people. and so that's one of the reasons. and medicaid side, you know, it's just i think for some people it does a great job, but overall it doesn't pay enough. 50% of doctors don't take medicaid patient that they have a very difficult time getting primary-care. i think it is widely perceived to be a second class program. you want to fold them into the system where they are with everyone else rather than segregate them out. plus there is a huge turnover there that makes it very difficult to get good, quality continuity of care. the average time i think in new york on medicaid i think is nine months. it's very hard to take care of people when they are in and out, in and out of the system. >> unfortunately, we are not the point where we have time for one more question. so i will ask an easy one. where is the patient responsibility and all of this?

[laughter] >> i think that is a tremendously good question. because about 35, 40, 50% of health is related to what we eat, our exercise and smoking. those three things we control a lot of our health care destiny. not everything, but a big portion of it. now, we don't control that alone, as you know. fast food didn't just grow up and we go to mcdonald's. the whole social infrastructure related to that, hold social network related to smoking. so it requires concerted action. that we do have to take our responsibility. let's flip it around. how might that happen under a new system, or the system i describe? again, think through what happened if you're an insurance company and you now have the same people year after year after year. suddenly you begin to think,

you, if i get too many kids who are obese, this is really going to be dangerous for me. let's think how we might think of how we might counter that. maybe we could go to the schools or to parents and really change the way they are dealing with kids. we could change the incentive structure. a lot of schools got budget cuts. what do they do? get rid of the gym, get rid of after school identities. very bad situation. so we have to empower the health care system to thank innovatively about how to help us be healthier and also. and i hope that, i mean, part of the thinking that has gone in our program, our plan is to try to do that or to create the incentive structure again that will make that possible. thank you very much. [applause]

>> please join me in thanking ezekiel emanuel, chair of the bioethics, the national institute of health and author of health care guaranteed. i also want to thank our audience here, especially for all your terrific question. i wish i could have gotten two more, and on the radio. this program has been generously underwritten by the california health care foundation. i am john diaz, and now this meeting of the commonwealth club of the california celebrating more than 100 years of enlightened discussion is adjourned. [applause] >> ezekiel emanuel is the chair of the department of bioethics at the clinical center of the national institutes of health. dr. emanuel is the author all co-author of several books, including no margin, no mission. health care organizations and the quest for ethical excellence. he is the brother of rahm

emanuel, president barack obama's chief of staff. for more information on the author, visit bioethics .in ih.gov. >> book tv today, the future of the american conservative movement with the direct-mail fundraiser and a panel with this year's freedom fest. today on c-span2. >> david kessler explains how american bodies and minds have been reprogrammed by too much sugar, salt and junk. politics and prose bookstore in to dc hosted this event. it lasts about an hour. >> it is very special to be here

at politics and prose, to carla into barber, the owners, the fact is this is without a doubt my favorite bookstore in the whole world. [applause] >> there is another reason why this is so special, and for those of you who are not part of the food and drug administration, who are here, indulge me, if you would. this is very -- a very special week and a very special people here that i have had the privilege over my life to be able to work with. and on a week, as you just heard, where the united states congress voted 79 senators in the affirmative, and 307 members of the house of representatives in favor of fda regulation of

tobacco. there are people here. i can't name all of you who spend your, much of your adult lives working on this. and my hat is off to all of you. and thank you for what you have done. [applause] >> let me tell you the journey tobacco took 15 years, since the day we started. it took 15 years to get to where we are, and along that path, you know, it's a long time. but if you are willing, one of you in the audience i still remember to this moment, we went around the table and i asked people what they thought. and you heard what you were expecting to hear. it's the big muddy.

is political suicide. yes, it is the right thing to do, but if you do it it will take all the energy and everything you have. and one of you looked at me and said if you are willing to take on tobacco, i'm willing to spend the rest of my career to work on this. that tommy that i could ever imagine. and along the way, across those 15 years, if you'll excuse me, but had a opportunity to do a couple of other things while tobacco was cooking, many of you continue to work on it very hard. i was sitting in my office about seven years ago, and i was up at you with a group of residents and fellows and having learned from tobacco and having lived that. asked the very basic question.

