City Journal Summer 2014

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Summer 2014
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Theodore Dalrymple
To Have or to Be? « Back to Story

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Dr. Daniels:
I know of two persons who have had bariatric surgery. One quit the diet and regained her weight within one year. The other had the old stomach-stapling surgery, and also regained her weight within a year. Illness? Whose hand is putting the food into their mouths? And what of the Jared guy who lost a couple or so hundred pounds by eating only Subway sandwiches?
F.R. Duplantier May 28, 2014 at 11:12 AM
BASKET CASE
My obesity just isn’t funny
And I’m suing for bundles of money:
When a basket of candy
Is too full and too handy,
Who’s to blame but the old Easter Bunny?

McPIG
You’ve grown by leaps and bounds;
Your super size astounds;
The fact is that
You’re really fat:
Four-three, three hundred pounds!

OLDER & WIDER
As a lad I was long and lean
And drank gallons of Ovaltine,
But I had to rethink
That rich chocolate drink
When I wound up an oval teen.
Kudos, Dr. Dalrymple, one of your best, but a little sad that so many seem to think it was about obesity.
I don't think it's a good idea to so casually conflate the UK and US in these discussions. The corn syrup stuff has been mentioned in earlier comments is one example of an 'issue' which does not transfer across the Atlantic. Another big difference is that in Britain, people have, on average, been eating less and less fairly consistently since the 1960s - so much of the talk about portion sizes, etc, is a lot less relevant in Britain.

To me, all that's happened is that physical activity levels have dropped faster than our ability to adjust our diet to match - much in the same way as improvements in diet and health in the late 19th / early 20th centuries caused a rapid rise in population, until people stopped having so many children.

Much like infant mortality, at some point, the amount of physical effort for life will start to level out (as it asymptotically approaches zero), at which time our behaviour will catch up with changing circumstances and we'll be thin again.

No doubt high fructose corn syrup is bad - perhaps worse than cane sugar, but the point is overeating has drastically increased - see relative pportion sizes circa 1950-1960 vs. today.
I assume “fructose” refers to high fructose corn syrup. The stuff is used by food processors as a cheaper substitute for sugar which is relatively expensive in the U.S. because of the protectionism given by Congress to the Louisiana and Florida sugar industry. The hard candy industry cannot make their product with fructose and that has driven it to relocate to Canada where sugar can be had at market prices. It is the crony politics of our politicians that causes fructose to be in so much of our food. Almost no processed food outside the U.S. contains it.
The significant rise in obesity in the U.S.corresponds nearly perfectly with the decrease in smoking.
I have seen studies that calculate the total calories of snack foods sold in the U.S. every year. The increase in this figure over the past 30 years very nearly approaches an amount sufficient to account for the total weight gain of the U.S. population over that same period. Clearly, the increase in obesity has a lot to do with changes in our eating habits.
Carmen Fernandez April 26, 2014 at 4:21 AM
You cannot run away from the truth and this article really says it! Guilty as charged!
Yes, being overweight absolutely is a matter of personal responsibility. Personal responsibility though is much easier to exercise effectively with good information. In my case, I tried dieting under doctor's supervision with minimal effectiveness. I was able to struggle down to 365, a loss of 25 pounds, over a two year period.
Using a low carb, high fat diet, I lost 125 pounds in eight months and have kept it off for ten years, losing more along the way. This is clearly not a psychiatric issue, nor one of self-control or character. I had a wonderful childhood and was slender until college. This is a matter of good information. The human body is run by hormones. Ever wonder why Type 1 (insulin dependent) diabetics tend to be thin while Type 2 (insulin resistant) diabetics tend to be fat? Type 1's don't produce enough insulin and have trouble storing fat. Type 2's produce too much (their bodies just don't utilize it well)and they can't release fat between meals.
If you have any doubts about the truth of this look up images under "injection site lipohypertrophy" to see the breast-like lumps from when diabetics don't rotate their insulin injection sites.
Why is it that each time you see an obese person they have some kind of food or drink going on??? Therein lies the problem--tape the mouth shut! The Bobby Sands diet works each and every time it's tried. Enough said.
Before reading this just a comment.
The bread lines of rthe 1930s had skinny people.
In a photo of a food distribution to the poor in 00s in Queensland Aust the people were obese.
The Korean War showed that the suvivors of the 30s suvived as POWs but the young died.

The future droughts with little food will kill the obese.

Just Darwin's suvival of the fittest!!
"a person with a BMI of 39 (or 34 with diabetes) might try to eat his way above the threshold level in order to have free surgery—free to him, anyway—courtesy of the universal health system, surgery for which he would not be eligible if he stayed at the lower weight. "
We are a great species!
I love us.
It is true that many of the foods we eat today are engineered foods; they are carefully designed in industrial laboratories to appeal to us. As the old ad used to say (about a brand of potato chip, "Bet you can't eat just one!"

Most of this change is post-WWII, as this the frequency with which people eat out. And (surprise) today's restaurant food is also an engineered product; in a popular-price restaurant, much of the food is actually prepared in a restaurant supply house.

