Thursday, July 30, 2009

How Can We Reform America to Make It Healthier?

With a new health care policy in the news, and the usual track of obesity declared as the nation’s number one threat, I wonder, as I drive home after another day sitting at my desk, how we can actually change American society so that we are healthier.

Aside from the constant stream of new drugs on the market, and the new movement for locally grown food, how can many Americans—sitting in front of screens all day and all night—actually change their habits? It’s one thing to constantly carp on “calories in, calories out”, that you need to eat less and exercise more, but that’s a simple statement for a complicated problem. How can American society truly change? How can we structure work, our way of life, so that this is feasible?

I’m not talking about better health insurance, less availability of junk food, even funky workplace amenities like gyms and treadmill stations, although those things will help. But how do Americans, with their time-strapped, hectic lives, actually go about to make changes?

Many workplaces now offer incentives, or wellness initiatives, to get their employees healthy. And that’s a start. But so many people get up, drive to work to sit at a desk for too many hours, then drive home and watch TV, because that’s what they need to relax. Fitting in even a 30 minute workout (it’s never just 30 minutes), is tough when you don’t have the space, it’s cold, rainy and dark outside, and you have to make dinner and take care of the kids.

Working out during the day isn’t often feasible either, and while riding bikes to work is the hip green thing to do, it’s largely impractical for a huge number of people. There is, simply, usually too much work to do to tear yourself away from the computer for a large enough amount of time, and then we add in our own leisure reading of the news, checking emails, and doing our banking that brings us in front of the computer for more time.

People talk about changing corporate culture, but that is often very difficult to do and based on a lot of factors outside of a person’s control, especially if they are a junior employee. If everyone eats at their desk, and you don’t, it can look like you’re slacking, even if they are just checking Facebook.

A lot of the initiatives to change Americans' working habits will take a lot of time, especially if that includes redesigning the country’s transportation system. And while I am all for a reorganization of the country’s priorities regarding food subsidies, that doesn’t necessarily mean that things will change all that much (especially as fruit spoils in a vending machine). But how do we put in place things that make it easier for people to move more during the day?

The key is to make it natural, not forced, and not mandatory, because people should feel free to eat a hamburger, smoke, or sit in front of screens all day long if that is what they want. But institutional, societal changes are what needs to happen, and often in America, it is policy that pushes the rest of the country in a direction.

Even if, over time, better quality food is more equitably distributed and the country becomes less dependent on cars as a main form of transportation, we will still be captive to the screens. And yes, of course there are plenty of people who do not have to sit at a desk all day to work—teachers, construction, retail and restaurant workers, to name a few—but more and more of our jobs are sedentary, physically rote. What will happen in the future? How can we stem this tide? How can we change our environment?

I had these questions in mind when I read Megan McArdle’s interview with Paul Campos, the author of The Obesity Myth. He argues that much of what is perceived as current wisdom on obesity as the country’s leading healthcare crisis is wrong, and that the focus on obesity is harmful and ill-effective when it comes to reforming care. McArdle’s interview is partly prompted by a recent study in Health Affairs (of which I am familiar) that says that a growing number of our costs is due to obesity; prevention is understood to be by a lot of leaders one of the ways in which healthcare costs can be reduced.

At first read, a lot of what Campos says sounds blasphemous. Of course there is an obesity epidemic! How can you argue that? Just look around! Costs have soared, the rates of people on chronic medications have gone up, there's an ongoing debate about making airplane seats bigger...every day there's new evidence of how heavy and unhealthy America is.

One of his major issues is the destructive mistake people make between failing to distinguish being healthy and being thin. Despite the perception that getting thinner is being healthier, that is not the cause, and often is a form of disordered or disruptive eating, merely a symptom of a real problem and not a (truly) desired result, and that that being healthy or thin has morphed into a true moral panic.

I wonder when this started. There’s long been a historical association, at least within Western Europe, regarding body type and the availability of food, as it is with cultural perceptions of beauty—when food was scarce, being plump and voluptuous was the height of fashion (as was being pale, since it showed that you did not have to physically toil for your livelihood), whereas now not being thin is a measurement of self-control and class. “Thin” all too often equates to healthy, but many people (especially young people) have no conception that this will not last forever, and that they will eventually pay for it.

Campos is right that BMI is a flawed system, a fact that has not infiltrated the popular consciousness yet. Just like the old food pyramid, it is a distortion that is widely accepted and can actually be harmful.

Too much media coverage focuses on fitness and being healthy as losing weight, and it infiltrates down to become fact. Everyone is under constant assault about the nature of their bodies. Why are you eating that? Why are you doing this? It’s not enough/it’s too much/you’re too thin/you’re too fat/and on and on and on.

