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May 09, 2005

Weighing in on obesity

Guest post from Revere

There is a lot of handwringing in public health circles over the obesity debacle. The latest CDC article (Flegal KM, Graubard BI, Williamson D, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861-1867) essentially repudiates an earlier one (Moktad et al. that featured CDC Director Gerberding as a co-author; JAMA. 2004;291:1238-1245). It has not only confused people, but given them license to eat whatever they want (with a little help from their enemies; see the first of several good posts from Lindsay; and one from Effect Measure along the same lines). We are now probably further back then we were when the first CDC article came out in 2004 touting obesity as the leading cause of death in the US.

Let's get the facts out of the way first. Americans eat too much and much that they eat is unhealthy. The definition of an "epidemic" is a sudden increase in incidence beyond the expected. The Behavioral Risk Factor Surveillance Survey (BRFSS)  found  that the obesity rate (BMIs above 30, where the Flegal et al. paper found marked increased mortality) went from 11.6% in 1990 (measured in 45 states) to 21.1% in 2002 (measured in 54 states, DC and US possesions). By that definition, "obesity" was an epidemic.

Whose fault is this? The Right wants to make it an issue of personal responsibility and choice. The Left wants to make it a structural issue. I'm on the "structure" side. But we can't win that argument and we shouldn't be tempted to try. What's worse, the public health community wasn't clear what it thought, addressing ordinary people and trying to convince them to eat a better diet. Public health essentially bought into a personal choice perspective.

The reason we can't win the structure argument is that most people--including those that espouse it--aren't completely solid themselves about it. I'd be willing to bet not a few were inwardly relieved and relaxed their diets as well. This isn't that surprising. How we think about things is strongly conditioned by our personal experience. When we were hunter gatherers we had no real choice about food; we ate what was edible and were able to catch or find, or later what we were able to grow for ourselves. But in today's world, where others produce our food in a competitive market, choice is at the center of eating. Our internal and largely unconscious experience is that we do get to choose what we eat. That sense may be largely illusory, but it is a powerful illusion. The public health campaign was directed at that experience: we should choose something different (healthier, purer, leaner, smaller). It didn't take into account that the fact that our choices are channeled, restricted and manipulated is not part of our conscious experience. As Lakoff and other cognitive scientists have emphasized, the facts are rarely enough to overcome unconscious inferences based on experience.

As long as public health confined itself to personal choice it was allowed to wage a "campaign against obesity." When it attacked the structure directly in the tort system or by applying pressure to schools to get junk food out of the vending machines, the Right took action, effortlessly identifying public health initiatives (occupational health and safety, for example) with "public health nannyism." It was a political bonanza. What made it so easy for them was the way their version fits so nicely and comfortably with ordinary (internal and unconscious) experience, while our story requires conscious processing, argument and some political "buy-in." This was a very, very tough game to win, and in today's media climate not possible. We should have foreseen it.

So how do we pick up the pieces? We should focus on aspects of the food supply where there demonstrably is no choice. Some possibilities: the idea of "chemical trespass" associated with involuntary exposure to food additives, pesticide residues and environmental contaminants (like the flame retardant polybrominated diphenyl ethers [PBDEs], the teflon feedstock chemicals perfluorooctanoic acids [PFOA], the plastic components bisphenol A and phthalates, etc.). Ordinary people don't know they are now carrying around substantial body burdens of these chemicals and don't like it when they find out. They immediately identify it as a "structural" issue, not a "choice" issue. There is a great deal of opportunity here to focus attention to agribusiness and the failing family farm and good groups working on it. We can bring in agribusiness's role as risk factors in obesity, attacking inadequate labeling laws (the "Right to Know" touches a core value and is a powerful lever we should use more), juices that have no juice in them or blueberry muffins that have no blueberries, trans fatty acids that aren't there because consumers want them but because it makes it easier for food processors. People would not willingly choose these things. We can make it work for us. People are forced to choose them by a structure beyond their control. Indeed, portraying a forced choice as the choice of a free subject is precisely the ideological message the Right wishes to reinforce.

