How obesity is a voluntary epidemic, and why we shouldn’t give up

As America comes to grips with the disastrous effects of a national obesity epidemic, there’s a new feeling in the air: defeatism.

Former Carter Administration advisor Amitai Etzioni seemed to succumb to it when he wrote an article entitled “dieting gets you nowhere” for CNN recently.

In it, the liberal sociologist citied a recent nutritional study that found 8 out of 10 Americans who try to lose weight fail. So in Etzioni’s mind, “all the hoopla about dieting” only diverts resources “from the one group in which healthy eating, especially if combined with exercise, can make a significant difference – children, the younger the better.” His message: adults should simply give in on obesity and move on to the next generation.

How individuals – and policymakers – react to claims like these is important to the future of the United States.

Obesity is a financial epidemic, since the collateral damage from obesity is driving health care costs out of control. Obesity is an economic epidemic, since a heavier workforce is a less competitive, less productive workforce. Obesity is a national security epidemic, since it cuts down America’s potential pool of military recruits before America’s future enemies have even fired a shot. Obesity is a tragic epidemic, since it shortens lives and crushes the self-esteem of millions of decent people.

But most of all, obesity is a voluntary epidemic. Most overweight people choose to eat poorly, and they make premature death more likely when they do. On the other hand, people who choose unhealthy diets today are equally free to choose a healthier diet tomorrow. Even a modest change can be important.

There’s no need for defeatism, for two reasons. First, preventing every new pound of excess, unhealthy weight is a victory, even though almost three quarters of Americans are already technically overweight. That’s as certain a fact as gravity.

In fact, it has a great deal to do with gravity. Bearing more weight than the human body was designed to carry puts premature wear on the joints, fuelling America’s rising quota of costly knee and ankle replacement surgeries. Being overweight makes muscles relatively weaker and breathing relatively harder, restricting a person’s ability to stay fit. Obesity increases pressure on blood vessels, with consequent risks for potentially lethal cardiovascular diseases. The greater your weight, the greater the risk of diabetes. And so on.

Those factors were at play in a study released this month in the New England Journal of Medicine. Researchers pooled data on overweight, non-smoking Americans to screen for the health impact of excess weight alone. Merely being mildly overweight increased the risk of premature death for women by 13% over periods of between five and twenty-eight years. Add more pounds, and the risk grows rapidly – to as high as 88% greater risk of premature death for obese women, and almost 250% increased risk for the morbidly obese.

These numbers give new meaning to the phrase ‘an ounce of prevention.’ The level of one’s excess weight is important, too. So obesity isn’t an either-or problem; keeping extra weight off even if you’re already overweight can make a real difference to your health.

But the flip side is also true. While crash diets, fad diets, and diet pills are sure to fail in the long run, medically overweight or obese patients should know that reducing weight  – gradually – is the surest way to bring immediate health benefits, too. Among the obese, even mild weight loss can dramatically reduce long-term diabetes risks. Mild reductions in weight can also have an immediate and positive impact on blood pressure and hypertension risk.

In short, even if just two in ten Americans are losing a little weight and keep it off, it’s more than worth the trouble – for their sakes, and for everyone’s sake.

“I am a student of public policy, not medicine,” Etzioni wrote. And it shows in his analysis, since he makes it seem as though it’s impossible for most adult Americans to gain anything from keeping their weight down.

Sure, it’s true that eating well and walking a block a day might not do much for a crash dieter who wants to fit into a new pair of jeans by next Tuesday. However, if we measure the fight against obesity the way it should be measured – by medical standards – then even a little progress can be a lot of progress.

David Gratzer is a physician and senior fellow at the Manhattan Institute. He is author of The Cure: How Capitalism Can Save American Health Care.

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  • anonymous

    As someone who was morbidly obese and now 14 lbs from a normal BMI I have to disagree with you. Obesity is not voluntary. it is an addiction. It is most likely the result of emotional eating and having known many obese people I can say therapy should be the prescription.

    Although some overweight people love to binge on junk and know nothing about nutrition the majority of truly obese people are addicts, emotional eaters, unable to control their food intake much like an alcoholic at a bar. It is more of a mental condition than a than a desire to eat fries and cupcakes.

