Body Weight, Clash of Ideologies

Doctors understand obesity as a social disease, even if most other people don't.

Few phrases turn me off as quickly as networking lunch. That’s only possibly outdone by networking foodless event. So it was strange that Tuesday morning as the networking lunch grew closer, and I had no exit strategy, I felt fine. I wasn’t thinking of phone calls I could make (or “phone calls” I could “make”), or stairwells that looked like neat places to eat. I was actually a little excited.

Earlier I’d watched the sun rise over Oakland, a mix of nerves and East Coast brain scheduling having landed me in a suit writing notes to my near-future self by 4:30 AM. I was to speak at a meeting of the Institute of Medicine (IOM) on the role of media in obesity. The reputation of the IOM doesn’t extend far beyond health professionals, but it’s an independent nonprofit that “works outside of government to provide unbiased and authoritative advice to decision makers and the public.” And often what the IOM says clearly changes the direction of medical culture. But apart from issuing its definitive reports, the institute hosts intimate roundtables on specific pressing issues. They are essentially brainstorming gatherings, of the sort that bring together academia, government, industry, and advocacy. This week the IOM’s roundtable on “obesity solutions” gathered in the California Endowment high rise, shades mostly drawn in homage to PowerPoint, to dig into questions ranging from the future of soda taxes and colonizing food deserts to roles of school recess, childhood poverty, and family dynamics in weight gain.

“Did you know that chewing gum could increase a person’s metabolic rate by as much as 20 percent?” offered a seasoned ex-government official, as a curiosity, from behind a podium in the corner of the small conference room. Many in the audience, seated actually at multiple round tables, chuckled. Others jotted down a note. Some of them chuckled but also secretly jotted down a note. I’m not supposed to say who did what. Most of what happened in the meeting, I was directed, is not intended for public consumption at this point.

As attention to obesity has increased, soaring national obesity rates seem to be leveling off. In certain places, and among certain age groups, obesity seems even to be on the decline. But it is still a major health issue of our time, involving a third of Americans directly and costing billions of dollars, despite the fact that by some expert accounts, if everyone took in around 30 fewer calories per day, the national obesity rate would be back down to where it was in the 1970s. Why, then, has progress been meager?

Much of it has to do with public perceptions of obesity: either as a purely biological disease of metabolic imbalances and inefficiencies, or, oppositely, as a failing of character. The IOM is increasingly embracing media as a way of conveying an answer to what obesity is, and how it’s really best understood as neither. It is a confluence of the biological, the psychological, and perhaps most importantly, the social.

But I can say that the group was important and eclectic. There was the national health officer from the YMCA, a CDC program chief, the director of the childhood obesity team at Robert Wood Johnson Foundation, the vice president of the NAACP, executive director of the Congressional Hunger Center, the global director of health and nutrition at Mars (yes, Mars, proprietor of Combos, has a director of health and nutrition), a professor of global health from Duke University, a distinguished professor from University of California at San Diego, and on and on. It was all headed up by the attorney and former mayor of Nashville, Bill Purcell. There was no audience, no corporate sponsorship, and no grandstanding; it was just a lively meeting where people came to ostensibly solve obesity.

After the gum-chewing provocation, the speaker dove briefly into the under-appreciated concept of non-exercise activity thermogenesis: burning calories through basic daily activities. Is there a way to make a person into a fidgeter? He said yes, possibly. And that everyone should always give standing ovations for speakers—which everyone duly did, for every speaker, throughout the day. All of this built to the more salient overarching point that, by various metabolic calculations, as he put it, “The notion that people with obesity have decreased energy requirements is untrue.”

I wanted to ask if kids should be allowed (encouraged?) to chew gum in schools. I didn’t interrupt, though I wouldn’t have been alone if I had. When the speaker was midway through talking about the role of adverse childhood experiences like abuse, poverty, and family dysfunction, in determining body weight later in life—a concept well described by Vincent Felitti in 1998 but only now gaining wide attention—a government official stood, reading from a Blackberry, to tell everyone that the department of health and human services had just approved a significant investment in research into the obesity-inducing effects of adverse childhood experiences. Much of the room sighed approvingly.

In another well-received monologue a private-sector executive explained that he had aggregated the insights from a swath of different obesity-prevention programs across the country. Some of the most salient findings involved the “school sector” and the proven importance of integrating physical activity in the school day, improving cafeteria food environments—particularly by limiting junk-food vending machines in schools—and nutrition education, and investing in school gardens.

“Thank you for that!” said a representative of school administrators. “Do you have a copy in writing of everything you just said?”

