Political Battles Over Nutrition and the Coming Economic Disaster of an Obese America
The Raleigh Tavern Philosophical Society
David J. Turell, M.D.
Political Battles Over Nutrition and the Coming Economic Disaster of an Obese America
The United States population is growing fatter and fatter. Just look around and it is obvious. The reasons are simple: too many calories, too little exercise and a loss of the cultural obligation for individual self-control. All this despite the fact that America is undoubtedly the most diet-conscious country in the world, inundated by an enormous variety of ‘fad’ diets, and also of so-called scientific diets. This fattening of America is going to create a unique economic disaster in the near future for this country.
We all know that obesity leads to increased odds for high blood pressure, for arteriosclerotic heart and blood vessel disease, for stroke, for diabetes, for increasing osteoarthritis, etc. With an aging population experiencing an increase in the incidence of degenerative diseases there will be an enormous increases in medical costs. We have a population that is more and more entitlement-conscious, demanding increasing government medical care as now suggested by both major political parties, i.e. the recently (November 2003) passed Medicare drug benefits low-ball-estimated to cost $400 billion a decade. And if Beltway predictions of ‘costs’ hold true the eventual price will be several times that figure. It was estimated at the start of the Medicare kidney dialysis program that initial costs per year would not exceed $800 million. It is now treating 300,000 patients, costs $16 billion and climbing. In fairness one should factor in 25 years of inflation. (Government by Political Spin,& Wall Street J. article page 1, Oct. 2, 2003; Houston Chronicle, pg. 7A, 12/2/03) As the population degenerates and loses income, and as life expectancy shortens, I can envision a loss of individual productivity, a drop in tax revenues coupled with a tremendous increase in medical expense by our government. If government deficits look large now, imagine what they may be like in the future.
At present I do not see a solution, only possible approaches to the problem. In this paper I will cover my own experience and battle with obesity, to afford the reader some insight to the background of my thinking. The physiology of energy nutrition will be explored. This subject must be understood, primarily to remove the underbrush of misinformation spread by the media, and surprisingly by the medical community. Since the urge in this country is now to turn to Washington for solutions, the record of the federal government and its nutritional advice will be reviewed. And finally a discussion of possible ways to mitigate the mess.
I grew up a chubby little kid. My parents, as first-generation native-born Americans, were taught by their European-born parents that a fat kid was a healthy kid. “Eat your food, there are starving children in Europe. Finish everything on your plate. Don’t waste food. Finish and there will be a great dessert”. Having doubles of anything was fine. I went off to college at 185 pounds and wanting to make the junior varsity basketball team, joined the cross country team and started running. Despite eating like a horse I came home at Christmas vacation weighing 155. My father made a point of taking me aside and telling me I was way too thin. I could run like a deer for the first time in my life, but no matter, to him I looked cadaveric.
As pre-med took more and more time, I had to drop back from the heavy emphasis on sports and devote more time to studying, and of course eating. I was back to 185 pounds by the time I entered medical school. Let’s stop here for a moment and analyze: I burned off 30 pounds by running, even though I increased my intake of food. Every study night at college was accompanied by hamburgers or ‘submarine’ sandwiches brought into the dorm. My calorie intake had to average over 3,000 calories a day, yet I lost 30 pounds. My weight came right back as soon as I quit the heavy exercise. I still played sports, still exercised, just not at the high intensity of cross country. Note, I did not adapt my intake of food to less activity. I ate by the habit I was taught as a child. At this point I didn’t know any better. I had not been taught to think about food.
Medical school changed all that. We got very fine nutritional training, I expect a lot more complex than the approach in medical schools today, based on the junk research I have seen in the medical journals I follow. More of the current approach to energy nutrition later. In my freshman year I ballooned up to 203 pounds, dressed. My parents were happy enough, but during my first summer off, based on the lectures we had, I determined to lost weight, and went on a 1,200 calorie diet. I also had a job stocking shelves at an A&P. In six weeks I lost 25 pounds. Four pounds loss a week is hard to achieve, unless intense physical activity is added. I played basketball and soft ball in the evenings. By the time I was back in school I weighed 170 pounds. Gradually over the next several years of medical training I watched my intake of food and weighed about 160 when I entered private medical practice in 1961.
My final weight loss occurred in 1967 when I put in my own swimming pool and worked up to swimming one mile in 30 minutes (channel-crossing speed). At 12.5 calories a minute I was burning 375 calories about 6 evenings a week. After 4-5 years I dropped the exercise to 20 minutes length where it remains today. My weight settled in at 142 pounds (undressed) and remained at that level until the past year, when upon the advice of my own physician I allowed my weight to settle at 150 (undressed). I was not comfortable with his advice, because inside my thin body is a fat man crying to get out, and I have been afraid of him for 50 years. As a result, when my wife decided to take off weight, I joined her and returned to my preferred 140-142, following my usual calorie-controlled diet.
An analysis of this case report points out a number of important factors which must be recognized in formulating any educational program to teach Americans how to achieve and maintain proper weight. First, the attitude of parents toward their children’s eating pattern is of prime importance in setting up lifetime eating habits. Second, Americans must come to recognize that weight is the result of a balance between intake of calories and physical activity which burns calories. Children need more calories while they are growing: growth requires calories. When growth stops intake must reduce. Third, once obesity has occurred the appetite control centers are damaged and a lifetime of proper weight maintenance will require individual will and constant intellectual study of diet energy requirements. Thus, fourth, a simple description of the physiology of energy nutrition must be available for study. Not everyone has the advantage of medical school training, nor do they need it.
Human energy intake and consumption is measured in calories, units of energy that are readily interchangeable with BTU’s, horse power, foot-pounds, joules, ergs and all other energy units. The calories listed on food containers are the same as the calories burned though activity. Human (and for that matter all warm-blooded animal) bodies must maintain an energy balance at all times to avoid starvation. The maintenance of a body temperature above environmental generally requires a constant burn of energy. On the other hand an over-abundance of energy intake will result in energy storage, providentially to protect against times of starvation. During the evolution of humans a number of mechanisms were set up to achieve these goals within reasonable bounds. If one is starving there is a mechanism to reduce daily metabolism by as much as 300 calories a day. This starvation mechanism has a number of bodily controls: genes, hormones, neurotransmitters and other body chemicals. But conversely, if there is an abundance of calories, the body will not stop weight gain. In evolutionary times it was good to gain weight as protection against the certain-to-arrive leaner days for food availability. This obviously tended to maintain a reasonable weight for the hunter-gatherer, in his environment, but in our low-labor high-availability of food environment, evolution has us in trouble. (The Scarlet Burger, David I. Katz, M.D., Wall Street J., 11/20/03)
Paleontologists have found that early Homo sapiens, our Cro-Magnon ancestors were over six feet tall and thin, the typical hunter-gatherers, extremely active, lean-meat and fruit and nut consumers. When the agricultural age began about ten thousand years ago, height diminished to the size we see in the clothing of our pioneer museums, males of five feet, five inches, with women at five feet. Therefore height and body composition are directly related to nutrition and activity patterns. With the current nutrition available in this country we are seeing the population again grow back to pre-historic size. Unfortunately, because of excess calories and loss of the need for extreme activity, this return of height is accompanied by obesity.
