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The ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started

Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic.

Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight

For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify

if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk

The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years

the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out.

adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time?

“All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories.

But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses.

Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm.

In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million.

It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life.

the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque.

Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.

“I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.

In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

he message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out.

although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,

that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions

Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it

She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid

By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look

The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity.

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism

But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events.

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell.

Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed.

In the meantime, thinness was coming back into fashion

In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight.

If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat.

Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now

Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies.

“The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways

When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.”

why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

as with climate change, the powers that be in this country are doing very little to head off the potentially disastrous results of expanding obesity, obesity specialists say.

Well-intentioned efforts like limiting access to huge portions of sugar-sweetened soda, the scientists note, are effectively thwarted by well-heeled industrie

With rare exceptions, the sugar and beverage industries have blocked nearly every attempt to add an excise tax to sugar-sweetened beverages.

Claims that such a tax is regressive and unfairly targets low-income people is shortsighted

“What people would save in health care costs would dwarf the extra money paid as taxes on sugar-sweetened beverages,” he said in an interview.

in a city like Philadelphia, where a soda tax of 1.5 cents an ounce took effect three years ago, total purchases declined by 38 percent even after accounting for beverages people bought outside the city

piecemeal changes like this are not enough to make a significant difference in the obesity forecast for the country

nationwide changes are needed in the ubiquitous food environment that has fostered a steady climb toward a weight-and-health disaster.

Americans weren’t always this fat; since 1990, the prevalence of obesity in this country has doubled.

Our genetics haven’t changed in the last 30 years. Rather, what has changed is the environment in which our genes now function.

“Food is very cheap in the United States, and super easy to access,”

We eat out more, consuming more foods that are high in fat, sugar and salt, and our portion sizes are bigger.

“You don’t even have to leave home to eat restaurant-prepared food — just call and it will be delivered.

As a society, we also snack more, a habit that starts as soon as toddlers can feed themselves.

“People are snacking throughout the day,” Mr. Ward said. “Snacking is the normal thing to do in the United States. In France, you never see anyone eating on a bus.”

We also eat more highly processed foods, which have been shown to foster weight gain, thanks to their usually high levels of calories, sugar and fat.

even when controlling for weight, consuming lots of processed foods raises the risk of developing Type 2 diabetes.

“Through marketing, we’re constantly being sold on foods we didn’t even know we wanted. We’re all about immediate rewards. We’re not thinking about the future, which is why we’re going to see more than half the population obese in 10 years.”

Unless something is done to reverse this trend, Mr. Ward said, “Obesity will be the new normal in this country. We’re living in an obesogenic environment.”

“if I could wave a magic wand, I’d make a tax on beverages a federal mandate because they’re the largest source of added sugar in the diet and are strongly linked to weight gain and health problems.

the link between beverage consumption and greater intake of calories may also apply to drinks flavored with no-calorie or low-calorie sweeteners.

prompting restaurants to gradually, surreptitiously reduce the amount of fat, sugar and calories in the meals they serve could help put the brakes on societal weight gain. “Menus could make healthier, lower-calorie meals the default option,

Controlling portion sizes is another critically important step. “Big portions are especially motivating for low-income people who reasonably want to get more calories for their dollar,”

Another policy-based approach that could reverse rising obesity projections might be to partner with climate control advocates, Dr. Bleich suggested. “If we pull more meat out of the American diet, it would help both the environment and weight loss,

“prevention is the way to go. Children aren’t born obese, but we can already see excessive weight gain as early as age 2. Changes in the food environment are needed at every level — local, state and federal. It’s hard for individuals to voluntarily change their behavior.”

health-promoting changes in the food packages provided to low-income women, infants and children since 2009 have helped to reverse or stabilize obesity in the preschool children who receive them.

“We have an [obesity] epidemic in the midst of a pandemic.”

And it is associated with a wide range of comorbidities, from heart disease to diabetes, that increase vulnerability to the worst impacts of the infection.

A constellation of factors can influence a patient’s outcome: Fat can physically compress parts of the lungs, impeding respiration. In the hospital, it can make calculating medication doses, inserting intravenous tubes and moving patients more difficult. It can stimulate parts of the body’s hormonal system, worsening covid-19, a disease that often provokes a powerful inflammatory response itself.

Early analyses point to obesity itself — rather than the comorbidities it creates — as a separate precursor to poor outcomes.

