Public Policy Targeting Obesity (may require answering a couple of marketing questions)
My favorite part:
"The word 'epidemic' doesn't even do this justice. It is one of the most profound medical crises we've had in generations," said Eric Topol, who as the chief of cardiology at the Cleveland Clinic treats the most serious obesity-related heart cases. "We are at the point now where it is so profound we have to be creative, and we can't take decades to fix this because it's happening so fast."... If he were a politician instead of a heart doctor, Topol said, he would have every American weigh in at the post office on tax filing day each year. (emphasis added)
To put my comments in perspective, I have been overweight as long as I can remember. I went from being mildly chubby as a child (although I thought I was enormous, since I took to heart the comments of my peers -- Hey, I saw you at the movies, Jabba the Hutt! -- and the disapproving looks of the school nurse) to being a plump teenager to a fat young adult. (The last phase took place when I watched my weight shoot up by about 50 pounds when I was in nursing school and then starting my career.)
First of all, Dr. Topol, have you not learned yet that shame and humiliation are not effective ways to get overweight people to lose weight? More on this to come.
How much of this obesity "epidemic" is real and how much is manufactured? I resent being asked to get all excited about numbers that seem inflated -- it seems like every time the government juggles the definition of "overweight" by twiddling with the BMI statistics or whatever, another ten million Americans wake up to find out the government thinks they're fat. When they get these numbers, are they factoring out the very fit and muscular, whose high BMIs make them statistically overweight? How about the outliers -- the very, very large people? If you have a couple of five-hundred-pound people in your sample, that's going to throw off your statistics. What about the aging of the population, as more and more boomers discover middle-age spread?
That being said, there are more and more overweight Americans, and more and more heavy kids. And a good deal of this collective weight gain is directly related to the fact that we as a nation eat more and exercise less than we used to. People got much more exercise in the 'forties and 'fifties just by going about their lives: they walked to the bus stop, they drove cars with manual transmissions, they used manual typewriters, they hung laundry on the clothesline, they went bowling in the evenings instead of hanging around watching cable. When they did stay in to watch television, they were getting up and down to change the channel and adjust the antenna. They did not eat out as often, and when they did, they were served smaller portions
I don't think that hectoring people with public service ads (Get off the couch, fatty!) is going to do any good, though. Has it yet? And the government can slap as many taxes as it wants on DVDs and sodas; I doubt it's going to make much of a dent. To me the real root of the problem is the frenetic pace at which we live our lives. Our society's disdain for housewives and traditional domestic arts has led to adults that don't know how to plan meals and cook in the best of circumstances. People are working longer hours now, and when you're putting in a ten-hour day and going home to small children and a house to clean, when are you going to have time to go to the gym and make some healthy food from scratch? So much easier to pick up some take-out and flop on the couch for a while. Take-out and convenience food, though, is highly processed and full of sugar and fat. Plus, all this grinding, day-to-day, never-goes-away job-commute-whining-tired-children-not-enough-sleep-dirty-house stress causes our bodies to release stress hormones that further aggravate obesity by increasing both our appetites and our bodies' propensity to store fat.
Look around -- food is everywhere, in restaurants, mini-marts, vending machines, and any kind of store you could think of. I don't buy candy on impulse, and I tend to just not even see it when I'm shopping. Having a toddler, though, opened my eyes -- candy is everywhere (and Hambet sees it all, of course, and loudly asks for it!) I just about gave up when I went to Borders and couldn't even get past the front door without Hambet pointing out the candy and soda displays by the check-out desk. (I suppose one never knows when one might pass out from hunger while waiting five minutes to pay for the books.)
It's just normal life now to be surrounded by food in large quantities, and when you're already stressed and not eating well, your body is not in logical, "It is not rational to purchase a Big Gulp and a Snickers. It is not rational to heat up a frozen pizza for the third time this week. It is not rational to eat ice cream out of the carton while standing in front of the open freezer. The rational choice is to go to the grocery store, choose some healthy food, stand in line to buy it, bring it home, find a clean pan, open your low-fat cookbook and learn to cook something." mode. If your body is starved for nutrients and crazy with stress hormone, that rational part of your brain is not operating at all. Your body is in that animal, Calories! Familiar food! Now! Eat it! mode.