Daily requirement for calories must cover basal metabolism, that metabolic rate measured just after awakening from sleep. The thyroid gland is responsible for the basal rate and is the primary source for the variability between humans in that rate. During sleep the rate is about 10 per cent lower. The requirement then varies with physical activity and body weight. Obviously massively obese persons must expend large amounts of calories just to move their bulk around. When their muscular efficiency is measured (I have a medical research paper on this subject) their muscles are much more energy efficient (twice as much) than the muscles of average weight subjects, to whom weighed back-packs are added. But the massively obese are less efficient in activity than normal folks because of the cost of moving the bulk. And there is a severe cost to joints: My mother-in-law had severe pain in her knees when she was 60. Physician-prescribed medication was of little help. At her marriage she weighted 102 pounds. With the knee pain her weight was 155. I convinced her to lose 30 pounds and the pain disappeared. The weight-bearing area of each knee is 2 square inches. Just seven pounds of loss per square inch did the trick. And she maintained the weight loss.
The average daily calorie requirement of adult women is between 1,500-2,200 calories a day, depending, again, on age, overall weight and activity. Men average 300 calories a day more, being larger and having more muscle mass which is more metabolically active and burns more calories. Age is a factor. After age 35, the metabolic rate drops 100 calories a day for each decade over that age. This is probably another gift from evolution. As the aging hunter-gatherer slowed down in his speed of movement, experienced loss of coordination, had diminished eyesight due to cataracts, and suffered the onset of arthritis, his self-obtained food supply would naturally diminish. Requiring less calories would tend to balance out the loss of calorie intake and help maintain the elder’s weight.
These figures do not apply to the massively obese, such as those people whose weight is double what it should be. Basal metabolism applies to all tissues, and although the maintenance storage fat (white fat) is less than muscle and more than bone, one can estimate that the metabolic requirements of a five foot, two inch, 220 pound woman is about 3,000+ calories a day. One final factor in overall daily requirement is individual basal metabolic rate. There is a variation among individuals of as much as 300 calories a day, following the usual distribution of the infamous bell-shaped curve. Some of as are lucky and at the high end, most of us are in the middle and some of the unlucky among us are at the low end. The basal rate is controlled by the Thyroid Gland which is the major source of the variation. However, the thyroid is controlled by a pituitary hormone which in turn is controlled by a hypothalamic hormone from the base of the brain.
All human activity has been measured in terms of calories per minute. When you are sleeping the rate of calorie burn is one calorie a minute or less. When awake and sitting quietly the rate of consumption rises to slightly over one calorie per minute. Obviously it doesn’t pay to be sedentary if weight loss is an issue. Traversing a mile on the flat costs 100 calories for the average 150 pound person, no matter the speed in which the distance is covered. House work is more physically demanding than activity of the business person working at a desk. For example, sweeping is about 3.5 calories a minute, but working on one’s computer is about 1.5 calories. Heavy exercise really burns up the energy. The four-minute miler is obviously consuming 25 calories per minute in those four minutes. Cross-country skiing is one of the costliest sports at 22 calories a minute. One doesn’t need to know the exact values of activities to lose weight, just to appreciate the role physical exercise can play.
The above is important background information to learn and understand before attempting a weight-loss diet. As calories are reduced below daily maintenance requirements, the body will burn storage fat and will also burn glycogen, which is glucose (sugar) stored in the form of a starch in muscle. If the calorie reduction is severe enough the body will burn protein, body muscle. This latter result is obviously extremely undesirable. One pound of human fat contains 3,500 calories. This figure should make it quite clear that the so-called weight loss programs advertised in the newspapers, claiming losses of 5-7 pounds a week cannot be true. If an adult woman usually burns 2,200 calories a day, how can she lose a pound a day or even four or five pounds in a week? Even absolute starvation cannot achieve that. Using diuretic medication may create the appearance of such a loss by dragging water out of the body. A pint of water is a pound. But just so much water can be pulled out before the water balance in the body is stabilized, and the water will come right back as soon as the diuretic is stopped. True weight loss still must be fat loss.
Using the information at hand, if a woman who burns 2,000 calories a day wants to lost a few pounds, at 1,000 calories a day diet, she will lose a pound about every four days. Why? Assuming that her body cuts back on calories by 200 a day, the mechanism to counter starvation, she will have a minus balance of 800 calories a day, and will lose 3,500 calories in just over four days. Now apply this to the 220 pound woman described above who is assumed to be burning 3,000+ calories a day. On a 1,000 calorie diet she will lose a pound every day and a half. But for how long? As her weight drops, her maintenance calorie requirements drop. Therefore her weight loss will slow. She must understand this so as not to become discouraged as time passes. If she is aiming to become a 2,000 calorie a day woman in body size, at some point she will be losing a pound every four-plus days.
Reducing calories means eating less and experiencing hunger. Understanding how food is utilized by the body can help reduce this problem. Both protein and complex carbohydrates (starches, not sugars) spend more time in the stomach than simple sugars and fats. Obviously, slowing stomach emptying time adds hunger problems. Further, in calculating calories, the cost of burning the food should be accounted for. This is referred to as ‘specific dynamic action’ of food. To burn carbohydrate, both starches and sugars, costs 10 percent of the food ingested. It is the same for fats, but protein is difficult to digest and the cost is 30 percent. Thus we can use 90 percent of the carbohydrate and fat calories we eat, and only 70 percent of the protein calories. This is why the Adkins diet works so well. It is a high protein diet. Net calories available to the body are much lower, and hunger is much less of a problem. Fruit and vegetable roughage does empty from the stomach fairly quickly, but helps give a full feeling. The other aid to dieting and having a ‘full feeling’ is to stop eating when the required portions are consumed. Wait 20 minutes and you will feel full. At this point the stomach has loaded itself with digestive juices and is literally fuller. It is at this time when dessert should be considered; recognizing the full feeling will mean that a small fruit portion, or something similar, will be emotionally satisfying.
