Dr. Charles Billington divides his obese patients into two distinctly different groups: those who have choices, and those who don’t.
“Demographically, we know that people in lower socioeconomic areas are greatly, disproportionately affected by obesity,” he says. “Folks in those lower-economic, lower-education situations have little or no access to whole foods. They also have a lack of options.”
A tall, lean, full-bearded man, Billington is laconic, more like a North Dakota farmer than a famous research doc. “When it comes to entertainment and reward, people with more money can go to the theater or to concerts; but the lower you go on the socioeconomic scale, the more important eating becomes relative to other affordable activities. We in the privileged class can join a gym, whereas lower-income people who want to exercise will probably end up at a community center, where there isn’t much. What it boils down to is this: Highly educated people with money tend to know how to change their lives. But people from a lower income and education bracket often feel a lack of self-efficacy, which means they feel like they have less ability to affect their own situation.”
In other words, it’s not simply the lack of grocery stores full of affordable fresh produce and whole foods that makes it harder for poor, inner-city residents to stay fit (though this remains a significant factor). It’s also lack of empowerment: Poor people have been conditioned to accept their circumstances—which all too often include growing fatter with every passing year. Billington is working to change that.
As an endocrinologist, a professor of medicine at the University of Minnesota, the team leader of the obesity program at the Minneapolis VA Medical Center, associate director of the Minnesota Obesity Center, and a nationally recognized expert on weight-related disease, there’s no question that Billington has an impressive track record. What makes it even more so is that he was warned early on (he is now fifty-four) that his chosen career path was a dead end.
Thirty years ago, when he graduated from medical school, Minnesota’s obesity rate was less than ten percent and “real” doctors didn’t think of obesity as an important area of study. Medicine had perfected drug therapies for treating chronic weight-related illnesses such as type 2 diabetes. When then-young Dr. Billington began telling his diabetic patients to reduce their body mass through diet and exercise rather than simply inject more insulin, he was branded a bit of a nut.
Today, however, his concerns are shared by leaders from the National Institutes of Health and the American Medical Association. More than twenty-three percent of Minnesotans are now considered obese (that is, they have a body mass index greater than thirty), and nationally—especially in urban, low-income, Southern communities—it’s ticking even higher. The rise in obesity has caused a subsequent surge in everything from high blood pressure, heart disease, and sleep apnea to arthritis, non-alcoholic cirrhosis of the liver, gallstones, infertility, incontinence, and certain kinds of cancer. On top of that, approximately twenty million Americans now have type 2 diabetes. The problem has officials in sectors ranging from public health to education to government casting about wildly for answers, coming up with some that appear to be taken directly from Lord of the Flies. For example, legislators in Mississippi, which has the highest rate of obesity in the U.S. at 29.5 percent of residents, actually drafted a bill earlier this year that will—if it is passed—make it illegal for restaurants to serve obese people.
The problem, Billington says, is that he and his colleagues spent decades trying to develop pharmaceutical and surgical solutions to type 2 diabetes and obesity. Now, however, the problem is too pervasive for that.
“We thought twenty years ago, and I still think now, that the key mechanisms are in the brain,” he says. “But that idea normally is interpreted as the need to find a drug that would allow us to control appetite or metabolism. I no longer think this will be the answer, because at this point about seventy percent of the American population is overweight or obese and that means a drug as the primary strategy would be fantastically expensive.”
Instead, Billington advises his patients to cook at home as often as possible. He helps them find ways to obtain fresh, wholesome ingredients, tells them to avoid fast food, and teaches them about NEAT: non-exercise activity thermogenesis.
The theory behind NEAT, which was developed at the Mayo Clinic, is that people with so-called “fast metabolisms” burn up to a thousand calories a day through spontaneous movement, such as fidgeting, pacing, and gesturing. But these things are governed both by genes and by girth. The fact is that heavier people move less than skinny ones, probably because their bodies have settled into stasis due to weight—it requires greater effort to move their bodies around. Studies show they sit an average of a hundred and fifty more minutes each day than people of normal weight. So Billington is training his patients, one by one, to twitch.
He admits, however, that the problem goes well beyond basic health care. Obesity is the natural outcome of a world in which foods that are cheap and plentiful are also calorie-rich and processed.
“Evolution dictates that we seek out energy-dense foods,” says Billington. “And it’s not just humans. Rats like them, dogs like them. All God’s creatures do. It’s a matter of survival—there are biological cues telling us to get calories when we can. But now we have access to energy-dense foods all day, every day, in the gas station and the break room at work. Their value biologically hasn’t diminished; in fact, it’s been enhanced by repeated exposure. People are just doing what their bodies tell them to.”
When caring for patients who do have means and options, Billington makes two additional recommendations. He likes Volumetrics, the diet plan conceived by Barbara Rolls (a Ph.D. nutritionist from Penn State) that advises people to eat satisfying portions of low-density foods, such as fruits, vegetables, and whole grains. The caveat, of course, is that these foods tend to be more expensive and quicker to spoil than Hormel cold cuts and Hostess pies.
“Rolls is the only diet book author I know who bases her writing on actual evidence,” he says. “Her theory is that you can train yourself to choose whole foods, and on average they will be low-density. The truth is, people who are doing well with their weight tend to eat quite a large volume of food, but it’s all of very high quality.”
An at-home chef who used to belong to a local gourmet dining club, Billington also advises his patients who can afford to dine out to choose places such as Meritage and Heartland, rather than steak houses or high-end restaurants where the entrées are swimming in butter or cream.
“Heartland is a perfect example of the way people should be eating,” he says. “The food is really good, of extremely high quality, and the vegetables are often the star of the plate. There is protein—which is an obligatory dietary requirement—but the portions aren’t huge. People tend to feel satisfied with this sort of meal.”
But that doesn’t solve the problem for people who cannot afford to shop at the Wedge or pay fifty dollars per person for dinner. Even educating people and telling them to avoid French fries and convenience store burritos won’t help those most at risk.
“If you learn to cook and you live in south Minneapolis, you can eat pretty well for not a lot of money,” says Billington. “But if you’re living in north Minneapolis and your only option is the local market because you don’t have a car, you’re not going to be able to eat well. We tend to frame this as an in
dividual choice, but for a very large number of people it’s not. Rampant obesity is, in this sense, simply an outcome of poverty.”
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