These days, it seems, almost everyone has a habit that he can't control. For millions of people, this habit is overeating.
Never have so many human mastodons bestridden the earth as now. At one time, not so very long ago, such mastodons were rare enough to be curiosities, charitably thought by others to be the victims of their "glands." We had such a fat boy at school: His cheeks were so adipose that his eyes had become mere slits. We thought that he was ill rather than a member of a cultural avant garde.
In America, more than a third of the adult population is now obese (obesity being defined as having a body-mass index more than 30). This is nearly three times as many as in 1960, and half as many again as in 1990.
But the increase has been greatest among those known as the morbidly obese—that is to say those with a BMI of more than 40. As a proportion of the population they have increased in America by more than six times since 1960, and three times since 1990. They are now about 6% of adults.
How Fat Happens
Science explains the factors that make us vulnerable; nutritional labels explain the rest
[FAT] Getty Images
Many scientists cite family upbringing as a trigger for weight gain.
The cultural meaning of obesity has changed at the same time. For most of human history, fatness has been a sign of prosperity, of having risen, socially and economically, above the day-to-day struggle to obtain enough to eat. But sadly now, in Western societies, obesity is concentrated among the poorest and least educated. In America, blacks are 50% more likely to be obese than whites, and Hispanics 20% more likely.
I once saw the change in cultural meaning of body size happening before my very eyes, when I practiced briefly in the mid-1970s as a doctor in Zululand in South Africa. The women who still lived in a traditional way, in mud huts, wanted to be fattened up for their menfolk, who saw in a fat wife a sign of their own success and prestige. These women would ask for medicine to become even fatter than they already were. By contrast, the young women who attended university wanted medicine to make them thinner than they already were. It almost seems as if, for human beings, there is no contentment with their body size.
If overeating is not in itself a disease, it certainly has health consequences. By now, there surely cannot be anybody left who does not know that obesity causes Type II diabetes, any more than there are smokers who do not know that smoking is bad for them. When I started out as a doctor, Type II diabetes was often known as maturity-onset diabetes, but as children have grown fatter and fatter, maturity has nothing to do with it.
The economic consequences of fat are enormous, if health economists are to be believed. Obesity-related medical costs were 9.1% of all annual medical costs in 2006, up from 6.5% in 1998, according to a study released last year from the Centers for Disease Control and Prevention and RTI International, a nonprofit research institute. The annual health-care costs of obesity in America have risen from $74 billion in 1998 to $147 billion in 2008.
According to a paper presented at the Obesity Society's annual conference last year, fat people are less productive than thin. They take more time off work because of their various ailments, and when they are at work the morbidly obese produce less, equivalent to 22 days of lost production per year. The health-care costs and lost production caused by obesity are driving American manufacturers to locate to countries where the population, for the time being, still has a lean and hungry look.
Weighing the Numbers
* $1,429: Additional amount obese people spent on medical costs over normal-weight people in 2006
* $12.8 billion: Annual losses billion to U.S. businesses from absenteeism due to obesity
* $30 billion: Estimated annual losses to U.S. businesses from presenteeism (reduced productivity on the job) due to obesity
* $60 million: Annual cost to the U.S. military of recruiting and training replacements for first-term enlistees discharged due to weight problems
* $2.8 billion: Additional automobile gas bought in 2005 due to extra body weight in vehicles, compared with 1960
* 5.6 million: Diagnosed cases of diabetes* in the U.S. in 1980
* 17.4 million: Diagnosed cases of diabetes* in the U.S. in 2007
*Both Type 1 and Type 2 diabetes. 90-95% of cases are estimated to be Type 2.
The fiscal consequences of obesity for America have also just increased, with the recent passage of the health-reform bill. Obesity is disproportionately concentrated among those previously uninsured, who will now presumably have access to more care, possibly including expensive bariatric surgery. Indeed, obesity is associated causatively to so many expensive diseases (rather as smoking is) that the health-care costs of treating the impoverished obese are likely to be enormous. Since treatment is unlikely by itself to make this sector of the population more employable or productive, America has just assumed an economic cost without an economic benefit. Truly, economics is the dismal science.
Is there no hope, then? In one rather peculiar sense there is. The whole world is becoming fatter, not just America. Not long ago in Bangkok I observed some children, obviously of the elite, emerging from a school. There are not many fat people in Thailand, but these children were fat.
Like so many of their counterparts in the West, they seemed unable, or unwilling, to progress further than a few yards without refreshing themselves with sweetened drinks and fast fatty food. And they were being collected by chauffeurs or adoring parents so that they might be spared the rather minimal exercise afforded by going home by public transportation.