When a desired weight level is achieved, the real battle begins. As an ideal weight is achieved, the diet to maintain that weight is obviously much lower in calories than the diet that maintained the much higher weight. The appetite centers that naturally control calorie intake have been severely damaged or destroyed. Emotional satisfaction in regard to eating is one major reason for overeating. Eating is fun, it is social entertainment. Think of the complex industry the French have made of it, the three-star Michelin Guide awards, the hysteria of a chef who loses one. In hunter-gatherer times eating was a necessity, now it is a social function and a form of entertainment: dinner parties, business lunches, dinner dates, etc. Without automatic controls, weight can only be maintained by taking a strong intellectual view of how much one eats. It can still be fun once the limits are learned.
The exact level of calorie maintenance can be estimated but is best found by a hunt-and-peck method. To do that, when a diet is ended a little food is added back every few days. This means weighing on the same scale every day. During dieting I recommend weighing every day at the same time without clothing. The time of day I prefer is before dinner in the evening when the body is generally at its lowest and driest weight. This is the most accurate way to see day-to-day loss, which does not occur day-to-day but in a stepwise fashion like stair steps if the weight is put on a graph. The reason is burned fat turns into carbon dioxide and water. Carbon dioxide is exhaled immediately, but it takes the body two-three days to recognize excess water and dump it. (Remember a pint is a pound) Now as food is added back weight will drop slightly below the ideal weight achieved and then level off. This is where the intellect comes in. The exact amount of daily intake must be identified and made into a conscious habit pattern. Over several years the temptation of social eating and of overeating will become easier and easier to control as the habit become more and more fixed. How many, if any, magic diets or diet pill manufacturers make this last point?
All of this has to be understood to make someone into a successful weigh loss dieter, one who maintains the weight loss indefinitely. That rate is currently 15 percent, the same percent as the recovery rate from drug addiction. No surprise, excess food is an addiction also, an emotional and intellectual addiction. What organizations are available to help the obese? Let us look at the medical profession and our Federal government to see what help they might have available.
The Medical Profession. Can it help?
The medical profession has been studying obesity for years. They do offer a stomach reduction surgery which is successful. Choices include stomach stapling and a ringing the stomach with a suture ligature, both to reduce stomach cavity size, and both now applied by laparoscope, minimally painful and minimally invasive. Careful dieting with small meals is a necessity, as there are stories of torn stomachs. One of the preferred surgical procedures is much more complex: it can be performed as open abdominal surgery or by laparoscope to make a small stomach pouch connected to the lower small intestine well beyond the duodenum, the first portion of the small intestine. About four feet of small intestine are removed to reduce the amount of food absorption that can occur. There are actually four types of procedures. All these procedures have all kinds of side effects and problems. Getting enough protein and calories are major issues. If the diet is too restricted weight loss is rapid and muscle protein is lost. High sugar loads must be avoided. Sugar causes liquids to flood into the small intestine, causing severe reactions, a drop in blood pressure with marked dizziness and copious diarrhea. Large amounts of vitamins and minerals are necessary to avoid deficiency states. Getting enough water is a problem because the bulk of water can block room for enough food. Immediate mortality rate is one in a thousand, but ultimately it may reach one in one hundred. Amazingly, it is estimated that 103,200 of these operations will be performed in 2003. (Houston Chronicle, pg. 6A, 12/1/03) These are desperate approaches but the fact that various surgical techniques are still being offered indicates that medical teaching of dietary control is lacking in acceptable results.
In the medical profession surgeons are always sure they can fix things. What they have invented here is a very poor form of a fix. That is proven, in part, by the finding that 5 to 20 percent of operated patients find a way of gaining back part or all of the weight initially lost, and some even exceed their previous weight. “In one study, 80% of patients reported that they regularly felt a loss of control over eating just six months after surgery.” (Wall Street J., 2/24/04) What the surgeons have found in a partial follow-up of surgery is the innate psychological drive of the very obese to try to stay obese. It is a deep-seated drive and post-operative care requires intensive counselling to combat this adverse psychology.
The internists are looking for a chemical fix. That means looking at genetic and hormonal controls over appetite and feelings of satiation. The hormone leptin, produced by fat cells, reduces appetite by sending signals to the hypothalamus of the brain. Obese patients are resistant to leptin’s effects. A more recent finding is a peptide hormone (PPY) produced in the gut which also reduces the urge to eat by affecting the hypothalamus. At a two-hour buffet obese patients were just as responsive to the hormone as lean subjects, with calories reduced 29.9 percent and 31.1 percent respectively, although it should be noted that obese patients did consume more calories at the buffet. By fiddling with this controlling hormone and others yet to be found, perhaps the obese can be medicated to eat less. (New Eng. J. Med. 349:10, 941-948, Sept. 4, 2003) However, physicians have warned “that it is unlikely that any one molecule or derivative will provide a magic bullet to induce and maintain weight loss and that any so-called solution will depend on targeting multiple systems that drive food intake.” (Wall Street J., 9/4/03) The ‘physicians’ are using a tunnel-vision approach in invoking a multiple system therapy unless they understand my point exactly: It is difficult to imagine that people will be willing to consume and pay for an expensive medication for a lifetime. There will have to be an assault on their mental state regarding food.
At present the medical community does offer obese patients 5 different drugs to act in reduction of appetite. All of them are stimulants to the sympathetic nervous system, mimicking the action of adrenalin. As such they can raise blood pressure or create rapid heart rhythms. They are recommended for short term use to ‘start’ a patient dieting, hoping that he can do it one his own when the drug is stopped. They lose their effect after several weeks anyway. A drug in this class had to be removed from the market due to damage to heart valves (Fenphen). Again, similar to gastric bypass surgery, not a very good solution. Newer drugs are on the way that may be safer. Some patients lose weight on anti-depressant medication. There is an anti-epilepsy drug, Topamax, that causes remarkable weight loss. There is an experimental drug that blocks the ‘munchies’ caused by marijuana. None of these are accepted at this time into standard medical practice, but they offer another approach to a drug ‘crutch’, but as I have indicated before, long-term solutions require a firm change in mental attitude.
