that directly result in higher morbidity and poor health outcomes.²⁸

For everyone else, obesity is not a disease but rather a risk factor associated with higher incidence of illnesses such as heart disease, osteoarthritis, and diabetes. Reframing obesity from being a risk factor for other diseases to a disease unto itself, and then reframing it again as an epidemic, had significant implications for research and policy, suggesting that little could be done to improve obesity-related health outcomes without addressing what experts increasingly viewed as a major culprit for the problem: unhealthy food environments.

But where lung cancer and other smoking-related diseases resist effective treatment, the obesity-related diseases of diabetes and hypertension are highly treatable. Remarkably, the rising obesity rate has not resulted in rising mortality from diseases associated with obesity, thanks in large measure to the fact that treatments of diseases like diabetes have improved faster than the obesity rate. Between 1997 and 2006, for example, the overall mortality of diabetic adults declined by nearly 25 percent. In that same period, cardiovascular death decreased­­ by 40 percent.²⁹ All this, and yet expanding the treatment of obesity-related diseases is rarely a priority of antiobesity efforts.

3.

The other critical shift necessary to fit obesity into the tobacco model was to define obesity as an involuntary risk. As such, public health advocates worked to replace the overweight adult, lacking the willpower to control her appetite, with two new archetypes. One was the innocent child, unable to resist the food industry’s predatory marketing tactics. The other was the low-income city-dweller living in neighborhoods devoid of grocery stores and farmers’ markets in which the only dietary options were unhealthy ones.“[S]tudents­­ do not determine what is made available to them in the vending machines in their school,” explained Dorfman and Wallack in their strategy brief, “just as students are not responsible for the food available in the cafeteria or snack bar.”

Experts pointed to evidence showing that by the time overweight and obese children become teenagers, they have great difficulty losing and keeping off weight.³⁰ In Fast Food Nation, Schlosser wrote about how McDonald’s deployed cartoon characters, toys, and playgrounds to create brand loyalty. In 2002, a 270-pound teenager who reportedly ate at McDonald’s twice a day filed a lawsuit against the chain. Her lawyer described McDonald’s fare as “physically or psychologically addictive.”³¹

Antiobesity advocates proposed a range of policies to keep children away from unhealthy foods. Schools started to ban junk food and soda pop from being sold in vending machines.³² A middle school garden project with a cooking component initiated by Berkeley restaurateur Alice Waters in the early 1990s to reconnect children with nature and improve the quality of school lunches was elevated as an important front in the war against the obesity epidemic.³³ In the same way that the antitobacco movement had convinced legislators to raise taxes on cigarettes, antiobesity advocates attempted to increase the cost of unhealthy food through taxes on soda, junk food, and fast food.

Many public health experts would increasingly come to see the poor in the same way — trapped in unhealthy food environments not of their own making. Researchers working for advocacy organizations produced studies demonstrating that poor communities in places like Philadelphia and Chicago were “food deserts,” with little access to healthy food. Scholars called poor communities “toxic” and “obesogenic.”³⁴ Other studies suggested that the poor were more likely to be obese because healthier foods are less affordable.³⁵

In response, social justice activists, inspired by the environmental justice movement, called for “food justice,” in the form of more grocery stores and supermarkets to combat obesity. Environmental critics of industrial agriculture like Michael Pollan made the case that the subsidies were responsible for cheap beef, potatoes, and corn, which were driving the supersizing of hamburgers, fries, and soda pop, in turn fueling the obesity epidemic, and lobbied to shift subsidies to smaller-scale agriculture and farmers' markets.³⁶

The effort worked. Today, the CDC lists “environment” as the major cause of obesity after basic caloric imbalance.³⁷ The Institute of Medicine child obesity strategy focuses exclusively on changing “marketplace and media environments.”³⁸ The editors of a 2010 special issue of the American Journal of Public Health listed “Encouraging farmers’ markets and inner-city supermarkets” as the top policy priority for addressing obesity.³⁹ In 2007, the Robert Wood Johnson Foundation announced a $500 million initiative aimed at “improving access to affordable healthy foods and opportunities for safe physical activity in schools and communities.”⁴⁰ In 2009, First Lady Michelle Obama planted an organic garden at the White House and made combating food deserts through grocery stores and farmers’ markets a high priority.⁴¹ In 2011, the California Endowment invested $200 million to bring grocery stores into poor neighborhoods.⁴²

What these efforts had in common was the narrative that the poor lack the agency, opportunity, and resources to seek out healthier foods or resist the temptations of food industry marketing and merchandising. As a narrative of deprivation — of food deserts and empty calories — the new obesity epidemic resonated strongly in the progressive political imagination, and so it is perhaps not surprising that the effort to bring healthy food to the poor so quickly mobilized such a broad and powerful coalition.

