Perhaps at no time in recent history has a threat to the public health been so great.

The
prevalence of overweight and obesity now affects two-thirds of the adult population and
more than one in seven of our youth, and it is getting worse. Projected adverse health
effects and reduced quality of life associated with overweight and obesity are staggering
and threaten to bankrupt our health care system in the coming years. An early vision of
what is to come is seen in the 10-fold rise in the past decade in the incidence of type 2
diabetes among children and adolescents in association with the dramatic increase in the
prevalence of obesity. Beyond the direct healthcare-cost implications, this worsening
situation among our youth raises the specter of dramatic increases in disease-related
morbidity and mortality and dramatic losses in human capital and quality of life, as a
consequence of the decades of treatment that individuals must undergo.
In response to these trends, public health officials and medical experts alike have
declared the obesity problem to be an epidemic. Unfortunately, although obesity has been
recognized as a serious problem for years, we seem little closer today to a clear solution
for prevention and treatment than we were a decade ago. More and more people are
beginning to ask, what has gone wrong and what can we do?
There is a growing consensus among experts that the secular trend in obesity sweeping
the nation is not caused by defective biology but rather is environmentally driven. In fact,
obesity may be viewed as a normal biological adaptation to the prevailing environment
rather than a physiological system gone awry. For many people, weight gain is the only
means to achieve energy balance in an environment that encourages excess energy intake
and very low levels of physical activity. Because levels of physical activity are so low,
energy consumption frequently exceeds energy expenditure, and the only way to restore
energy balance is to increase body mass, which elevates the resting metabolic rate.
Energy balance is thus, restored, but at the expense of a greater fat mass.
The series of articles published in this volume examine three key aspects of this alarming
public health issue. First, Jeffery and Utter (1) provide a comprehensive review of the
current scientific literature concerning environmental contributions to obesity,
emphasizing current understanding of environmental factors that affect eating and
physical activity behaviors. Next, Lowe (2) examines whether it is feasible, given the
prevailing environment, for individuals to self-regulate energy intake to maintain weight.
Finally, Baranowski et al. (3) describe current knowledge about the effectiveness of
behavioral change models and their potential application to obesity prevention.
Each of these groups of investigators has done a thorough job of reviewing the literature
in these key areas. Rather than discussing their particular findings and conclusions, in this
brief introduction I comment on some of the overarching challenges that we face in
dealing with obesity in the United States and the implications for making meaningful
progress in stopping the advancing epidemic.

Environmental Pressures

So, what is wrong with the environment? What specific environmental factors are
responsible for the dramatic increase in the prevalence of obesity? Numerous features of
the food and physical activity environments can easily be pointed to as possible causal
factors by applying old-fashioned common sense or what might be called kitchen logic.
On the surface, it just makes sense that people are heavier in a world where food is nearly
everywhere in giant portions, and it is possible to lead a gainful life without having to do
any appreciable physical activity. Unfortunately, however, little hard scientific evidence
can apportion a role for any specific factor to the alarming rise in the prevalence of
obesity that has occurred within just the past two decades. Many of the data are
observational, and, therefore, causal inferences cannot be drawn. Likewise, different data
sets do not always agree, making interpretation difficult. For example, as Jeffery and
Utter (1) point out, nationwide food consumption surveys between the 1960s and the
present indicate that total energy intake has not increased appreciably, despite the
increase in the prevalence of obesity. Other data sources, however, indicate that per capita
food availability has increased by 15% since 1970. The latter data are difficult to
interpret, given that food wastage has also increased over the same time frame (4),
making it hard to estimate how much actual food consumption may have increased.
Clearly, other trends related to food intake correspond temporally with the rise in the
prevalence of obesity, and Jeffery and Utter (1) also enumerate these trends. Overall,
there seems to be a unidirectional trend toward increasing convenience in food
availability, both in the home and away from home. The rise in the proportion of meals
consumed away from home, including the increased numbers of fast food offerings, and
the relatively high energy densities of many of the most popular foods, may increase the
probability of excess energy consumption. Portion sizes have also increased dramatically
over the last two decades, and human feeding studies have indicated that total energy
intake tends to increase with increased portion size, at least in the short term (5). In
addition, the composition of the U.S. food supply has shifted in the past few decades,
providing relatively less red meat, less refined sugar, and less whole milk and butter,
whereas increases in the amounts of chicken, fruits and vegetables, cooking oil, cheese,
corn sweetener, and both regular and diet soft drinks in the common diet have been seen
(1). At the same time, the cost of food continues to fall as a portion of disposable income
(6). In consumer terms, this means that the cost of eating has gone down and food is a
better deal now than ever before.
Even less information on temporal trends in physical activity behaviors in the U.S. is
available. Recent surveys indicate that the amount of physical activity performed during
leisure time has not changed in recent decades (1). However, less information is available
on how patterns of non-leisure time physical activity have been affected by the changing
environment. Certainly, the increased reliance on personal automobiles, automation in the
workplace, and the shift from a manufacturing-based economy to an automation-,
service-, and information-based economy have likely contributed to a reduction in the
amount of daily physical activity required on the job. The requirement of physical
activity in schools has been systematically eliminated in favor of more classroom time,
and even the provision of opportunities to engage in physical activity at recess seems to
be a thing of the past. Likewise, in nearly every other aspect of daily life, we have