The final chemical approach is to study genes. This is just beginning. It requires collecting a large group of subjects and setting up studies of weight loss and gain and then comparing results to DNA findings. Diet energy genes, and there are probably hundreds of them, must be identified and then correlated with results. Since there is a wide biologic variation among all humans, some genes will be found to speed weight loss and some to impede it. One group which historically endured repeated bouts of starvation and now has an evolutionary genetic tendency to gain and hold on to weight very easily are the Pima Indians. An increased number have mild hypothyroidism. Now that food is readily available they have a very high obesity rate. Fifty percent of all Pima adults have diabetes, with 70 percent having diabetes in the 55-65 age range. Ninety-five percent of those with diabetes are obese. (diabetic.com/education) It is not surprising when one remembers that these folks were primitive hunter-gathers just over a century ago.
I not convinced that the medical community really understands the problem of obesity. They keep looking for metabolic quirks, for regulatory mechanisms, and other chemical and hormonal controls. All give lip service to mental determination but only a few do understand the need for a striking change in mentality. One relatively successful approach has been hypnosis with post-hypnotic suggestion. It does work, but I haven’t seen long term studies that indicate the effect lasts without continuing support such as in Alcoholic Anonymous. Regarding the medical profession’s attitude let me briefly describe a research article’s conclusions, which set my teeth on edge and caused me to write the editorial staff to complain. The editor’s reply was just as bad.
The article studied energy expenditure in both normal weight and obese subjects and followed a group of obese subjects who managed to lose 10 to 20 percent of original weight. The intent of the authors was to find out if there were adverse physiologic changes after weight loss that made maintenance of that loss so difficult. They found that the anticipated reduction in calorie burn due to smaller body size was larger than the percentage of weight loss predicted, that is, a 10 percent weight loss resulted in a 15 percent reduction in calorie requirement for 24 hours, making it more difficult to maintain weight loss, unless a further reduction in calorie intake was achieved. The study was relatively short-term, up to 14 weeks long. It is possible that the discrepancy between weight loss and expected reduction in calorie requirement would have straightened itself out if the subjects strictly maintained their weight loss and were followed for a much longer period. I suspect the starvation-reduction mechanism was still in play but would have stopped with a period of weight maintenance. The result, is disturbing as it indicates that maintaining weight loss is initially more difficult than thought. However, scientific results have to be accepted on face value, and used to counsel patients. It is the conclusion of the authors that upset me. (New Eng. J. Med. 332:10, pg. 621-628, March 9, 1995)
In bringing their discussion of the results to an end they offer the opinion that “the sense of hunger that may accompany this state of reduced energy expenditure will promote increased food intake, further widening the gap between energy output and intake. Physicians should be aware that for some obese patients the achievement of …a more healthful body weight may be accompanied by metabolic alterations that make it difficult to maintain the lower weight.” Surprise!! Isn’t conquering the feeling of hunger a major part of the dieting and maintenance battle? Where is the call for individual patient responsibility, guided by the physician’s advice.
As mentioned I was so angry I wrote the editors. This was one of my comments: “In line with the following TV ad by one of our leading drug-counseling psychiatrists in Houston: ‘It is not your fault, but it is your problem,’ must the current medical generation, in line with a general trend in this country, look to establish victimhood in place of guilt. Who is in charge of one’s body?? Did any prisoner at Auschwitz remain obese?? What is wrong with the old New England Puritan concept of self-responsibility?” The editor who handled the article gave this infuriating response: “Self-discipline, yes, but I am inclined to the view that this alone is not enough. Learning new diets and exercise habits, etc. is important, but something else has to happen for the so-called set point [for stable weight] to change (both to allow weight gain and to allow permanent weight loss.) But what….?” His reply makes no sense to me. Is weight gain so difficult? If it is, the epidemic of obesity must be an aberration. Remember evolution set us up to permit weight gain whenever extra calories are available. As far as he is concerned my point about self-reliance is to be ignored. He feels we cannot exert full control over body weight even if we sincerely exert full self-control. Nonsense. And this attitude is characteristic of many articles I have read since then from the current medical researchers. Victimhood has taken full hold of their psyches, along with an appalling degree of political correctness.
My conclusion is that we will not get a great deal of help from the current brainwashed medical profession other than their production of ‘magic bullets’ for weight control. Unfortunately the American Public expects this kind of magic and does not want to be told about self-control. There has been lots of magic in other medical areas with miracle cures, but this is an instance where that cannot happen. There will be pills that help, that adjust hormone levels that drive appetite and alter other chemicals to reduce the feeling of hunger, but for success self-control must take over, and the American obese population must be taught that their brains must take over for proper self-control. The pills will be an additional expense for the dieter, and it is doubtful that such chemical bodily adjustments can be safely permitted for a lifetime.
Drug Company Help?
The title of this section is meant to cover all types of ingested help, to include true pharmaceuticals, nutraceuticals, and herbal remedies. The scientifically controlled pharmaceutical industry will have to await several more years of medical research to identify biologic mechanisms that might respond to chemical intervention. Then blocking agents or alteration agents will have to be identified, tested in animals, then tested over several years in humans before release to physicians to prescribe to the general obese public. Since the United States is now the primary source of pharmaceutical research dollars, the cost of this research will be borne by the drug consumers in this country in the cost of their prescriptions. It is well-recognized that prescription cost-control laws in the rest of the world has forced this burden upon our country. The situation is grossly unfair to the American public. Currently, as stated before, only appetite suppressants are available, none very satisfactory. We will have to wait for very expensive true pharmaceutical help.