4.

Even as the antiobesity movement was coalescing around the fight against unhealthy food environments, the presumption that the poor were obese because they lacked healthy food options was falling apart. In 2004, a cross-sectional study of 7,020 low-income preschoolers in Cincinnati, Ohio, found no relationship between children’s being overweight and their proximity to playgrounds or fast food restaurants.⁴³ Three more-recent studies, by the United States Department of Agriculture, researchers at the RAND Corporation, and myself (publishing in Social Science and Medicine), have all found that low-income neighborhoods have at least as many and often more grocery stores and supermarkets than do wealthier communities. One can certainly find poor neighborhoods with lower access to grocery stores and supermarkets than wealthier ones, but on average they appear to have equal or better access. More importantly, like the Cincinnati and RAND researchers, I found no statistical relationship between the availability of healthy food (at least as measured by proximity or density) and lower risk of obesity development.

On the whole, this research suggests that Americans have extraordinary access to a wide variety of foods, healthy and unhealthy. In fact, most Americans, including the poor, typically travel beyond their neighborhoods to shop at the grocery stores associated with their class status — e.g., Whole Foods for upper-income Americans and Albertson’s for the poor.⁴⁴ Some evidence does suggest that one reason the poor prefer high-calorie foods is that they get more calories­­ for the dollar. In turn, public health advocates routinely cite this evidence­­ as proof that the poor can’t afford healthy foods.⁴⁵ But opting for perceived­­ value over nutrition doesn’t mean that nutritious food is out of the poor’s reach.

For some foods, the healthier option is indeed more expensive than the less healthy counterpart, but for many other foods, the price between the healthy option and the unhealthy option is more or less equal. Lentils are as cheap as potatoes. Skim milk costs the same as whole milk. Low-sugar cereals are typically no more expensive than high-sugar brands. Many seasonal fruits and vegetables are extremely inexpensive — bananas average just 60 cents per pound.

The evidence shows that “the poor choose their foods not mainly for their cheap prices and nutritional values,” noted Abhijit V. Banerjee and Esther Duflo in Poor Economics, “but for how good they taste.” They quote George Orwell’s observation about poor British workers in The Road to Wigan Pier: “A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits; an unemployed man does not … When you are unemployed you don’t want to eat dull wholesome food. You want to eat something a little tasty. There is always some cheap pleasant thing to tempt you.”

Meanwhile, federal agriculture subsidies appear to increase, not decrease, the cost of unhealthy foods.⁴⁶ But even so, the impact of subsidies on food costs is negligible. This is because raw ingredients contribute very little to the overall cost of most processed foods. For example, raw potatoes cost 50 cents a pound, while potato chips average $4 a pound. The sugar in a $1.39 Big Gulp soda at 7-Eleven accounts for only a few cents of its cost. For such items, processing and marketing costs are what determine their prices. Eliminating subsidies would have little effect on what consumers pay for them.

The picture painted by advocates of grocery stores and gardens in the inner city was compelling to so many in no small part because it combined an established way of thinking about poor neighborhoods as materially deprived with rising cultural support from middle-class Americans for eating healthier, locally grown foods. This explanation of the obesity epidemic fostered a highly misleading, and negative, picture of the poor as essentially passive victims of their food environment.

5.

With the benefit of hindsight, it is not at all clear that the tobacco control efforts of the past three decades represent a particularly promising model for reducing the disproportionate impacts of obesity on the poor. Smoking rates have come down substantially among Americans of all incomes over the past fifty years, but the long decline in smoking rates began well before antitobacco efforts began targeting children, secondhand smoke, and tobacco industry malfeasance.