what do we know, what is the evidence. if you want to stay alive, what are the things you can do really to prevent dying from the major killers. and the major killers, three quarters of us are going to die from cancer, heart disease or stroke. and tobacco is easy. the number one preventable cause, and certainly when we started the number one preventable cause today. but what are the other things you could do when you look at cardiovascular disease, stroke, and certainly many forms of cancer. i noticed something was happening. we were pulling all the articles that i had this library, a wonderful librarian at yale was helping me pull all of the articles. and i noticed that along the way as she was doing this over a three-month period she lost 30 pounds. because all the articles on

prevention, and we know that excess weight is not good for us, but it was striking the contribution to health. just one, you know, very basic numbers. 10 years ago there were four cases per thousand of type two diabetes in this country. four cases per thousand. today, there are nine cases per thousand. we spent in 2000, $7 billion on drugs for type two diabetes. today, we spend $13 billion on drug. type two diabetes i could just as well write excess weight in the medical chart, because that is the mechanism that contribute mightily to that disease. we all want health reform. no one in this town is not talking about health care reform, but how are we going to be able to get a handle on these costs when we can't get a handle

on something as basic as excess weight. and what is going on? i asked my friend catherine slagle at the centers for disease control, how has weight changed over the decades? adult weight, tell me, you know, if you go back into the '60s what was going on and what is going on today and what is different than what was striking, when she sent me those grass, what i saw, what she plotted, back in the '60s you entered your 20s, you may gain a few pounds. until you are in your 40s or 50s but you are probably stable. and then you plateaued and then you lost a few pounds in your 60s and 70s and in your senior year's, in your 80s. the wait was relatively stable over an adult lifetime. today, you enter your adult years and the way keeps on rising.

certainly until your '50s. it doesn't plateau, but what is most striking is when you enter your 20s, back in the '60s, if you were here, today you are entering your 20s here. so as with tobacco, excess weight really does begin in childhood and adolescence, at least for a significant part of the population. but what to do about this. diet and exercise. if they are worth everybody would be doing it so i started to understand why was this so difficult. why couldn't we get a handle on it, what was going on in this country, and that has been the journey for the last seven years. so one night i am watching the debut rerun of oprah. and i am listening to this woman, very well educated, very well dressed, very successful in all aspects of our life.

and she was being interviewed by doctor phil. don't get me started on doctor phil, please. [laughter] >> but i was listening to this woman, and what she said was i eat when my husband leaves for work in the morning. i eat before he comes home at night. i.e. when i am happy. i.e. when i'm sad. i eat when i'm hungry. i eat when i'm not hungry. and in that moment, she said i don't like myself. so i was trying, i was sitting there and trying to listen as a clinician, as a doctor because i don't think we as a profession, certainly as a medical profession, have really been thinking or doing the research to really understand why was this woman accessible in all aspects of her life, doing things that she didn't want to be doing, and doing them anyway

knowing that it wasn't good for her, what was going on? what was going on clinically? what was going on scientifically, and that was the journey for the last seven years that i wanted to understand. so with colleagues, a number of great institutions, let me just give you four pieces of the science, and then try to put together this puzzle, this mystery. why does that chocolate chip cookie have such power over me? that really is the question. i could relate to that woman on oprah pick i have suits in every size. and i probably gained and lost my body weight over my lifetime, several times over. what was going on with that woman? let me give you the pieces of the site. we published an article recently, not a typical scientific title for scientific journal, it was called deconstructing the mundelein

milkshake. what do you think it is about a vanilla milkshake that drives intake? do you think is the sugar? do you think it is the fat? do you think it is the flavor? how many do you think it is the sugar? raise your hands. how many think it is the fact? how many think it is the flavor? let me tell you how we actually did the experiment is a very simple experiment. we wanted to know what drives intake. how do you measure that and how do you measure that in animals and in humans? in animals, what we looking for was how hard an animal would work to get the food. some of you are shaking your heads because you understand that test. that is self administration. that is the test that fda, try to control substance, a drug. but the real question is how hard, motivation, how hard will and animal work. would you do is make an animal pressed the level once, give him food, press applies and then you

