Shape Up!

Tommy Thompson isn't afraid to tell you that you're fat. In March, the Secretary of Health and Human Services pointed into a crowd of several hundred reporters, government workers, advertising executives and others who had filed into the HHS lobby for the launch of an ad campaign promoting healthy lifestyles. "I can tell by looking out at the audience, a couple of you are chunky," he said. As his pointing finger weaved across the room, audience members shrank into their seats, creating the opposite effect of sports fans performing "the wave." Thompson gave the crowd an order: "Try to do 10 sit-ups tonight and five push-ups."

Since arriving at HHS in 2001, Thompson has become a cheerleader for exercise and healthful diets. "We are just too darn fat, ladies and gentlemen," he told the audience. Roughly two-thirds of American adults are above a healthy weight, and one-third are obese. It's not just a matter of aesthetics; the national weight problem has triggered a public health crisis. The combination of poor diet and physical inactivity will soon eclipse cigarettes as the leading cause of preventable death in the United States, if it hasn't already. And soon we likely will see heart disease related to excess weight even in adolescents, says Dr. David Katz, founder and director of the Yale Griffin Prevention Research Center in Connecticut. "For the first time in modern memory, we're raising a generation that will likely have a shorter life span than their parents," he says.

Preventing obesity also makes good fiscal sense. Our national weight problem costs $117 billion in medical and other expenses each year, a large chunk of which is paid for by the federal government through Medicaid and Medicare.

Propped up around the HHS lobby were oversized versions of ads that have since appeared in newspapers and magazines and on billboards and bus shelters nationwide. The ads are the fruits of a collaboration between HHS, the nonprofit Ad Council, which recruits advertising agencies to work pro bono on public service campaigns, and the team of marketing whizzes from McCann Erickson Worldwide Advertising that created MasterCard's "Priceless" commercials.

In one of the HHS ads, a man's sagging, stubbly double chin features prominently. The topography of his body fat is marked with dotted white lines, indicating stages of weight loss that could be achieved through the campaign's signature "small steps," such as sit-ups during TV commercials and 30 minutes of exercise five times a week. At the third layer of weight loss, he's "no longer dependent on vertically striped shirts," the ad proclaims. The other ads are similar, depicting ski-sloped tummies, cascading love handles and protruding derrieres that their owners could lose by working basic exercise into their daily routines.

Battle of the Bulge

Former Wisconsin Governor Thompson, who admits a weakness for his home state's beer, cheese and bratwurst, seems an unlikely candidate to become the Richard Simmons of the executive branch. But he has been outspoken about ending America's swelling obesity problem. "I'm passionate about it," he says. His crusade includes a very public personal diet. The 62-year-old cut down on carbohydrates and late-night meals, and trimmed 15 pounds from his 5-foot-11-inch frame. He says he does 160 push-ups per day, walks the stairs and hits the department's gym when he has time. (He seems to have reached a plateau, however. Thompson has said for at least six months that he wants to lose 10 more pounds.)

Thompson also ordered all of HHS to get healthy, and says his employees frequently tell him how much weight they've lost. "When I came in here and saw so many fat people in the department, I said, 'We're the Department of Health, and the only way we can really be credible on the thing is to start looking the part and start exercising," he told The Washington Post in March. One woman has shed more than 100 pounds. This fall, Thompson plans to take his message governmentwide in a partnership with the Office of Personnel Management. "I've challenged my department," he says. "Now I'm going to challenge the federal government."

But his vision extends beyond the confines of government. "I'm trying to get America healthy," he says. It's a task that promises to present hefty obstacles both in the magnitude of the problem and the growing debate over the role of government in an issue that rests in large part on personal behavior. One of the least controversial of Thompson's tools is the public service announcement, or PSA. Shortly after he arrived at HHS in 2001, Peggy Conlon, president and chief executive officer of the Ad Council, proposed a joint campaign to promote exercise and healthy eating. Thompson enthusiastically agreed. "What we really wanted to get across is that you don't have to dramatically change your lives in order to eat right and integrate exercise into your life," Conlon says.

Cue a beach scene. Waves crash and seagulls screech in the background. Two teenage boys are playing catch when one spots something in the sand. "Check it out, man!" he calls.

"What is it?" asks the other.