Moreover, smoking rates among the poor over the past three decades have hardly budged, while smoking declined among those with higher levels of education and income. Today, the smoking rate today among American adults with less than a high school degree is 29 percent, compared with just 10 percent among college graduates and 6.3 percent for those with postgraduate degrees.⁴⁷ If antismoking efforts of the past 30 years had much impact, it was mostly among the middle class and the rich, not the poor.

The opposite trend has occurred with obesity, with the rich catching up with and even becoming heavier than the poor, a dramatic turnaround from just two decades ago. High-income men today have higher obesity rates than low-income men, a reversal from 1980. While rates of obesity have risen among virtually all Americans during this period, the gap between rich and poor has actually declined over this period.⁴⁸

But while disparities in obesity rates have narrowed, those in health outcomes associated with obesity have grown. One study found that the gap in diabetes-related mortality across education levels widened from the late 1980s to 2005. The authors argue that while progress in diabetes care has helped people of all education levels, it has been “of greater benefit to those with higher education.”⁴⁹ Given improving treatment of diseases for which obesity is a risk factor and the very weak relationship between garden variety obesity and health outcomes among middle- and upper-income Americans, it is not even clear that obesity represents a particularly serious health risk, much less a public health crisis, for much of the American population.

It may be that the problems associated with obesity are impossible to disentangle­­ from the problems associated with simply being poor. Lifestyle factors, including differences in smoking, diet, and exercise, can’t fully explain the life expectancy gaps between the rich and poor, and neither can health care coverage­­, especially since most elderly Americans have the same health insurance payer source, Medicare. Education and income remain the most salient predictors­­ of higher risk of death, even after age, sex, race or ethnicity, health insur­­ance, smoking, and BMI are taken into account.⁵⁰

This suggests that poor health outcomes associated with obesity among low-income Americans probably have more to do with being poor than being obese. One obesity prevention worker doing outreach in a poor African American neighborhood in Oklahoma recently told a New York Times reporter, “If you ask, ‘What would help your health the most?,’ people say, ‘More money.’”⁵¹ The answer is understandable. With limited resources and an uncertain future, poor Americans must make trade-off decisions frequently, at times creating a vicious spiral of self-fulfilling prophesies. “They say, ‘When my time is up, it’s up,’” a grocery store cashier in the same neighborhood told the Times. Poor youth, in particular, as classic ethnographies like Ain’t No Makin’ It and Learning to Labor have eloquently documented, are prone to believe that their paths to mobility are highly constrained, no matter how hard they work to prove otherwise.

At the same time, a growing body of sociological research finds that the poor have multiple sources of social capital and are active subjects shaping the world around them, albeit in ways that are sometimes self-defeating.⁵² But instead of embracing the agency of the poor, focusing on policy interventions that reinforce behaviors associated with better life outcomes, public health officials and philanthropies have too often done the opposite, embracing obesity strategies that reinforce the notion that the poor are victims of an environment that is rigged against them.

6.

During the latter half of the 20th century, the public health community came to see our overall health as irreducible to single factors. Seven years after he raised the alarm bell at the APHA about obesity, Dr. Lester Breslow began what would become a landmark study in Alameda County, California. He found that a 45-year-old with healthy practices in at least six of seven areas — drinking moderately or not at all, not smoking, managing one’s weight, getting regular sleep, exercising, eating regular meals, and eating breakfast — could expect to live 11 years longer than someone of the same age who followed good habits in just three or fewer. “In the long run, housing may be more important than hospitals­­ to health,” Breslow said. In early 2012, Breslow, who had gained the moniker “Mr. Public Health,” died at the age of 97.⁵³

In focusing not only on obesity but also, more narrowly, on diet, much of the public health community has forgotten the meaning of Breslow’s work. Fatness and diet are but two factors among many that shape health outcomes. While there is reason to believe that much of the rise in weight gain can be explained by higher calorie consumption, this is not an argument against more physical exercise, which is strongly tied to better health outcomes, regardless of whether it reduces weight gain. And yet several leaders in the public health community are quick to criticize efforts to expand physical activity as a diversion from changing what people eat. When First Lady Michelle Obama promoted more physical fitness, nutritionist Marion Nestle sharply criticized her for having “given up on encouraging food companies to make healthier products and stop marketing junk foods to kids,” suggesting that Mrs. Obama had buckled under pressure from the food industry.⁵⁴

