It takes a thin village by mattsteinglass
October 14, 2009, 5:03 am
Filed under: Health

Heather MacDonald argues that the idea that the health care system should focus on prevention is nonsense because

Prevention lies overwhelmingly within the realm of individual behavior, but our modern reflex of transferring agency from favored victim groups—in this case, millions of artery-clogged, waddling Americans—onto less-favored entities guarantees that we see the problems of Fat America as the failure of doctors to practice the right kind of medicine.

Well that’s sure wrong! Prevention lies overwhelmingly outside the realm of individual behavior. For instance, basically none of the foods we eat are prepared by our individual selves. We’re either eating meals that were cooked by a family member for our entire family, or meals that were prepared by a restaurant or cafeteria, or we’re eating snacks that were made by companies and sold by corporations. In rare instances, we may be eating a piece of fruit, or something we cooked ourselves from scratch, and in that case prevention really does lie within the realm of individual behavior. But that’s pretty uncommon.

To put it more clearly: the amount of healthy fruits and vegetables we consume is largely predicted by our socio-economic class. In what sense is this “in the realm of the individual”?

Similarly, how much exercise we get during the course of the day is pretty much determined by the transportation layout of the neighborhoods and conurbanities we live in, which, unless we’re named Robert Moses, we probably didn’t individually shape. How much particulate matter we breathe is determined largely by regional power generation and transportation choices and government rules. And so forth.

Ah, but there’s no way for society to intervene to make a purposive change in those sorts of things! Except of course for how public anti-smoking campaigns and taxes have slashed the rate of smoking to less than half what it was in 1965. Was that “in the realm of the individual”? Or how when France instituted a nationwide campaign to stop the rising rate of child obesity through school-based monitoring and exercise and diet interventions, it, well, stopped the rising rate of child obesity. At a level less than 1/4 that in the US.

Scotland is adopting the French small-town anti-obesity program, known as EPODE. But we can’t do that because…what’s the conservative/libertarian argument again? That Americans are stupider, less disciplined and naturally fatter than French people? Or something?


10 Comments so far
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Matt- Have you read Kelly Brownell’s argument about the default option? He recently presented data about organ donation in Europe versus the US that I think would sort of blow the roof off. But its a strong case for changing the “default options.” Not unlike Emmanual’s argument in JAMA about how participation in biomedical research should be the default -everyone benefits from the results, everyone should participate. Not sure it would be convincing to those who dont like taxes. But it does all make your eyebrows go up.

Comment by joannasmd

The libertarian position is pretty simple. It’s not that we can’t do it. Obviously we can–we create programs all the time in an effort to control people’s behavior (although I prefer not to say “we” since the people behind these social engineering schemes have never asked my opinion on them). It’s that we shouldn’t do it–because we’re not here to serve the interests of “society,” at least not as defined by some government busybody. And because it’s oppressive and demeaning to adults in a supposedly free society to be constantly nagged about what they should and shouldn’t be doing.

Comment by Joe Ermigiotti

Joe, trying to convince someone to change his ideology never works, and I could respond to you with some kind of deceptively nice response that tries to build common ground without addressing the basic thrust of your comment. But I’m not going to do that, because the fact is that I disagree with your entire ideology. You write: “we’re not here to serve the interests of “society,” at least not as defined by some government busybody.” This is false. “We” build highways. This entails the government deciding that people should be driving cars rather than taking trains or bicycles. “We” have mandates for parking availability, building height and density, business vs residential zoning, and on and on. The government regulates everything about the way that neighborhoods in the US can and can’t be constructed. And it could not be otherwise, in a modern society. The question is whether the government should continue shaping neighborhoods and transit systems such that they make Americans fat, or whether it should instead shape neighborhoods and transit systems such that they keep Americans fit.