    It’s unfortunate that some MDs do not understand this.

    • Smart Doc

      “Anonymous” is 100% correct. Best regards and prayers to you.

    • gzuckier

      another blog post here discusses “what to do with the picky eater” I.e., how to condition your child to eat more than his/her body tells him to, in order to grow up and become a good upstanding American overeater. Maybe there’s something wrong with me, but I really find it odd that the majority of otherwise well-educated, intelligent, nutritionally aware adults seem to become robotically fixated on getting as much as possible stuffed down their kids’ throats, like birds reacting to the gaping beaks of chicks, with transparently self-defeating strategies, healthy-eating-wise; “Here, have some more broccoli, it’s good for you; let me slather it with a ton of butter and a lot of salt”. “If you eat more of the ‘healthy’ food than you want to, you will be worthy of a reward, i.e. a huge bowl of ice cream”. etc. etc. etc.

  • http://drpullen.com Health blog

    Although the premise that obesity is voluntary is true to a degree, there is a great deal about morbid obesity that is poorly understood. There is some recent evidence of an infectious component, certainly there is some genetic component, and it’s just plain complicated.

  • catswym

    Wow, when you said “obesity is a financial epidemic” I thought you were going someplace good–like the fact that the less money you have the more likely you are to be fat.

    People do not choose to be fat. People eat what they have available to them and they eat enough so that they don’t feel hungry. If you have few dollars then nutritionally dense foods make more sense to you.

    • Disillusioned Citizen

      Hear hear. When you can buy so much more from a dollar menu than from the grocery store, it just makes more sense to buy those foods to stave off hunger than to stave off the growing waistline.

      • Dave

        Beans are the cheapest food in the universe. Instead of spending 3 bucks on a dollar menu you could get a huge package of dried garbanzo beans and make your own humus. You can even substitute non-fat Greek yogurt (its actually quite good) for some (or all) of the olive oil and have it be mostly fat free (beans have some). Just add some garlic and spices and you are set. Get some pita and/or carrots and you’ll have a ton of food (several meals worth) for less than the same price per meal as a $1 menu.

        While white rice isn’t the best for you (there was some study done on physicians that showed that those eating white rice 4 times a week were at greater risk of diabetes than those that didn’t), brown rice is readily available and there are tons of beans and rice recipes (red beans and rice/etc.).

        My wife and son are currently on foodshare. We are able to use those benefits pretty much exclusively (we stay within the budget) and don’t buy anything that is pre-made or frozen and do get lots of fresh stuff. It’s totally doable if you are smart about it, but it does take work/time.

        • http://Fatwaitress.com FW

          Unfortunately not everyone has the time to spend preparing food. While, yes there is the ability for people to eat healthy with a small budget there are always going to be factors that can make it extremely hard.

          Also if someone is so poor that they risk starvation, the thing that they need to worry about is getting enough calories not the quality of food that they are eating. If someone only has $1 for their entire meal, it is smarter for them to buy a burger from McDonalds then a healthy option that is not as calorie dense.

    • WhatPaleBlueDot

      This exactly. Look at the demographics. Obesity is worst in poor, rural areas where good food can be difficult to obtain. If the nearest quality grocery store is more than 2 miles away, it’s out of reach for those who often have trouble with reliable transportation. And, fresh food preparation is labor intensive, putting it out of the reach of people who may work two and three jobs while attempting to raise families and care for relatives.

      And, of course this view of weight issues results in patient blaming for all manner of symptom complaints, which delays diagnosis of chronic disease.

      • gzuckier

        our local urban slum (one of the ten poorest cities in america, centered around the local huge thriving teaching hospital as is traditional) just celebrated the opening of a supermarket, the only one in the urban core, otherwise served by a sprinkling of mom and pop stores of less desirable quality/cost ration and a zillion fast food emporiums. This store will close in a couple of years because the corporation can make more profit by investing in a higher income location, the residents will not have access to the same quality food at the same prices as suburban areas do for a few years, then the cycle will repeat itself. I’ve seen it recur a few times in the thirty years I’ve lived here. “the self-perpetuating nature of poverty” indeed.