give him food, and then they have to press for times and then they have to press 16 times and then 32 times, 64 times 120 times before they get food. so you have a sense of what the breakpoint is. what do you think they will work hardest for? the answer was, it was sugar. sugar was the main driver. but when you add to that sugar, you at that. it is synergistic pick it is more. second piece of science. with my colleagues in italy, one of the great pharmacologists, he has dedicated his career to understanding how drugs hijack the brain. he studies amphetamines, he studies cocaine's. and the window is when you administer drugs like amphetamines and cocaine, what you see is bumps in the brain circuitry involving dopamine. every time you give amphetamines

or cocaine you see this elevation in the brains dopamine and that is the chemical responsible not for pleasure. dopamine is responsible for locking and our attention. that preoccupation. it did under a circuit of what enters working memory and what you end up thinking about. and what he found working, and we were working together, i said let's test food. it was always assumed that drugs elevate dopamine levels, food can get a little bumpy the first time but on other times you don't get about. i said lets me good, let's not just take sugar but let's make good highly palatable. this multisensory mixer. and what happened to dopamine? and i remember the e-mail, the subject line was important results.

dopamine continues to be elevated every time to make food multi-century, when you mix sugar and fat together. you can get elevations to the brain dopamine on a repeated basis. it doesn't habituate. third piece of the science. i want to understand this woman on oprah, what was i hearing and how common was that in the population. so let me give you three characteristics. let me describe them to you. first one is loss of control in the face of highly palatable food. a hard time resisting. 2, a lack of feeling full when you are eating, a hard time stopping. the third, a preoccupation, thinking about foods between

meals and sometimes thinking about foods, you know, when you are eating, as you are eating you are thinking about what you're going to be eating next. sort of bizarre, write, but those three characteristics. loss of control, lack of sensation, claque of, thinking about foods. those three characteristics. sometimes i say that to people and there is a small percentage of the population who have no idea what i'm talking about. they look at me with absolute blank stares. those are the people i think we really should be studying. those are the ones that are the most interesting scientifi scie. but we look at the epidemiology and with my colleague, what we did was we looked at how many people self-report those three characteristics. and we found that 50% of these

individuals, 30% of overweight individuals and 20% of healthy weight individuals scored very high on all three characteristics. so certainly more people who are bigger and have those characteristics, but a significant percentage of people orlean have those characteristics. and if you extrapolate, and there are risks of extrapolation, that turned out to be some 70 million americans who self-report loss of control, lack of sensation and preoccupation with thinking about foods. last piece of science and this is the most interesting. we took those individuals who have that constellation of characteristics, what we call condition type reading because those are the characteristics of a conditioned and driven behavior. and we study them. we studied the nero imagery. and redesigned the experiment really into phases.

the first is the anticipation. not actually eating. the power of food comes from what? from the taste? yes. but it is also the anticipation of food. every time i land in san francisco airport, as soon as the plane hits a taxi, i start thinking about these chinese dumplings. [laughter] >> so the plane just have to land in the taxiway, all right? and i start thinking about it because there is a place in the food court that has these. if i could only make it to baggage claim, it's out of my working memory. i'm walking down howell street in separate cisco and i start thinking about chocolate covered pretzels. why? because six month earlier i had been on that street on powell street, and i would in a place

and i had forgotten all about it, but just the location, that thought entered my mind, and those thoughts of wanting. so what we did in this experiment is we took people that loss of control, preoccupation, with food, and we scanned their brains. we queued them. we just gave them the smell. you can give them the smell, the site, sometimes just location, just getting in your car can be a queue. you know, the car just drives automatic because you have driven past. once you get in the car to start thinking about what you're going to eat because you have been the. there is always a past experience that drives the anticipation. but the first part of the experiment was we queued people and what we saw in people who had these three characteristics, this condition type are eating, the center, it is not a disease, might you.

but it is very much a normal part of our makeup. what we saw was people who had this condition type had a hyper activation in the anticipation phase, indy reward pathways of their brains compared to controls. and it was pronounced. and what we further saw was that when actually consumed the food, when they tasted the food, that elevation which we always thought was just the queue, remained elevated. sofa knurled pathways remained activated and hyper activated until all the food is gone. so for the first time we have evidence, certainly evidence is emerging, that lack of control, hard time resisting. it's not a matter of willpower.