The bottom line is we can't win on obesity or any food issue if we portray it as a problem of "wrong choices," which is what we have done. Even those who don't espouse that view went along with it because it seemed like it got us to a healthier place. It was a trap. And we fell into it.

(cross-posted at Effect Measure)


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I really think that the obesity problem is structural, but I'd locate it differently. I don't think it's mostly junk food.

I think it's mostly being able to eat whenever you want to. Plus a general culture of self-indulgence. (The Chinese I knew in Taiwan were scarcely even religious, but they would feel guilty about gluttony). Plus an unstructured life style (as I understand, the French make a big ceremonial deal about meals, but don't snack all day long.) And including the fact that you can buy food 18 -- 24 hours a day wherever you are. And then throw in the elimination of physical work for most people.

I think there is a strong element of easy accessibility, as you say. So it isn't only junk food (I didn't mean to imply that so I am glad for your clarification). There are many factors that alter or channel what we believe is choice, among them placing food ready to hand, working conditions that don't allow meaningful exercise but allow easy steps to the vending machine, urban design that discourages walking and many other things that others have more expertise than I about. The main point I wanted to make was if we frame this as a matter of personal choice we have lost the game at the outset.

Undergirding the 'nannyism' broadsides (especially Paul Campos') against public health measures designed to combat obesity are the fatness v. fitness scientific data. These data, which are open to interpretation, show that heavy but active folks are healthier than thin but sedentary people. This observation is used to discredit the notion that obesity (alone) kills, and is also used to paint public health interventions designed to encourage weight loss as bureaucratic 'madness'. However, a closer look at the data, coupled with the public arguments, shows that there is one place where both sides agree - sedentary behavior kills, on an epidemic scale. This convergence would seem to provide a strong basis for coalition-building on public policy advocacy designed to promote active lifestyles. The likely result (weight loss) may not even need to be mentioned as a constituent of the argument.

Gordon: I don't think that solves the problem. I don't believe the question relates to the specific risk factors involved (e.g., what is BMI a surrogate for) but where we apply the fix: with individuals (convincing them, perhaps with some incentives to live a healthier lifestyle); or with those that make a healthy lifestyle a difficult or impossible choice, e.g., with pesticide or other unwanted residues in food; ingredients not properly labeled or not informatively so; formulations that are for the manufacturer's convenience, not the consumer's but for which choice is largely absent [trans fatty acids]; etc. When those aspects of the obesity epidemic were raised the reaction was swift and quite effective because we had directed attention to the wrong issue, consumer choice. At least that is how I see it. I am always persuadable by cogent counter arguments.

I'm confused about what you mean by "choice." Sometimes it seems like you're talking about 100% free choice (which I agree is an illusion), and sometimes it seems like you're talking about choice in the everyday way that we experience it.

If you want to get people -- many people -- to change their behavior, structural changes are necessary; for example, people aren't going to start walking more if their commutes and most of their errands are impossible or impractical to do on foot. But at a certain level choice does have to come into it.

Several years ago I was diagnosed with type 1 diabetes, and when that happened I had to start making very deliberate and conscious choices about every single thing that went into my mouth. I had to start thinking about food in a completely different way. (Of course, I first had to decide that it was worth it to me work hard to control my condition.) I suppose you could argue that these choices aren't really my personal choices, but that they emerge from the structures within which I live my life (social, geographical, political, etc). Obviously, the fact that I have a good education and resources to take care of myself makes a huge difference. But looking at it that way makes the concept of choice pretty meaningless. I'm not crazy about determinism, whether it's spiritual, biological, or environmental. In thousands of years of debate we haven't been able to come up with a consensus on free will, but it seems pretty clear that it's a psychological fact, and any attempt to change behavior has to take that into account.