        • http://Abnormalfacies.wordpress.com Jim

          Yes, that’s often how it goes. Actually, one of my first blog posts was about “food deserts” and though people usually reserve that term for more rural areas without access (i.e. the stroke belt), its true in urban settings and I believe the definition needs to be expanded.

          Reading other posts, there seems to be a great disconnect here between readers of this article and those familiar with the struggles of those who live in poverty. I notice the same in comments on my article about the HPV vaccine, wherein one reader suggests abstinence.

          Oh, Right! Why haven’t we thought of that?

    • Leo Holm MD

      Right. Most people cannot afford to eat healthy. Even when they can, what “healthy” is has been so distorted that people have no idea what to do any more…so they just give up.

    • gzuckier

      For somebody who doesn’t have the time, inclination, or indocrination to spend a good deal of time making things from scratch, which includes most working people these days, you discover that there is a strangely inverse relationship between the cost of prepared or semiprepared food (restaurants or stores) and excess calories. “I have to overeat, I can’t afford the time or money not to”.

  • BK

    If the medical community would relearn their biochemistry and start recommending high-fat (non-veggie oil fat!) diets then people wouldn’t be so damn hungry all of the time.

    The three evils: Wheat, excess Fructose, and excess Linoleic Acid.

    Unless you have some sort of advanced autoimmune disease this pretty much all you need to know.

    BTW, Gary Taubes the author of “Good Calories, Bad Calories” recently released online his blood chemistry results. He eats tons of bacon, eggs, etc and it looks great! Nice big fluffy LDL. :-)

    • http://Abnormalfacies.wordpress.com Jim

      Did you have to bring Taubes and his propaganda into this?

      The medical community, in general, is behind the curve when it comes to nutrition science – but it’s not because anyone needs to relearn their biochemistry.

      Gary Taubes is an example of someone who, like a rottweiler, latched on to an idea for dear life without understanding the entire scenario. I don’t know why he gets so much praise for advocating a low-carb diet.

      • gzuckier

        he’s got the cover article in the sunday NY times magazine this week.

  • Jackie

    My Sister-in-law has a PhD in nutrition and has been a college professor/instructor for almost 30 years. She has inherited the exact body type/temperament from my late Mother-in-law who had suffered from type II diabetes, heart attack and Alzheimers before passing away few years ago at 81.

    Sister-in-law and her mother had made a pact to lose weight by walking and dieting before my wedding 20+ plus years ago, and actually had lost quite a few (10-15)pounds. Once the motivation was gone, they went back to their eating habit and sedentary life style.

    Sister-in-law has been trying to get in more exercise which is not easy as she has a busy schedule teaching and taking care of her father, her husband, her daughters and grand children.

    My Mother, who’s been chubby all her life and has given birth to six children, adopted a vegeterian diet because of her religion in her early 60′s and dropped about 20 lbs. She resumed regular diet after being diagnosed with Non-Hodgkins Lymphoma when she’s 75. She’s now a healthy 87-year-old.

  • Ellen

    BK … you are absolutely right! I was once slender, but then, following the recommended nutrition guidelines put out by the USDA and the Fed .gov – low fat, lots of whole grains, fruits and total avoidance of any saturated fat – and I GAINED over 50 pounds doing so. I found Gary Taubes’ book, “Why We Get Fat” and have not looked back. I have lost 30 pounds and I have never felt better since I started eating healthy, whole foods without a boatload of sugar and carbs.

    • Diora

      I am normal size (126, 5’2″) trying-to-lose 4 pounds by summer to look better in a swim suit and to comfortably fit in my favorite skirts again, but you are right about the guidelines.

      I remember looking at these guidelines and laughing: are they serious? Pasta is OK? if I were to eat that many servings of grain, I’d be fat. I figured I’d just eat what I’ve always eaten maybe with some minor modifications e.g. cutting fat off meat, eat more fruit/veggies. A friend of mine though took these guidelines to heart, and yes, he is obese.