As for childhood anti-obesity programs, these are carried out in institutions called “public schools”, where government officials are paid to hector kids all day long in order to instill various moral and aesthetic precepts: belief in multiparty democracy, respect for the flag, discipline and hard work, and even, if the kids happen to play on the basketball team, precepts about diet and exercise. The question is whether some of the government officials in those institutions should also be monitoring kids’ weight and teaching them how to eat and exercise to stay fit. The evidence is that it works. You may think schools shouldn’t be trying to keep America’s kids fit and teaching them habits that will keep them healthier and fitter in later life, but that’s an arbitrary belief; there’s no principled reason why schools should teach homework discipline but not fitness discipline. Certainly traditional schooling has always taught both.

Comment by Matt Steinglass

You asked what the libertarian position on the issue was. Now, maybe you didn’t mean for the question to be taken seriously—maybe you just wanted to mock libertarians as just a bunch of mean-spirited contrarians—but I thought I’d take a shot anyway. At any rate, I don’t see how my comment could be viewed as a “deceptively nice” attempt to change your ideology. But even if it was, so what? Isn’t the point of debating political issues to change the other person’s mind? If not, then why bother?

As to your other points, yes, we have all kinds of rules and regulations covering just about every aspect of our lives. But we’re really talking about the government here, and I don’t think the average citizen’s input is significant enough to make “we” anything but a meaningless abstraction. Contrary to what we’re taught to believe by the media and our “educational” system, the government is essentially a racket—a handful of elected “representatives” pass laws that primarily benefit the well-connected financial interests who fund their campaigns, and the rest of us get the privilege of paying for the results. I also don’t buy your assertion that we couldn’t possibly have a functioning modern society without a strong central government. I see no reason to believe that people couldn’t shape their own neighborhoods in whatever ways they see fit, without having to kneel before the local board of petty tyrants to see if they’re allowed to have a bike path.

Finally, regarding anti-obesity programs in public schools: I can’t say I have much enthusiasm for them, but whatever—I’m not going to pull my kid out of school because they’re teaching her to eat her fruits and veggies. The larger concern, for me, is that the whole enterprise of public schooling is not about promoting the health and well-being of individuals; it’s about creating citizens that are useful to the state.

Comment by Joe Ermigiotti

@ Joe Ermigiotti – I couldn’t agree with you more.

However, there are simple policy changes that would have dramatic effects on the nation’s health as a whole. For example, If you have read “Omnivore’s Dilemma” by Michael Pollan, you know that corn costs more to produce per bushel than it is worth on the market; Washington fixes this problem with subsidies to the farmers. Corn (and it’s subsequent derivatives, including the animals that are nourished by it) is a primary ingredient in most of the processed and fast foods that could be implicated in the obesity epidemic.

If the policy was to gradually shift from subsidizing monoculture farms to subsidizing farmers to use our nation’s farmland to grow fruits and vegetables and raise animals according to their evolutionary blueprint (i.e. cows are ruminants, they are supposed to eat grass, not corn. . . ), more nutritious food would become more affordable and abundant, and fast food would become less economical. If Matt’s link is correct in assuming that your socio-economic class helps predict how you eat, people with lower incomes would likely consume healthier food by default if it was more economical and available.

Promoting this sort of policy change (and the one mentioned above is but one of many) skips the annoyance of government directly interfering with our lives while at the same time encourages a more preventative lifestyle. In the end, it is an individual’s choice about whether to exercise and eat properly, regardless of neighborhood or socio-economic bracket. Those factors may make certain decisions easier or harder, but they do not decide for you.

I think we might find it would be beneficial for our environment (monoculture farms and CAFOs are hardly green ways to produce food. . . ) as well as our health to focus at least a little bit of our healthcare debate in this country on how we produce the food we consume.