More than 42 percent of U.S. residents are obese, defined as a body mass index of 30 or greater, and more than 9 percent are severely obese, with BMIs of 40 or more

A 5-9 person weighing 203 pounds has a BMI of 30. The same person would weigh 271 pounds if his BMI were 40.

For some groups, conditions are worse: 56 percent of African American women, for example, are obese,

The Centers for Disease Control and Prevention lists 5,614 covid-19 deaths where obesity was a contributing factor, but this is probably a sharp undercount

Sara Tartof, a Kaiser Permanente research scientist who led the analysis, speculated that large amounts of visceral fat — the fat stored in the abdomen around body organs — may play a role in producing severe covid-19.

Fat is not inert; it secretes chemicals that can influence bodily systems. It may affect the angiotensin system that helps regulate blood pressure and blood flow, leading to more severe symptoms,

Lighter said people with obesity seem to have more ACE2 receptors, the gateway the virus uses to invade cells. “So there are more opportunities to attack,

people under age 60 are two to three times more likely to be admitted to the hospital for covid-19 if they are obese

“Obese people have more androgens and male hormones. Maybe that’s impacting the virus affecting the cells,

At times, there was not enough staff for the delicate task of turning him onto his stomach — a procedure called “proning” that helps open airways — or returning him to his back, Zymet said. Five people were needed to accomplish the task because of Place’s weight and the medical devices he was attached t

“Instead of needing four people to do it, you might need six or eight people to do it.”

Intubating very obese people also can be more complex because fat deposits around the neck can make proper positioning more difficult,

Place lost 49 pounds during his hospital stay while he was being fed through a tube and on a ventilator, leaving at 199 pounds. But the physical cost was enormous. When he awoke, the only part of his body he could move was his left arm, from the elbow to his fingers.

“It’s supposed to be going down, as it is in other countries,” said the lead author of the report, Steven H. Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. “The fact that that number is climbing, there’s something terribly wrong.”

The opioid epidemic is a major driver of the worrisome numbers, but far from the sole cause. The study found that improvements in life expectancy, largely because of lower rates of infant mortality, began to slow in the 1980s, long before the opioid epidemic became a national tragedy

Some of it may be due to obesity, some of it may be due to drug addiction, some of it may be due to distracted driving from cellphones

Given the breadth and pervasiveness of the trend, “it suggests that the cause has to be systemic, that there’s some root cause that’s causing adverse health across many different dimensions for working-age adults.”

The risk of death from drug overdoses increased 486 percent for midlife women between 1999 and 2017; the risk increased 351 percent for men in that same period. Women also experienced a bigger relative increase in risk of suicide and alcohol-related liver disease.

The all-cause death rate — meaning deaths per 100,000 people — rose 6 percent from 2010 to 2017 among working-age people in the United States

There’s something more fundamental about how people are feeling at some level — whether it’s economic, whether it’s stress, whether it’s deterioration of family,” she said. “People are feeling worse about themselves and their futures, and that’s leading them to do things that are self-destructive and not promoting health.”

. The general trend: Life expectancy improved a great deal for several decades, particularly in the 1970s, then slowed down, leveled off, and finally reversed course after 2014, decreasing three years in a row.

Obesity is a significant part of the story. The average woman in America today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more

Princeton professors Anne Case and Angus Deaton, whose much-publicized report in 2015 highlighted the death rates in middle-aged whites, published a paper in 2017 pointing to a widening gap in health associated with levels of education, a trend dating to the 1970s. Case told reporters their research showed a “sea of despair” in the United States among people with only a high school diploma or less. She declined to comment on the new report.

“When they get up into their 20s, 30s and 40s, they’re carrying the risk factors of obesity that were acquired when they were children. We didn’t see that in previous generations.”

Most people in the United States are overweight — an estimated 71.6 percent of the population ages 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population ages 2 to 19 is obese.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998 and since then, the gap has grown steadily. Experts refer to this gap as America’s “health disadvantage.”

Death rates from suicide, drug overdoses, liver disease and dozens of other causes have been rising over the past decade for young and middle-aged adults, driving down overall life expectancy in the United States for three consecutive years, according to a strikingly bleak study published Tuesday that looked at the past six decades of mortality data.

The 33,000 excess deaths are an estimate based on the number of all-cause midlife deaths from 2010 to 2017 that would be expected if mortality was unchanged vs. the number of deaths actually recorded by medical examiners.