How about the herbal medications, products generally referred to as dietary supplements or ‘natural health products’? These are mainly appetite suppressants and natural diuretics, and complete phonies. Obviously, water loss just fools the dieter, which leaves us with the appetite suppressants. The major substance has been Ephedra, a stimulant similar in action to the pharmaceuticals on the market, and also caffeine-containing herbals. The Food and Drug Administration (FDA) has issued severe warnings against Ephedra starting in 1994. “These reported reactions vary from milder adverse effects known to be associated with sympathomimetic stimulants (e.g., nervousness, dizziness, tremor, alterations in blood pressure or heart rate, headache , gastrointestinal distress) to chest pain, myocardial infarction, hepatitis, stroke, seizures, psychosis, and death.” And this worry about Ephedra has been borne out in the intervening years. Unless carefully controlled Ephedra is dangerous. Unfortunately the FDA was considered almost powerless to step in and remove Ephedra from the marketplace. “In 1994 [the] Dietary Supplement Health and Education Act classified herbal medicines as dietary supplements and effectively freed them from regulation by the [FDA]. As a consequence, products that are poorly standardized and that may be contaminated by pesticides, heavy metals or undeclared prescription drugs are frequently found on the U.S. market.” (Dr. Donald M. Marcus, professor of medicine and immunology at Baylor Coll. Med., Houston Chronicle, 7/14/03) “A recent review by the Federal Trade Commission [FTC] of more than 300 advertisements for weight-loss products found that 57 percent contained misleading claims.” (Marcus)
The 1994 Act is the direct result of intense lobbying by the herbal industry. “In enacting DSHEA, Congress was responding to an industry-led campaign framed as giving Americans the ‘freedom to choose’ dietary supplements. Although the industry earned annual revenues of just $4 billion in 1994, its constituency included at least half the adult population.” The FDA is prohibited “from enforcing any ‘unreasonable regulatory barriers’ that might deter anyone from buying the products.” (Food Politics, Marion Nestle, U. of Calif. Press, 2002) And so the herbals are out there, basically uncontrolled, and being sold to a very gullible and desperate public.
But, sometimes things are so bad even the FDA can act. After 155 documented deaths related to Ephedra, it was banned by the FDA, the announcement coming on December 31, 2003. (H. Chronicle, 12/31/03) But is it banned yet? Perhaps not quite. Only after a rule banning the sale is published, allowing sixty days to halt sales. And even then it will be difficult to stop Internet sales from foreign countries.
Currently in this year one-third of us are on a diet to lose weight. In 1993 it was one-in-five. (Parade Magazine survey conducted by Mark Clements Research, 11/16/03) At the same time, “Americans spend some $50 billion annually on diet remedies.” (news.bbc.co.uk/2/business/2665793.stm) Among the sales pitches, some of the claims are out-and-out pseudoscientific. There is a current television ad for “CortiSlim’. To paraphrase, “It is not your fault you are overweight, it is your stress level which raises the cortisol level in your body and forces you to deposit fat. CortiSlim reduces the cortisol level, reduces your appetite and increases your metabolism. [!] Lose 15-50 pounds quickly and lose it for life with CortiSlim.” The announcer, sounding medically professional, tells us that his ‘associate’, a Ph. D. biochemist has had his ‘research’ reviewed by articles in magazines like Redbook and Ladies’ Home Journal and confirmed by CBS reporters!! The implication for the dumb consumer is if it is in print in such prestigious magazines then it must be true. Advertising agencies know just how gullible the public is. The truth: cortisol (hydrocortisone) is a natural hormone in the body produced at about 25 milligrams (mgs) a day, slightly more if in mild psychological stress and in huge amounts if undergoing severe stress such as surgery (300 mgs). Cortisol does play a major role in fat metabolism, mainly in the breakdown of adipose tissue to provide energy under stress situations. However, in the presence of large amounts, such as overproduction by tumors (Cushing’s Disease) and in medical situations requiring large doses (autoimmune diseases, severe allergic reactions, etc.) fat is deposited on the abdomen, between the shoulder blades and on the hips and cheeks. For example think of Jerry Lewis of Muscular Dystrophy fame who, in order to stay alive has been on enormous doses to combat primary pulmonary fibrosis, and is a ballooned-up caricature of himself. But for that to happen, enough extra calories have to be present to permit the fat deposition.. CortiSlim advertising takes a kernel of truth and then disappears into never-never land, using the American Public’s love of victimhood as part of the propaganda. What does it contain? Among other things in its laundry list: calcium, chromium (a dangerous heavy metal), magnolia bark and green tea extracts (!), and the plant hormone beta-sitosterol. Another rival product, CortiDrene, contains ‘Vitapril’, whatever that is, and grape-seed extract. The product claims to have a “power packed Cortisol control and Antioxidant Proprietary formula. It provides a sense of ‘Wellness’ and ‘Vitality’, burns fats, boosts metabolism, controls appetite and maintains healthy blood sugar levels.” This all comes from the official CortiDrene web site. Isn’t anybody controlling this stuff for the very gullible American Public?
The Federal Trade Commission is primarily responsible for regulating this kind of advertising, and the FDA is pretty much prohibited from interfering by the DSHEA 1994 Act. However, “neither the FDA or the FTC would be likely to pay much attention unless somebody filed a complaint of an adverse effect. Both agencies deal with dietary supplements on a case-by-case basis after people start reporting problems with their use.” (Food Politics) A good portion of that $50 billion dieting cost is spent on this pseudoscientific junk, playing on Americans’ expectation that there can be magic and little need for self-control.
From what I have presented it can be seen that regulatory government help is sorely lacking. But we need to do more than regulate drugs and food. The U.S. Department of Agriculture (USDA) is primarily responsible for offering nutritional advise with some contribution from the Department of Health and Human Services (DHHS). The Food Guide Pyramid appeared in 1992. Mandated by Congress it must be reformulated every five years to reflect ongoing nutritional research. The current pyramid has a tiny triangle at the top for fats, oils and sweets, the small size cautioning that one should eat this stuff sparingly. The next layer down has milk group 3-4 servings on the left and meat group 2-3 servings on the right. The next layer down has veggies on the left with 3-5 servings and fruit on the right with 2-4 servings. The lowest level (base) is 6-11 grain servings, breads, cereals, etc. Remember that it is a basic tenet of capitalism for each company to want to sell as much product as possible to make the most profit. With food the companies involved have to appear as if they are worried about proper nutrition, but the primary tenet overrides all else. They literally fight government regulation tooth and nail.
