Saturday, December 13, 2014

Is Obesity more like Crime, Cigarettes, or Sex?

Obesity is a massive problem.  35℅ of America is obese.  Democrats are worried that their prized social welfare programs will collapse under the weight of the problem.  Republicans are worried that they will only be able to invade 1 country every 8 years, as the military finds itself forced to accept increasingly sluggish recruits.  Regardless of how you look at it (and how many puns I can make), this is a serious issue.  But how to frame it makes a massive difference in what tactics and tools it makes sense to pursue.

The traditional approach is one of blaming/encouraging the individual.  Quite simply, people choose to eat, and it makes them fat.  Thus, fat kids and adults are to blame for their obesity and can choose to stop doing so by eating less.  This was (and maybe still is) the favorite tactic of gym instructors everywhere, and needless to say it doesn't work at all.  Personal responsibility is the approach that society takes towards crime.  Whether or not it is successful is up for debate but still- we hold that committing crimes is an individual choice, and (try to) punish all those who commit them.  Year after year, proposals are bandied about to adapt this approach to solve obesity.  One idea I've heard is to weigh people and set their tax/insurance rate when they apply for their driver's licenses.  Needless to say, for a variety of sound reasons (poor people are disproportionately obese, lack access to healthy food, and would be hurt by this tax; massive incentives to cut weight right before the weigh-in time) this proposal is shouted down wherever it is made.

A diametrically opposite approach is espoused by Dr. David Kessler MD, former commissioner of the Food and Drug Administration.  He has spoken at length about how the problem should be viewed as analogous to the fight against the cigarette industry.  In his view, the problem is that a high salt/fat/sugar diet results in a suppression of the brain's normal cravings, and dishes with these ingredients are purposefully and scientifically created by the food industry to addict Americans.  The obvious solution?  Regulate the food industry and force them to limit the amount of fat/salt/sugar that they put in foods.  Limit food advertising on television.  Ban Big Macs for anyone under 18 (I jest, but only slightly).  Basically treat food like a drug.  This approach has the advantage of being something that might actually work.  On the flip side, we'd have to overcome several billion dollars of food advertising to get it implemented.  However, this approach is what ultimately took down the smoking problem in America.  Far fewer Americans smoke than Europeans, and for decades American public health officers have made slow but steady progress to reduce smoking rates.

But this view has an important flaw.  Smoking has no positive effects.  It is a total and unmitigated evil that no one should do.  Eating however is critical to life.  It is linked with many basic biological drives and motivations.  This is why attempts to develop drugs to stop hunger pangs run into massive problems: the drugs we know that affect appetite end up affecting everything else.  Amphetamines like phentermine, the only effective FDA-approved appetite suppressants we have, are very very bad to take long term, as they can easily cause addiction.  Meanwhile, varenicline (Chantix) is prescribed like candy to reduce tobacco cravings if a smoker is trying to quit and needs help.

But what's another approach to the obesity problem?  How about sex?

Up until the late 1800s/early 1900s, sex was dangerous.  Sex could result in pregnancies, which often ended terribly in a number of ways.  Dying in childbirth was still not particularly uncommon.  The more children one had, the greater the risks.  Sex also resulted in rampant spread of STDs, and thousands of women died of attempted home abortions of babies they didn't want. Public health advocates, the clergy, and politicians pushed for abstinence- it was all they could do, and really it was the only available option ineffective as it was.

What changed?  Technology.  In the 1960s, reliable and effective hormonal contraception was introduced for women.  Condoms gained in quality and reliability while dropping in price- and became legal.  As a result, the epidemic of STDs abated, and abortions and pregnancies dropped dramatically.  In effect, a technological innovation allowed people to have sex freely, without suffering the negative health consequences of promiscuity.  While to this day, abstinence programs are promoted by the more conservative (and deluded), the evidence is clear that they do not work and that it is better to teach methods of contraception if we want to cut down on the spread of STDs and reduce teenage/unmarried pregnancies (and abortions).

So, what is the take-away point?  If regulating the industry is unlikely to ever take place, and individual incentives like taxes and fines aren't going to work, why don't we go big or go home?  Let's design an implantable device that will literally filter fat, sugar, and carbs from our blood.  Our goal should be to let people to eat whatever they want without consequence- just as they can now have sex with whomever they want without consequence- or at least public health consequence anyway.  (It is interesting to note here that the only proven weight-loss technique on the market with long-term efficacy remains surgery- gastric bypass, though it has many risks)  This holy grail device is what our funding and efforts should be directed to- not ineffective dietary and motivational campaigns that are the equivalent of abstinence-only sex-ed programs.  I know many will be upset and dismayed at the thought of implanting a device into everyone in America- but think of it as the modern equivalent of a vaccine: a medical procedure that prevents diseases that arose as a result of humanity living in such close quarters (as opposed to the hunter gatherer society from which we arose).  We now live in an era with an abundent availability of food that our ancestors 10,000 years ago could never dream of.  At this point, I don't see any other viable solution than to strive towards a device that will let us indulge in a basic human function with less consequemce.