There is an old saw, which you doubtless know as well as I, about a $100 bill. The bill comes to you at first with just a tiny bit torn out of one corner. If you are reasonable, you accept it as the $100 bill it is, and barely take any notice of the insignificant missing fragment.
Then it comes to you with two such bits missing, and it's still of no consequence. Then three. And so on.
At some point of course, if this keeps up long enough, there simply is no bill left at all. The question is: At what point between one tiny missing fragment and the bill torn away to nothing do you stop accepting the money at face value?
The point of this adage, which we all seem inclined to share with one another, is obviously not limited to $100 bills. It's about the fact that overwhelmingly, this world of ours is not an either/or world; it's a world in which reasonable people have to choose where to draw reasonable lines. And the fact that deciding just where to do so can be tough.
We presumably know what the adage means when we tell it, otherwise why would we bother? But then we go on to forget all about it. Either every random citizen has a right to carry a high-capacity assault weapon or the Second Amendment is under assault. Either/or.
Just as seemingly everyone wanting to lose weight signs up for the "as fast as possible" program, forgetting entirely about the tortoise and the hare, and what that fable was intended to mean. We all know that "if it sounds too good to be true, it almost certainly is"—but we forget that one too, at the most inopportune moments.
The $100 bill has, if we bother to think about it, direct relevance to one of the more vexing debates in modern health promotion: Is health promotion and weight control all about the environment, or is it all about personal responsibility? We might get somewhere with this if we ante up that $100 from the archives of folksy wisdom.
[See Is Obesity Cultural?]
Let's start with the extremes. At one end, representing the $100 bill in pristine condition, we have a Stone Age environment, where tobacco doesn't exist, all food comes direct from nature, and physical activity every day is necessary for survival. Like the bill with no missing bit, this is an easy call. Everyone will eat "well," or at least as nature intended; everyone will be active; no one will smoke. To the extent that good use of feet (routine physical activity), forks (a healthful diet), and fingers (no cigarettes!) represent adequate personal responsibility, everyone will have it.
At the other end of the spectrum—represented, perhaps, by the movie WALL-E—there are simply no good choices left to make. Physical activity has been totally banished from the culture, and the only foods accessible to anyone are junk foods. In such a world, personal responsibility for eating well and being active would be entirely irrelevant. Neither would be possible, and nobody would manage it—no matter how innately responsible.
I trust you see where this is going. Where, on the spectrum from "it's impossible not to eat well and be active" to "it's impossible to eat well and be active" does personal responsibility start, and stop, mattering?
Starting with a pristine native environment, we might first introduce some labor-saving technology. No one is obligated to use it, of course, and there is still ample opportunity to be active. Personal responsibility still carries the day.
Then let's introduce some very tasty fast food. And then some suburban sprawl. And not just tobacco, but very clever tobacco advertising. And then, more labor-saving technology. And then let's transition everyone to long days of almost entirely sedentary work. And then let's build a huge advertising industry devoted to promoting the uptake of all the stuff we are now selling: food designed to be irresistibly tasty, and technology designed to do everything muscles once did.
Then let's distort everyone's understanding of what is truly healthy with marketing and media hype. Then let's make the least nutritious foods the least expensive, and market them the most. And let's engage scientists and cutting-edge technology to design foods people can't stop eating. And then let's keep this all going so children are born into it, and grow up not knowing any other kind of world. And then ...
If we did keep going this way, eventually we would wind up with that world where the only food that existed was highly processed junk, and making any other choice would be impossible. And we would wind up with a world where physical activity was so irrevocably exiled from our daily routine and experience that no one would even remember what it was.
Were we to reach that point, any argument about personal responsibility would be absurd. Admittedly, we are not there. But objectively, we are closer to that end of the spectrum than the other.
I can't say exactly at what point between a Stone Age environment, where there is no choice but to eat naturally and be active, and an exaggerated modern world, in which the opportunities to do either no longer exist, the role of personal responsibility becomes moot. I rather doubt you can either. For now, all we need to agree on is that this scenario is like the $100 bill, that there is a line crossed somewhere. We needn't decide exactly where that line is to know there must be one.
Once we acknowledge there is a line, what we are really saying is this: Personal responsibility matters, and can compensate for environmental challenges up to some point. Beyond that point, the average human endowment of personal responsibility is no longer enough to carry the day. Much beyond the point, even the most supreme examples among us may no longer be up to the task.
Which invites consideration of another matter: the average endowment of personal responsibility. For one thing, we have no indication it has changed over the years during which epidemic obesity and diabetes have developed. There is no documented decline in personal responsibility to account for deteriorating use of forks, and degenerating use of feet. In contrast, the changes to our environment are very well documented.
Since a decisive majority of our population eats poorly, is inactive, and has either weight or health problems if not both to show for it, we might simply stipulate that the average human endowment of personal responsibility simply isn't enough. We might assert it—but we'd be presumptuous fools to do so—because average is the best measure we have of what's reasonable and manageable for the lot of us.
After all, from the perspective of a gorilla, all humans are weaklings. From the perspective of a horse, no human can run. From that of a dolphin, no human can swim. From that of a kangaroo, it's not just white guys who can't jump. It's what humans actually can do that defines what humans should be able to do.
Nor need we go quite so far as to cross the divide between species. From the perspective of Einstein and Newton, the lot of us are dummies. From the perspective of Michael Phelps, we can't swim, and from that of Usain Bolt, we can't run.
In spite of it all, when it comes to eating well and staying active, I am elite. Not because I'm a special person, but because I have a special skill set, and expertise. It is, after all, what my career is about. So while I do eat well, exercise daily, and am fit and healthy and lean, am I really entitled to assert that everyone else should be able to do the same? That's a bit like Stephen Hawking telling me I really should just keep up when the conversation turns to theoretical astrophysics.
We all seem to embrace the pop culture wisdom that with great power, comes great responsibility. It's past time to embrace the corollary: To take responsibility, we must be suitably empowered.
How much is suitable? Hard to say—but asking the question is a good start. And a good initial answer might be: enough to meet average needs.
Right now, a landslide majority of the total national population is overweight or obese. Globally, the percentage of us subject to chronic disease is stunningly high already, and rising steadily. How do those dodging these bullets presume to blame the majority for being struck by them? Those who survived the Titanic might just as well blame those who drowned.
That is the nature of human experience: Inevitably, it's a bell curve. Some, through a combination of native gifts and luck, do far better than average. Some, alas, do worse. But the average experience is exactly that: the most likely thing to happen to most of us under given circumstances.
Now, don't go thinking I am trying to exonerate us of our responsibilities for our own health. Not at all. What I do with my feet and my fork is up to me, and what you do is up to you. Even with both a will for health, and a way to it– we still have to walk there. We should not expect to be carried.
Yes, we must share in the responsibility. Bolt has to run; Phelps has to swim; Hawking needs to think.
We, too, must take responsibility—but can be expected to do so only to the extent we've got the power.
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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.