"They don't understand how this could happen. I tell them that they have crushed their knees under their own weight."
I'M AT THE annual meeting of the West Virginia Medical Association, and the conversation has turned to obesity. My colleague, an orthopedic surgeon with a local practice, explains how his clientele has grown younger with each passing year. Whereas he used to operate on people in their 70s for hip and knee replacements, he now sees patients as young as 40.
How can a 40-year-old ruin his knees? The doctor describes patients with body mass index (BMI) values of 45the equivalent of 152 kilograms (335 pounds) for a man witha 1.8-metre (six-foot) frame. No one at my dinner table is shocked. In West Virginia, such stories are too common. The state ranks as one of the fattest in America, ranked second overall for obesity. Whereas obesity rates in America are high, West Virginia is the ground zero of this ailment: 30% of the population has a BMI exceeding 30. And like the rest of North America, this is a new phenomenon: in 1991, no state's obesity rate exceeded 20%.
More troubling still is the fact that, on paper, West Virginia seems to have done everything right. For a generation, schoolchildren have learned about good nutritionit is part of the curriculum. Public officials have gone as far as to study the use of video games such as Dance Dance Revolution in physical education classes. And politicians have implemented a variety of policies favoured by Seeman and Hobbs in their papers: bringing together stakeholders and nudging people in the right direction with everything from taxes on junk food to regulating school lunch options. Yet, it doesn't seem to matter. West Virginia's problems have been getting worse in recent years.
Is West Virginia the future of North America? It could be. How are we to avoid this fate? Start by looking at the rise and fall of public health.
A Brief History of Public Health
Dr. Sara Josephine Baker was a pioneer, helping to save the lives of tens of thousands. She did this without magnetic resonance imaging or even a computed tomography scanner.
Like many of the leaders of public health in the early 20th century, she focused her work on the poor. Among her initiatives was setting up a milk station in Hell's Kitchen, thereby enabling poor children to get clean, pasteurized milk. Dr. Baker didn't invent pasteurization, nor did she perfect it. Her work simply aimed at making basic food products safe and available.
For much of the 20th century, public health focused on a handful of goals to improve the environment people live and work in: sanitation, clean water and safe food. Across North America, Dr. Baker and her colleagues made it possible to grow up and grow old. Coupled with a long-standing commitment to immunization, public health officials can largely take credit for the incredible leap in life expectancy over the first half of the 20th century. Their methods may have been straightforward, but the results wereextraordinary: the expansion of life expectancy during the age of Dr. Baker exceeded the expansion seen during the medical revolution of the latter half of the century.
But public health did relatively little to change people's behaviour. That is, until 1964, when a government committee issued a report and saved millions of North American lives.
In a balanced review, the Surgeon General's Advisory Committee Report Smoking and Health acknowledged the benefits of smoking (including its relaxing qualities); it also concluded definitively that tobacco is linked to cancer. The report had a profound effect. Today, people widely accept the connection between tobacco and cancer. In the 1950s, people were less certainin 1958, only 44% of Americans saw the link.
Why? It wasn't for lack of evidence: by 1950, the Journal of the American Medical Association (JAMA) had shown in a large sample that 96.5% of the lung cancer patients were smokers." By 1958, JAMA published another landmark study showing that cancer and smoking go hand in hand. But the tobacco industry had been clever, buying advertising and physicians to contradict the evidence.
But the report of 1964 was a game changer. The committee members spent 14 months reviewing the world scientific literature and concluded that "cigarette smoking is a health hazard of sufficient import in the United States to warrant appropriate remedial action" (page 33). By the late 1960s, 71% of Americans believed that smoking causes cancer. And so began a decades-long fall in smoking rates. When the report was issued, roughly half of adult Americans smoked; today, the rate is down to one in five.
If the surgeon general's report changed America, it also had a profound effect on public health. Gone were the days when it focused on environmental factors in health. Inspired by the success in the war on smoking, public health now focuses on bettering people and the choices they make. Today, public health is as much concerned with safe sex as it is with safe food.
But there is a problem with this approach: it applies a 1960s solution to 21st-century problems. The surgeon general's report was issued at a time profoundly different from todaybefore the Internet and mass health literacy. Indeed, the war on smoking itself has fallen on hard times, with smoking rates remaining relatively stable over the past decade despite a record amount spent by governments on education.
How Are We to Address the Obesity Epidemic?