literally, the brains of millions of people are being hijacked by these cues, by this highly palatable food. let me put it together. for the washington post, the washington post outed me. because i wanted to know really, i wanted to understand the science but i also want to go inside the industry. and we worked when we were at fda a number of you together, we worked, that nutrition facts panel that we worked on, someone in the food industry said to me, tester, obesity epidemic is all your fault. and i looked at him and i said what are you talking about? he said you folks in the fda were so successful with that

nutrition facts panel that you kept some check on what was being put on including a supermarket. what happened was it exploded in restaurant, and that's where the real problem lies. ♪, the food industry knows where the inputs are. they understand the output. fat and sugar, fat, sugar and salt, they call it the three-point of the compass. they stimulate, they stimulate. i thought i was eating to fill me up, fat and sugar, salt, sugar and fault stimulate into a. they make you work harder. it is not just conditioned behavior. it is conditioned. so i wanted to know, you can tell what's on processed foods. in supermarket you can see that label. but going into restaurants and try to understand what is in

there. and so i went dumpster diving for about six months because it's not easy to find out when you just ask the major change was in the food. and even for me as a physician, someone, you know, i was in charge of regulating food. it was eye opening. the grilled marinated chicken, you think it is healthy. it is based in the sugar and fats are a. our foods are injected with needles. pick any american, you know, favorite american dish. i mean, pick an appetizer. pic buffalo wings. what are they? when you think about it. so is the fatty part of the chicken, fried usually in the manufacturing plant, refried in the restaurant.

the red sox, what is it? fat and sugar. that white creamy sauce, fat and salt. sure, it tastes good. what is it? fat on fat on fat, sugar on fat, and salt. i could go through an entire basket. the food industry has said all we are doing is giving consumers what they want. that's the argument. we now know that what's going on is that our brains are being hijacked. let's just put this together clinically so everyone understands the cycle of consumption. how does it work. has to mimic, past experiences. that learning, those learning circuits of the bring it activated so you get queued. that you activates the brain circuitry. it arouses you. it grabs your attention.

fetlock shoo-in. -- it locks you in. and then you consume the food. and in the next time you get queued, what do you do? you do it again. and every time you engage in that cycle, you strengthen the knurled circuits and come back for more. so you all remember pavlov. you understand the conditioned behaviors. but this is more than just conditioned behaviors. this is really the science of the last decade. it is conditioned and driven behavior. because it's not just learning circuits. is that learning and motivational circuits. try to stop that cycle in the middle. you know the inner dialogue? once you have been queued, and your brain is activated, that inner dialogue, yes, i would love it. no, it is not good for me. yeah, that would be good. no, i shouldn't have it.

that inner dialogue, what does it do? it only increases the reward value of the food. you try to stop it. this is the difference between conditioned behavior and condition and driven behavior. you try to stop it. and to increase the reward die of the figure to end up wanting it more, and that is the stuff of obsessions and cravings. what's been the business plan? what's been the business plan of the modern american food company? is to take fat, sugar and salt, put it on every corner, make it available 24/7, and make it socially acceptable to eat anytime. content of a. how did the french, how did the french control their intake? they always have highly probable food, what is the difference? the coulter, right.

[inaudible] >> so what we have done is we have taken down any barriers. because you can eat anytime, because it is socially acceptable. the french, this is for the canadians to it certainly when i was growing up with tended to eat at meals. we didn't snack all day long. but what is happening now is fat, sugar and salt on every corner available 24/7, and it is acceptable, that social norm to eat anytime. you could be sitting here eating. no one would think any different of it. but i was invited to talk to a major food manufacturer, and i put it, i said let me give you a comparison. and we have to be careful with comparisons with tobacco, but let me see if i can explain how this works.

nicotine, nicotine is a moderately reinforcing. animals will self administer nicotine. but if you look at humans and how it works, nicotine is a moderately reinforcing. add to that nicotine the smoke, the throat scratch, the color of the pack, the imagery that the industry created 30, 40 years that it was sexy, glamorous to smoke, the image of the cowboy that you needed it, the time of day. what did we end up? we took a reinforcing chemical and we made it into a significantly addictive and deadly product. i give you a package of sugar, and i say go have a good time. you're going to look at me, what are you talking about? now add to that sugar, add fat, add texture, at temperature, add color. put it on every corner. say you are going to do it with

your friends. say it is entertainment. and the emotional loss of advertising, you will love it, you will want this. walk into any of the food court, walk into the food court at union station. watch the kids. is a food carnival. what did we end up with? we started with a reinforcing substance, and we have made it into one of the great public health crises of our time. we now know, we have the evidence, the brains of millions of americans are being hijacked by sugar, fat and salt. industry understands the end but. they understand that sugar, fat and salt stimulator they understand that people come back for more. they understand the real science, probably not? but they understood what works. once we have the evidence, that we now have, what are we going to do about it?

