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Monday, November 16, 2015

How to End the 'Obesity Epidemic' in America: Stop Talking About It

It is really hard to refrain from eating, especially when feeling hungry is not the only reason to eat.

In today's developed world socialization includes the art of conducting business over eating and drinking. Similarly, we meet friends and woo dates by seeking places featuring cheap eats and drinks. As communal participants we eat to celebrate, collaborate, and commiserate.

Consuming food is also a means for individuals' to cope with the stress. Back in an era of few affordable low calorie food options, I was gaining so much weight studying for the bar examination that I attempted to take up smoking. The latter vice promised a distraction similar to eating as well as a potential appetite suppressant. Alas, when my ineptness and refusal to inhale disabled me from keeping my pipe lit, I gained seven pounds. It took a lot of time and effort, including risky late night runs after work, to lose some of that weight. Keeping it off has been a lifetime challenge.

As a professor of public health law and policy, I yearly encounter law and bioethics students who examine policies and scholarly writings and begin by embracing the conventional wisdom about the need for government action to address an obesity epidemic. In the course of delving deeper into the subject, however, several questions emerge, which not only challenge the current narrative but also illustrate the complexity of the issues. The students develop a healthy skepticism about their understanding of the nature of the problem as well as the efficacy of laws and policies in addressing them.

Ironically, we come to the topic after a unit on smoking, in which we examine actions that have contributed to a significant reduction in tobacco use. While most students are anxious to discuss adapting anti-tobacco policies, few consider whether the decline in smoking may be contributing to increased food intake. When talking about cigarette package warning labels, many students have noted their horror at learning--thanks to mandated posting of calorie content--that a Starbuck's muffin has "mega calories." While most reported that they initially opted for a lower calorie alternative, they also admitted that after a while they no longer paid attention to the numbers or rationalized that they would eat the muffin and exercise later in the day. Many acknowledged, however, that new class assignments or commitments frequently prevented them from following through on their trip to the gym.

The exercise issue, they realized, complicated the obesity calculus in several ways. First, the mantra associated with reducing obesity is "diet and exercise," but few government policies address how to facilitate exercise. True, led by First Lady Michelle Obama, the nation has been sensitized to the issues of childhood weight gain, healthy eating habits and physical activity. But, we do this at the same time that the nation embrace's yearly testing in elementary schools, resulting in increased stress, reduced recess, and replacement of playtime with extra homework, and afterschool and Saturday tutoring sessions. In some communities, parents anxious for their children to succeed academically send their children to homework summer camp.

Moreover, in reviewing the literature that indicates income impacts exercise opportunities and that exercise alone may not be a particularly useful means of losing weight, students confront the complexity of the challenge facing Americans. They recognize that how we frame the issue and identify the problem is crucial to the search for remedies.

Should we as a nation be concerned about excess weight, identifying at-risk individuals by labeling them based upon a calculation of body mass index determined by a formula that few can remember let alone compute without a calculator? Have we embraced numerical indicators because they are accurate or because they are a convenient basis for offering political interventions? Perhaps, they ask, the issue is not really weight but health. If one eats a basically healthy diet and exercises fairly regularly is it the government's role to encourage women to be a size 8 rather than size 14?

To be sure, there are policies that government can adopt to facilitate access to affordable healthy food options and to educate consumers about unhealthy practices. It can also do significantly more to promote exercise as a way of life, especially for children. Most importantly, it could initiate serious conversations about our capacity as a society to reduce stress. This would take us into critical and uncomfortable conversations about the public health consequences of income inequality, food insecurity, and the barriers faced by low-income citizens to decently paid employment and quality healthcare.

It is true that chronic diseases, especially the high prevalence of diabetes and heart disease, are associated with higher weight. But the recent news of an increase in the number of Americans who have a body mass index above the obesity threshold suggests we should take a different approach. We might start by asking whether giving excess weight a medical designation of obesity and treating it as an epidemic is enlisting Americans--as opposed to policy makers and nutrition advocates--in the effort to improve their health. Admittedly, a new conversation will not be easy since changing how we frame the issue and acknowledging its complexity will challenge a diet and pharmaceutical industry that is investing over $20 billion in addressing America's singular focus on weight loss.

To "cure" obesity we to end our obsession with policies for facilitating weight loss. Rather, we need to commit to enabling all Americans to experience the benefits of healthy living.

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