Human Limits

A couple of weeks ago I floated the idea that for many problems facing the world a sort of collective grieving process is going on. In this post I want to pick up on that theme again as it applies to obesity. In general, for obesity I believe we have mostly moved beyond denial and are now “bargaining” about what to do about obesity both as individuals and society as a whole.

Costs of Obesity

Last week the big consulting firm McKinsey released a report on the global costs and consequences of obesity and what to do about it. Incredibly the report put the global costs of obesity at about 2 trillion dollars per year. This is about equal to the global costs of smoking and also the global costs of “armed violence, war and terrorism”. The report concluded that no single action is likely to solve the problem but that a range of policy options might work. The chart below is an example of what various anti-obesity interventions might do to obesity related years of life lost in Britain. My guess is that similar calculations would also apply to the U.S. and most countries where obesity is a serious problem. Of note I see at least three things missing from this chart:

1. Taxes on high calorie foods or sugar sweetened beverages
2. Higher insurance premiums for obese individuals
3. Re-engineering the built environment

Denial Not Gone

At the same time the McKinsey report was coming out, the U.S. CDC was being pressured to take down a website called “lean works” that included an obesity “cost calculator”. The concern was that such a tool might lead to workplace discrimination against obese individuals. So, perhaps denial that obesity is a problem and that something needs to be done about it is not totally gone.

Who Stays Lean?

Last month I was giving a talk in Denmark about what to do about physical inactivity and obesity. The talk was to a group of health care professionals who were uniformly lean and fit. Being Danes, many ride their bikes to work. So, at some level I was preaching to the converted. What occurred to me as well during the talk was that I was also talking to a group of highly educated people who all had a suite of behavioral characteristics that let them control their current behavior to prevent a future undesired outcome. In other words these people all had a sense of delayed gratification and conscientiousness. These traits likely permitted them to adopt and adhere to “healthy” lifestyles and remain lean in an obesogenic world. From what I can tell only a modest fraction of the population has a high level of these behavioral traits and skills. So what do we do in a world where so many people have so much trouble with what might be described as “self-control” and personal responsibility?

Beyond Personal Responsibility?

This brings me to the built environment and other big picture interventions to address the obesity and inactivity problem. The next chart shows how the battle against infectious disease was largely “won”. A lot of this had to do with things like sewers and clean water supplies. In other words, basic sanitation and civil engineering vs. medical care or medical interventions made a big difference.

When big, dirty and disease ridden cities were being re-engineered and rebuilt in the 1800s and early 1900s, no one was telling the general public that clean water was their “personal responsibility”.  Instead slums were cleared and sewers and water works were built and things like cholera epidemics stopped. That having been said, I wonder how many people in today’s world would consistently boil their own water over days, months, and years in the absence of reliable clean water supplies. My guess is that over time only the most conscientious people would do it. At some level our current world is just as toxic and maybe larger scale interventions are needed.

Going Far Enough?

I applaud the McKinsey report, but does it go far enough? My guess is that many of the food policy recommendations will likely work if they can ever be implemented in a comprehensive way. However, I also have serious doubts about whether that can be done. I also believe (as cigarette taxes have shown) that humans are price sensitive and that economic tools have to be part of the solution to the obesity problem. There also probably needs to be a serious discussion about how car “unfriendly” the world needs to be if we really want to make a dent in the inactivity element of the obesity epidemic.  It is hard to imagine that our physical world might be redesigned in a way similar to what happened in cities 150 years ago, but perhaps it will happen. There are innovative proposals on the table in London to promote more bikes and fewer cars.

None of this will be easy, but the partial success of the anti-smoking movement in some countries shows that over time it is possible to change bad societal habits, but it takes more than simple personal responsibility.   So let the bargaining begin!