does the food industry need to change? absolutely. does government have an increased role? absolutely. the implications, school lunch programs, the subsidies, advertising, but just because our brains are being hijacked, now we can link to that woman on oprah. we can expect to millions of people it's not your fault. but just because your brain is being hijacked as a mean you can't take responsibility, you can't fight back, that you can't put the tools together. to protect yourself. let me give you one other fact. two -year-olds. two -year-olds compensate for their eating. what do i mean by that? if you get a two year old excess calories over lunch, they're going to eat fewer calories later in the day. by four or five, after having

sugar, fat and salt throughout their toddler, four or five -year-olds, you measure the ability to compensate and gc they have lost the ability to compensate. they no longer regulate their intake. you have children who are four and five who have never been hungry, have any sense of being hungry anytime during the day. they eat constantly. it's as if the reward circuits of the brain are being hijacked and override by the homeostatic mechanism. what's the task? tobacco, a great, great, great lead, for 15 years of effort. tobacco is easy. why? because you can live without tobacco. you don't need tobacco. food, food we need to live. so how'd are we going to handle

it? the problem, the problem isn't all foods that we have taken in food and we have processed it to such an extent, we processed it to such an extent that it is predigested. we are eating in essence babyhood. if you don't believe me, adult baby food, just count the number of. the average by 20 years ago was about you chewed about 20. today food goes down in a wash. it is so pre-digested and so processed. and what happens when food is so pre-digested and it is made out of fat, sugar and salt, it hijacks the brain, it goes that wash, and it is in essence oral sensory is what is going on. what these key? how did we succeed? how did this country succeed over the last 50 years with tobacco?

we finally, finally in the next couple of days, matt when is the president going to sign it? finally, there is going to be legislation. but it wasn't legislation or regulation that has done a. what has been a success so far? what has been a key ingredient? that's accounted for the success to date over the last 50 years. we didn't change the product. the product is the same. education? what was the one thing that phillip morse and the other companies cared more about than anything else? money? no. image. but what about image? what they cared about was the social acceptability of their product. back 30, 40 years ago tobacco was a reinforcing substance. and it was positively viewed. they made it as something you wanted to be made as something that was your friend.

that was the key. what was the real change? what was the real success? what did we collectively do as a country? we change the reinforcing substance from something that was positively available, to something that was negatively balanced. the social norm, social acceptability. we didn't change the product. social norms have a great deal to do with how, whether we are going to approach something. that isn't my friend, i want it, or that is my enemy, i'm going to avoid it. where do we have to focus? the problem, i think the problem is very much, not only sugar, fat and salt, but it is a big food. and i don't just mean the industry. i am talking literally about big food. the challenge, it is part of public health challenge as we

can imagine. it's not just about us. it's not just about that woman on oprah. it's about our kids, because once you lay down that nero circuitry, what you lay down that foldering, the only way to deal with this is to lay down new learning and new circuitry. and the fact is and we have to be up front that old circuitry never goes away. the greatest gift you can get somebody is to not have that circuitry that responds constantly to sugar, fat and salt, that has really been laid down in brains of millions of americans. once you recognize that our behavior as a nation is becoming conditioned and driven, not just the learning circuits. because of putting sugar, fat and salt, that is the result, that is happening to us in our society.