"Looks like someone's belly," the first boy says casually, poking a stick into a flabby male midriff that's partially buried in the sand. "Eh, probably lost it walking on the beach." Unconcerned, the boys go back to their game. Peppy music comes on, and against a blue screen, the ad scrolls to "Small Step # 92: Walk instead of sitting around."

This and similar ads-in which people stumble upon other missing body parts, including love handles, a double chin and a fleshy rear end-have aired on prime-time programs, such as American Idol, Law and Order, The Tonight Show With Jay Leno and America's Most Wanted. Because PSAs are sometimes relegated to 3 a.m. spots, government agencies have moved increasingly toward paid advertising, but through its partnership with the Ad Council, HHS paid only for basic production costs. Conlon says the broad appeal of the message helped them line up valuable evening ad slots. The total cost to HHS for the campaign was just over $2 million. In addition to the print and TV ads, that amount covers a one-hour original program for Lifetime Television, additional PSAs created with the Sesame Workshop, which produces Sesame Street, and a Web site, www.smallstep.gov, which offers information and resources on diet and exercise and has drawn more than 80,000 visitors each month since its launch in early March.

The Ad Council has a strong record of implanting messages in the collective consciousness. It wrote slogans such as "Friends don't let friends drive drunk" and "A mind is a terrible thing to waste." But some critics of the obesity campaign doubt that it will make a significant difference, especially since the food industry spends far more money promoting unhealthy fare. Measurements of PSA effectiveness can be murky. A September 2002 report by the General Accounting Office found that outcomes of federal media campaigns aimed at changing behavior-including HHS' anti-tobacco "truth" campaign-are difficult to assess.

The best PSAs sound a clear call to action. One of the Ad Council's success stories is a campaign for Big Brothers Big Sisters of America, an organization that pairs volunteer mentors with kids ages 5 to 18. The organization had been receiving 90,000 volunteer applications per year, but in the first nine months that Ad Council PSAs aired, 620,000 people offered to be mentors. In other cases, the positive results seem less directly attributable to the ads. In 1985, the Ad Council and the National Highway Traffic Safety Administration began airing ads starring the crash test dummies, who told viewers to buckle up. By 2003, seat belt use had increased from 14 percent to 79 percent. Still, it's hard to isolate the impact of the ads from other forces, such as seat belt laws.

Heal Thyself

On March 10, the day after the launch of the healthy lifestyles campaign, The Wall Street Journal's Marketplace section published two front-page articles related to obesity. One described the HHS ad campaign: "It's built around a central creed of the Bush administration: that resolving the obesity crisis depends largely on whether individuals take personal responsibility for their own health and weight." The other article, which was featured more prominently, reported that an experimental "magic bullet" drug called rimonabant being developed in France has been shown to help people lose weight and quit smoking. One cardiologist called the drug "exercise in a pill."

The different approaches described in the articles-encouraging individuals to take control of their weight versus finding a way to make it easier for them to shed pounds-reflect a larger debate about how to address the obesity crisis. At its heart is the question of who or what is responsible for making us so flabby. There's no clear answer. Instead, we have a long list of things that have been shown to make us fat: soft drinks, TV, desk jobs, bigger portions, stress, poverty, fast food, driving and even diets, since most people eventually gain back more than they lose. Some even argue that the education law No Child Left Behind contributes to the epidemic because the costs of complying have forced schools to cut physical education and rely on revenues from sales of soft drinks and snacks in vending machines.

Conservatives tend to see weight loss as a matter of choice. "I think what you put into your body is probably the most personal, private decision we make," says Radley Balko, a policy analyst with the Washington think tank the Cato Institute. "In my opinion, we'd do a lot better if government got out of the way instead of getting involved." Balko wants health insurers to be allowed to give credits to fit subscribers, just as car insurance companies offer good drivers lower rates, but it's a practice that some states don't allow. Thompson also supports this measure. But critics of the personal responsibility approach-and there are many-argue that it ignores important genetic, psychological and environmental conditions. "Once the obesity is established, it's extremely difficult to take that weight off," says Morgan Downey, executive director of the American Obesity Association, a nonprofit organization in Washington. "This image that it's just a matter of individual willpower is archaic."