      I did gain weight after my ovaries failed – a little at a time year-by-year mainly because of eating same way I was eating and not exercising and maybe following some of these “guidelines”. Then one day I looked at the mirror and noticed that I can no longer wear the waist-showing clothes that I like. I think I got to the lower overweight range. I started eating less, replaced all refined grains with whole grains, exercise more and gradually lost about 18 pounds in a year. That was years ago, since them I gained about 6 pounds which I am trying to lose now. Vanity is a big help as it causes you to notice a few pounds long before doctors do.

      But yes, you are right about the guidelines. Also, I think many people don’t realize that good old college days when one could eat almost anything and still stay thin are gone, that as one gets older one needs to eat less to maintain the same weight, especially for a woman after the menopause.

      • gzuckier

        ain’t that the truth. when i was young i could (and did) put away tons of food, and remained the stereotypical 98 pound weakling. but soon as i hit 50, it was like a switch was thrown; i have to eat like a bagel and a salad most days a week if i don’t want the bmi to start creeping up again, even with a concerted attempt to exercise a lot more.

  • http://bit.ly/huPCPz Dulsea

    I know people who just smile back at you and say, that they’re happy, so why should they worry about their weight.

  • Leo Holm MD

    Obesity is a symptom more than anything else. The underlying problem is the way the food supply is structured, funded and rewarded in our society. Corporate food is the disease, as is massive abundance of non nutritional substances. Yes, obesity is a financial epidemic…we need to stop rewarding the people causing it.

    • Kristin

      Seriously! It’s amazing to me that people continue to disregard the food industry’s blatant overproduction. In a system where we’re manufacturing 4,000 calories per person per day, and where advertising dollars go to making us believe that low-fat or low-carb or low-whatever-the-buzzword-is-this-week will save us, rather than into educating people about their bodies and their choices, in what way is it surprising that we eat too much? When manufacturing refined corn products has a much larger profit margin than selling diverse unprocessed vegetables grown in healthy soil, why wouldn’t corporations use their massive lobbying power to make it easier and easier for us to eat what they want us to eat, rather than what’s good for us? Follow the money–it’s easy. It’s painfully easy.

      You want to cut down on obesity, reduce or eliminate corn subsidies.

      Additionally, from a behaviorist’s standpoint, this author’s argument misses the point. The question isn’t why people aren’t doing what they “should”–the question is how to alter the stimuli so that it’s easier for people to choose what we want them to choose. If that seems manipulative, consider the fact that the food industry is already doing exactly that, every day. It’s not a secret that everything from marketing to designing supermarket layouts is psychologically tested.

      Casting obesity as a moral failing is not productive. Examining the environment in which we make our food choices, and altering that environment as needed to produce the desired results, is productive.

      People behave in predictable ways, and the food industry uses that to their advantage every minute of every hour of every day. Corporations are responsible to their shareholders, not society, and the incentive system is geared to make us eat more and more food that is produced more and more cheaply. Ignoring that is exactly what the government, with its revolving-door executives making the rounds from Cargill to the FDA and back again, has been doing. Because the people we put in charge of protecting us from corporations are people with vested financial interest in those corporations.

      None of this is a secret. Corporations are profit-driven, and there are limited ways to increase profits once the market is saturated with providers. Making people eat more is one of them. You can blame individuals all you want, but until the government is out of the food industry’s pocket, we’re going to stay obese.

      • gzuckier

        when i was a kid in canada, you could easily tell american tourists by their size and sort of “cornfed” look. at that time, canada didn’t have macdonalds, for instance; there were some chains like A&W but in general we didn’t get the same fast food or junk food marketing yet. Now, however, the marketing in both countries has ratcheted up spectacularly compared to that time, and the old distinction seems less evident.

        In addition, of course, the reduction in physical activity has rolled along in both countries.

  • Diane D’Angelo

    Nice slam about the “liberal sociologist” there, doc. Keep it classy, ok?

    In the meantime, let’s not ignore the impact of antidepressants and other big pharma marketing efforts on obesity rates. With so many Americans taking these drugs (now typically “enhanced” with atypical antipsychotics which are known to cause diabetes and further slow the metabolism), in addition to the factors mentioned in the other comments, it’s no wonder the phenomenon exists.

    • http://Abnormalfacies.wordpress.com Jim

      I had the same thought, initially, but was less surprised when I saw the title of Dr. Gratzer’s book.