that has profound application i. but as many of you know in this audience, you have not shied away from big tasks before, and i will tell you, 15 years ago, a number of us when we started had serious doubts whether tobacco was possible and changing, and getting regulation for the fda. sometimes, just sometimes things that you think are impossible can really happen. thank you very much. [applause] >> we have time for questions. >> first of all, thank you, doctor. and bravo to everyone in this room who helped walk the journey of on all of our behalf's with

respect to tobacco. tank you. a specific question for the future, the next steps, and time of timeline concept about when the behavior is individuated. now the behavior we know, given the diabetes type two statistics and the percent of our population already contaminated from want of a better word, what about the breaking of the individuation, the neural networks that you mentioned and the developing literature around relapse behavior and learning that can be taken from some of that related to the various addictions that are being studied no. >> wonderful, wonderful question and we could spend an hour, several hours talking about that question. is one of the reasons i wrote the book. but the question has a degree of specification. you recognize by asking that question that the only way to overcome that past learning that

his link down event neurocircuitry is to lay down new learning on top of that. ito, i joke a little bit, but it is true. what is the definition of rehab? we have is really laying down new learning, new circuitry. let's just agree on something. diets are not going to work. yes, they work in the short-term, but short-term diets can't work. and with great admiration for karl and barbara, all of those books on diet, i don't think there are many in this bookstore, but some, right? diets by their very nature can't work. why not? once that neurocircuitry is lay down, can you lose 30, can you take 30 days, 60 days, 90 days, and just white knuckle it and lose weight? of course. but what is going to happen when you finish doing that?

you have not lay down new learning on top of that old learning. and you go back into your environment. and you constantly get bombarded with the old accused. it's a state of complete you're going to gain it back. the only way to deal with this is to add new learning, new circuitry. how do you do that? i mean, what is the rehab? what is that process? because it's not something that you do in a day or even a week. again, people don't want to do this because people always, what's the magic pill that is going to work. it's not going to work. why not? because you're involving the learning memory and habits are good to the brain. and if you start mucking around in those circuits with any pharmaceutical agent you are not going to be selected just to trick you will have significant

adverse reaction. because let me assure you, we need the learning memory and habit circuits of the brain to be able to be so -- to survive. understand, this is not, this is not about some, this order to for disease. i, this is what makes us human. because we are wired to focus on the most daily stimuli as human beings. if they bear walked in here, right, you would stop listening to me, i promise you. if your child, if your child is sick, right, if your job is that you are thinking about your chaptered for some people, the most stimuli and might be a call, others and nicotine, some gambling, some mac. but too many of us, one of the most stimuli in the environment is food. at the core of that food is

sugar, fat and salt. so how do you cool down the stimulus? and the answer is you have to change how you do that stimulus package a look at that stimulus and say i want that, that is my friend, that is going to make me feel better, there is nothing i can do. there really is a shift that you have to undergo to the point where you say you look at that stimulus and you say that's not my friend. but how do you get there? because you look at that and say that is going to taste good, i want that. and it is going to taste good in the short run but you want they have to want something more. >> i am a general internist and i've been laid to ask this question for a long time. i face this every day. diet and exercise. and i figure that we are hardwired to like sugar, fat and salt. sugar in the fourth, when we evolve, there wasn't very much food. we had to live in a situation of

semi- starvation. sugar was the fastest form of energy. that was the most efficient form of energy and salt was essential to life. and that is where it comes from and that is why it is so fixed. >> the very stimuli that trigger receptors in the oral centuries in the mouth, and they are linked directly to the thalamus to the reward centers of the brain. that is why they are so powerful. drugs, the kind of drugs where talking about, they go through the bloodstream, and they go to the specific receptors. but the real pathways that we are talking about, the learning memory, motivation and habit circuits of the brain, sugar, fat and salt, they are wired in. that is why, it was from an evolutionary perspective, and that is why they are so powerful. stack we are hardwired. >> we are hardwired to focus on the salient stimuli.

and fat, sugar and salt, because of the receptors, and because of the learning, but understand it is learning and conditioning that occurs. that two year-old regulators, you expose them. if you expose them to sugar, fat and salt they will lose the ability to compensate because sugar, fat and salt become, especially when you put it on every corner. we had their ears in this country, four or five decades ago that protected us. we only ate at meals. we ate real food. my hat is off to michael pollan and alice waters. we used to eat real food. now all we are eating, we are eating stimulators to ourselves and we are stimulating the reward circuits. >> but we also need to do manual labor and have a woman at home to cut the. we didn't need to eat fast food. >> i won't get into the last one. i will stay away from. [laughter] >> but look, there is no doubt that my grandmother, you know,

