Even proponents of the Affordable Care Act, or so-called Obamacare – and yes, I am among them – acknowledge that in all its administrivial detail, the new law is "numbingly complicated." Even a "concise" summary of what the law says runs128 pages.
But that's bureaucracy, not biology. We humans invented bureaucracy, and if we excel at anything, it's extracting mischief from these oversized (and undersized) brains of ours and complicating the potentially simple.
More importantly, as good and important and even financially advantageous as it is to provide medical coverage for all, it is rather a misnomer to call this "health" care reform. There is nothing in the behemoth legislation that will, or even possibly can, make you or me healthy. No one can do that for us – we have to do it for ourselves.
[Read: 6 Ways to Make Time for Your Health.]
I'm a doctor; I treat patients. I have, any number of times over the years, literally and vividly saved lives. But even so, I readily confess I cannot make health. Health is not made in hospitals – disease is treated there. Health is not built in clinics, or enhanced by MRIs, SPECT scans or robotic surgery. The so-called "health" care system is overwhelmingly a "disease" care system and will remain that no matter the fate of reform.
Health, alternatively, is built and cultivated daily by us and those we love, evolving or devolving in the places we live, and love, and learn, and work, and pray and play. Health permeates life and living, or it doesn't. Hospitals and clinicians cannot pick up the slack.
I don't consider any of that bad news. Frankly, I like to be in the driver's seat – and I suspect most of us do. We are in charge of our health, and so much the better.
And better still is this: Health is simple. Or at least, I have always thought so. We have known for literal decades that both years in life and life in years are overwhelmingly dependent on a very short list of factors we all can potentially control each day. That list is dominated by what we do with our feet (physical activity), forks (dietary pattern), and fingers (not holding cigarettes). It extends to the quality and quantity of our sleep; how effectively we dissipate our stress; and how well we cultivate loving relationships with others.
I refer to feet, forks, fingers, sleep, stress and love as the "super six" of health. When we fire on these six cylinders, the probability of a long and vital life is dramatically shifted in our favor. The likelihood of both losing (and permanently controlling) weight, finding (and keeping) health is very high indeed.
Now, I readily acknowledge that simple does not mean easy. I don't think it's easy to get to health and weight control in the modern world, because the modern world conspires against them. That is a long story itself, and I won't bog down in telling it here. Suffice to say that this modern world of our devising is not our native habitat, and we are poorly adapted to it. Obesity and chronic disease are all too often the consequence of that mismatch.
There are two solutions: change the world, or change ourselves. Actually, I advocate for both. My work is mostly about changing the world in ways that make it easier to get "there" from here, "there" being the vitality we all want and (at least most of us) deserve. But the world changes slowly no matter who is on the case, so don't hold your breath!
While waiting on the world to change, each of us can acquire the relevant skill power to navigate through the world as it is. It isn't rocket science, but it isn't trivial either. An expert like me can teach the skills, but it takes two to tango; those at the receiving end have to commit to learning them and applying them. The "return" on this modest investment of time and effort is rich indeed and makes it very worthwhile. I am disheartened to see so many forego this empowerment while holding out for magic that of course will never come.
[Read: Welcome to Fantasy Diet!]
So there we were, frankly, with enough problems on our hands: complicated disease care reform being used as an excuse to shutter our government; and simple, true "health" care reform tantalizingly within reach but all too often left to whither on the vine. Alas!
But now, it seems, we have a new problem. An associate forwarded me a blog, just published, referring in turn to a peer-reviewed paper in BMC Medicine published earlier this year. Both argue that the reason we haven't yet fixed epidemic obesity, and by extension the panoply of chronic diseases that follow in its wake, is because we haven't made things complicated enough. Blog and paper argue that a focus on mere energy balance is too simple-minded, that we need to account for all the minute details of homeostasis and its dysregulation.
I could take you into those weeds, but I see no real need. Instead, let me pose a riddle. A horse and a mouse have the same body mass index: Which, do you suppose, needs more calories every day?
I am guessing this riddle isn't causing you much difficulty. The horse needs more calories. Why? Because the horse is bigger, and matter and energy relate. We know this, as surely as we know that apples fall from trees, rather than flying out of them up to the stratosphere. By the way, I have a horse – and, yes, Troubadour eats … like a horse!
But now, what if the horse is lean and the mouse is fat – who needs more calories? Still, of course, the bigger horse. Here comes the tricky part: What if the horse loses a lot of weight for some reason? Will he now need the same number of calories to maintain his weight as he did before?
Of course not! Why? Because now he is smaller than he was before. Not as small as a mouse, naturally, but smaller than the prior version of himself. Less mass needs less energy. And yes, this pertains to people as well. If we diet and lose weight, we need progressively fewer calories to maintain the lower weight we achieve. This, by the way, accounts for the common and notorious weight-loss "plateau" that bedevils dieters.
But since all this comes down to recognizing that horses and mice need different amounts of food every day, I am not seeing the complications here.
Blog and paper argue that the reason we have yet to fix epidemic obesity and the attendant metabolic mayhem is the failure to appreciate such subtleties. But I beg to differ. Within the span of living memory, there was no epidemic obesity – and that wasn't because everyone was analyzing their leptin levels, calculating the area under their post-prandial insulin curve or adjusting daily calorie intake on the basis of VO2max. It was simply because physical activity was a routine part of our days; and glow-in-the-dark foods, engineered to be irresistible, in ridiculous and ubiquitous quantities, were not.
Why haven't we yet fixed epidemic obesity and related chronic disease? Because the world is profoundly obesigenic, and we have done far too little to change it. We look on phlegmatically as sonorous announcers tell our 6-year-old sons and daughters that artificially-flavored, psychedelically-colored marshmallows are "part of a complete breakfast." Seriously, folks – are we surprised to be reaping exactly what we are sowing?
We simply haven't done enough to change the world or to change ourselves to deal effectively with the world as it is.
Yes, it's true that hormonal balance matters. It's true that homeostasis, metabolic dysregulation and alterations in resting energy expenditure matter. But this was all true before epidemic obesity and chronic disease also. And people back then weren't bringing calculators to breakfast – they were just eating better stuff and moving more. Really.
It's also true, of course, that we are comprised ultimately of atoms that are emptier than the solar system, and that the solidity we impart to ourselves is an illusion of our limited perception. If we want to invoke real complexity, we might go there and wrestle with obesity at the level of physics. But let's not. I don't think it takes a particle accelerator to figure out we should drink less soda and eat fewer French fries.
[Read: Soda, Calories and a Full Accounting.]
Fixing obesity and attendant chronic disease at the public and/or personal level is not for want of knowing what, but for want of knowing how. It is not a deficiency in what we know but rather a deficiency in what we do with what we know.
I see nothing to be gained by complicating the simple, and I think losing weight and finding health are simple. They just aren't easy. But what truly worthwhile thing ever is?
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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. His latest book, "Disease Proof: The Remarkable Truth About What Makes Us Well," was released in September.