Sunday, August 21, 2005

Making Excuses for Obesity

The most important advances in human medicine either help people avoid becoming ill, or bring hope to those who are already suffering. Some of these advances, such as new drugs or new medical procedures, make headlines. Others, such as teaching care-givers to wash their hands, or recognizing dietary deficiencies and correcting them, are generally unheralded, yet have had far more impact on human health than all of the drugs and devices ever invented. So, imagine the impact if we were to discover a simple, painless and effective way to treat cancer, something that didn’t require doctor visits or toxic drugs. Is there any question that millions of cancer patients and their families would embrace such a development with joy and relief?

We are still waiting for such a development for cancer, but for another major medical crisis, obesity, the answer has been known forever. Having bullied us into officially calling obesity a disease, why is it that fat people don’t seem to want to hear good news? Tell them that the solution to their illness is simple—better diet, more exercise, less sitting around—and they typically react with anger, indignation, or resignation. They retort that we are just “blaming the victim”. Many of them prefer to wait for a medical fix, and they rationalize their inaction by claiming there is no other hope. The question, then, is: Does medicine offer that hope?

There is only one medical treatment that reliably works today: bariatric surgery, or stomach stapling. It is a gruesome, painful procedure. Recovery times are long. It has a high rate of fatalities compared with other kinds of surgery. But it works!

How does it work? By reducing the volume of food people can eat. Nothing more, nothing less. So the great irony of bariatric surgery is that it it actually proves that the root cause of obesity is how, or how much, people eat. It is tragic that many people would rather risk being butchered on the operating table, than manage their own behaviour more effectively. The problem is that lots of "experts" have been telling them the problem is beyond their control.

There has been a surge of interest in obesity research, evinced in recent years by a stream of major stories in Time, Business Week, etc. about the “fat epidemic”. These stories all weave together some combination of recent research into genetic explanations (“thrifty genes” etc.), and environment (eg. fast food, supersizing, automobiles, and television). The gospel of the day, “thrifty genes”, runs as follows: “Your ancestors evolved over thousands of years of lean times, to store fat in case they might starve one day. Now those genes are working against you. So it’s hopeless—you can’t help that you’re fat. It’s in your genes!” Instead of taking charge of our lives, we rush, with overt gratitude, to embrace these theories, which essentially take away our hope.

The problem is that, while all this is all very plausible and reasonable, and, in a narrow sense, scientifically accurate, it is also intellectually dishonest, because it ignores the most important, most obvious fact about rates of obesity in our societies: they are increasing. Researchers all agree on this fact. Three generations ago, there were few fat people; today, most of us are fat.

Now, there is no evidence to suggest that only people with “fat genes” bred during the past 100 years. Therefore, we have essentially the same gene pool as our ancestors. Therefore, genes cannot explain the worldwide increase in obesity. Yet, scientists who know these facts ignore them in order to pander to the growing population of the obese, and to the food industry. In fact, more and more of this research is being funded by companies in the food industry. They have a huge interest in fostering our delusions: It relieves them, and us, of responsibility.

Is our environment the explanation? To listen to some “experts”, it is. And, in a narrow sense, they are right—our environment is toxic. But they take it too far, pretending that we are completely passive recipients of that environment. A behavioral geneticist, who should know better, is quoted in US News as saying that it is not the fat person’s behavior that is the problem, but his environment. Really? Then why is it that there are people who have different outcomes? There are still some people who walk past McDonalds repeatedly without going in and ordering. Yes, our environment is toxic, but it takes certain kinds of choices to succumb to it. Those who make different choices tend to be less fat. Is that such a surprise?

This is not an apology for fast-food chains, advertisers, food mass-marketers, or any of the other culprits who have created our toxic environment. To the contrary, they may have to be hog-tied if we are going to have a realistic chance to reverse the epidemic of obesity. They are desperate to shift unwelcome attention from themselves onto other targets, such as our genes. They have fought every attempt to educate children about healthy eating. That, right there, is presumptive evidence that eating their products is the problem.

This only reinforces the proof that the solution is, of course, to change behavior. McDonalds does not kill us by forcing us to eat. It kills us by persuading us to eat. Why let ourselves be persuaded? For a fraction of the amount invested in research on the genetics of obesity, we could truly blanket our schools with positive food messages. (Heck, if some of that funding were to go directly to schools, it would solve the budgetary shortfall that has compelled many of them to sell promotional rights to Coke and Burger King.) And if we are going to go after the food companies directly, we must go after their advertising. Making them hang calorie charts in their stores is a joke.

A major part of the problem in trying to educate people, is that it has become all about blame. Fat people are desperate to be told it is not their fault. We have a growing industry focused on relieving people of blame without helping us fix the problem. That industry doesn’t want us to focus on the answer, but we don’t have to be suckered. We must find ways to reach people that get away from “blame” but still deliver the core message: The solution is largely in our own hands. If we behaved more like our grandparents, very few of us would be fat. Meanwhile, as long as we choose to fall back on explanations that rob us of control, we will keep getting fatter.

Thursday, August 11, 2005

Playing Chicken with Iran

Let's make no mistake about it: we don't want Iran to have nuclear weapons. But the main reason is not the one we are led to focus on. Iran does not, and will not, pose a threat directly to the U.S. In fact, it is unlikely Iran has any intention of initiating a nuclear exchange, even with its neighbors. The truth is, Iran sees its nuclear ambitions in much the way France did in the 1950's: as a deterrent. France developed its nuclear "Force de Frappe" as a deterrent to Soviet aggression. They never deluded themselves into thinking that they could win a nuclear war--their goal was purely to have enough punch to deter the Soviets from launching first. The same is obviously true of Iran, despite all the hot-head rhetoric from its President. Let's not forget that he has little power in his own country.

Wednesday, August 03, 2005

How can it be?

Whatever you think of his other policies, the President's attitude toward science is a threat to this country. He persists in his dogmatic refusal to allow funding of stem cell research, and he announced yesterday that we should put creationism (disguised as "intelligent design") on the same footing with science. Obviously, the vast majority of people, on both sides of the debate, do not have the scientific training to carry the argument against someone with such training. So it is not surprising that a lot of ordinary joes believe creationism may be intellectually legitimate (just as many who believe evolution probably aren't sure why.)

But the leaders of the pro-creationism movement, the ones who have hauled out pseudo-scientific arguments to attack science, know perfectly well what they are doing, and a lot of them are knowingly dishonest. The unfortunate thing is that our president is apparently among those who believe the creationist propaganda. I'm all for our leaders being cut from the same cloth as the rest of us, but in our era, when science has so much power in our lives, shouldn't our president at least have a clue?

Tuesday, August 02, 2005

Vioxx: Everyone loses

I've been despondent for weeks over this. We should not have lost a drug this good because its sponsor, Merck & Co, were a bunch of unethical jerks. We should not have lost it because a zealot at the FDA decided that sacrificing the people who need Vioxx was worth it to punish Merck. We all lost. I know I am not the only one for whom this drug was a godsend. The risks were tiny, even after all the revelations of data suppression. So what if Merck screwed up? The proper solution would have been 1) to require a "black box" labelling, to let us, the patients, decide what kind of risk to take, and 2) to punish the dishonest executives personally, and perhaps to fine the company. Instead of punishing the liars, we let them off and punished the shareholders of the company.

It is symptomatic of our all-or-nothing society that no one was able to come up with a solution that didn't involve throwing the baby out with the bathwater. It's disgusting.