When salmon swim against the current of a river, running a gauntlet of grizzlies, we are impressed by the fortitude nature endows. When many of them die trying, it's no great surprise. I can't recall ever hearing anyone suggest that the many salmon who die along the way lack the personal responsibility of those who make it. All are striving; some succeed, but most fail. The species survives (so far), but less than 5 percent of the fish overcome the obstacles. Things play out predictably: Overall, the current and the gauntlet prevail.
The advent of some good news about obesity trends might have lulled us into a false sense of security, or at least accomplishment. We have heard, for instance, that obesity rates in children and adults alike seem to have plateaued. We have examples of seemingly effective interventions.
But to whatever extent optimism was tempted to take flight on the basis of such news, its launch was aborted by this week's findings from the Rand Corporation. Their just-completed study shows that rates of severe obesity have been rising briskly over recent years—or, as USA Today put it, skyrocketing.
Not only is a skyrocketing rate of severe obesity a bad thing in its own right, it actually undoes the apparent good news that overweight and obesity rates overall might have been leveling off. Here's why. Some 65 to 80 percent of Americans are overweight or obese now. It may just be that everyone who is vulnerable, with rare exception, has already succumbed; those who haven't succumbed likely have robust defenses in their genes, their environments, their behaviors, or some combination of those.
If the only real plateau we have is that almost everyone, and certainly everyone who is vulnerable, is overweight already, then the real measure of our status is no longer how many are overweight, but how overweight the many are.
If the overweight are becoming obese, and the obese are becoming more severely obese, and all concerned are ever more prone to the metabolic perils of obesity, then things are going from bad to worse, and our ship is sinking. This is exactly what the Rand study tells us is going on.
There are many reasons why, but let's focus on just the one that got this conversation started: culture. America runs on Dunkin', right? That tells us something.
As we struggle against the obesigenic currents of our culture, our success rate only a little better than that of salmon, what are the grizzlies that are grabbing us in their claws and jaws?
Cultural anachronisms. Elements of culture that once made sense in context, but no longer do.
For instance, I was on a 51-minute flight from Washington, D.C. to Hartford, Conn. yesterday. Flight attendants did the usual: dispensed "free'" soft drinks and snacks. And for the most part, everybody imbibed.
In an age of epidemic obesity, are we really convinced there's an upside to filling every 50-minute interval with high-calorie liquid candy, and highly processed, energy-dense, nutrient-defunct snack foods? I guess it's not quite as extreme as handing out cigarettes on an oncology ward, but it's misguided in all the same ways.
The flight, of course, was just an illustration. This scenario dominates our culture. There is food everywhere, all the time—and most of us are on the "see food" diet: We see food, we eat it.
Why? Because our culture encourages and endorses exactly that. And why, again? Because throughout most of human history, food was relatively scarce relative to our needs. By eating all we could, whenever we could, we just got by. It made sense.
But in modern context, Stone Age cultural impulses backfire rather badly!
Consider the notion that more food for less money is a bargain, a notion that reaches its fullest expression in the all-you-can-eat buffet. What, really, is such a buffet in modern context? An opportunity to get fat at no extra charge, and then spend a fortune to lose the weight that you gained for free. Come on, folks—let's wake up and smell the SlimFast! This isn't a bargain any more.
It was, when food was scarce. But it's obsolete thinking—a cultural anachronism.
Ditto on the other side of the energy balance equation. Since we first used a rock as a hammer or missile, we have been improving technology and reducing the daily demands on our muscles. This, too, is a cultural imperative—and was good for a long time. But now, sedentariness counts as a leading cause of premature death around the globe. Oops.
So, imagine flight attendants who—instead of dispensing calories almost no one needs at the first opportunity—led an isometric exercise routine instead. You could opt out if you wanted, and you could ask for a snack or a soda. If activity were the default, and calories the special request, the flow of culture would carry us toward health, rather than from it.
I realize this is so far removed from our common experience it probably sounds bizarre. But consider that if humans had always struggled to keep weight off rather than on, this is just how things would be. Culture was designed to make sense—for those who designed it. Do we really want to be held hostage, forever, by cultural imperatives selected for us by cavemen, Mesopotamians, or medieval feudal lords?
Our culture is also the reason that health is something we tend to ignore and neglect until it's broken. The things we can do to promote health are mostly limited to diet, exercise, avoiding toxins, sleeping, bonding with one another, and managing stress—and throughout most of human history, those things just took care of themselves. The only kind of health promotion that's built right into us is the flight-or-fight response, and in modern context, that's more liability than asset.
And so it seems our culture has taken its cues from our biology; we never got used to the idea of nurturing our health. We nurture our wealth, because our culture has always told us to do so. But health was always on its own. We tended to illness and injury of course, but there was nothing to do for health when it wasn't broken.
Imagine if we treated wealth the way we treat health. We would not invest, or save, or budget. We would ignore our financial status until it was broken, and then in panic, take desperate measures—like crime, perhaps. I'm not quite sure what financial recovery method is comparable to coronary bypass, or bariatric surgery, or dialysis, but whatever it is, it would be neither pretty nor painless.
But barring calamity, we never let this happen to our personal finances in the first place. We tend to them right along, because our culture tells us to.
So here's the thing: We made up culture, and we can change it. We are not masters of our genes, despite our knowledge of the genome. Genetic engineering is in its infancy. But culture is a medium entirely of our own devising. We created and designed it, and if it's gotten silly or outdated, or dangerous, we can update it.
For proponents of personal responsibility, it's worth noting that no matter the current, the fish still have to swim. So, too, for us: No culture will carry us to health without our active participation. But how much better for us all—and our children's futures—if we could get to health by going with the flow, rather than against it.
Hungry for more? Write to firstname.lastname@example.org with your questions, concerns, and feedback.
David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.