Government should play "a very major role" in fighting obesity, Thompson says. In addition to the healthy lifestyles campaign, HHS has undertaken a number of outreach and education efforts that focus on changing behaviors. The agency awarded $44 million this year to communities that developed innovative anti-obesity programs. The CDC encouraged preteens to exercise more through its "Verb" campaign, and the National Cancer Institute promoted eating fruits and vegetables with its "Five a Day for Better Health" program. Thompson also meets with representatives of the food industry. Coca-Cola is handing out pedometers, he says, and McDonald's has added more salads to its menu. The Food and Drug Administration is revising the nutrition label to help consumers count calories, and it's encouraging restaurants to list calories on their menus. In July, Medicare removed a statement from its coverage manual that said obesity is not an illness, which had blocked the program from paying for anti-obesity treatments.

On the scientific front, the National Institutes of Health is working on an obesity research strategy to examine behavioral, environmental and medical approaches to the problem, as well as the link between obesity and type 2 diabetes, certain cancers and heart disease. Obesity research at NIH receives $400 million, up significantly from fiscal 2003 but still well below other research areas. The National Cancer Institute, by comparison, has a fiscal 2004 budget that is 10 times larger.

Health activists say these efforts fall far short. In May, the World Health Organization approved a global plan for fighting obesity that recommends that governments take aggressive steps, such as taxing unhealthy foods and curbing food and beverage advertising to children-measures unlikely in the United States. After the WHO introduced its draft strategy, HHS Office of Global Health Affairs Director William Steiger wrote a 28-page letter to the organization objecting to some of its scientific findings and saying that the administration "supports personal responsibility to choose a diet conducive to individual energy balance, weight control and health," according to Mother Jones magazine. Critics blame undue influence from the sugar industry and other groups for HHS' stance, but the department has denied such a connection.

Health advocates would prefer greater emphasis on urban planning to make walking and cycling safer and easier, even more explicit food labels and tighter rules on school vending machines. "Consumers face a very hostile food environment," said Bruce Silverglade, director of legal affairs at the Center for Science in the Public Interest, a consumer advocacy group in Washington, at a House Government Reform Committee hearing on government's role in obesity. "Fast-food outlets across America heavily promote high-fat, high-sugar and high-salt foods and beverages. Vending machines in schools, hospitals and airports offer mostly high-fat, high-sugar and high-salt snacks and soft drinks. Food companies fill the airwaves, magazines and Internet sites with more than $7 billion worth of marketing messages for mostly high-fat, high-sugar, high-salt foods ultimately consumed by children."

At least for now, though, it seems most Americans agree with the administration's personal responsibility stance. In a poll conducted by Time magazine and ABC News, 87 percent of those surveyed said "individual Americans in their choice of diet and lack of exercise" are to blame for the national weight issues, while 41 percent identified "government policies and laws on food content and marketing" as an important factor.

Ad Blitz

Given the debate swirling around government's role in obesity, it's no surprise the healthy lifestyles campaign has detractors. The ads, with their perky music and jokes about bellies and love handles, are intended to be "fun and catchy, but also compelling," Thompson says. But not everyone sees them that way. Judith Stern, vice president and co-founder of the American Obesity Association, calls them "misguided and an insult to obese people" because she says they make losing weight look easy. The campaign "tells obese people all they have to do is walk a little bit and they won't have a belly, and they won't have love handles and they won't have a double chin-and it's not so," she says.

But if Stern isn't a fan, she's in the minority, says the Ad Council's Conlon. In focus group tests before the launch, 87 percent of viewers said they liked the ads. The average "likeability rating" for commercial ads is 79 percent, and the average for nonprofit ads is 77 percent. Stern's criticism-that the ads make weight loss appear easy-was one reason they went over so well. "The biggest challenge is that most people when they look at the objective of losing weight, they see it as a Sisyphean task," Conlon says. Viewers found the ads encouraging. "You don't always have the motivation to start an exercise program, but these are the kinds of things that you can do," one person said after watching the PSAs.

Those who would like Health and Human Services to take a more aggressive stance on obesity may find hope in looking back at the anti-smoking movement, which began with public awareness campaigns but escalated to include banning smoking in public areas and high taxes on cigarettes, despite protests from the tobacco industry. Thompson, too, compares his anti-obesity efforts to the early outcry about smoking.

"We have to first make the clarion call," he says. "Nobody was that concerned about obesity until I made it a cause célébre. Now it's becoming quite trendy." Thompson says he's still determined to lose those last 10 pounds.