      • Leo Holm MD

        Capitalism might save American Health Care. We should try it sometime. It will require a transparent system with an informed consumer. Good luck getting that from the corporate food industry and those they lobby in government. Even more luck to you if you want that same transparency and free flow of information from the medical establishment.

  • Rob S

    Obesity is not voluntary. The author is misinformed and uneducated. America’s obesity epidemic is increasingly tied to the food industry’s choices to maximize profit at the expense of public health. More than ever our diet has less fiber, more sugar and fructose sweeteners. This combination interferes with body’s natural food intake autoregulation systems and fooling the brain and stomach.

    It’s unfortunate to read that the author assumes people eat poorly. People (especially in these economic times) eat cheaply. And the cheapest food is fast food, filled with “empty calories.” Has the author looked at the relationship between per capita income, obesity and access to fast food? I think he may be surprised to find that the poorest in our country have access to the cheapest and yet least healthy food more so than another other demographic.

  • http://Abnormalfacies.wordpress.com Jim

    Given its title and opening line, I thought this article would be an inspiring piece on what we can do as a country to stop the obesity epidemic. If you ask me, it is voluntary on the large scale – we are complicit in the epidemic if we are not fighting for change.

    Unfortunately, it turned out to be more of a personal attack on the overweight. Sure, many people need a kick in the butt, but telling them they want to be the way they are (i.e. discrediting their emotions) is not what’s going to fix the problem.

    I do agree, Dr. Gratzer, that most overweight people choose to eat poorly. It’s simple mathematics: most Americans choose to eat poorly, and given that most Americans are now defined as overweight, most overweight people in America do choose to eat poorly.

  • http://www.dialdoctors.com Dial Doctors

    I agree with your analysis of the situation. It’s easy to assume that because people have failed then there’s no chance. But people have shown time and time again that even a little goes a long way. Did you read the article on the woman who worked out without even standing up? She lost almost 50 pounds and she’s still going. As doctors we need to believe that even a little goes a long way and truer words have never been spoken than in the fight against obesity.

  • jenga

    Food is only a portion of the puzzle and none of these comments mention exercise. A patient could eat off the dollar menu the rest of their life and if they exercised regularly, they would probably be fine. Activity choices are just as important as foot choices. Everyone wants to come up with the magic food or passive exercise (sketcher’s shapeups) that will solve everything. It doesn’t exist now and probably won’t. Such an event is about as likely as my car someday running on rainbows and smiles. Our diet is far worse than other countries, but so too is our activity level.

    • Leo Holm MD

      I’m not sure any normal person can exercise off malnutrition or the abundance of empty calories corporate food has to offer. We agree, an active lifestyle is important. But too many of the “exercise more” crowd ends up blaming the victim of a truly deranged food system.

  • http://www.brightonyourhealth.com Mary Brighton

    Remembering that 97% of dieters actually lose weight and continue with this weight loss over time.
    During years of counseling clients on how to lose weight, my first words were “are you ready to make significant changes in your lifestyle to have a successful weight loss diet plan? ” Many said, “Yes”, (but too difficult to follow through, we are creatures of habit), Some said ” No, give me a menu that I could follow, that works best for me” (I said I cannot ethically do this, these fad diets and menus rarely work over time).
    Of the 3% who lost weight and kept if off for a long time (2-5 years as a start) it was those who had major changes in their lifestyle, including eating more fruits and vegetables, lighter foods and exercising at least 5 times a week.

    In my experience, I do not feel that all overweight/obese clients are this way “voluntarily”. There are many reasons, both physiologically and psychological on why some are overweight.

    Do believe strongly that children are our future. Resources should be pooled to educate parents, children, pregnant women, school lunch program on eating healthy especially targeting the youngest population with their parents. By ensuring a good, healthy start for babies (including increasing breastfeeding rates), educating families on feeding toddlers, the drinks especially we give kids, promoting an active lifestyle. All these are positive preventive tools to give good waves for these children as adults.