So it probably is more difficult to maintain a good weight today. BUT does that make it (like drug addictions) a disease? On one side there are those who insist, "It's 100% medical!" and others who insist, "It's not a medical problem at all!" Although I continue to lean strongly toward the "not a medical problem," other than for a few exceptions.

We should at least be aware of the danger of declaring that all maladaptive behaviors are medical problems, since if they are harmful and beyond our control then there's a strong possibility of being forced into treatment (as with mental illness), or at least subject to some very strong nudges.

We should never forget that public health is inherently coercive, that although actions like quarantine and forced mental health treatment may sometimes be necessary, it will always be a trade off of freedom for security. And the public health apparat- having reduced the incidence of infectious diseases for which it was created- is beginning to view violence and all sorts of other social problems as within its domain.

And then there's the inherent problem with socialized medicine- that although I may not be all that interested in my neighbor's health, I suddenly become a whole lot more interested if I have to pay for my neighbor's medical treatments.
One fact that shouldn't be overlooked is that people wait too long to start a diet. It's easy to lose weight when you're 10 pounds overweight, much harder when it's 20+. Diets must begin when the belt starts feeling tight.
I come of a long line of drunks-three out of four grandparents, both parents. All my siblings drink heavily from time to time. I've never been drunk in my life and not because of sterling will power. The sensations of intoxication just don't appeal to me, those genes passed me by. Instead, I'm fat. Food _does_ appeal to me. A lot.
Thanks to bariatric surgery, I'm lost a lot of weight simply because I feel satiated earlier than I did before.
I've spent my life being hectored by people who never had a weight problem. The fact is that most fat people _cannot_ permanently lose weight. We Yo-Yo. Diets succeed until they don't and they fail because we can't comply any longer. For those who've succeeded in controlling their eating in the face of urges not to, good for you! I'm not that "strong willed", whatever drives my appetite, whether it's brain chemistry, stomach physiology or endocrine system, I can no more "exert more will power" on a long term basis than my drunken grandparents could remain sober.
Yes, there are people whose appetite isn't so strong that their will cannot overcome it. Most fat people demonstrably can't do that. The physiological underpinnings of obesity aren't well understood but they are there none the less. Bariatric surgery often works but for those whose appetites are strong enough, even that can be evaded.
Given the societal pressures against being fat, if it were easy, there would be _no_ fat people. Simply saying suck it up, avert your eyes, control yourself is remarkably unhelpful.
Dr Dalrymple, I would like to direct your attention to Gary Taubes' book "The Diet Delusion" (British edition; first published in the USA as "Good Calories, Bad Calories"). As a doctor, you will have no difficulty with the simple biochemistry and other scientific concepts the author uses to make his case. Essentially, he argues that it is precisely the low-fat, high-carbohydrate diet based heavily on grains that has contributed most heavily to the recent epidemic of obesity. There is nothing entirely new about this; see, for example, Mr Banting's 1869 "Letter on Corpulence", available in several places on the Web including http://www.citigraphics.net/citigrafx/stories/food/Banting%20Book.PDF.
The obesity epidemic seems to have begun precisely when the US government adopted the McGovern Committee's guidelines, which warned people to stop eating traditional foods such as red meat, butter, cheese, and eggs, and to replace them with "healthy whole grains" and artificial fats such as margarine. Recently, beginning in Sweden, the scientific and political establishments have begun to see sense and start recommending that people eat more healthy natural fat and stop stuffing themselves with cheap, harmful carbohydrate foods. If you care to get in touch with the Nutrition Science Initiative (nusi.org) I am sure they will be happy to tell you more.
jorod: Nutrition is taught in schools (at least in British state schools). Unfortunately, the intellect and the will are not identical, and we all do things we know to be bad for us: over-eating is just one of them. Education cannot be a replacement for self-control.
Why not teach nutrition in schools?
"Do not these golden rules require precisely the kind of self-control the supposed sheer impossibility of which for the fat person is the justification in the first place for regarding obesity, and not merely its consequences, as a disease? " THIS SAYS IT ALL! If you must do this after bariatric surgery, why can you not do it before????
I've gone from about 250 pounds to 200 and now after winter I'm at about 210. I'm aiming for 190. I've hit the weight with diet control and exercise. I don't ban any foods but realize what I eat comes out of a budget that I have to hit on a very regular basis and eating cakes and the like means I'm not eating the stuff I like and the stuff my body really needs. I allow for occasional blowouts and do not become upset when I have a four beer night with a big steak and big potato dripping with sour cream and butter. I strive to keep that an annual event instead of a monthly event.

A buddy of mine had bariatric surgery and I've seen the before & after photos and big difference, but he is moving back to the before photo. Another friend of mine is a candidate for the surgery but his doctor will not authorize it before he starts losing weight w/o it and that is not not happening.

There is a doctor I follow on Twitter and that is his specialty and he runs a class on food and cooking, his big thing is not banning foods but on reducing portions.