In many ways, the solutions outlined in the papers by Seeman and Hobbs simply wish to continue on as public health has for the past four decades, seeking to inform and push people toward better choices. Professor Hobbs, as an example, writes, "As a business owner, for example, I may prefer not to reveal the high level of artery-clogging saturated fat or trans fat in the cookies I market. However, government regulationsthe rulesmay require me to list on the package label the nutritional content of my product." Later, she argues for some type of government leadership in this field, and I assume that she applauds the efforts of cities like New York to make caloric counts mandatory on some restaurant menus. It's hard to argue against such transparency measures. It's also hard to feel that this is particularly useful. In this day and age, does anyone really consider cookiesheavy with trans fats or otherwiseto be healthy? Speaking of New York, do people really walk into a McDonald's with a milkshake on their mind but not understand that this is a high-calorie snack? Hobbs bemoans the "underfunded educational campaigns" of the Bush Administration, but has it ever been easier for people to get informed about good eating habits?
Seeman, too, finds much comfort in education and transparency. He envisions teenagers mentoring children on how to be physically active. Again, it's hard to argue against such a measure. But is childhood obesity really stemming from children who don't know how to run around? Will such programs teach children how to play tag or monkey-in-the-middle
Hobbs and Seeman do of course advocate many other ideas. That said, these ideas seem antiquated. Both Hobbs and Seeman think that it's the government's role to make exercise more available; they have fashioned themselves as modern-day Dr. Bakers, except that they want to regulate sidewalks and parks (Hobbs) or grant tax-subsidized gym memberships (Seeman) instead of building milk stations.
The approaches of Hobbs and Seeman differbetween the stick and the carrotbut the goal is the same: to get America off its couch and out of the house. But what to make of the West Virginia experience? The state is one large rolling park. Surely the problem there is not a dearth of green space but people's lack of motivation to use it. In fact, American's have never had more disposable income or leisure time, making it easier than ever to buy a skipping rope from the local Wal-Mart and then use it.
How are we to deal with the obesity crisis? First, we can all agree that government policy shouldn't directly foster bad habits. Hobbs is right when she points out that some cheap food, particularly corn syrup-based food, is a consequence of agricultural subsidies. FDR's New Deal may or may not have lifted America out of the Great Depression, but the ongoing subsidies of corn aren't helpful.
Second, we can consider the various indirect subsidies of poor health decisions. Many Americans receive their health coverage from Medicaid (the poor) or Medicare (the elderly). Should taxpayers foot the bill for morbidly obese Americans without any restrictions? Non-government healthcare, whose underpinning is the US Tax Code, also indirectly subsidizes the unhealthy with the health dollars of the healthythe three-packa-day smoker two cubicles down from the fit gentleman pays basically the same monthly premiums. Is that right?
Ultimately, though, I wonder about the limits of government policy. FDR's corn subsidies existed for decades before America grew fat. For all the indirect subsidization of healthcare, being medically ill seems a more overwhelming deterrent than a good deal on an insurance premium.
The recent obesity trend seems to be more about cultural acceptance than government policy. Lawsuits argue that the obese are discriminated against; overweight actors win prized roles and then proclaim their win for the overweight; prominent citizens discuss their inability to lose weight. Even our language has changedwe talk about the "obese" and not the "fat." What then should our politicians do? Legislation will take us only so far. For other major cultural trendsfrom the decline in divorce to the drop in drinking and driving ratesit has largely been about people speaking up and leading by example.
Maybe our politicians can toughen up their language and speak more like this: "We talk about people being 'at risk of obesity' instead of talking about people who eat too much and take too little exercise. We talk about people being at risk of poverty, or social exclusion: it's as if these thingsobesity, alcohol abuse, drug addictionare purely external events like a plague or bad weather. Of course, circumstanceswhere you are born, your neighbourhood, your school and the choices your parents makehave a huge impact. Butsocial problems are often the consequence of the choices people make." The speaker isn't from West Virginia but from Britain: David Cameron, the leader of the opposition. But his fundamental idea, that one's life is his or her responsibility, is distinctly American.
Cameron, D. Speech in Glasgow. Retrieved July 7, 2008. <http://www.telegraph.co.uk/news/newstopics/politics/conservative/2263705/David-Cameron-attacks-UK-moral-neutrality---full-text.html>.
Surgeon General's Advisory Committee on Smoking and Health. 1964. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Department of Health, Education, and Welfare.
Wydner, E.L. and E.A. Graham. 1950. "Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma; A Study of 684 Proved Cases." JAMA: Journal of theAmerican Medical Association 143(4): 329-26.
Hammond, E.C. and D. Horn. 1958. "Smoking and Death RatesReport on Forty-Four Months of Follow-up of 187,783 Men." JAMA: Journal of the American Medical Association 166(11): 1294-1308.