Outside researchers praised the study for knitting together so much research into a sweeping look at U.S. mortality trends.“This report has universal relevance. It has broad implications for all of society,” said Howard Koh, a professor of public health at Harvard University who was not part of the research team.

The average life expectancy in the United States fell behind that of other wealthy countries in 1998, and since then the gap has grown steadily. Experts refer to this gap as the United States’ “health disadvantage.”

For example, in the late 1960s and early ’70s, cigarette companies aggressively marketed to women, and the health effects of that push may not show up for decades.

Obesity is a significant part of the story. The average woman in the United States today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more. Most people in the United States are overweight — an estimated 71.6 percent of the population age 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population age 2 to 19 is obese.

Myth 3: ‘Being overweight doesn’t impede me’

Myth 4: ‘My family and friends don’t think I need to lose weight’

Myth 5: ‘Obesity is largely due to your genes’

Genes create a basic situation, but they don’t oblige anyone to be fat. Things that can genuinely be explained by genetics are appetite, preferences for certain flavours (such as sweet or fatty) and the natural urge to be physically active.

Several studies have shown that carriers of so-called obesity genes consume on average 125-280 kcal a day more and have no differences in their metabolic rates. To say that some children have a genetic propensity towards obesity means only that they have an inherently larger appetite than naturally slim children, who feel hungry less often.

But the deciding factor in whether children have a tendency towards being fat is the set of conditions created by their parents and the rest of their environment (such as school meals), which can serve either to encourage or discourage obesity.

Living in a household where high-calorie food is constantly available won’t necessarily make children fat if their genetics mean they have a naturally small appetite. Children with naturally large appetites, by contrast, will pounce on the proffered fare.

However, studies have shown that food preferences are not an inescapable fate

In the end, our genes just set out the path we will follow if we don’t actively strive to change its direction (which can take great effort). However, those efforts are only temporary: once we have become habituated to new behaviours, we no longer have to struggle to maintain them.

The study demonstrates this with the same level of confidence that linked cigarettes and lung cancer in the 1960s.

“You could not enact a real-world study that would be more conclusive than this one.”

The study controlled for poverty, urbanization, aging, obesity and physical activity. It controlled for other foods and total calories. In short, it controlled for everything controllable, and it satisfied the longstanding “Bradford Hill” criteria for what’s called medical inference of causation by linking dose (the more sugar that’s available, the more occurrences of diabetes); duration (if sugar is available longer, the prevalence of diabetes increases); directionality (not only does diabetes increase with more sugar, it decreases with less sugar); and precedence (diabetics don’t start consuming more sugar; people who consume more sugar are more likely to become diabetics).

for every 12 ounces of sugar-sweetened beverage introduced per person per day into a country’s food system, the rate of diabetes goes up 1 percent. (The study found no significant difference in results between those countries that rely more heavily on high-fructose corn syrup and those that rely primarily on cane sugar.)

the closest thing to causation and a smoking gun that we will see.

just as tobacco companies fought, ignored, lied and obfuscated in the ’60s (and, indeed, through the ’90s), the pushers of sugar will do the same now.

The next steps are obvious, logical, clear and up to the Food and Drug Administration. To fulfill its mission, the agency must respond to this information by re-evaluating the toxicity of sugar, arriving at a daily value — how much added sugar is safe? — and ideally removing fructose (the “sweet” molecule in sugar that causes the damage) from the “generally recognized as safe” list,

Perhaps most important, as a number of scientists have been insisting in recent years, all calories are not created equal. By definition, all calories give off the same amount of energy when burned, but your body treats sugar calories differently, and that difference is damaging.

it’s become clear that obesity itself is not the cause of our dramatic upswing in chronic disease. Rather, it’s metabolic syndrome, which can strike those of “normal” weight as well as those who are obese. Metabolic syndrome is a result of insulin resistance, which appears to be a direct result of consumption of added sugars

it isn’t simply overeating that can make you sick; it’s overeating sugar.

A study published in the Feb. 27 issue of the journal PLoS One links increased consumption of sugar with increased rates of diabetes by examining the data on sugar availability and the rate of diabetes in 175 countries over the past decade

In other words, according to this study, it’s not just obesity that can cause diabetes: sugar can cause it, too, irrespective of obesity. And obesity does not always lead to diabetes.

But as Lustig says, “This study is proof enough that sugar is toxic. Now it’s time to do something about it.”

