Fat City

The public health perspective on obesity is actually quite well developed by now, but that doesn't mean we have good answers. Let me respond to some comments and then expound a bit from my own point of view.

Revere at Effect Measure is obsessed with influenza, for some reason. Obesity is certainly associated with respiratory difficulties, including obstructive sleep apnea, in which people repeatedly wake up during the night because they stop breathing -- often without knowing that it is happening. Since the cardio-pulmonary system -- the whole set of functions that gets oxygen to the tissues -- is already stressed in obese people, obviously any respiratory infection -- and I don't know why you'd single out flu particularly -- is going to be more difficult to deal with and more dangerous.

Bix is 100% right -- obesity is clearly strongly socially determined because the prevalence varies dramatically across time and place. It is meaningless to assert that the current epidemic in the United States is "caused" by a sudden, spontaneous deficit of self control or responsibility.

Addressing obesity as a problem in social epidemiology is greatly complicated by the cultural issues people have raised. Sadly, there is a stigma associated with obesity. We currently have a prevalent aesthetic that strongly prefers very lean bodies, especially in women; and what is worse, many people view fat people with moral disapproval or presume their condition is their own fault. Fat children are commonly ridiculed and bullied, and there are all sorts of cruel jokes that people tell about fat people. The National Association to Advance Fat Acceptance addresses body diversity as a civil rights issue, and combats both discrimination and prejudice.

Unfortunately, NAAFA can go a bit too far in denying the demonstrably real negative health effects of obesity. It may be a defensible stance that since obesity is often intractable, we should look for ways of promoting the best possible health among the obese rather than focusing solely on weight loss; but it simply isn't honest to deny that people are better off without excessive adiposity. Sure, the conventional standards are set too low -- there is growing evidence that people who CDC classifies in the "overweight" category aren't really at great risk, especially if they exercise and maintain good cardiovascular fitness and blood lipid profiles. Yo yo dieting and fad treatments are worse than just staying fat. Stigma, moral disapproval, and discrimination just compound the ill effects of obesity and actually make it harder for people to control their weight.

But -- obesity is bad for your health. We're talking osteoarthritis, diabetes, heart disease, stroke, sleep apnea, limitations of mobility and stamina, and shortened life expectancy - a whole lot of problems, and as we discussed yesterday, a substantial burden of medical costs. At the heart of the cultural challenge of getting people to see obesity as an affliction rather than a personal failing is our deeply embedded, and faulty, view of free will.

Eating is not simply a choice. It is a fundamental drive that does not originate in the cerebral cortex, the seat of consciousness and planned behavior, but in the oldest parts of the brain. Most people are as helpless to override this as they are to stay awake for a week straight or to force themselves to die of thirst.

Next: The etiology of the obesity epidemic: political, economic, and social dimensions.