I was recently invited to speak at a conference in what is likely the nicest hotel I have ever set foot in. Partially hidden by an array of palm trees and adjacent to a golf course, I could easily see why the conference rate was $350 per night. Before making my way to the conference room, I paused in the dining area to go over my slides one last time and work on the timing of a few quips: “This is my first time in Scottsdale, and I have to say that this hotel is pretty much what comes to mind when I think of the Garden of Eden, only it’s the price that makes the fruit forbidden.”

As I looked to my left in the dining room, I saw a man in his mid-40’s with a svelte wife and two healthy-appearing children under the age of ten wearing clothes worth more than my suit. For our purposes, I will call the man Will and the children Catherine and Graham. The family enjoyed a nutritious breakfast complete with fruit and vegetable-based dishes and low-fat options.

I contrast this situation with an encounter I recall from the neighborhood of my upbringing. Waiting in line in a convenience store, I witnessed a woman in her late 40s tell a group of 5 sibling grandchildren to get what they wanted for an afternoon snack. Hurriedly, they grabbed from a shelf with packaged 500-calorie foods, namely powdered sugar donuts and honey buns. With a smile on her face, the grandmother paid for the snacks using a debit card issued to her by the state for nutritional assistance. The nearby mother of the children (not quite 30) commanded that the kids say, “Thank you to Grandma” before purchasing a pack of cigarettes and a few lottery tickets using her own cash. I will refer to this group as the low-income family.

The low-income children are clearly wired into the physiologic drive that is producing childhood type 2 diabetes (formerly called “adult-onset diabetes”) at alarming rates. Over recent decades, rises in the insulin resistance that produces this condition have undoubtedly been linked to changes in the way we eat.  The way I think about this condition is that it results when the pancreas and liver have encountered the amount of sugar that was intended to take place over a lifetime which makes these organs literally exhausted and unable to respond to more sugar. While this seems like it would result in permanent morbidity, luckily, insulin-resistance is often treatable through diet.

Catherine and Graham benefit from a childhood that I never knew. The only way I would have gotten into their hotel as a kid is if I would have jumped the fence to break into the pool. The $350 nightly fee was more than my family’s monthly house payment when I was their age. My family worked extra hours cleaning a medical office building to save enough cash to afford much more meager annual vacation experiences. Catherine and Graham will likely have college subsidized for them if they choose to go, and they will mostly likely attend high school among peers who value academic excellence. Their health will undoubtedly be affected by the culture around them.

The need to marry socioeconomics, public health, and medical care is long overdue.

Doctors get very little education in nutrition let alone the forces that result in the health crises more omnipresent among the indigent. I do remember looking around my lecture hall in medical school one day to observe what everyone was drinking, and I don’t think a single medical student was drinking something with calories in it. In other words, this very successful subset of individuals had obviously been conditioned to a healthier lifestyle.

In the meanwhile, efforts at intervention are hindered by arguments from both conservative and liberal ideologies. On one hand, we heavily value the freedom to make ourselves ill with food and other substances if we choose to do so. On the other hand, we run the risk of “fat-shaming” people who are larger. While I am sure, every doctor champions the pursuit of sound psychological health and positive self-image, am I wrong to teach people that weight control will lead to decreased heart disease, pre-cirrhotic liver conditions, kidney failure, and cancer? In a health system that guarantees care for life-threatening consequences of undiagnosed maladies, why are we so centered on the pound of cure rather than the ounce of prevention? I haven’t even touched on the issue of those kids on the opposite end of the spectrum who endure daily hunger.

While I do not possess expertise regarding cultural/racial trends related to this issue to comment more fully, I can tell you that Will’s family is one of color. As for the low-income family presented above, I see them every year when I go home for the holidays. Needless to say, the term “all-you-can-eat” buffet is a concept that I regularly put to the test as a child, only I still pay for the low monetary cost of such dining experiences over and over again into adulthood.

For those interested in the topics of wealth inequality and spiraling health care costs, I posit the following scenario. If there are five disadvantaged children in the home of a young parent, and those five children fail to break free from poverty, and each have five children shortly after achieving reproductive maturity, there is a propensity to have a cluster of 25 disadvantaged kids. The original young parent may have a sibling who developed a career before having kids and may only have two children the same age as the other sibling’s 25 impoverished grandchildren. If the “job creators” out there can’t find work for those who start life behind the proverbial eight-ball, the cycle spins out of control.

While giving my speech at the conference, I saw Will among my audience. Will is a radiologist, too. He told me during a break that he liked my talk (not just the bad jokes), and we discussed collaborating on a project regarding health services research.

Contemplating situations like the above made me think about my own behavior. A child in front of me in the cafeteria line yesterday could not afford his slice of pizza, so I bought it for him, but I made him take my apple, too. The concept of “forbidden fruit” should not apply to childhood nutrition.

Cory Michael is a radiologist.

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