As yet in Thailand, the poor mostly cannot afford to be fat, but that time will come, and then the great reversal will occur: The elite will abandon its fattening habits, and take seriously the advice of the late Duchess of Windsor: that one can be neither too rich nor too thin.
In the West, the march (or waddle) of obesity is in step with other social (or antisocial) developments. Obesity in Britain, for example, has increased pari passu with the splintering of families: and now it is never too early to teach children lack of self-control.
The connection between the fragmentation of the family and obesity is easy to understand. Of course, there is no one-to-one correspondence between the two phenomena—in human affairs there never is such a close fit—but there is nevertheless a strong and comprehensible correspondence.
For much of the population, family meals are a ritual of the past: Thirty-six percent of British children never eat a meal at a table with another member of their family or household (we have now passed the milestone long desired by radical social reformers, more children being born illegitimate than legitimate). In the homes of the poor, the unemployed and the single parents that I used to visit as a doctor, I would find no evidence of cooking ever having been done there. Fatty take-away meals and ready-prepared foods heated in the microwave were the diet, together with almost constant snacks. There was not even a table to eat at: an absence that was not the consequence of raw poverty, since the flat-screen television would have been large enough, turned horizontal, to serve as a dining table.
In these circumstances, children graze or forage; but unlike previous hunter gatherers, they do not come up against a scarcity of food, but rather a surfeit of it. Nothing is easier for them than to overindulge, and the appetite grows with the feeding. Their tastes never develop beyond the most instantly gratifying types of food, sugary and fatty, and they eat like children for the rest of their lives; they never learn the discipline of subordinating their appetite to the exigencies of family life and social convention. They are like Pooh Bear, for whom it is always time for a little something. It is hardly surprising if, like Pooh Bear's, their waistlines expand until they can't fit into a normal seat.
Family and social meals are among the most powerful teachers of self-control in the human repertoire. They teach that the appetite of the moment is not, or rather ought not to be, the sole determinant of one's behavior. The pattern of grazing or foraging independently of everyone else teaches precisely the opposite lesson. It is hardly surprising that those who do not experience family or social meals early in life exhibit the lack of self-control that underlies so much modern social pathology in the midst of plenty.
These social, or antisocial, developments have taken place precisely at a time when electronic means of entertainment have become available to all. For the uneducated, the world is an intolerably dull and slow-moving place by comparison with the excitement available at the press of a button or the flick of a switch. Why, then, move off your couch and risk the ennui of the real world? You can satisfy your appetite and occupy the vacuum of your mind at the same time, at most wriggling like a maggot in sawdust. The availability of constant entertainment is one of the causes of obesity.
By taking on responsibility for the health consequences of obesity, the government has given itself the locus standi to interfere in many aspects of human existence. If obesity kills, is it not the government's duty to prevent it? He who pays the doctor decides the prophylaxis. Positive encouragement of healthy eating won't work, nor mere printed warnings that some foods are unhealthy (people who are prepared to eat doughnuts with pink and blue icing are unlikely to desist on learning that they contain nothing good for the bowels or any other organ).
As usual, therefore, prohibition beckons. Regulation of the sugar and fat content of ready-prepared and fast foods is likely to be proposed and perhaps eventually accepted, though not without a very fierce rear-guard action by the food industry. If John Doe will not eat his greens, Uncle Sam will make him, if necessary by restricting the availability of other foods. No one will raise moral psychology of the question of obesity, for fear of sounding uncompassionate and reactionary.
In search for an amelioration, the temptation is to an intemperate authoritarianism, forgetting that the avoidance of obesity, pace the Duchess of Windsor, is not the whole purpose of life. But teaching children to cook and eat together might help overcome the crudity of their eating habits: the price of more refined, and in this instance nonfattening, pleasures always being effort.
To reduce the attraction of fast food, prepared meals and soft drinks, and to save the planet from polystyrene dishes, a system of returnable deposits on packaging might be tried. This would slow down fast food a little, and tip the balance in favor of home preparation.
No doubt the government will also promote sports as a remedy for and preventive of obesity. This, of course, would be an extremely irresponsible solution, for sports are already, even with the slothful population that we have, by far the most common cause of injury in Western societies. If the obese were suddenly to start exercising, emergency rooms would not be able to cope. For the sake of our health, let us have no sports.
Theodore Dalrymple is the pen name of Anthony Daniels, a British physician. His latest book is "The New Vichy Syndrome."
