I suppose one potential response to the worsening global obesity pandemic is: Just cut it out! That, of course, has two potential meanings, and I don’t much like either of them.
One implies it’s all about willpower. If we interpret “cut it out” to stand for “deal with it” or “get over yourself” or “suck it up,” then that’s where we land. The second meaning, more literal, is a call for the surgical approach to fixing what’s broken. In this case, that suggests we turn to deftly wielded scalpels to compensate for injudicious use of forks and inadequate use of feet.
Both connotations have certain traction. The issue of willpower, typically framed as “personal responsibility” for weight control, is a topic that comes up often in cyberspace and professional conferences alike. I have addressed this topic before, and won’t belabor it here. I will briefly note only this: Choices we make are subordinate to choices we have. And if great power brings great responsibility, then disempowerment obviates responsibility. There is an argument, in other words, for a middle path toward the marriage of personal empowerment to personal responsibility. The argument all too often goes unheard; the path remains, alas, the road all too seldom taken.
The latter meaning – more surgical strikes at this problem – is the ostensible basis for a lead article in last week’s Wall Street Journal indicating that Middle Eastern countries, notably Saudi Arabia, are turning to bariatric surgery with increasing frequency to address severe obesity in very young children. Leaving aside the lack of data regarding long-term efficacy or potential unintended consequences of rerouting the gastrointestinal anatomy of growing children, let us acknowledge the disquiet this situation invites. Lacking the capacity and resolve to feed our children less or better, or get them to exercise more, we send them through the operating room doors instead.
I have encountered the Middle Eastern version of this global travesty before, and more intimately than by reading a newspaper article.
I had a brief stay in Qatar last year, invited by colleagues to speak at a medical conference. Before my visit, I knew that obesity and chronic disease rates were high and rising fast in that part of the world. Not having made a particular study of Qatar before, however, I did not know that the prevalence of diabetes there is roughly twice as great as in the United States, some 17 percent of the population as compared to our 8.3 percent. Given how often we speak of the United States as the veritable epicenter of the global obesity pandemic, I did not know that obesity prevalence was slightly but decisively higher in Qatar, at 40 percent, as is the overall prevalence of overweight and obesity at roughly 75 percent – and the rate of childhood obesity. The situation in other Middle Eastern countries, including Saudi Arabia, is much the same.
[Read: Best Diabetes Diets.]
The rapid rise of the very public health problems that bedevil the so-called West in a very different Middle-Eastern population highlight the extent to which vulnerability to these perils is universal. The perils of modern epidemiology are not national perils; they are human perils. As a species, we have no native defenses against the lure of the couch and caloric excess, and as a species, we succumb all too readily to both.
The rapid development of these issues in the Middle East over a span of years, not decades, indicates the potential folly of excessive focus on genetics or physiologic variation. It’s true, some of us are more vulnerable than others to obesity and Type 2 diabetes alike. And it’s true that genetic variation plays some part. But genes, hormones and metabolic pathways have not changed in Saudi Arabia or Qatar in a span of 10 or 20 years. Changes that did not occur cannot be the explanation for changes that did. For the salient causes of salient effects, we must look for corresponding change – and we see it in the environment and in culture. The same genetic variation was here a generation or three ago, when obesity in children was rare. What has changed is not the children – but the world we are bequeathing them.
[Read: Don't Blame
Your Children for Their Weight.]
When native culture and lifestyle prevailed in the Middle East, there was little or no obesity. Foods were simple and close to nature, and physical activity was required for accessing water and managing animals. Oil and affluence, of course, changed all that. Qataris, for instance, have the highest per capita income in the world. Middle Easterners increasingly have access to the world’s food and technology. A diet limited to simple, wholesome, native foods and routine physical exertion are yesterday’s news. Today’s news is all about what happens when lifestyle runs off its traditional rails.
My colleagues in bariatric surgery know I respect their work, and from time to time, rely on their skills to address the acute needs of my patients. Bariatric patients know I encourage surgery when I think it’s warranted, and advocate for access to this recourse for all appropriate candidates.
But that is the issue: appropriate candidates. Should ever more of our sons and daughters at ever younger age be appropriate candidates? If current trends culminate at their apogee, should every child?
What does it say about modern culture – a medium of our own devising, and under our control – that it sanctions putting children under general anesthesia to compensate for its anachronisms, profit-driven excesses and exploitations? Nothing very flattering.
There are, of course, alternatives. We might update the ways we show love, helping one another to health rather than contriving against it. We could raise children who aspire to health rather than just wealth – for after all, the latter is the ultimate currency. No other is worth much in its absence.
We might remold the clay of culture to foster vitality rather than profit from its surrender. We might rely on schools rather than scalpels, the acquisition of life skills rather than the deep sleep induced by anesthetics. We could fix epidemic obesity, and it would not even be complicated – although it would be hard. Change is always hard. But so is waving to your 6-year-old daughter as her gurney rolls into the operating room.
Epidemic childhood obesity is a cultural crisis. Turning to the literal cutting edge of biomedical advance to address it is not a solution, but an abdication. Clinics can treat the effects of the ills of culture, but they cannot cure the causes. But collectively, we could.
The U.S. exported the problem of epidemic obesity in adults and children alike by exporting the causes. Now, we seem to be in the business of exporting a preference for the wrong cures. True, scalpels can address this issue. But feet and forks can do so far more safely, more effectively, less expensively, more universally, and with vitality – more years of life, more life in years – as the only likely side effect.
can treat childhood obesity with ever more surgery, but I really hope we don’t. We can keep lamenting the ill effects of
modern living and abdicate when it comes to fixing them – but personally, I
think that’s gone on too long already, and we really ought to cut it out.