The study found that increased sugar in a population’s food supply was linked to higher rates of diabetes — independent of obesity rates — but stopped short of stating that sugar caused diabetes.

This explains why there’s little argument from scientific quarters about the “obesity won’t kill you” studies; technically, they’re correct, because obesity is a marker for metabolic syndrome, not a cause.

Obesity is, in fact, a major risk factor for Type 2 diabetes, as the study noted.

With such a huge food supply, food marketing got better and restaurants got cheaper. The low cost of food fueled the growth of the fast-food industry. If food were expensive, you couldn’t have fast food.

The epidemic was caused by the overproduction of food in the United States. Beginning in the 1970s, there was a change in national agricultural policy. Instead of the government paying farmers not to engage in full production, as was the practice, they were encouraged to grow as much food as they could. At the same time, technological changes and the “green revolution” made our farms much more productive. The price of food plummeted, while the number of calories available to the average American grew by about 1,000 a day.

Well, what do people do when there is extra food around? They eat it! This, of course, is a tremendously controversial idea. However, the model shows that increase in food more than explains the increase in weight.

There’s no magic bullet on this. You simply have to cut calories and be vigilant for the rest of your life.

Americans are wasting food at a progressively increasing rate. If Americans were to eat all the food that’s available, we’d be even more obese.

What new information did your equation render? That the conventional wisdom of 3,500 calories less is what it takes to lose a pound of weight is wrong. The body changes as you lose. Interestingly, we also found that the fatter you get, the easier it is to gain weight. An extra 10 calories a day puts more weight onto an obese person than on a thinner one. Also, there’s a time constant that’s an important factor in weight loss. That’s because if you reduce your caloric intake, after a while, your body reaches equilibrium. It actually takes about three years for a dieter to reach their new “steady state.” Our model predicts that if you eat 100 calories fewer a day, in three years you will, on average, lose 10 pounds — if you don’t cheat. Another finding: Huge variations in your daily food intake will not cause variations in weight, as long as your average food intake over a year is about the same. This is because a person’s body will respond slowly to the food intake.

People don’t wait long enough to see what they are going to stabilize at. So if you drop weight and return to your old eating habits, the time it takes to crawl back to your old weight is something like three years. To help people understand this better, we’ve posted an interactive version of our model at bwsimulator.niddk.nih.gov.

we should stop marketing food to children.

weight change, up or down, takes a very, very long time. All diets work. But the reaction time is really slow: on the order of a year.

I could see the facts on the epidemic were quite astounding. Between 1975 and 2005, the average weight of Americans had increased by about 20 pounds

People think that the epidemic has to be caused by genetics or that physical activity has gone down. Yet levels of physical activity have not really changed in the past 30 years. As for the genetic argument, yes, there are people who are genetically disposed to obesity, but if they live in societies where there isn’t a lot of food, they don’t get obese. For them, and for us, it’s supply that’s the issue.

I think childhood obesity is a major problem. And when you’re obese, it’s not like we can suddenly cut your food off and you’ll go back to not being obese. You’ve been programmed to eat more. It’s a hardship to eat less. Michelle Obama’s initiative is helpful. And childhood obesity rates seem to be stabilizing in the developed world, at least. The obesity epidemic may have peaked because of the recession. It’s made food more expensive.

I think the food industry doesn’t want to know it. And ordinary people don’t particularly want to hear this, either. It’s so easy for someone to go out and eat 6,000 calories a day.

researchers found that people with obesity who caught the coronavirus were more than twice as likely to end up in the hospital and nearly 50 percent more likely to die of Covid-19. Another study, which has not yet been peer-reviewed, showed that among nearly 17,000 hospitalized Covid-19 patients in the United States, more than 77 percent had excess weight or obesity.

Similar links were unmasked during the H1N1 flu pandemic of 2009, when researchers began to notice that infected people with obesity were more likely to wind up in the hospital and to die. Flu vaccines administered in subsequent years performed poorly in individuals with extra weight, who fell ill more often than their peers even after getting their shots

Large amounts of fat, for instance, can compress the lower parts of the lungs, making it harder for them to expand when people breathe in.

When obesity enters the picture, Dr. Beck said, some of the immune cells found in 30-year-old people “look like those of an 80-year-old.”

If the immune systems of people with obesity are more prone to pathogen amnesia, then they may need different dosages of a vaccine. Some products might not work at all in people carrying extra weight

Ms. Franklin’s case of Covid-19 was more moderate than her sister’s. But she still deteriorated quickly, to the point where she could no longer reach the bathroom without assistance.