As we get older, our bodies change—as a result of age, pregnancy, stress, the environment, hormones, medication, lifestyle—and there’s only so much we can do to prevent it. It’s silly for the media to point to celebrities or athletes, because they have the resources—time and money—to afford the best care, the personal attention, the babysitter, chef, housekeeper, trainer, assistant. We can’t be Madonna, and honestly, most of us wouldn’t want to be, because we don’t want to be a slave to some figure that’s close to impossible to attain (and maintain). Even shows like "The Biggest Loser" don’t return to the contestants afterward, because it’s exceedingly difficult to go back to a normal life and sustain a major change without the help afforded to them on the show from trainers and chefs, without the unlimited time to only focus on their body and their health.

But I do question Campos on one thing about this obesity myth: What about the soaring rates of diseases like diabetes? That’s not the result of a newfangled calculation or the overprescribing of medications, and this is serious. We can argue about whether or not all those statin drugs are necessary, but I know that I do not want to be on these thirty years from now.

Public health remedies have focused on incentives to get people to adopt healthier behaviors, and that is where the idea to tax junk food and unhealthy substances like tobacco took root. But while this may work in theory, it seems counterintuitive for those windfalls to go back to merely preaching and prescribing the proper healthy behaviors, constantly reinforcing the cycle. Some smokers in particular find this galling, targeted as a result of behaviors they engage in; others welcome it as a deterrent. But as the population of smokers dwindles, it seems like a good bargain to the rest of us, because it doesn’t affect us. But widespread taxes will.

Campos returns several times to the point that the culture, with the government behind them, demonizes fat people, that the government is “abusive” when it puts these conditions in place. But we, as a society, demonize all weights. How do we stop doing that? It’s an essential part of human nature: we criticize, we gawk, we comment.

Likewise, he also makes excellent points on physical activity as it’s tied to weight. While it’s true that most publicized success stories do feature lines about feeling healthier, stronger and energized, it’s usually accompanied by other major (physical) changes. A success story that didn’t involve much, if any, weight loss isn’t interesting, because the change wasn’t physical.

McArdle does point out that no one encourages Americans to get married, get religion or move to the country, though that’s not true; it's just on a small scale, and nowhere near as pervasive as the confluences of weight, body image, and health.

It’s sadly true that fatness has become associated with “poverty and lack of self-control”, even though we are all powerless when it comes to certain foods. But self-control is too prized, and too tied with restrictive eating, so that it becomes less about discipline than deprivation.

And that’s where food porn comes in.

As I finished reading Megan McArdle’s post, I was lured into the living room where my father and brother were watching “Best Places to Pig Out” on the Travel Channel. They were calling for me, but since I heard “New Brunswick” and “food”, I was already on my way. The segment was on Rutgers University’s famous grease trucks. These sandwiches (which I’ve never had the opportunity to taste) are monstrous concoctions of fried foods stuffed in a sub: chicken fingers, eggs, bacon, burgers, gyro meat, mozzarella sticks, and of course, French fries. They are meant to give you indigestion, and are only supremely palatable to college students, who do not have to fear an upset stomach, which my father was getting just by watching. This was followed by The Heart Attack Grill, where burgers are named after coronary procedures and the waitresses are hot “nurses” who will wheel you out if you finish a triple or a quadruple. If you weigh over 350 lbs., your meal is free. (They have a scale.)

The restaurant was actually started by a nutritionist. But while the amount of lard used horrified me (I ate half a potato chip fried in lard last week and it tasted like an industrial metal), I was more annoyed with the senior patrons, who commented on their meal by merely announcing they will take an extra cholesterol pill that night, as if these pills would neutralize the effect a 1600 calorie lunch will have on their arteries.

These meals are ok once in a while, but these giant-sized gastro gymnastics are a reaction to what’s seen as a cracking down on pleasurable eating (despite the many such outlets for anyone who’s interested in food). But to say that Americans are getting healthier when a lot of evidence points to the contrary is misleading. Americans might have more pressure, more awareness of what they should do to be healthy than ever before, but they are also thwarted by both human nature and their own environment to be in optimum shape.

7 comments:

Emily said...

This was a great post. I also read that interview on Megan's blog, and found it to be very interesting and much like what Kate Harding writes about for Salon occasionally. Kate has pointed out many times that the BMI is totally inaccurate, and that some very muscular people can have a "overweight" BMI since muscle weights more than fat. She's been on a crusade to debunk the myth that obese always means deathly ill (including a upcoming book).

What I found most disturbing about this interview, though, was how Campos said over and over again, there is no proven way to make fat people into thin people. If you think about it, he's totally right. Sure, maybe someone can go from 180 pounds to 165 (which he points out), but going from 180 to 130? And staying there for 5 or more years? It's rarely done. Even people who get gastric bypass surgery put back on a lot of weight.

Getting the entire culture to change their views that fat doesn't always mean unhealthy (or that you are lazy, have no self control, or never exercize) seems almost impossible as well.