developed technologies and products that save time, increase convenience, and reduce the
need for physical effort. In many cases, we spend the saved time engaging in attractive
sedentary pursuits like watching television or surfing the Internet. Taking all these trends
together, one might conclude that we have systematically engineered physical activity out
of our lives.
Despite the circumstantial evidence that numerous environmental factors may promote a
positive energy balance and obesity, it is essentially impossible, retrospectively, to assign
proportional causality to any of these factors. Too many things have changed
simultaneously over the past three decades to disentangle what is cause, what is effect,
and what is simple association. Even if we knew which factors were responsible for
fractions of the variance associated with a given weight outcome, would this ensure a
solution to the obesity problem?

Social Forces
I hypothesize that the factors examined thus far are not the core drivers of the obesity
problem. The environmental characteristics discussed above may merely be surface signs
and symptoms of deeper causal forces. In effect, what some have described as a toxic
environment (7) can be viewed as an unintended consequence of economic and social
choices made for reasons not related to concerns about health.
In searching for an environmental solution to the obesity epidemic, the first question that
we should ask is why is the environment the way it is? If the environment is being driven
by a larger set of economic forces and social values, it seems reasonable to ask whether it
is feasible to expect meaningful individual or population behavioral change by targeting
only certain environmental features associated with eating and physical activity
behaviors, without changing the larger system within which these behaviors operate and
are encouraged, penalized, and rewarded.
It can be argued that obesity is a social problem (8), driven in many dimensions by our
deeply held values and beliefs and the systems that we as a society have constructed to
develop, reward, and perpetuate this value system. Our forefathers founded this country
on strongly held beliefs about the value of personal liberty and being able to pursue one's
own dream. At the core of these values is the seemingly inherent drive to secure a better
future for ourselves and our children. This may mean different things to different people,
and the way social systems evolve to sustain this drive may change over time, but in
today's more uncertain world, being able to secure a better future seems to translate to
earning more money and to raising your standard of living, and to do so as quickly as
possible. This equation seems to operate at the societal level as well. As a nation, year
after year, we pursue the goal of increasing the total output of goods and services, of
growing the economy. To increase output, however, productivity must increase, and this,
in turn, demands that more technology be invented and that more effort be spent in the
pursuit of making and selling more goods and services.