This was a room where, before anyone stood to talk, it was already well-understood that blaming obesity on poor personal decisions is an extremely reductionist approach. It’s at many levels misleading and has proven time and again to be ineffective if not counterproductive. Yet still, according to a presentation by Berkeley researchers, the most common “solution” that most people propose for obesity is personal behavior change.

Three years ago, an IOM report concluded that the obesity “epidemic”—a touchy and divisive word among this crowd, in part because it technically refers to the spread of a contagious disease, which may or may not be a good way to think about obesity (“crisis” is safer)—has been fueled by an extremely complex and dynamic set of circumstances, in schools and offices, in community planning, in media and technology, in food development, packaging, and marketing. And these factors can’t be divorced from the individual choices they inform, consciously and otherwise.

Still, only 18 percent of Americans identify external factors (like the ubiquity of junk food, lack of opportunities and places for kids to play, et cetera) as the primary causes of childhood obesity. Most people, Colleen Barry and colleagues reported recently in the New England Journal of Medicine, blame things like “overeating,” “lack of exercise,” and “watching too much television.”

Blaming those things is not wholly wrong, just indicative of an incomplete understanding of the problem. These things are better regarded as symptoms than causes. The differences in public understanding of the causes of obesity hew eerily to political ideologies, in ways that, a decade ago, they did not. A breakdown here from Barry, Jeff Niederdeppe, and Sarah Gollust, who also spoke at this week’s IOM meeting:

Who Is Responsible for Childhood Obesity?

Barry et al., 2012 (New England Journal of Medicine)

Gollust made the point that most people agree the national problem of obesity is a serious one. But while 87 percent of people who identify as Democrats believe the federal government should intervene to address the issue, only 27 percent of Republicans do.

That was doubly clear when, over drinks after the meeting, one member who has been involved with Michelle Obama’s “Let’s Move” campaign explained to me how cleanly divided the public is over it. Only about half of Americans support the initiative, even though it is almost as simple and irrefutably positive in concept and implementation as any health initiative could be. Kids: move more. It’s not that people really oppose the idea, the official explained. It’s that they oppose Michelle.

In 1972, economic theorist Anthony Downs described a life cycle for social problems, and it’s one to which obesity seems susceptible. Initially people care a lot, but the sense of urgency fades when the need for public sacrifice and displacement of powerful societal interests becomes evident. (“I strongly agree that you should feed your kids less and exercise them more, but I also strongly disagree that I should pay to build public parks and create safer neighborhoods, or compromise my access to giant, giant sodas.”) Prolonged exposure to the idea leads to politicization and polarization that compound inaction.

In its report three years ago, the IOM called for public awareness to catalyze change, through communication campaigns, grassroots community mobilization, cross-sector advocacy, and political champions. This week the vibe was much the same. These are spaces where doctors are not trained to perform, but where doctors can do a world of good.

Almost inevitably when I tell people that I’m no longer practicing radiology, they say something about what a big decision it must have been to “leave medicine.” But no one at this meeting said that. Of course what I do now is in no way intended to replace any traditional medical structure, the importance of a personal relationship with a physician, but I feel increasingly less like it’s accurate to say I left medicine. Daily inroads are small, but in sum, messages from the media are critical. Do we in media depict obesity as a personal affliction, a moral failing, or a social disease? And how do those depictions change the way people feel about governmental policies? The current consensus seems to be that obesity can accurately be regarded as a disease, but as a biopsychosocial one.

When the networking lunch finally came, it did go fine, I thought. But that’s not to say it was without confrontation. Near the end, a man in a blue blazer kneeled down beside my chair and asked me, with some urgency, why media outlets insist on publishing undignified images of fat people.

“Why do you cut off their heads?” he asked, referring to a trend that’s been called out on various blogs, termed “Headless Fatties.” It’s where, in a story about obesity, an article will include a photo of an overweight person devoid of head. Typically the person is in an unflattering position, incompletely clothed or in clothes that are too small, and often doing something unhealthy. An optimistic explanation might be that outlets are trying to illustrate obesity using stock photos without identifying a single person—it’s not an overt attempt to dehumanize, though it does come off that way. But Yale University's Rudd Center for Food Policy and Obesity recently found that 72 percent of news stories on the websites of CBS, ABC, MSNBC, FOX, and CNN depicted overweight people in a “negative and stigmatizing manner.”

“There are better ways to illustrate obesity,” the concerned man said, still concerned. It’s these subtle messages that slowly build a public perception that influence policy. The Rudd Center, among others, has an open-access database of photos of overweight and obese people intended to minimize stigma. The images show people not languishing on couches, but out walking in parks and at grocery stores choosing judiciously among the produce. The people look happy and real, as people are. They are neither victims nor offenders. They make good decisions and bad, as all people do, in every case inseparable from the context in which those decisions are made.