“The prevailing story is that this is the best of all possible worlds — cheap food, widely available. If you don’t think about it too hard, it makes sense,”

A closer look, however, reveals a much different story, he said. “To put it in stark terms: The diet is killing us.”

Part of the problem, he added, is a natural tendency for people to overeat as they can afford more food.

The prevalence of obesity has doubled in 73 countries since 1980, contributing to four million premature deaths, the study found.

The story is as much about economics as it is nutrition. As multinational companies push deeper into the developing world, they are transforming local agriculture, spurring farmers to abandon subsistence crops in favor of cash commodities like sugar cane, corn and soybeans — the building blocks for many industrial food products.

the rising clout of big food companies also translates into political influence, stymieing public health officials seeking soda taxes or legislation aimed at curbing the health impacts of processed food.

For a growing number of nutritionists, the obesity epidemic is inextricably linked to the sales of packaged foods, which grew 25 percent worldwide from 2011 to 2016, compared with 10 percent in the United States,

The same trends are mirrored with fast food, which grew 30 percent worldwide from 2011 to 2016, compared with 21 percent in the United States

For some companies, that can mean specifically focusing on young people, as Ahmet Bozer, president of Coca-Cola International, described to investors in 2014. “Half the world’s population has not had a Coke in the last 30 days,” he said. “There’s 600 million teenagers who have not had a Coke in the last week. So the opportunity for that is huge.”

, Brazil is a microcosm of how growing incomes and government policies have led to longer, better lives and largely eradicated hunger.

now the country faces a stark new nutrition challenge: over the last decade, the country’s obesity rate has nearly doubled to 20 percent, and the portion of people who are overweight has nearly tripled to 58 percent. Each year, 300,000 people are diagnosed with Type II diabetes, a condition with strong links to obesity.

on average, the rate of black fatalities is 2.4 times that of whites with Covid-19

In states including Michigan, Kansas and Wisconsin and in Washington, D.C., that ratio jumps to five to seven black people dying of Covid-19 complications for every one white death

one interpretation of these disparities that has gained traction is the idea that black people are unduly obese (currently defined as a body mass index greater than 30)

According to the Centers for Disease Control and Prevention, 42.2 percent of white Americans and 49.6 percent of African-Americans are obese. Researchers have yet to clarify how a 7 percentage-point disparity in obesity prevalence translates to a 240 percent-700 percent disparity in fatalities.

has served to reinforce an image of black people as wholly swept up in sensuous pleasures like eating and drinking, which supposedly makes our unruly bodies repositories of preventable weight-related illnesses.

When I learned about guidelines suggesting that doctors may use existing health conditions, including obesity, to deny or limit eligibility to lifesaving coronavirus treatments, I couldn’t help thinking of the slavery-era debates I’ve studied about whether or not so-called “constitutionally weak” African-Americans should receive medical care.

The New York Times’ 1619 Project featured essays detailing how the legacy of slavery impacted health and health care for African-Americans and explaining how, since the since the era of slavery, black people’s bodies have been labeled congenitally diseased and undeserving of access to lifesaving treatments.

the legacy of redlining that pushed black people into poor, densely populated communities often with limited access to health care

black people are overrepresented in service positions and as essential workers who have greater exposure than those with the luxury of sheltering in place

Even before Covid-19, black Americans had higher rates of multiple chronic illnesses and a lower life expectancy than white Americans, regardless of weight. This is an indication that our social structures are failing us

The answer to both lies in one word: satiety. It’s a concept that we don’t use much in everyday life but that we’ve all experienced at some point. It describes the sensation of having had enough and not wanting any more.

The primary reason we have gained weight at a pace unprecedented in human history is that our diets have radically changed in ways that have deeply undermined our ability to feel sated

The evidence is clear that the kind of food my father grew up eating quickly makes you feel full. But the kind of food I grew up eating, much of which is made in factories, often with artificial chemicals, left me feeling empty and as if I had a hole in my stomach

In a recent study of what American children eat, ultraprocessed food was found to make up 67 percent of their daily diet. This kind of food makes you want to eat more and more. Satiety comes late, if at all.

After he moved in 2000 to the United States in his 20s, he gained 30 pounds in two years. He began to wonder if the American diet has some kind of strange effect on our brains and our cravings, so he designed an experiment to test it.