And as for exercise, there are still a lot of people out there who think that exercise means looking like the models in the Bally ad -- that exercise is for other people, people who are already thin and beautiful, not for people like me. Other people simply don't have a safe or pleasant place to walk. Try walking to lunch in Tyson's Corner, Virginia! I dare you! In my county, more people are killed by cars than are killed in homicides. Some women are embarrassed about their appearance, especially wearing exercise clothes. I wonder if Dr Topol has ever gone for a walk, and had men lean out their car windows and call him a fat bitch?
Add to this that our society is not big on temperance and delayed gratification... (go ahead! buy that car! have sex! don't worry about waiting for marriage, just take a pill now or take care of it later -- not that it's really a baby...)
Doctors and anti-obesity harpies would be a lot more successful if they would be a little more sympathetic and remember that "eat less and exercise more" can involves enormous amounts of relearning and reprogramming. People who were once thin and then gain a little weight may have more skills to call on. People who have always been fat and don't know what it's like to be thin -- who can't even imagine themselves thin -- may not have those skills.
I also think that it would be helpful if doctors would realize that sometimes obesity is the symptom and not the disease. There are over 200 genetic components, yet to be studied, that control appetite, satiety, and metabolism. There is so much that is unknown about how our hormones and nervous system work together in our incredibly complex bodies.
I know for myself it was very discouraging to rapidly gain about fifty pounds in my early twenties and not be able to figure out why. Of course, at the time, I was preoccupied with the fact that I was depressed, had bad acne and a deranged menstrual cycle, and was trying to launch my nursing career even while feeling stressed and very lonely. It took ten years before I was finally diagnosed with polycystic ovarian syndrome, which is a hormonal disorder that, among other things, makes it easy to gain, and difficult to lose, weight. And even after I had this diagnosis, I consulted an endocrinologist for help (Can you please tell me about treatment options for this disorder that makes it almost impossible to lose weight?) and his "help" was, "Well, first, lose some weight -- you could easily lose at least sixty pounds...." Easily? Thanks, pal. I much preferred the candor of another doctor who, after I asked him "tell me how to lose all this weight you want me to lose", admitted, "well...I don't know."
(While I'm ranting, I'd also like to give a shout-out to the doctor who told one of our patients that the reason that her legs suddently started hurting was because she was morbidly obese (never mind that she had been obese the week before and had not had leg pain.) She did get a second opinion, but by the time her doctor discovered the genetic blood disorder that was causing her blood to clot abnormally, the clots in her legs that were causing the pain had led to so much tissue damage that she had to have both legs amputated below the knees.)
Some practical public policy initiatives might include subsidizing more exercise programs, including more innovative "starter" classes reserved for those who are very fat or unfit. Some health insurance companies already offer their members discounts at certain gyms; maybe more companies could do this. Local governments could encourage developers to make new projects pedestrian-friendly. Go ahead and get those candy machines and Channel One freebies out of the school. Reinstate P.E. (perhaps you could free up some time by cutting sex ed?)
We could also tone down the immoderate way in which we approach health, in which we get all excited about the latest study and look at food as aggregations of biochemicals instead of as nourishment? First it was cholesterol, then it was dietary fat. Food manufactuers happily put the American Heart Association seal on any low-fat, low-cholesterol food that met the AHA's numbers, leading people to think low-fat Lucky Charms are good for you -- they're low in fat, aren't they? Now trans fat is the villian du jour, and Dr. Topol thinks it should be not just labeled but outlawed. How long until we move on to the next dietary bad guy? All we're doing is training people to either become food fanatics or roll their eyes and say, "well, everything's going to kill you, so pass the ice cream."
And, memo to the medical establishment: how about doing more research into why people become fat? Why do some people become fat and some people stay lean? How in the world do some people gain hundreds of pounds -- are their brains or their metabolisms wired differently? Tell us more about why women gain quickly and lose slowly. Maybe there's a reason for middle-age spread that we haven't discovered yet. Maybe people are somewhat right when they say, "It's in my family" or "it's my hormones." How about doing more research into therapeutic strategies to overcome poor body image, eating disorders, and learned helplessness?Maybe we should focus on fitness and health instead of on weight, so that people don't wreck their metabolisms with yo-yo dieting.
Ultimately, I don't think this problem is going to be solved by having the government throw money at it and having doctors nag at us. This problem is not going to be solved until we address the crazy way we live our lives; until our society winds down to a saner pace that affords us enough time to take a walk, get some rest, and learn to cook real food and eat it with our families; until we remember what real people look like (especially women who have had babies), stop worshipping youth and beauty, and stop expecting women to look like adolescent boys all their lives; until we leave perfectionism and gluttony behind and embrace temperance.