“Food companies use every means at their disposal--legal, regulatory, and societal—to create and protect an environment that is conducive to selling their products in a competitive marketplace. To begin with they lobby. They lobby Congress for favorable laws, government agencies for favorable regulations, and the White house for favorable trade agreements. But lobbying is only the most obvious of their methods. Far less visible are the arrangements made with food and nutrition experts to obtain approving judgments about the nutritional quality or health benefits of food products, and the personal connections made with legislators or agency officials who might be in a position to promote favorable regulations.” (Food Politics)
The Federal Trade Commission is mandated to promote business competition in a fair capitalistic system. It therefore gets involved in reviewing advertising to make sure that it is truthful and fair, remembering that the agency is promoting capitalistic business activity. The Food and Drug Administration is mandated to promote safety. Both agencies are advised by committees of expert nutritionists as implied by the quote above. Food Politics is a 386-page complaint by Marion Nestle, a diary of her frustrations in trying to give the government the best of her advise and being constantly frustrated as noted in her quote above. Nestle is Professor and Chair of the Department of Nutrition, Food Studies, and Public Health at N.Y. University and Editor of the 1988 Surgeon General’s Report on Nutrition and Health. Those are potent credentials and she is very frustrated by the pull and tug of politics which always softens the advice given. In a chapter entitled “Deconstructing Dietary Advise”, she describes battles over nutritional advise to ‘definitely eat less’ of whatever component of the diet was under discussion to ‘moderate your intake’. Some food industry might be forced to sell less product if the wording is too strong.
The food companies have been forced by the government agencies to put calorie content on packaged foods, and cooperate only as far as they are forced to. While these companies have been increasing the size of boxes of prepared foods they sell to increase profits, they play games with the calorie and fat, carb, and protein content panels. (Food Fight, Brownell & Horgen, Ph. D’s., 2004)At home we enjoy Michael Angelo’s Vegetable Lasagna. While we have not noted an increase in size of the box or the price, the calorie panel is laughable and symptomatic of food industry games. These companies know that the American Public has learned the lesson that food calories are the enemy. Michael Angelo lists five servings at 230 calories each. Why that sounds much better than four servings at 287.5 calories, or three servings at 383.3 calories I don’t know. But less calories per portion sounds better. Any reasonable person who understands a little simple arithmetic knows that the package contains 1,150, and two can split it for a reasonable 575 calories each. I have yet to figure out how to split that box five ways.
Another instance of the food industry having its way is an episode after World War II. (Forgive an older man for his memories.) Margarine appeared after the war as an inexpensive butter substitute. It was a relatively awful-looking whitish-gray substance which tasted OK. The margarine producers obviously wanted to color the stuff to look like butter, but the dairy states, think Wisconsin for example, arranged for a national law prohibiting adding color to margarine, limiting a potent competitor from reducing butter sales. For several years margarine came with a little pouch of yellow powder to be mixed inconveniently by the consumer with the margarine to make it look better, until common sense in the non-dairy states took over. Keeping that in mind, just how cooperative will the food industry be in asking our population to reduce food consumption? How cooperative will they be in not applying pressure on Congress to help their sales, and instead lobbying Congress to reduce food consumption and help limit the obesity epidemic?
Estimated Costs of the Obesity Epidemic
Before getting into the dollar estimates a little medical background into the conditions related to obesity, some obvious, some not so obvious. The list includes arthritis, breast cancer, heart disease, colon cancer, type 2 diabetes, endometrial cancer, gallstones, hypertension, liver disease, chronic low back pain, kidney cancer, end stage renal disease (think of the cost of dialysis), stroke, urinary incontinence and sleep apnea. As the population gets simultaneously older and fatter, the morbidity represented by these conditions will be enormous as will the costs to the country. (Am Obesity Ass.: obesity.org/treatment/cost.shtml) From 1986 to 2000 the population of those 100 pounds overweight increased 389 percent and those 30 pounds overweight was up 216 percent. (Arch. Internal Med. 2003:163:2146-2148) Two-thirds of us are overweight to some degree.
Medicare, which is directly in the line of fire of the obesity epidemic, had 20 million participants at the start in 1970, and 40 million in 2000. By 2010 it will be around 46 million. In 1980 spending was about $30 billion, obviously $0 at the 1970 start, is currently $250 billion, is predicted to be rapidly approaching $300 billion, and is estimated to be $410 billion by 2010. (Wall Street J., pg. A1, 9/16/03) These figures do not fully take into account the onslaught of obesity related illnesses. The Center for Disease Control (CDC) has predicted that one-third of all children born in 2000 will be diabetic unless childhood obesity and adult obesity are controlled. Almost half Hispanic and black children will be diabetic, due to known racial differences from whites. The prediction is 45- 50 million cases of diabetes by 2050. This is based in part on a 50 percent rise in diagnosed cases in the past decade after recording a tripling of the cases from 1965 to 1995. (Houston Chronicle, pg. 1A, 6/15/03) The other disease consequences of obesity will undoubtedly rise in a similar manner.
The CDC has also ‘discovered’ the obvious: most of us are eating more: Daily caloric intake in women is up 22 percent since the early 1970’s, and men are up seven percent. Women eat an average 1,877 calories and men 2,618 now. The actual totals are surely much higher. (H. Chronicle, 2/6/04 & Wall Street J., 2/6/04) This study is from an estimate of what people think they eat, and they always underestimate. (Nestle) When actual weighed intake is measured the calories are higher. “’Obesity is a complex issue with a lot of underlying factors---lifestyle behaviors, environmental factors, genetics,’ said Jacqueline Wright of the CDC’s National Center for Health Statistics, who conducted the study. ‘We need to focus on our overall calorie intakes.’” Thank goodness, someone is cutting through the garbage, and offering the proper and simple approach, calories!
If the public cannot be made to respond it will be at great economic cost. The Surgeon General’s, “Call To Action To Prevent and Decrease Overweight and Obesity”, states that in 1995 the direct and indirect costs of obesity added up to $99 billion. Direct costs are payments for health care, indirect costs are the losses in wages and eventually net worth. In 2000 that had risen rapidly to $117 billion, an astounding rise of 18 percent in five years. (surgeongeneral.gov/topics/obesity/call to action/1_3.htm) Using the rule of 72, if that rate of rise holds, doubling will occur at four times the five year interval, and in 2020 will be $234 million, by 2040 will be $468 billion, and by 2060 $936 billion. These estimates are quite accurate as direct medical spending is well known. The indirect economic cost to individuals as stated in net worth related to obesity was carefully studied by the University of Michigan and reported in 2000. 7,000 men and women in their 50’s and 60’s were surveyed. Among normal to slightly overweight women net worth was $145,000 in 1992 and $226,000 in 1998. However moderately to severely obese women were much poorer: $87,000 in 1992 and $90,000 in 1998. Interestingly obesity did not affect the men surveyed. Net worth for men was statistically the same regardless of weight. The authors of the study theorized that the obesity effect on women may be “due to cultural norms of attractiveness.” (umich.edu/~newsinfo/Releases/2000/Nov00/obesity.html) But certainly productivity of both sexes affected by complications of obesity will be reduced eventually and there will be a concomitant loss of personal wealth.