He and his colleague Paul Johnson raised a group of rats in a cage and gave them an abundant supply of healthy, balanced rat chow made out of the kind of food rats had been eating for a very long time. The rats would eat it when they were hungry, and then they seemed to feel sated and stopped. They did not become fat.

then Dr. Kenny and his colleague exposed the rats to an American diet: fried bacon, Snickers bars, cheesecake and other treats. They went crazy for it. The rats would hurl themselves into the cheesecake, gorge themselves and emerge with their faces and whiskers totally slicked with it. They quickly lost almost all interest in the healthy food, and the restraint they used to show around healthy food disappeared. Within six weeks, their obesity rates soared.

They took all the processed food away and gave the rats their old healthy diet. Dr. Kenny was confident that they would eat more of it, proving that processed food had expanded their appetites. But something stranger happened. It was as though the rats no longer recognized healthy food as food at all, and they barely ate it. Only when they were starving did they reluctantly start to consume it again.

Drugs like Ozempic work precisely by making us feel full.

processed and ultraprocessed food create a raging hole of hunger, and these treatments can repair that hole

the drugs are “an artificial solution to an artificial problem.”

Yet we have reacted to this crisis largely caused by the food industry as if it were caused only by individual moral dereliction

Why do we turn our anger inward and not outward at the main cause of the crisis? And by extension, why do we seek to shame people taking Ozempic but not those who, say, take drugs to lower their blood pressure?

The first is the belief that obesity is a sin.

The second idea is that we are all in a competition when it comes to weight. Ours is a society full of people fighting against the forces in our food that are making us fatter.

Looked at in this way, people on Ozempic can resemble cyclists like Lance Armstrong who used performance-enhancing drugs.

We can’t find our way to a sane, nontoxic conversation about obesity or Ozempic until we bring these rarely spoken thoughts into the open and reckon with them

remember the competition isn’t between you and your neighbor who’s on weight-loss drugs. It’s between you and a food industry constantly designing new ways to undermine your satiety.

Reducing or reversing obesity hugely boosts health, on average: We know from years of studying bariatric surgery that it slashes the risks of cancer, heart disease and diabetes-related death. Early indications are that the new anti-obesity drugs are moving people in a similar radically healthier direction,

But these drugs may increase the risk for thyroid cancer.

Do we want these weight loss drugs to be another opportunity to tear one another down? Or do we want to realize that the food industry has profoundly altered the appetites of us all — leaving us trapped in the same cage, scrambling to find a way out?

Coca-Cola and other multinational food companies, operating through a group called the International Life Sciences Institute, cultivated key Chinese officials in an effort to stave off the growing movement for food regulation and soda taxes that has been sweeping the west.

in China, ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

The close relationship with the highest government health policymakers goes significantly beyond what the companies have been able to achieve in the West.

Professor Popkin was not involved in the study, but he has spent decades working in China to help the country develop nutrition guidelines and food policy — efforts he said were often thwarted by well-placed officials aligned with ILSI.Given his experience, he said Professor Greenhalgh’s findings were not surprising. “Over the course of several decades, Coke and ILSI have worked to prevent any kind of food policy that would benefit public health,” he said. “What they’ve been doing in China is insidious.”

the industry efforts have been wildly successful, in part because China lacks a free media or watchdog organizations that might have been critical of the relationship.

In just a few decades, China has gone from a nation plagued by food shortages to one buffeted by soaring obesity and chronic diseases tied to poor diet. More than 42 percent of adults in China are overweight or obese, according to Chinese researchers, more than double the rate in 1991. In Chinese cities, nearly a fifth of all children are obese, according to government surveys.

“The key is that no matter what Cola-Cola or other beverage companies say, these drinks are just a product,” he said. “No one is being forced to buy them.”

These groups, he said, support and publicize scientific studies whose results sometimes muddy the waters on contentious issues like smoking or alcohol and soda consumption.“They often cherry pick data in ways that mislead while portraying these issues as so terribly complex that nothing can be done,” he said.

these are central to our national well-being. Our lives are threatened less by the Taliban in Afghanistan than by unregulated contaminants at home.

Initially, this concept was highly controversial among obesity experts, but a growing number of peer-reviewed studies have confirmed his finding and identified some 20 substances as obesogens.

The most important time for exposure appears to be in utero and in childhood. It’s not clear whether most obesogens will do much to make an ordinary adult, even a pregnant woman, fatter (although one has been shown to do so), and the greatest impact seems to be on fetuses and on children before puberty.