When it comes to body weight, obesity, and health, the public health community needs to relearn the lesson imparted by Breslow. For the poor, the problem has less to do with food deserts and more to do with income deserts, college degree deserts, and quality health care deserts. Empowering the poor to take control of their social, economic, and health circumstances requires changing the larger life settings and socioeconomic circumstances that situate agency and habit setting. If the goal is to reduce poverty and create opportunities for advancement, then building grocery stores in the inner city should be evaluated against other antipoverty strategies, like increasing income transfers, workforce development services, and improved preschool and early learning opportunities alongside higher-education funding.⁵⁵

Indeed, attending and finishing college is highly correlated with lower obesity levels and better health and life outcomes across the board. In fact, some research suggests that higher education is not just correlative of lower obesity risk, but also causally improves the odds of having a healthy body weight.⁵⁶ This would suggest that junk food tax revenues might be better spent on scholarships for low-income families than on explicit obesity prevention strategies — measures unproven to work.⁵⁷ A college degree is likely to be a more reliable obesity prevention tool than any amount of school gardens, farmers’ markets, or new grocery stores.

Similarly, increasing long-term access to high-quality health care for low-income individuals will likely improve health outcomes more than banning soda vending machines and ending agricultural subsidies. Effective therapies for heart disease, hypertension, and diabetes have already weakened the relationship between obesity and mortality for Americans who can afford them. The same Oklahoma cashier who told the Times “They say, ‘When my time is up, it’s up’” lacked health insurance, couldn’t afford regular doctor visits or medicine and eventually had to get heart surgery.

Extending better health treatments to a wider spectrum of the public would not only be a victory for public health, it would also help low-income individuals in broader ways than more-targeted investments aimed at improving food and activity environments can. Every dollar invested in improving health care access to reduce diabetes and hypertension can also help reduce other poor health outcomes that afflict low-income people with little access to health care, including many that have little to do with obesity or dietary habits.

All this should challenge the application of the antismoking model to obesity. Where smoking can be banned, overeating cannot be. The two behaviors are similar only in that they, like much else we do, are factors in health. There is no secondhand eating. Nor can there be “no overeating” sections of restaurants and airplanes. Overeating and unhealthy foods are fuzzily, subjectively, and variously defined, whereas we can all agree on what smoking and cigarettes are. What that means is that unhealthy foods will remain widely available — even more available than cigarettes, which can still be found at any corner store. If history is any guide, food availability and diversity are likely to increase, not decrease.

The focus on food environments also led school-based efforts themselves to be too limited. “If the framing of the public remains around individual willpower,” Wallack and Dorfman wrote in their analysis for the Robert Wood Johnson Foundation in 2004, “approaches that seek to improve environments are less likely to be understood by the public.” But if environments, as measured by food deserts and fast food proliferation, have little or no impact on obesity rates, and are unlikely to be expunged of unhealthy foods, the public health focus should rightly consider ways of empowering children to exercise more willpower.

The past decade has seen growing evidence that things like self-control, character, and emotional self-regulation can be taught, and some educators are exploring ways to integrate these techniques more fully into the classroom. As such, nutrition education and school gardening programs are probably a lot less valuable than curriculums that show young people how to manage desires for unhealthy foods. Helping children mentally connect current behavior with future goals won’t just affect their behavior at mealtime. It will impact their behavior at home, on the streets, and eventually at the workplace, where they will make the decisions that shape not just their bodies but also their lives.

In the late sixties, Breslow became a fierce critic of the “complaint-response” nature of the medical establishment. Today, the criticism applies to the public health establishment itself. In place of a narrow focus on diet, we should concentrate on a broader set of factors. Instead of being narrowly focused on disease, we should embrace a larger vision of health as, in Breslow’s words, “the capacity for full living.” In an interview with the Los Angeles Times ten years before his death, Breslow urged experts to look for deeper causes. “Some people think of health as a state, they speak of health status … but I think of health as what underlies, what comes before health status, namely the competencies that people have … in a variety of physical, social and psychological rubrics.”⁵⁸ /