How to really make America healthy again

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The writer served as commissioner of the US Food and Drug Administration under Presidents George H W Bush and Bill Clinton and co-led Operation Warp Speed. His recent book is ‘Diet, Drugs, and Dopamine: The New Science of Achieving a Healthy Weight’

Americans are ill. The majority are on a path to developing cardiometabolic and kidney disease, diabetes, certain cancers and neurodegenerative diseases that will result, if not in death, in years of disability when they are old. It should have been otherwise. The successful 73-year campaign against smoking, the development of lipid-lowering drugs, and the targeting of the molecular mechanism of cancer added years to life. The dramatic rise in metabolic disease undermines all that progress.

The administration of President Donald Trump tapped into a populist vein by promising to make America healthy again. The resonance of the MAHA campaign is so deep that some have credited it with swinging enough votes to Trump to hand him the election. US health secretary Robert F Kennedy Jr, who brought those voters to Trump, rhetorically pivoted from an anti-vaccine message to one that tackles chronic disease, a message for which there is broad support.

The problem is that Kennedy and Trump have no idea how to truly make America healthy. The focus to date has been on removing artificial food dyes and seed oils. However laudable tackling food dyes may be, the number of lives that will be saved is uncertain. There is even less data to suggest that removing seed oils will affect Americans’ health in any significant way.

Kennedy is right that the problem begins with the food we are eating. Medicine is coming to recognise that excess toxic fat is the central culprit in what is making America ill. Toxic fat is the fat that gets into the liver, pancreas, heart and muscle, and releases a plethora of pro-inflammatory molecules.

But public health efforts to tackle obesity over the past several decades have failed. Life expectancy in the US continues to lag behind peer nations, due in significant part to obesity. In the 1980s, about 47 per cent of the US population was overweight or obese. Today, it’s 74 per cent.

Telling people to eat less and exercise more does not work. Putting fat, sugar and salt on every corner, making it available 24/7, making it socially acceptable to eat any time, all this has resulted in a carnival of energy dense, highly palatable, high-glycemic-index — ultraformulated — foods. 

These foods are deliberately engineered to contain the potent trifecta of fat, sugar and salt that triggers the brain’s reward circuits in a way similar to nicotine. Both trigger cue-induced wanting, cravings and relapse into bad habits, which in the context of weight means regain.

But the addictive nature of these foods is only part of their harm. For the most part, they contain rapidly absorbable carbohydrates. Excessive calories and carbohydrates result in elevated insulin levels circulating in our bodies that give rise to increases in liver fat, abnormal blood lipid patterns, type 2 diabetes, and many other chronic diseases.

We have been down this road before with cigarettes. It took more than 70 years to reduce smoking in the US. That happened because there was a fundamental change in how we viewed cigarettes. Once considered glamorous, sexy and associated with adventure, cigarettes came to be seen for what they are: a deadly, addictive, disgusting product. Demonstrating to the public how they were being manipulated by the tobacco industry resulted in a critical perceptual shift.

Likewise, we need to be clear today that the problem is not food, but foods that do not exist in nature, designed to keep us coming back for more while unleashing metabolic havoc on our bodies. 

The good news is that we now have tools to treat this metabolic chaos. Although they are not miracle drugs, new anti-obesity medicines are highly effective at reducing the toxic fat that is causing chronic diseases, especially cardiac and kidney disease and diabetes. However, they are often not covered by insurance and are priced so high that people who need them are buying copycat versions whose safety is not assured by the Food and Drug Administration. The effectiveness of the new anti-obesity medicines demonstrate unequivocally that obesity is the result of biology, not willpower. We are discriminating against people with obesity and denying them access to necessary medications.

Treating the cause of chronic disease will require access to both good information, reliable therapies and appropriate care. Saying we want to make America healthy and actually doing it are two different things.