    Mary Brighton
    http://www.brightonyourhealth.com

  • Patricia

    There is no doubt that our sedentary life styles and addiction to processed foods have contributed to the obesity epidemic, but I would love for someone to take on the contributing factor of antidepressant therapy. I am not talking about the atypical antipsychotics, which we know cause weight gain, hyperlipidemia, high blood glucose, etc., I am talking about SSRIs and their companion drugs. I do not think that it is a mere coincidence that obesity and the use of SSRIs have climbed together. I watched my 20-something thin daughter, who was suffering from depression and panic attacks, but never had an eating disorder, gain 75 lbs in less than a year when she started on antidepressants. Back in the 70s, I was given a tricyclic antidepressant and did not have a problem with weight gain. A few years ago, I was prescribed one of the newer meds and gained a significant amount of weight that I have been unable to lose. I would never want either of us to go back to the depression, pain, and panic attacks, but the weight gain is nearly as depressing. Has anyone else seen this correlation?

    • Ann Smith

      During my days of psych med “fun” which are thankfully over, I gained 30 pounds while on Prozac. I was previously thin.

      What was scary was that in spite of not overeating, my weight showed no signs of stabilizing. I literally feared I would look like a house. When I switched to St. Johns Wort, without doing one thing to change my eating habits, I lost all the weight I had gained.

      It frustrates me greatly that people aren’t considering psych meds has a possible contributory factor to the issue of obesity. It is alot easier to blame the patient vs. blaming the meds. Sigh!

  • gzuckier

    and yet, i imagine everybody knows somebody (i have one particular person in mind) who lives on a diet of beef, butter, cheese, and ice cream; to whom vegetable is a dirty word; and who is now hale, hearty, and fit in mind and body at age 90+. and that despite having smoked up a storm when it was still condoned by the AMA.

  • Jackie

    Just thought about another possbile reason for the obesity epidemic.

    From observing the eating and food preparing habits of my In-laws and their children, I begin to wonder if growing up in depression has caused the WWII generation to feed their children the wrong types of food and deprive their kids too much (plus the ‘old-fashioned discipline method) in certain psychological needs.

    My Sister-in-law, the nutritionist I had mentioned in previous post, provides ample food ‘choices’ for her children. She paid for all the piano lessons and gymastic/cheerleading lessons, though none of her kids grow up to be a good piano-player like her.

    None of her children are overweight (at least not yet :)

  • http://rdfeinman.wordpress.com Richard David Feinman

    It may well be a financial epidemic but it’s not corporate money. It’s NIH money. If you want to study low-carbohydrate diets honestly, if you want to find out how much of what Gary Taubes says is true, if you do not set out to trash the Atkins diet, there is little chance that your grant will be funded.

    I and my colleagues will be seeking a dialogue with the American Diabetes Association and are setting up a large clinical trial funded by private donors where all interested parties will participate. In this study, we will write the paper first, that is, indicate possible outcomes and what they would mean, leaving room for the data. No Monday-morning quarterbacking, no excuses. If you want to participate or help in some way, contact me directly (feinman@mac.com). (Whereas the focus is diabetes, the implications for obesity will be evident).

    Richard David Feinman
    Professor of Cell Biology
    SUNY Downstate Medical Center.

  • Mairead

    Funnily enough, the very headline made me think “this guy is a right-wing Libertarian”. And sure enough, I get to the bottom and see “Capitalism can save…”. uh-huh.

    Blaming the victim is a diagnostic marker for psychopathy (currently “Antisocial Personality Disorder”), a pathology that should be more widely diagnosed than it is, especially since the real sufferers are not those who merit the diagnosis, but those around them who become their victims.

    Today, the average person can afford neither a truly healthy diet nor medical care. They lack the money to buy the food or consult the physician, the time to cook from scratch, and the high-quality education that would motivate an appreciation of their position.

    Moreover, few people lead physically-active lives. Most of us sit or stand in one place all day, commute long distances, and are exhausted (for many different reasons) when we finally get home. And we self-medicate to relieve the constant stress created by the realistic fear that we may lose everything at the whim of some corporate autocrat.

    To assert that those factors are inconsequential and that everyone’s obesity is therefore voluntary is the conclusion either of an ignoramus or a psychopath. It’s saddening to see that such a person has an MD credential.