It is noteworthy that at no time in history have more individuals been invested in the
stock market (9). This in itself creates even greater pressure for industry to make and sell
more, because a much larger proportion of the population is directly invested in the
productivity-prosperity equation. Aside from these direct investors, large segments of the
population have a sizeable piece of their retirement nest eggs tied to the fortunes of the
stock market. What individual or institutional shareholder does not want his or her
investment to grow? This broader participation in the global economy by increasing
segments of the population undoubtedly helps perpetuate the more frenzied pace of
commerce that seemingly has but one objective: to make and sell more products and
services.
It is interesting that many of the Fortune 500 companies that dominate retirement funds
and institutional investment portfolios are industries involved in producing and selling
food, inventing and selling technologies that save labor and reduce physical activity, and
offer ever more attractive forms of sedentary entertainment. So, the very industries that
we rely on to build our own economic future are integral to the environment that we now
recognize as helping to promote obesity.
As if these forces were not enough to drive us toward creating an environment that
promotes obesity, the challenge of preventing obesity is made even more daunting by our
own biology: a blueprint that seems to reinforce our predisposition to find even better,
cheaper ways to deliver high-energy food and to find even more ways to provide
incentives for sedentariness. Humans are essentially hardwired to prefer foods high in
sugar and fat and, hence, rich in energy, and we are not predisposed to engaging in
physical activity for the purpose of being physically active per se (8). Thus, it is not
surprising that after reviewing the evidence about factors affecting human food intake,
Lowe (2) concludes that it is essentially infeasible for humans to self-regulate food intake
under current environmental circumstances, at least not without applying substantial
cognitive control.
So, what is the point? The point is that at an overarching level, the environment is the
way it is because that is the way we want it to be. It best serves the needs we currently
value most as a society. In addition, economists would likely argue that the current
configuration approximates the most efficient way to meet those needs within the
prevailing set of social and economic priorities. As former U.S. Department of Labor
Secretary and social economist Robert Reich wrote recently, If people wanted to live
according to different priorities and were willing to accept the sacrifices that those
different priorities entailed, presumably they'd do so (Ref. (9), p. 218).
We have more fast food restaurants and packaged foods because people want more
convenience. Convenience foods are generally high in fat, sugar, and calories because
they make foods taste good and those ingredients are inexpensive, made so by years of
agricultural advances designed expressly to provide more of these ingredients at lower
cost. In addition, supersizing, which amounts, of course, to paying relatively less to get
more, is part of our American culture and has become the definition of the deal.
However, environmental factors affecting body weight control go beyond the food

environment. We engineer the need for physical activity out of workplaces because it
takes time away from being more productive. We design communities and businesses
alike to be drive-through to save time, so that we can devote more time to being
productive or spend more time with our families, because we have spent too much time
being productive. Our incentive and reward system is also set up to perpetuate this
situation. In the U.S., we reward hard work in a manner that encourages people to work
harder (Ref. (9), p. 273).
The role of economics in driving environmental trends and perpetuating our social system
cannot be overstated. Our drive to earn more and to be more productive as a society
affects not only decisions made by individuals, but also pervades institutional decisions,
many of which affect the shape of our environment and the attendant consequences for
promoting obesity. In reference to how economic forces affect social choices, Reich
writes, Judges, legislators, editorial writers, and average citizens alike typically form
their opinions on the basis of what alternative best promotes economic growth or best
advances the well-being of consumers by lowering prices and generating better products
(Ref. (9), p. 235).

Social Choices
Even if one accepts that the current shape of our obesigenic environment is driven by
deeper social and economic forces and that we are all a party to its current form, does this
mean that we really want the world to be this way? Does this mean that we are powerless
to do anything about it? Certainly not. As a society, we are empowered to choose the
direction in which we go. So, why have we not acted? Perhaps it is because we have
never before been faced with such a crisis driven by myriad factors affecting multiple
behaviors. In addition, we have only limited experience (e.g., creating smoke-free
environments) in figuring out how to make socially relevant decisions that change the
environment in ways that reinforce positive individual health behaviors.
What changes will be necessary to have a meaningful impact on obesity in the next
several decades? How do we make healthy lifestyle choices more socially normative,
increasing demand for goods and services and policies that perpetuate a new healthier
future state? How do we change the current value equation to make this happen?
In this issue of Obesity Research, Baranowski et al. (3) point out that current behavioral
change models have not been very successful at changing long-term eating and physical
activity patterns and may be inadequate to support successful interventions that would
reverse the obesity epidemic. Why have we been largely unsuccessful? One might argue
that we have attempted to change eating and physical activity patterns, behaviors that are
motivated by multiple drivers not necessarily related to health, through mediators that are
not of primary importance to the individual at the point of decision, given the totality of
immediate personal priorities and rewards facing the individual.
Why would someone want to make a healthier food or physical activity lifestyle choice in
today's world? Our natural biological drive is to eat more and move less, behaviors that

