Overregulation to Modify Behavior?
Dr. Topol: This is about the government regulating things. Is this the best approach, setting this kind of mandate or boundaries to modify behavior?
Dr. Farley: Where government public health has its greatest value is when we protect people from environmental risks, such as reducing the levels of air pollution, which we just did in New York City. We are saving 800 lives a year [by reducing pollution] and also creating an environment where healthy choices are easier. Now, if you create an environment where healthy choices are easier, people can still behave in an unhealthy way if they choose to, but we make it so that the default choices are more likely to be healthy. We don't think this is a regulation of behavior at all. If people want to drink 32 ounces of soda, if people want to buy 32 ounces of soda, there is nothing in this rule that prevents that. This is a regulation of how companies can market their products. If they are marketing their products in ways that are distinctly unhealthy, we think it is an appropriate role for the government to set some rules there for the sake of public health.
Dr. Topol: The opposition has been well beyond just the soft drink companies, right? There were a lot of people who said, "I don't want to have this regulated. I want to do what I want."
Dr. Farley: There have been several polls on this, and the polls are split about 50-50. It's about half and half. I don't think people who are against it feel strongly against it, although of course you see some on television. The real opposition comes from the industry. It is either the soda industry or the restaurant industry because this is the way that they market things, this is the way that they make money, and there is a lot of profit in sugary drinks.
Dr. Topol: You also mentioned that you think this is at the core of the obesity epidemic.
Dr. Farley: Absolutely right.
Dr. Topol: Is that clear, though? There are a lot of other moving parts in this story.
Dr. Farley: We certainly don't think that sugary drinks are the entire cause of the obesity epidemic, but if you look at which food products have contributed to the greatest increase in calories during the time that we have had an increase in the total calorie consumption in the United States over the past 30 years, those products are sugary drinks. Then there are an increasing number of studies that are linking sugary drinks with obesity in a cross-sectional way, or with weight gain in a prospective way, including randomized controlled trials. So there is no question that there is something about dumping in this heavy load of sugar in liquid form that increases people's weight over time.
Dr. Topol: You also get the whole insulin surge and all sorts of secondary effects of eating more, too.
Dr. Farley: There are 2 theories as to why. One of them is the insulin surge and the effect that it has on food storage and the effect that it might have on appetite down the line. The other is that if you consume something in liquid form, it doesn't have the same satiety effect of consuming something in solid form. There are studies that support that as well. Maybe it is a combination. It is not entirely clear why, but it is entirely clear that the empiric data show a strong relationship between sugary drink consumption and weight gain. Again, that's not the entire epidemic, but if we can isolate one thing that clearly is contributing to this, which doesn't need to be there, that is it.
Paying People to Lose Weight
Dr. Topol: There was a randomized study that I wanted to ask you about where researchers basically paid people to lose weight, like $500. You probably saw it published in JAMA a few years back, and it was pretty effective. During the course of getting paid to lose weight, people did it. Is that a reasonable thing to consider in the future?
Dr. Farley: About two thirds of Americans are obese or oversight. Do you think that we can afford to pay two thirds of this entire nation's population to lose weight, and not just for a few months but over their entire lifetime? I don't think so. I don't think that is a cost-effective way of dealing with this problem.
Dr. Topol: Do you think that would work if funds weren't a limiting factor? Is that an effective way to modulate behavior?
Dr. Farley: I question whether it would work over the long term. I don't know, and the studies haven't been done over the long term. One thing we know about diets is that people who are put on a diet generally lose weight for about 6 months and then they bounce back. About a year later they are more or less where they were to start with. To me there is no question that the obesity problem is an environmental problem. Nobody wants to be overweight. Lots of people, most people, in this world are gaining weight despite the fact that they are trying very hard to avoid it. There is something about our environment that is beyond our control that is making us gain too much weight, and to me it is the way that food is marketed to us. You can ask people individually to fight those environmental forces. Some people can do it over the short term. Some people can do it over the long term, but most people can't do it over the long term.