In this case, a starting point would be to boost research of endocrine disruptors and pass the Safe Chemicals Act. That measure, long stalled in Congress, would require more stringent safety testing of potentially toxic chemicals around us.

Science-based decisions to improve public health — like the removal of lead from gasoline — have been among our government’s most beneficial public policy moves

Dr. Blumberg, the pioneer of the field, says he strongly recommends that people — especially children and women who are pregnant or may become pregnant — try to eat organic foods to reduce exposure to endocrine disruptors, and try to avoid using plastics to store food or water. “My daughter uses a stainless steel water bottle, and so do I,” he said.

Endocrine disruptors are a class of chemicals that mimic hormones and therefore confuse the body. Initially, they provoked concern because of their links to cancers and the malformation of sex organs. Those concerns continue, but the newest area of research is the impact that they have on fat storage.

The role of these chemicals has been acknowledged by the presidential task force on childhood obesity, and the National Institutes of Health has become a major funder of research on links between endocrine disruptors and both obesity and diabetes.

Just this month, a new study in the journal Environmental Health Perspectives found that endocrine disruptors that are sometimes added to PVC plastic cause mice to grow obese and suffer liver problems — and the effect continues with descendants of those mice, generation after generation.

Today, these rates have doubled or tripled.

The United States does, however, hold the dubious honor of fattest population of children, tied with Scotland.

the roughly 90 million Americans who are formally considered obese — that’s about 30 percent of the population — aren’t just in imperfect health. They’re downright ill, and we need to heal them.

Brian Elbel, a population-health expert at New York University’s school of medicine, examined fast-food receipts from four chains in New York both before the city law went into effect and after, to see if customers were altering their orders to reduce the calories they consumed per visit to the restaurants. He found no meaningful difference, and his subsequent research in Philadelphia, which in 2010 implemented a mandate like New York’s, echoes and bolsters that conclusion. “It’s becoming increasingly clear that nothing big is happening for a large group of people,”

New York City commissioned a broader survey than Elbel’s, looking at thousands of receipts from 11 chains. At three of them — Au Bon Pain, KFC and McDonald’s — there was proof of calorie reductions after the law. But at seven there wasn’t, and at Subway, which was promoting footlong sandwiches for $5 during the post-law survey period, calorie consumption per visit actually increased.

“Calorie reductions were highest in high-income, high-education neighborhoods (where we believe obesity rates to be lower),

. “The people who tend to be most responsive to information may be those we least aim to target.”

Starbucks customers ordering sugary, creamy coffee beverages kept on doing so, seemingly because they had already figured that the drinks were fattening and had made a flabby peace with that. But customers indeed adjusted their food orders upon realizing that a pastry could easily exceed 400 calories. They hadn’t bargained on, or planned for, that. “What really matters is what your prior beliefs are,”

education and information could be effective in influencing a discrete, relatively easy behavior, like persuading someone to get vaccinated. “But when it’s habitual and even addictive behavior, you’re in a whole new ballgame,

the principal reasons for the remarkable decrease in smoking in New York City and elsewhere over the last few decades weren’t ominous commercials and warning labels. They were taxes and the bans on indoor smoking. People kicked the habit when it became onerous, in cost and convenience, not to

that — not any itch to play nanny — is why he and Mayor Michael Bloomberg support such measures as new taxes on sodas, which may never happen, and a ban on sugary drinks over 16 ounces

We’re not as plump as we are because we’ve never had our eyes opened to the wages of a Whopper. We’re this way because it’s all too easy, in a pang of hunger and collapse of resolve, to turn a blind eye to the toll

These conditions may be particularly prevalent in communities of color, who are likewise disproportionately affected by the pandemic.

Several people I know packed on quite a few pounds of health-robbing body fat this past year, and not because they lacked the ability to purchase and consume a more nutritious plant-based diet or to exercise regularly within or outside their homes. One male friend in his 50s unexpectedly qualified for the Covid vaccine by having an underlying health condition when his doctor found he’d become obese since the pandemic began.

The government subsidizes the production of both soybeans and corn, most of which is used to feed livestock.

Early in the pandemic, when most businesses and entertainment venues were forced to close, toilet paper was not the only commodity stripped from market shelves. The country was suddenly faced with a shortage of flour and yeast as millions of Americans “stuck” at home went on a baking frenzy. While I understood their need to relieve stress, feel productive and perhaps help others less able or so inclined, bread, muffins and cookies were not the most wholesome products that might have emerged from pandemic kitchens.