there was sugar, fat and salt. that was occasional. i didn't have it for breakfast, lunch and dinner. i didn't have it throughout the day. that is what the change for the last, but understand, making it available and socially acceptable on entrant and adding, look at an ad tonight on tv that it is not about nutritional night of food. it may be the economic value. but look at what the ad does. it is adding the emotional loss, you will want it that you will love it. it is the social acceptability to want this product, and once you add that social acceptability, you are only amplifying the reinforcing circuits and amplifying the brain's response. thanks for being here. >> good afternoon, dr. kessler, and thank you for coming. i have a follow-up to your answer to the first question. how do you change the things you

tell yourself in the food rehab, like i don't want to eat this because i will feel bad later on, or you know, something similar to something down here, where that's the first thing you think of, what you are looking at a picture of chili cheese fries on the menu and you are not thinking i should eat something else because the chili cheese fries will make me feel bad later. and something like this, which is faster, which we all know that kids say, gross, i don't want that. that's more down here and it is fast. you know, and just saying this is good. the rehab is good up here, but if you want something fast and saying not just okay, i don't want to eat the chili cheese fries because it will make me feel bad, but i would rather eat, no, a baked potato because i want to. i want that there. i want that better here, not just i want that more of your.

>> so what you need, the goal, scientifically, and i know this is not intellectual. it is to avoid that circuitry from being activated. that's the only way you're going, you're going to stop eating excessive eating, is just not have your brain constantly activated. so there are a lot of triggers. there are all the cues that, sigh, snow, location, time of day that will set off. but what is key, what is key for that brain to be activated, is the fact is that past experience, that past wanting, those thoughts of wanting. what we did with tobacco, by making it viewed as a deadly addictive product that people didn't want, it cools down the stimulus. now, what is so hard, what stimulates those pathways, if

you have any inner dialogue, any ambivalence, that's not good for me. that only increases that activation. why does take if you look in alcohol, and you look at aa, why has it been so successful? i'm not going to get into the religious aspects of it, but the fact that it has absolute rules. and sometimes that sound anti-intellectual, but rules work. i know if you put that huge plate of fries in front of me i am going to start having the first one i'm going to eat the whole thing. so it is just easier for me to have a rule that i'm not going to do it and it would be black and white. if you know something is impossible, and there is no ambivalence about that, your brain is not going to get activated which i can show you the sights. if you look at smokers and you say to a smoker, it is impossible for you to smoke for the next four hours, and you do that smoker, their brain doesn't

get activated because they know it's impossible. watch a smoker. no smoker, i have never seen a smoker opened an emergency exit on the plane and jump out. because they know it is impossible during the period of time that they are on the plane pic but watch him toward the end of the flight. that's when the brain becomes activated. so if you can develop rules for yourself. one of the reasons why plant eating or structure as we talked about helps, if you know what you are going to be feeding and when you are going to beginning and you will not allow yourself to eat all the time, then over time all those cues are going to extinguish. you will never get rid of them entirely. if you are stressed, if you're 50, the old circuitry will show its head. but in order to cool down the stimulus you really have to not want it, but it can't be, it can be an ambivalent i don't want it. it has to be i really don't want that and the only way you're going to don't want it is to want something more.

>> thank you. >> just a general note, and in a specific question about your time at the fda, if you wouldn't mind. i think a lot of, i appreciate you talking about the symptoms and not just the problems, but if i could just add a caveat. i think a lot of this is about loneliness. and foreigners who have come and written book about america, robert frank, referenced the loneliness in america. and i am wondering, i just saw this as a rhetorical, not for you to necessarily answer, but in a society, no society in history has been founded on the individual, and i think the pressure that the average american has put onto self regulate is unheard of in human history, including comparing modern-day other societies and having lived outside this country a lot, over and over again you hear as other

societies pick up the fourth and fifth gears lifestyle, the fast food, the valley of efficiency versus nurturing human relationships, which isn't usually food brought us together. but in this land, it efficiency is valued. in other words, it is a basic, primal biological thing called food as opposed to nurturing heart mind candidness and a lot of this as she pointed out in some of her lectures is the loneliness of the society because the individual just ups all the values of the collective. but i just threw that out for something for folks to think about. but you can't underestimate the indoctrination that is going on as far as the industry. they started this with advertising with promoting smoking. that was very calculated. i wanted to ask in your tenure at food and drug administration, the kissing cousin to this whole