In general, this reads like a an old column I used to read in The National Review (a magazien that publish's Ted's work from time to time) -- Delecatations by Digby Anderson.
Excellent piece! Remember Thomas Paine arguing against Burke, that each generation ought to invent their lives anew and tradition is nothing. And also Hayek saying, like Marx: we are the masters of our actions but not of their design. This is of course enlightened nonsense. Judaism and Burke as well teaches, we can chose and cherish tradition and can reinvent ourselves if tradition is not good enough. But freedom of choice incurs responsibility for the consequences. Obesity is the rejection of possibility and hope or choosing Athens over Jerusalem.
Bravo, Dr. Dalrymple. As you know, all homo sapiens have a thing called the brain. We can think, think about reducing our calories.

Now, I had a stroke 31 years ago, I blew up. I weighted 255 pounds, now, I'm 170, no magic, no diet just changing my eating habits. It took some time but I did it.

As Nancy Reagan said, "Just say no!"

I have enjoyed your commentaries in the past (and in the future too).

-Peter Seissler
At the risk of sounding cynical, it seems to me that the vast increase in conditions requiring some sort of medical intervention is proof positive that the "caring professions" have, indeed, come to believe that "there's gold in them thar 'ills."

And, Beverly, AA doesn't work unless the individual wants it to work. Simply forcing attendance is insufficient.
As that famous comedian, Jasper Carrot, said: people are fat "because one hole is bigger than the other."
the simplest way to persuade people to avoid getting fat is to make life difficult for them and not think of new ways to make it easier. This is how nature has successfully improved species for millions of years.Increasing air fares for anyone over a certain weight and similar measures would certainly be unpopular for many but, as they say, that`s life.
Interesting
Nothing will change until it is widely understood that carbohydrate makes us fat. Lustig is ok, but read Gary Taubes to get the best information about nutrition an obesity.
Most overweight, esp. severe overweight, is due to emotional overeating. Psychotherapy is indicated. There is a lot of bad parenting in the West, and, so, a lot of emotional misdevelopment and a lot of self-medicating, much of it with food.
to Tionico: I do agree for 1000% with what you commented. !!
John Bell Smithback April 20, 2014 at 11:20 PM
Maybe making obese people pay their way would help change things. My wife weighs just shy of 100 pounds. When she travels by air her baggage is weighed and if it's slightly over the limit, she has to pay an extra fee. Yet the person in front of her and the person behind her at the counter weigh more than my wife and her baggage combined.
I recall a commentator on NPR recalling how he would provoke his schoolyard tormentors with the rejoinder "I'm not fat, I'm rotund!"
so the medical "professionals" in imposing their post-op mandates/suggestions for food intake are, as ever, cart before horse. When an obese patient applies for the surgery to "correct" their symptoms, require they revise their eating and activity (yes, I mean get OFF your thick end and GET MOVING) habits, and carefully document this revision, including ALL recepts from their greengrocer, daily logs of exactly what was consumed at what time each day, and precisely what distance was walked and in what amount of time. Require this for six months to a year prior to authorising the surgery. If they can't manage those "lifestyle" changes prior to the surgery, they are highly unlikely to do after. And disciplining themselves to manage their caloric intake and expenditures carefully for that year will turn the lion's share of them right about. I'll lay long odds at high stakes that well above the half of them would not require the surgery after one year. For about $16K saved on the surgery, some real motivation could be built into the programme. At the very least, build in a VERY large co-pay prior to authorising the surgery when at initial weight. Work out a declining co-pay formula based upon how much weight is lost prior to the surgery... and, again, high stakes at long odds, few will actually require it, opting instead to continue on their new regiman indefinitely. Their increased self-esteem, energy, strangth, vigour, will be such welcome by-products they will be motivated to persist. I've known a number of unhealthily obese people to suddenly decide to wrestle the bear of their condition, and the total transformation over the past year has been amazing.
I'm a medical editor for a fine university press, and I've just been working on a book about this sort of thing -- genetic contributions to, inter alia, obesity. It seems that there are dozens of genes, even over 100, that have partial contributions to make to the propensity to get fat. (Most genetic or genetically affected disorders aren't Mendelian, or single-gene, disorders; often a panoply of genes is involved.)

So it's complicated. Some people crave sugar; others are indifferent. For the former, the self-discipline to eschew surplusage is a bit harder to come by.

A bulimic friend of mine said she wasn't able to kick the craving until she just gave up "white foods" altogether: no breads, only brown rice; no sugar. She said it took a month, and was the hardest-fought battle she'd ever waged -- but at the end of it, she was free.

I see obesity/gluttony, if you will, as being akin to alcoholism: the person may not be responsible for being an alcoholic, but he is responsible for getting his keester into AA to get help.
Why not a tax on being fat? It's perfectly congruent with liberal ideology, after all. Every tax is a good tax. And then there is the sheer justice of it, which libertarians should appreciate. The tax could be levied indirectly, by taxing the foods that make us fat, just as we now tax the cigarettes that give us lung cancer. That way, as with cigarettes, it would serve as any immediate and tangible disincentive.

If people are utterly helpless in the throes of appetite, then at least the tax captures for society some of the money that would otherwise go to food giants. If they are not, then the tax picks up part of the money, consumption goes down, and societal costs of coping with obesity go down.

Truth is, incentives matter. How else could it be? Brains are biology's way of letting living things shape behavior to suit consequences.