Not only is alcohol a source of nutritionally empty calories, its wanton consumption can result in reckless behavior that further raises susceptibility to Covid.

“you can’t eat just one.” (Example: Corn on the cob is unprocessed, canned corn is minimally processed, but Doritos are ultra-processed).

As Marion Nestle, professor emerita of nutrition, food studies and public health at New York University, says, “This is not rocket science.” She does not preach deprivation, only moderation (except perhaps for a total ban on soda). “We need a national policy aimed at preventing obesity,” she told me, “a national campaign to help all Americans get healthier.”

Europeans, with two 20th-century experiences of cataclysmic societal fracture, are bound to the idea of social solidarity as prudent safeguard and guarantor of human decency.

The French see the state as a noble idea and embodiment of citizens’ rights. Americans tend to see the state as a predator on those rights.

To return from Europe to the United States, as I did recently, is to be struck by the crumbling infrastructure, the paucity of public spaces, the conspicuous waste (of food and energy above all), the dirtiness of cities and the acuteness of their poverty.

It is also to be overwhelmed by the volume and vital clamor of American life, the challenging interaction, the bracing intermingling of Americans of all stripes, the strident individualism.

In his intriguing new book, “The United States of Excess,” Robert Paarlberg, a political scientist, cites the 2011 Pew survey as he grapples with these divergent cultures. His focus is on American overconsumption of fuel and food

Per capita carbon dioxide emissions in the United States are about twice those of the other wealthy nations of the 34-member Organization for Economic Cooperation and Development. American obesity (just over a third of American adults are now obese) is running at about twice the European average and six times the Japanese.

A resource-rich, spacious nation, mistrustful of government authority, persuaded that responsibility is individual rather than collective, optimistic about the capacity of science and technology to resolve any problem, and living in a polarized political system paralyzed by its “multiple veto points,” tends toward “a scrambling form of adaptation” rather than “effective mitigation.”

Whether it comes to food or fuel, they don’t want measures where “voting-age adults are being coerced into a lifestyle change.”

Individualism trumps all — and innovation, it is somehow believed, will save the country from individualism’s ravages.

Rather than cut back, they prefer to consume more — whether fuel or food — and then find ways to offset excess.

With the strong policy measures needed to control excess consumption — taxes, regulations and mandates — blocked, political leaders are “tempted to shift more resources and psychological energy toward the second-best path of adaptation,

Easier, and potentially more profitable, to develop drought-resistant farm crops or improve coastal protection systems than tackle global warming by cutting greenhouse gas emissions.

His conclusions are pessimistic. The world should not expect America to change. Its response to overconsumption is inadequate.

On global warming, the country adapts but does not confront, content “to protect itself, and itself alone.”

On obesity, it shuns the kind of coordinated policy action that will help the less fortunate, particularly disadvantaged minorities.

The fact that the body weight of Americans today is influenced by factors beyond their control is a sign, Kuk says, that society should be kinder to people of all body types.

“There’s a huge weight bias against people with obesity,” she said.

U.S. life expectancy has been below that of other advanced countries for a long time.

The death gap has, however, widened considerably in recent years as a result of increased mortality among working-age Americans. This rise in mortality has, in turn, been largely a result of rising “deaths of despair”: drug overdoses, suicides and alcohol. And the rise in these deaths has led to declining overall life expectancy for the past few years.

In 1990, today’s red and blue states had almost the same life expectancy. Since then, however, life expectancy in Clinton states has risen more or less in line with other advanced countries, compared with almost no gain in Trump country.

blue-state residents can expect to live more than four years longer than their red-state counterparts.

Consider our four most populous states. In 1990, Texas and Florida had higher life expectancy than New York and almost matched California; today, they’re far behind.

there has been a striking divergence in behavior and lifestyle that must be affecting mortality. For example, the prevalence of obesity has soared all across America since 1990, but obesity rates are significantly higher in red states.

the facts are utterly inconsistent with the conservative diagnosis of what ails America.

The secularist assault on traditional values, Barr claims, lies behind “soaring suicide rates,” rising violence and “a deadly drug epidemic.”

But European nations, which are far more secularist than we are, haven’t seen a comparable rise in deaths of despair and an American-style decline in life expectancy

within America these evils are concentrated in states that voted for Trump, and have largely bypassed the more secular blue states.