We're Not Fat Because We're Lazy

David L. Katz

You, of course, know that obesity is epidemic in the United States among adults and children alike. You would have to be living under a rock not to know at this point!

But why, exactly, are so many of us fat? Those who rant loudest and most emphatically about personal responsibility have an answer: It's your fault. We are fat because we are irresponsible.

I have some trouble with that, as, apparently, do some of my Eat + Run colleagues. For one thing, we have no scientific evidence--none--that the current generation of adults in the United States has less personal responsibility, self-control, or willpower than every prior generation. Since we DO have more obesity than every prior generation, if personal responsibility is the explanation, then we must have less than all other humans throughout history. It's possible, I suppose--but we have no evidence.

Maybe you just want to go ahead and believe that we are the greatest generation of lazy, gluttonous, slackers in history--and that's why we're fat. Well, then, what about the 7 year olds? And for that matter, the 5 year olds? And the 12 year olds? Because they, too, are fatter than every prior generation. Are we inclined to blame epidemic childhood obesity on some rampant decline in personal responsibility among kids? Not only do we not have any evidence to support this--it just doesn't pass the sniff test! Kids are the same as they ever were. If their health has changed, it must be because of changes in the world around them. We can extend similar thinking to adults.

Yes, personal responsibility does matter--how each of us uses our feet and forks each day is, to a large extent, up to us. And even if the path to health were well-paved through our culture (it is anything but!), each of us would still have to walk it; we can't expect to be carried.

But the world we live in exerts a massive influence on our behavior, no matter our responsibility level. Perfectly responsible people living in the Sudan can starve, despite responsible efforts to get enough to eat. Perfectly responsible people living in the U.S. get fat, despite responsible efforts not to.

Everything that makes modern living modern is, to one degree or another, obesigenic. And responsible or otherwise, the simple fact is that our species has no native defenses against caloric excess or the lure of the couch, never having needed them before. Throughout most of human history, calories were relatively scarce and hard to get, and physical activity--called survival--was unavoidable. Today, it's the reverse: Physical activity is scarce and hard to get, and calories are unavoidable. Aspects that have traditionally defined responsible adulthood--making dough, being bread-winners, bringing home the bacon, and inventing labor-saving technologies--are suddenly part of the problem.

What we're all up against--in our efforts to find health--may be likened to a flood. A vast, obesigenic flood. A flood of highly processed, energy-dense, nutrient-dilute, hyper-palatable, glow-in-the-dark, betcha'-can't-eat-just-one kind of foods; a flood of marketing dollars encouraging us to eat ever more of the very foods that propel us toward obesity and chronic disease; a flood of gadgets and gizmos that do all of the things muscles used to do; a flood of agricultural policies that subsidize corn to fatten cows rather than vegetables and fruits to vitalize people; a flood of obligations that leave no time for attention to health.

There are only two ways of dealing with this: build a levee to contain the flood and turn the tide, or captain a ship (or arc) across the floodwaters. One is all about us; the other is all about you.

Let's consider both.

The anti-obesity, health-promoting levee would be comprised of a comprehensive array of programs, practices, tools, resources, and policies that would make eating well and being active the path of least resistance; a comprehensive counter-measure against the obesigenic flood.

We could make everyone a nutrition expert by displaying an objective, evidence-based, at-a-glance measure of overall nutritional quality wherever people and food come together, thus closing every loophole to marketing deceptions. We could build from there, and attach to such a metric a system of financial incentives that would "reward" nutritious foods by lowering their cost. The incentives could be paid by the entities that currently pay the costs of disease care--insurance companies, large employers, and the federal government, say. Incentivizing healthful foods costs a lot less than bariatric or coronary bypass surgery.

We could make physical activity a readily accessible and routine part of everyone's day at both worksites and schools--with programming that embraces the time-honored adage "sound mind, sound body." Little by little, we could modify the environment so that as neighborhoods grow, evolve, or begin, we'd restore the options for person-powered transportation we once had, such as walking and biking to school and work. We could, and should, change agricultural subsidies so they are less about sustaining giant factory farms, oceans of corn used to fatten cattle, and the status quo--and more about growing the vegetables and fruits most likely to promote the health of people.

Every school could, and should, teach children and their parents the skills required to identify and choose more nutritious foods. Every cafeteria could be designed to encourage, without forcing, better choices. School food standards should be unimpeachable--and a slice of pizza should not qualify as a serving of vegetables!

Businesses could adopt schools (as they now adopt highways) to provide the resources required for state-of-the-art, health-promotion programming that would allow parents and children to achieve health together. (We are otherwise unlikely to do so at all.)

Food marketing to children can, and should, be regulated. Not because we want government telling us what to have for breakfast, but because highly paid executives on Madison Avenue versus your 6 year old is NOT a fair fight! There is no reason why highly trained, highly paid, and very clever adults should profit from talking young children into doing things likely to make them chronically ill. It is, in fact, unconscionable.

We could ensure that all clinicians be trained experts in lifestyle counseling, thus serving as effective agents of health-promoting behavior change.

We could do all of this, and more, until the 80 percent of all chronic diseases we know we can eliminate are actually eliminated. This, in brief, is what building the levee could look like. Chronic health could replace chronic disease. And the burden of making it all happen wouldn't rest with you, or me--but with all of us. The best defense of the human body resides with the body politic; it takes a village to raise a levee. The Institute of Medicine's report this year, "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation," says much the same.

But on the other hand, I wouldn't just keep waitin' on the world to change, if I were you. Powerful elements conspire every day to slow down the levee building--or, if they have their way, to preempt the project altogether. Victory will be take time and be hard won--and you or someone you love could be a victim of the obesigenic flood long before.

Noah showed us the alternative. If you are stuck dealing with an unprecedented flood, you need a vessel to ride it out. In Noah's case, the flood was divine retribution. In our case, it's of our own devising. But the need to deal with it is the same. Noah needed, in short order, to learn carpentry and sailing. For us to ride out the obesigenic flood, we too need skills: for eating healthfully in spite of it all, and for fitting fitness into your crazy modern routine. This may sound daunting, but honestly, it's a lot easier than managing diabetes you didn't need to get, or dealing with chronic heart disease, or the aftermath of a stroke or cancer diagnosis. Those really are the stakes here.

If we're committed to shielding our families from the crisis all around us, we must commit to acquiring the skill set for healthy living. Unlike the flood Noah confronted, we caused this one--and we can contain it, so no one else--no next child, drowns in it. We can, and we should. That's the case for building the levee.

But we're not there yet, and you may not want to gamble your health or that of your child on the waters receding fast enough. In a sink or swim scenario, it's not a moment too soon to learn to swim--or to get the skills you need to build and sail your family's health across this restive sea.

Hungry for more? Write to eatandrun@usnews.com with your questions, concerns, and feedback.

David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.