issue of obesity, etc. etc., i'm surprised you never mentioned the other profiteers in this drug, and it is a drug which industry. let's call it what it is, the other drugs that as much as you seafood being advertised on television is the kissing cousin called big pharma at work product. and i'm thinking about since then, which killed tens of thousands, primarily women in this country, no one went off to jail but if it was an inner-city or some person, hillbilly out there shooting south of the people, as this american home products did, no one was held accountable and people are still dying as a consequence of that, primarily due to primary pulmonary hypertension. you are at the fda at the time of this whole fallout of sin sin, and i would like to hear what you have to say.

>> very eloquently said. a lot of different points. just on the first point, on loneliness, and why we, you know, what are the things that trigger. understand with food, food is a very powerful stimuli. is a reward. how we use the word report, jerome, the great psychologist to find reward as something that will change how you feel. so food, because it is wired into the reward pathways of our brain, very motivational circuits, it can change how we feel it is a very powerful stimulus and there is no doubt that millions of us, i think a fast maturing of us are using food to self medicate. because when you're in this cycle, what happens? you have the thoughts of

wanting, the thoughts that this will taste good. it captures your attention. and it occupies working memory, and when that happens, you're not thinking about all the other thoughts of the day. why do you eat at the end of the day? i mean, why do people eat at 10, 11:00 at night a few of you are shaking your heads. is to calm down. is to change, and essence, it is to regulate emotional level. and when you use it like that, that's because you are stimulating this reward pathway and doing it over and over again. comments about the intent of ink are especially important that there is a chapter in the book, and i put the chapter in the book it worked directly on the reward circuits. it is in essence, it is an

amphetamine like compounds or it has been around for 30 years fenfluramine affects serotonin levels. understand that these drugs are affecting the circuits that make us human. i think as we have this evidence, that this overheatin , drugs that messer and in those circuits are going to, by their very nature, affected very important human circuits. and they're going to affect intelligence. they will affect memory, psychiatric symptoms and i think we are learning that and we are smarter today than we were. i think it is going to be very hard, if not impossible, once you understand that reading is a result of stimulation of the surrogates and we need those for other things, find something that is selective for just food. and i think that is, you know, i don't think it's going to work

and i think the agency is becoming much more, much smarter and much more skeptical, certainly -- these are circuits that involve what makes us human. we need the circuits, and the circuits are being hijacked by what we are doing in society by putting fat, sugar and salt on every corner and to think that you will have a drug that will decrease stimulus of those circuits and cool that down, we have to find a better way. >> thank you. both sides this week -- >> we have time for about two or three more questions. >> both sides this week on the menu labeling question made some big concessions that mean the regulation might actually pass this time. but what i hear you saying is that you could have manually bailing out the do and unless the basic food is not changed, that it is not going to change

the problem. >> i think i'm a very big fan of menu labeling. i strongly, strongly support congresswoman rosa delauro's will, senator tom harkin still. we need to get that. because it will change how we respond to this game is. we need a range of tools. i was giving a talk at google and i went into the cafeteria. and it was striking. in front of food, i mean each food, is either a red, yellow, or green sign and it is writing her face and i will tell you it has a real effect. the red means eat it in small amounts foretaste, yellow ebay moderate amount, green you can have as much as you want. i was in charge of regulating food and i will tell you still, it had a major effect on the. we have to change how we perceive the stem is. we to have greater disclosure. we have to change, i mean, we don't stop with just menu

labeling. what served in the schools, vending machines, i mean, parents, it is so harder to try as hard as you can and you send your kids with school and they are being stimulated with fat, sugar and salt. they have to change. how we regulate advertising. we have to make progress. menu labeling is a key step in changing how we perceive the product. >> thank you very much. >> thank you. >> good afternoon. quick question, despite her comment on rules, we can't just telco, burger king, mcdonald's to stop serving food, or at least we can try but it will not work. what would you suggest since you are no longer an official and can actually talk about these things, general practices that the government could take to push us in the right direction, short of just banning stuff. >> the freedom of being