Preventive Medicine Column
Dr. David L. Katz
We might, I suppose, hold all victims of Hurricane Sandy, or our recent blizzard here in New England, or Hurricane Katrina personally responsible for the various ills that befell them. We might assign all of the consequences to some chink in the armor of personal responsibility.
But thankfully, we don’t. We recognize that some exposures are simply bigger than any individual. We accept that some forces can overtake and overwhelm us. We accept that we can be responsible people, and still not be responsible for everything. That’s a good start.
Epidemic obesity and chronic disease is, like a perfect storm, the product of massive and protean forces. It is an emergency in slow motion, but an emergency just the same.
Whereas a hurricane devastates one part of our country over the span of a few days, obesity and attendant chronic disease have been battering at our entire population over a span of decades. The consequences are concisely epitomized by noting that what was “adult onset” diabetes less than a generation ago is now routinely diagnosed in children under age 10. Other chronic diseases– heart disease, stroke, and cancer- are following diabetes down the age curve.
The view that an “obesigenic” environment trumps personal choice tends to prevail among public health advocates, and with good reason. In 2005 and 2006, the Chicago Tribune highlighted food industry practices, including the use of functional MRI scans of the brain, to determine flavor combinations most conducive to endless eating. An updated overview of food industry efforts underlying the addictiveness of snack foods is the most recent New York Times Magazine cover story. The links between industrial profits and prevailing pandemics is elaborated in a current issue of The Lancet, a prestigious international medical journal.
But such arguments may get caught up in their own inertia, and go too far. In the movie Super Size Me for example, not only was the potentially adverse influence of McDonald’s food on health highlighted, but so was an exaggerated variety of individual helplessness. One interview in the movie features a man whose last resort for obesity management is gastric bypass surgery. But his obesity is ascribed to the consumption of nearly four gallons of soda a day! That he might have cut back to, say, three gallons was not addressed. There would seem to be some opportunity for personal responsibility in that scenario, as there is when choosing coat and footwear in a blizzard.
Realistically, we must invoke both environmental reform and personal responsibility to promote health. After all, if in our enthusiasm for environmental determinism we renounce personal responsibility altogether, we risk both ineffectiveness and irrelevance for failing to consider that you can lead people to carrot juice but you can’t make them drink- any more than you can make them use stairs instead of elevators, rakes instead of leaf blowers, or soccer balls rather than video games.
On the other hand, any fair-minded person must recognize that the playing field of opportunity for weight control is not level. Implying that people struggling with poverty, unsafe neighborhoods, and resource-poor environments are personally “responsible” for their weight can be the literal addition of insult to injury, a blame-the-victim mentality that ignores access, affordability, and social privilege.
Calamitous storms give us all a vivid demonstration of what failure to develop a prudent crisis response can cost. Like such storms, epidemic obesity and chronic disease are a storm perfectly suited to breech our meager defenses- and in a veritable flood of tasty calories and labor-saving technologies, they have. And potentially all Americans are living below the level of this threatening sea.
To rise above the floodwaters of this crisis will require a blend of bold actions by those in power, and empowerment of those we ask to take responsibility for themselves. At some point, the interaction of environment and behavior does come down to choice, and we can ask individuals to make good ones; just as we can ask them to make personal preparations for a dangerous storm. But the levees will remain our collective responsibility.
Dr. David L. Katz; www.davidkatzmd.com