Diabetes is the major illness that will push the medical costs of obesity to much larger numbers. The primary component of the1995 cost of $99 billion is diabetes: $63.1 billion, made up of $32.4 billion direct cost and $30.7 billion indirect cost. This supports my contention that future costs are currently underestimated. Since diabetes is such a major portion of the obesity costs, its anticipated rapid rise in incidence should drive the overall cost much higher. Diabetes, of course, leads other complicating illnesses, to higher rates of arteriosclerosis as patients age, which means higher heart attack rates, loss of leg circulation leading to gangrenous loss of limbs. Retinal defects reducing vision will become much more common, requiring laser beam sealing of vascular leaks in the retina. The laundry list of related complications of diabetes is much longer, but this suffices to make the point. Diabetes, causing roughly two-thirds of the 1995 obesity costs, may well produce an even greater percentage of the total costs in the future. My prediction of obesity costs approaching half a trillion dollars by 2040 may not be far off the mark and may in fact be low. My estimates are in today’s dollars, not corrected for probable inflation.
An argument against my worry about this problem is by 2040 our GNP and DNP will be so huge, based on recent growth, that this obesity cost will be only a small percentage of the national product. I would remind the objector that we have a population that is being trained by politicians of both political parties to expect government entitlements to take care of all problems. We also have an aging population with a huge overhang of baby boomers about to enter retirement age, so that the ratio of workers to retirees in dropping dramatically, and Medicare is a pay-as-you-go program. Medicare has a $36 trillion unfunded liability, according to recent economists’ estimates I have read, although Senator John McCain gave a figure of $27 trillion on Fox News Sunday, November 30, 2003. Either figure is frighteningly enormous and the increasing obesity of our population can only make it worse.
Is there a Solution?
I’m not sure. The authors of, Food Fight. The Inside Story of the Food Industry, America’s Obesity Crisis, and What We Can Do About It, 2004, offer an enormous list of possible remedies, with a prominent emphasis on the tobacco fight. (I thought of my name for this paper before their book appeared.) Brownell and Horgen are both Ph.D.’s at the Yale Center for Eating and Weight Disorders, but all one has to do is think of a possible ‘no-eating area’ at restaurants to realize that the comparison with tobacco is of little help. No one has to smoke, but everyone has to eat. You can tax cigarettes heavily, but it is very difficult to tax food, hurting the lower income population, and which foods are best taxed? Everything has calories. Eat enough of it and gain. (There are exceptions, I know: For example celery. It costs more to chew it than it is worth, 12 calories to gain four calories.)
Brownell and Horgen, to be fair, have many other reasonable suggestions, but none of them are magic bullets. We are facing a national problem where individual responsibility is the key, and we know that most Americans are impatient, want magic cures and solutions, and since the 1960’s want the freedom to ‘do their own thing’. It is obvious that it is not going to be easy to convince Congress to control the bureaucracies from always bending to the will of the food industry lobbyists. Congress hates to make constituents angry; re-election is always at the forefront. The food industry will always want to sell more food for bigger profits, not less food, as must be suggested. Can we pass laws to make their food advertisements less appetizing? Print warnings on food packages that too many calories are bad for your health, according to the surgeon general?
There is something dramatic that Congress can do, but I’ll bet the only way it will happen is by a miracle. End or alter all agricultural food subsidies. Between 1982 and September 2003, the consumer price of fresh fruits and vegetables increased 127 percent. But the price of fats and oils rose only 57 percent; carbonated soft drinks, 26 percent, and ground beef fattened on cheap grains, 50 percent. The reason these foods that help make people gain weight are so cheap is about $20 billion dollars from our government’s agriculture policy to subsidize the production of rice, soybeans, sugar, wheat and most importantly corn. Cheap corn feed is the main source to fatten cattle and grow chickens; it becomes corn oil for fast food deep fryers, and high fructose corn syrup. American corn syrup consumption has multiplied by 40 times in the past 20 years. The subsidy programs currently encourage overproduction of the foods subsidized and hold down prices. There are no limits on what amounts the farmer can produce, increasing supply and lowering prices. Half of farm income is currently supplied by these subsidies. (Consumer Reports, pgs. 15-16, January 2004). My suggestion is end the subsidies and let the prices rise as they will. I said a miracle. Can you imagine the farm states and their Congressmen howling over this suggestion?
The medical-pharmaceutical industries will search for safe drugs to block appetite, and will be successful: those drugs will be very expensive if the current climate of having American consumers support the world’s drug research, and the issue of the safety of taking appetite-suppressants for life must be addressed. Once off pills most dieters tend to gain the weight back (85 percent), since they really haven’t learned to follow intellectually a new eating habit. Changing a fat America won’t be easy in a land of lots of food and less need to spend calories at labor, but there are some approaches that offer hope.
(As an aside, one step that can be taken to reduce the cost of medication to the American consumer, is to introduce medication price controls here or threaten to do it. All the major countries in the first world have price controls but the USA. Major pharmaceutical research occurs in this country, Japan and Germany, and our drug consumers pay the major costs. If we assume or threaten price controls we will force the research costs to be spread over the world, or there will be little research.)
From the history of the fight against tobacco it may take a long time to have the public respond in a meaningful way. In the late 1940’s, Dr. Oscar Auerbach, a pathologist at the Newark, N.J. V.A. Hospital studied smoking beagles, and found an increased incidence of coronary heart disease and lung cancer. In the 1950’s Dr. Alton Oschner of New Orleans, a thoracic surgeon and founder of the famous clinic, would not operate on lung cancer patients unless they promised to stop smoking forever. If they resumed smoking he fired them as patients. In the 1970’s I noted the disappearance of smoking at doctors’ conventions. Congress finally put warning messages on cigarette packs. Now 55 years after Auerbach, 25 percent of adults still smoke, but just about everyone has gotten the message. It has taken a tremendous advertising and public relations campaign to get there.