People usually think that if people are fat, that's their fault. But look at the lifestyle you point out- sitting at a desk for 8 hours a day, going home, making some quick dinner for the kids, and hanging out in front of the tv. And what if you have a long commute? That's 8 hours at a desk, two hours in a car/train...sheesh. The corporate world can offer all the free gym memberships it wants, if they are keeping their employees tied to their desks, when the heck are they going to get there?

mikhailbakunin said...

Marc Ambinder had a great response to all this.

I agree that stigmatizing obseity is the wrong approach, but Ambinder is right that there are other sensible policy options.

My problem with Campos and McArdle is that they overstate their case. BMI is an arbitrary measure of obesity, sure, but McArdle especially takes this to mean that obesity is an arbitrary problem.

That's just not true. Research indicates that obesity can cause heart disease, diabetes, and respiratory problems. Obesity also contributes to higher rates of knee-replacement surgery.

In the aggregate, obesity produces all sorts of negative externalities -- especially when it comes to public health.

I'm sympathetic to McArdle's libertarian perspective, but I think that in this case she's taking her point too far.

mikhailbakunin said...

Ezra Klein also savaged Megan on the obesity issue.

Damn. I can't wait to read her response. Ezra's right that Megan rarely cites actual data. She usually talks in generalities or makes up numbers to illustrate her point. This always drives me crazy -- even when I agree with her.

MediaMaven said...

Marc Ambinder's post was fantastic. I'm thinking about writing a follow-up post, just because there are so many things he mentions that I want to address. Thank you.

I read Kate Harding's blog, Shapely Prose, occasionally, and she was the first person I thought of when it came to BMI. I think it's also very difficult to keep a low weight over several decades if you're body is not naturally crafted that way, just because as you age, your metabolism slows down, and other factors work against you. But it seems we're only engineered to praise lifestyle changes if they result in something measurable or tangible, like weight loss or a smaller waist, not "I have more energy."

Another beef I have with gastric bypass surgery is that the risks are often diminished. My mother had a friend from college who died a few years ago from the surgery. This was a real risk, and she knew that going in.

My biggest problem with the interview, as you could tell, was that Campos and McArdle just ignored all the evidence that proves obesity is the problem, and that government policy can and does indeed affect a huge number of people with this issue (as Ambinder explains).

petpluto said...

Great post, MM. I do wonder how much the individual can do, though, to really change the nature of how we live. I really think that there needs to be a two-tiered attack on this sort of thing - possibly because of that whole "Redesigning the American Dream" book that described how housing complexes themselves facilitate a dependence on things like cars. So even the very structure of our neighborhoods lend to not really healthy habits!

In the aggregate, obesity produces all sorts of negative externalities -- especially when it comes to public health.

I wonder, though, if it is truly obesity or if it is a certain kind of obesity that develops from eating certain kinds of food - like high fructose corn syrup (or a lot of corn in general).

In a very real way, corn subsidies and the like can create a falsely cheap product that puts way more corn (in more ways) into our bodies than we would ordinarily be able to handle, which then helps amplify health risks.

For people who are naturally larger, who would be considered obese by the BMI scale or other factors, but don't eat certain foods (or don't eat certain foods in the amount others do), I wonder if the risk for certain ailments like heart disease or type two diabetes.

petpluto said...

*Finishing the last sentence*
is lower.
*slinks away, kind of embarrassed*

MediaMaven said...

I really think that there needs to be a two-tiered attack on this sort of thing - possibly because of that whole "Redesigning the American Dream" book that described how housing complexes themselves facilitate a dependence on things like cars. So even the very structure of our neighborhoods lend to not really healthy habits!

Absolutely. I hope that over the next few decades, the structure of our neighborhoods and towns changes to facilitate walking, for starters. One of the most telling signs of our dependence on cars is the percentage of children who walk to school, which is staggeringly low.

I wonder, though, if it is truly obesity or if it is a certain kind of obesity that develops from eating certain kinds of food - like high fructose corn syrup (or a lot of corn in general).

In a very real way, corn subsidies and the like can create a falsely cheap product that puts way more corn (in more ways) into our bodies than we would ordinarily be able to handle, which then helps amplify health risks.

For people who are naturally larger, who would be considered obese by the BMI scale or other factors, but don't eat certain foods (or don't eat certain foods in the amount others do), I wonder if the risk for certain ailments like heart disease or type two diabetes.


It’s a confluence of factors, and the foods we eat definitely contribute to it. Michael Pollan’s In Defense of Food goes into this; we clearly are eating too much processed food, and the chemicals we are consuming are effectively us negatively (though this might be hard to prove at the micro level). But you can be large and be healthy, and have low risks for cardiovascular disease and diabetes. If America became healthier, collectively as a country we might shrink, but there would still be plenty of “large” people—but there’s quite a difference between someone who is obese and someone who is just big, and someone who is overweight and unhealthy versus someone who is healthy but just physically bigger.