Comment by jaymichaelsmith

jay, it’s a good comment, but in fact

“In the end, it is an individual’s choice about whether to exercise and eat properly”

isn’t really true, or not in the more meaningful sense. The evidence is that intensive exercise, the kind you have individual control over by deciding whether or not to go to the gym or go running for half an hour, doesn’t often help people lose weight or become less fat. That’s probably because it leads to increased appetite. In fact studies have found there’s basically no difference between spending half an hour a day jogging and spending half an hour walking around your house, in terms of losing weight.

In other words, in environments where you spend your entire day walking or biking to get from place to place, you’re likely to be trim. In environments where you sit on your ass all day, in cars or in front of computers and TVs, you’re likely to be overweight. And you’re very unlikely to lose that weight and keep it off by going to the gym.

There are reasons why people’s daily routine in New York City, Boulder, or Paris involves a lot more physical activity than people’s daily routine in Loudon, VA, McAllen, TX, or Dunkeld, Scotland. Those reasons aren’t about individual choice. They’re about built environment and culture. So the point of intervention, if you don’t want people to be fat, is at the point where decisions are being made about built environment and culture. Alternatively, you could decide you just don’t care how fat people are; but that tends to be an unacceptable conclusion for people with kids who don’t want them to be fat, and it also tends not to be true. Almost everyone has subconscious prejudice against fat people. To say “being fat is the result of individual choices” means you blame fat people for being fat. I, in general, don’t.

Comment by Matt Steinglass

Matt, I think we are arguing at least in part for the same thing, but our paradigms are fundamentally different. We both agree that lifestyle is the primary underlying factor in obesity (and I would contend other serious, life threatening diseases too). We both agree that there are reasonable policy shifts that could potentially have dramatic effects on public health.

I must disagree on the issue personal choice. There is no iron fist forcing a twinky wielding hand into a complacent mouth. There is no infinite weight chaining someone to a recliner next to a six pack of Bud heavies and a TV dinner. There is no mandate forcing someone to order pizza rather than bake some chicken and steam some broccoli. Our society has made it increasingly easy to eat garbage on a regular basis (which is where I fault our broken policies); but in the end, only you have the final say about what goes into your mouth.

I’ve read the studies that say exercise is futile; I’ve also read plenty of studies touting the benefits of exercise for cardiovascular health, weight loss, (some of the most recent studies would contend that you are right about running for half an hour a day, and that weight bearing exercises are much more effective at weight loss and management.), and longevity. I’ve lived the benefits of exercise myself. Walking is one of the best weight loss exercises (after all, we evolved to roam around in the plains in search of food), so naturally people who walk more are more prone to leanness. But I know plenty of people who exercise 45 minutes a day 4 days a week and eat salad instead of burgers and they are fit, lean and vibrant. I live in Dallas; we don’t have bike trails or mountains to hike, everyone (unfortunately) drives SUVs, has a 30-45 minute commute to work and drives literally everywhere because nothing is in walking distance – but they adapt to their lifestyle and make choices that allow them vitality.

I commented initially about diet; diet is approximately 80% of any given weight loss program. I still contend that this is where the policy needs work. I think education about proper eating, encouragement towards proper exercising will have the most benefit in our information driven society. But in the end, if a person sits on the couch for 4 hours every night with chinese take out and a few tall boys watching Dance Your Ass Off, that is their decision. I fail to see how that individual’s weight problem is anyone’s fault but their own.

Comment by jaymichaelsmith


I agree with most of what you say here. Where I disagree is with the idea of shifting the subsidies from the monoculture farms to fruits and vegetables. Subsidies are pretty much always a bad idea. I think just removing the subsidies from corn and the other big commodity crops would do a lot to move things in the directions you talk about, without putting a whole new set of special interest groups on the federal dole.

Comment by Joe Ermigiotti

Matt, it seems like you have little faith in people’s abilities to think for themselves and overcome societal/structural pressures so they can “do the right thing” (in this case, eat right and exercise)

Is that a fair assessment?

Comment by johnbr

Hi JB — nice to see you over here! I’m responding in a separate post at top because the response got too long for comments.


Comment by Matt Steinglass

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