The anti-fat campaign must start by educating congress and the public as to the medical and economic disaster that awaits. Whether it is a special presidential commission or an in-depth Congressional investigation doesn’t matter. Medical experts in obesity must be teamed up with economists. Their results will have to be incorporated into an intense publicity campaign educating everyone as to the crisis and the danger to the country and to individuals of doing nothing. A crisis atmosphere must be created because we can’t afford to wait the same 55 years it took the smoking campaign to get results. The FDA, the FTC and the USDA will have to act with authority instead of listening to food company lobbying. For example the games now being played with portion sizes, the surreptitious increasing of package size, and the inaccurate nutrient descriptions must be actively stopped. The alternative and herbal remedies, now touted on TV and elsewhere, will have to be submitted for rigorous scientific testing before advertising is allowed. This will reduce the enormous spending by a gullible public on these ‘magical’ remedies to only those few alternatives that have some real effect. The school districts, now selling soft drinks and snack foods in the schools, making extra income for the districts, will be forced to stop. School lunches will become models of proper nutrition, which they are not at the present time. (Food Fight)The spending of food stamps should be tied to an indexing of foods, with high calorie junk foods and dessert foods costing more stamps, and vegetables, fruits, and salad greens costing less. We have the fattest poor people in the world. Restaurants will have to label portion size and calories of all dishes, if not in exact amounts of calories where that is impossible, in reasonable ranges for unique recipes.
The Department of Education will introduce a requirement at all grade levels to teach courses in energy nutrition. Like other science courses passing the course will be a requirement for graduation from high school. Obviously this won’t teach dropouts as much as they should know, but teaching in the earlier grades will hopefully help. The nutrition and dieting education of adults will have to be part of a continuing government-driven program in the newspapers, on radio and television, through magazine articles and books, and with web sites on the internet. Life and health insurance companies can offer ‘lean’ preferred premium ratings along with high ratings for the very obese. However, raising health insurance premiums has a draw back: we already have 15 percent of the population without health insurance: some of the very obese may be forced to drop their health insurance. This is of no consequence with life insurance. There are 45 states that allow this practice. The others have anti-discrimination laws that block it. Federal law should force a change in those states. In South Africa Destiny Health has set up an incentive program for weight loss. Employers establish medical expense funds for individual employees to pay for health care. With weight loss the interest paid on these funds rises and there are other awards like frequent-flier miles. (Wall Street J. 10/21/03)
I have not mentioned exercise up to this point in this crisis program. I have no idea how to make adults like to exercise or perform exercise. Certainly it makes one feel better with internal morphines (endorphins) being produced. One lives longer, has less infections and stays thinner, but overcoming the couch-potato syndrome still must rely on how to motivate adults to exercise. Education may stir up a few, but it appears that a majority of Americans would rather sit and watch than do exercise. However, the children are a different matter. Some school districts have no physical education, some pay lip service to a little PE, and some have a fair, but not adequate program. This is a captive audience. Again, the government should mandate that PE with a attendant course in simplified exercise physiology be required of all students in public and private schools three hours a week. It need not be too scientific, for example, if the coach tells his students that the Big Mac with cheese at approximately 800 calories will require eight miles of walking or running to burn it off.
These are some of the suggestions that I have thought of and have read. There are many others in Food Fight, but many of them sound like academic pie-in-the-sky to me. I know my suggestions sound quite draconian, but the human tendency in this country and I’m sure elsewhere, is not to worry too much in the present about something that is coming 40-50 years in the future. It is easier to enjoy things as they are now. That is why the obesity epidemic must be presented as an immediate crisis, to be dealt with now. It will be best driven from the Executive branch at the presidential and cabinet levels; also by the medical profession, as Congress for the obvious reasons will be all aflutter, and the Judiciary will be faced with a tidal wave of law suits to stop it. Will this all happen? I hope so.
Experience elsewhere suggests that my hopes are just that, hopes. In Sweden 18 percent of children are obese, despite already having governmental programs of the type and more so than I have suggested. School lunch meals are low fat, TV commercials cannot be aimed at kids under 12. Eight year olds are taught in school how to cook healthy meals. Sports programs are heavily subsidized to seduce kids into exercise. No use: the number of children who are obese has tripled in the past 15 years. The problems are increasing availability of fast food, heavy TV watching and the access to international internet gets food advertising to the kids anyway and creates more inactive sitting time in front of the computer. The problem is the same in other first world countries. Does anyone have a solution? Heavy individual therapy does work, but is an answer which is fiscally impossible to implement to deal with whole population problems. (Wall Street J. , pg. B1 & D7, 12/2/03) As I said in the beginning, there may be no solution. The evolution of our economic success may have totally outrun our biologic evolution.
In contrast to the philosophy of this tract, I must make it a little fatter, and bring it up to date. It is my habit to write these papers several months before the scheduled presentation, allowing for proper gestation and reconsideration. However, with the subsequent outburst of superficial activity by our government, the food industry and the schools, both medical and public, I need to comment.
The governmental propaganda machine is in full cry. The newspapers have picked up the threat, and they love threats and any bad news. Ephedra should be gone soon. The FDA has insisted the nutrition label on foods be revised so that it will be “easier for people to count their calories.” (H. Chronicle, 3/13/04) The IRS will let you write off stomach stapling (H. Chronicle 3/2/04), and bariatric surgery has now been reviewed in the New England Journal (3/11/04) with the profound comment that “the sickest ones are the ones who benefit the most, but they are also [at] the highest risk [for mortality].” The U.S. House has just written a law banning class action obesity law suits against the fast food industry, (W.S.J. & H. Chronicle 3/11/04) and McDonald’s is downsizing ‘supersize’ portions, which it has been noted will improve their profits, since smaller portions are sold at a higher price per ounce, a review of food companies by the Wall Street J. has shown. There is further new promise in research, an experimental drug (mentioned earlier) that cuts appetite and now is shown to suppress the urge to smoke at the same time: the drug attacks the brain controls affected by ‘pot’ causing the ‘munchies’, resulting in loss of both addiction and appetite!! (WSJ, 3/10/04) And finally the State of Texas has told the schools, cut out the junk food.
The best comment on all this was in a letter to the Editor in the Chronicle (3/14/04). Noting the State ban on school junk food, the writer observed: “Nothing the schools do will change how these children act and eat at home. Until parents start being adults and stop allowing themselves to be ruled by their children, nothing we do as a society will fix anything.” And that relates to the issue I have raised throughout this paper. American adults are the most self-indulgent on earth. They want what they want when they want it, and they are just victims of their hunger. I don’t think all this flurry of activity will work. It may slow down the rate of obesity, but unless something like the ‘pot’ pill really succeeds and is cheap (probably government subsidized) and safe, America will grow larger and larger. And obesity will be controlled only if the folks will take their pills. Want to bet?