are inherently rewarding. Why would we do otherwise, unless there is a greater incentive
to behave differently? In the context of obesity and healthy lifestyles, we are rarely
provided incentives or rewarded for making healthful lifestyle choices, whether the
choices concern food or physical activity. The rewards currently must come from within
the individual, and these rewards alone have not been successful in motivating large
segments of the population to change their health behaviors.
It is time that we seriously examined what external incentives and rewards would be
required to change the behavior of a significant fraction of the population. It seems
unlikely in the short term that we can rely on more people reaching a high enough state of
self-actualization that health behaviors ascend to a priority level of importance in their
lives. Rather, we must begin examining what conditions would be required to make more
people see that making healthy lifestyle choices is in their immediate self-interest.
As a society we have made certain choices that served us well in the past, and these
unintentionally led to the current obesity-promoting environment. Given the obesityrelated health crisis that is looming, we clearly need to make some new choices: about
what we want the future to look like, about what consequences and tradeoffs we are
willing to accept, and about what we will adopt as new social norms.
So, what will we choose, and how should we engage in moving ahead? At one end of the
social change spectrum there are voices calling for policies that would limit or restrict
choice and that would penalize people for making certain choices. At the other end of the
spectrum there are those who would have us do nothing, keep going full speed ahead.
For these stakeholders, the status quo looks better in immediate economic terms. For
many, I would venture to guess that a better future state lies somewhere in between: a
state that balances our American ideals of personal liberty (e.g., choice) and opportunity
(e.g., commercial freedom) with social policies that ensure that as we continue to modify
our environment, we examine publicly the consequences of our actions for the health of
the population, and we make informed choices. In the end, we will have to find the right
balance of tradeoffs and consequences that the majority of Americans will be able to live
with.
As for how to proceed, we also have choices. Some would argue that positive change will
happen faster if we eliminate commercial interests from engaging in the dialog, as they
are blinded by self-interest and would only work to delay moving ahead from the status
quo. Others would embrace all sectors and interests to get to the endgame sooner, that is,
to identify what is needed from each sector to support and perpetuate the new state and to
get on with creating the future, unleashing the power and innovation of the market that
will certainly drive rapid change once the target is identified.
There are no experimental data that can answer the question of which approach will be
better and take us to a solution faster. One thing is clear, however, at least for the food
environment. There will always be a need for an industry to produce and sell food. When
that industry has been called on in the past to respond to consensus public health needs, it
has responded quickly and efficiently. For example, in the Healthy People 2000 report

(10), the food industry was challenged to introduce 5000 new reduced-fat food products
by the year 2000. The industry met the goal by 1995, five years ahead of schedule. This
example highlights, in essence, a form of publicprivate partnership that can be used as
a model of how involving private interests in addressing public health issues can be
effective.
Because the obesity issue is tied so strongly to economics, and economics is tied to social
change, I conclude with a final quote by Reich (Ref. (9), p. 250), in which he writes about
the impact of the new global economy on social evolution. I believe that this applies
directly to the obesity situation in the U.S. today.
This cannot beit must not besolely an economic conversation. It is more
fundamentally a moral one. We are not mere instruments of the new economy. We are not
slaves to its technological trends. And we should not misdirect the blame for its less
desirable, more worrisome consequences. As citizens, we have the power to arrange the
new economy to suit our needs and, in so doing, to determine the shape of our emerging
civilization. Every society has the capacityindeed, the obligationto make these
choices. Markets are structured by them. Families and communities function according to
them. Individuals balance their lives within them. It is through such decisions that a
society defines itself. The choices will be made, somehow. They cannot be avoided. The
question is whether we make the most important of these choices together, in the open, or
grapple with them alone in the dark.
Perhaps the single most important thing we can do to combat obesity is to engage in an
honest, open, and inclusive dialog, and soon.