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10,000-Step Program
On Kosrae, Skilling is skeptical that people have so little control over their weight. The Rockefeller study, she says, was an eye-opener for islanders, who didn’t realize what was happening to them. The islanders were also subjected to something quite unexpected when results of the 1994 study were published in 2000: a mini media blitz that portrayed Kosrae as a land of fatties. The Atlantic published an article called “New World Syndrome,” whose introductory blurb declared, “Spam and turkey tails have turned Micronesians into Macronesians.”

“It is unfair,” says Skilling. “You really have to come out and see. If you are just looking at the study files, you might think these people are really unhealthy, but you come out here and you see it’s not so bad.” But media scrutiny has also spurred many islanders to improve their diets and exercise more. “Ironically, this media attention may save us,” says Skilling.

Nena has adopted a back-to-nature gambit to improve the diet of his family. “I have banned turkey tails from my house,” he says, walking through his garden of breadfruit, tangerines, limes, and taro root. “We eat almost nothing from cans.” Some years ago he learned that his wife, Christina, who was overweight, was an early-stage diabetic. “This was shocking to us. We had not thought of eating or what we ate as something bad.” Soon after, he and his sons began expanding their garden, creating arable land from a patch of jungle above a mangrove swamp and a beach on a shore that even on this remote island is isolated. Christina emerges from the house, a short, typically stocky Polynesian woman wearing one of the ubiquitous loose-fitting dresses in colorful floral patterns introduced by the missionaries in the 19th century. Nena and Christina tell me that since changing their diet and exercising more, they feel better. “I wake up at dawn and walk and work in my garden,” says Nena. “Before, I got tired more easily.” Christina has slimmed down, too, he says, but she still has a mild form of diabetes. They show me a shrub that Nena says is a local remedy for diabetes: noni, or the Indian mulberry, whose fruit works better than Western drugs, they say.

Skilling says the island has launched a campaign to promote exercise. It has issued bumper stickers that ask, “Have you walked 10,000 steps today?” The Kosraean government, with grants from the U.S. government and money from Rockefeller University, has launched a public-health project at the island’s main hospital and in village clinics to improve awareness of healthy diets and treatment of weight-related maladies.

“I don’t force my patients to lose lots of weight,” says Skilling. “I try to work with them to lose 20 percent of their excess weight rather than try for the ideal body weight. Even those that want to lose lots of weight on this island have not been able to get to their ideal weight. Is it obtainable to get to an ideal weight? I think it’s more attainable to lose 20 percent of their excess fat.” The campaign, says Skilling, is beginning to work. “People talk about eating sugar and eating fat and needing to exercise. Now we need a means to implement what we’ve learned.”

Indeed, as I walk and drive around the island, I don’t see an unusually high number of fat people, and I see more thin people than I expected. Does this mean that people have slimmed down since the original study in 1994? “We see people are eating more fish,” says Skilling. “Many gatherings are now serving local foods, especially church groups. One hundred percent of the island dwellers are churchgoers, so much of the social life is church centered, and the churches are very influential, so this is a real plus.” Each of the island’s five villages has launched exercise groups. “The last time I counted the registries in three of the villages, we had over 300 people sign up for some sort of exercise,” Skilling says. “This is mostly walking. They walk three times a week, in the morning, because it’s cooler.”

Friedman contends that exercise and better eating will make Kosraeans healthier but probably will not solve the obesity problem. Studies that measure the amount of calories burned during sessions of modest exercise indicate that hungry genes counter even the effects of physical activity. This contradicts a wealth of anecdotal evidence that exercising more slims waistlines, and Friedman concedes that more work is needed to understand the role of exercise in weight gain. But he does believe that the weight increases of the past 20 years in the United States represent a steady progression of people eating enough food to reach their set points, rather than a sudden spike in bad eating habits or more sitting around. What really intrigues Friedman is why everyone doesn’t get chubby when there is plenty to eat. Analyses show that the number of lean people has remained steady for the past 30 years, he says. “One’s size is not an environmental effect. Nor is it a matter of willpower.”

Friedman acknowledges that what he suggests is counterintuitive, since people can resist jelly beans up to a point. But he insists that, for the majority of the obese, free will in weight control is an illusion. “This is a way of thinking that needs to change,” he says, suggesting that for the overweight, drugs that modify weight-gain set points may be the only remedy. He says pharmaceutical companies are developing obesity drugs that work by influencing the NYP and POMC neurons or by tweaking chemicals such as leptin that might reduce the hunger impulse.

So who is right? Friedman? Or Nestle and, on Kosrae, Skilling, who believe the island is slimming down through a combination of attitude, change of diet, and exercise? Undoubtedly, both genetics and lifestyle play a role.

But once again, Kosrae could provide valuable clues. “Hopefully, there will be a follow-up,” says Skilling of the Rockefeller study, which might reveal if the islanders have really willed themselves to slim down, or if their set points have prevailed. We’ll have to wait and see if the fat habit can truly be shaken. If it can’t, we need to radically rethink how we view a condition that may be a genetically determined disease that few can control. And we will need to stop treating it as a personal failing – a malady that we can fundamentally fix without pills and other medical interventions, in concert with improved diets and exercise.

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