Janet: I think you got my point exactly right. I was talking about the ordinary use of the word choice, which our experience tells us exists (with you, I won't get into the free will debate). Because that experience, even for those of us who believe "structure" matters, is such a brute fact of our consciousness, trying to argue it is our burden to make better choices seems the wrong strategy because those choices are made so difficult for us. Instead we should focus on those things that it is our experience we have no choice in (I mentioned a few in the post).

You are completely correct: choice and free will are a psychological fact for most people, which also means that the blame for bad behavior rests totally with the victims themselves This is an unconscious inference people make which suits the Right just fine.

You lost me there somewhere. PFOA? How is grumbling about perfluorooctanoic acid residues going to get people to eat healthier? It's an almost ubiquitous toxin, so it really gives people no choice at all but to grumble. Is the grumbling the goal here? It sounds like you want to "win" on obesity and food issues, but why is winning important?

The belief in our individual agency can be turned to progressive purposes, too. After all, people who feel at the mercy of fate aren't likely to be interested in resisting oppression, especially if that's the path of least resistance. So while there is nothing that aggravates me more than the attitude that good health is something you choose, and that if you have a health problem it must be because of something you did wrong -- aka the self-righteousness of the healthy -- I also think it's important for people to feel that they have some control over their daily choices. Otherwise, the likely response is despair.

A second structural point on obesity is that when food is always there, but the rest of your life is unsatisfactory, you can turn to food (or alcohol) simply because it's something that is actual in your power to do. It hooks up to the related phenomemon that some people go shopping whenever they're depressed, just because it's actually in their control to do.

This is all pretty philosophical, though. Making this an issue in electoral politics (or even regulatory politics) in a serious way strikes me as unlikely. For example, if all restaurants closed at 8:00, and all grocery stores at 6:00, impulse eating might go down. (Or if vending machines were banned in most public space.) But people would see that as a loss of freedom, and that's what it would be.

I think a lot people are also suffering a bit of a cognitive disconnect. Many of us --- myself included --- descend from farming people, meaning people who did a lot of physical work. And these people weren't necessarily thin. And they ate a lot. A LOT.

So people have these strong memories of grandparents and great-grandparents and aunts and uncles as hearty, healthy people who were anything but thin and regularly ate these huge meals and lived to be 98 and were still plowing the fields at 94 and etc and on and on ...

... but they forget to connect the dots --- namely, that these people were also very physically active and their foods weren't shot through with trans-fats and high fructose corn syrup and whatever.

But there's another problem, as well, and that's that we now have at least one generation (maybe two) which has been raised on fast foods and television, and they wouldn't know a vegetable if it introduced itself to them and shook their hand. Nor would they care.

Lots to reply to. Michael: My point about PFOA was that there is quite a lot about food where there is clearly no choice involved but would also implicate the food industry. Once implicated--and there are many ways to do it--it becomes easier to discuss some of the structural issues that restrict choice with respect to nutrition. Perhaps PFOA is not the very best example because it isn't put there by the food industry, but it winds up in food and then in us. Pesticide residues are probably better. I'll concede the point. Why is "winning" important? The way I phrased it ito mean "not losing" which is what we just did on the obesity issue. I think it is important not to lose, because the Right scores points across the board when this happens, not just on food ( consider the "nannyism" argument which they then use to attack all kinds of regulation).

John: I'm not suggesting this is an issue for electoral politics. Democrats are pretty hopeless on this issue anyway. This is a question of the obesity attack re-inforcing a right wing ideology. This is a more complicated argument that I only vaguely indicated by linking to Wolff's essay on Louis Althusser at the end. It deserves another post or series of posts which I may try to do if I ever have time (I am not giving up my day job yet!).

Cookie: Interesting point. I'm not sure how healthy our older agrigultural population really was. But it is true we have idealized them and it is also true they were much more physically active than we are.

Thanks to all those who have commented so far. I am working this out as I go along. I never thought much about obesity before the last month or so (you may have noticed). I'm a doc who got his medical education at a time when they taught almost nothing about nutrition and that's what I know: almost nothing. But I've been an activist for over 40 years, so that's where I'm coming from on this one.

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