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To Have or to Be?

from the magazine

To Have or to Be?

Personal responsibility plays a role in obesity. Spring 2014
The Social Order

What’s in a name? That which we call a rose by any other name would smell as sweet. Would a fat person be any the slimmer or any the fatter for being called obese? Obviously not: yet the words we use to describe people or things sometimes matter greatly and reveal more about the way we think than they are intended, perhaps, to reveal. Recently, I received a message on my telephone alerting me to a series of articles in The Lancet, one of the world’s most important medical journals, about bariatric surgery, which seeks to reduce the weight and correct the metabolic imbalances of the grossly fat. The first phrase of the message caught my attention: “More than 500 million adults worldwide now have obesity.” Have obesity, please note—not “are obese,” much less “are fat.” Would anyone have written “500 million adults worldwide now have fatness”? So it seems that there might be something in a name after all.

Certainly, there is a difference between being and having, so much so that the once-fashionable psychologist Erich Fromm made the distinction the title of one of his best-selling books excoriating modern materialism, To Have or to Be? To have obesity is to suffer from an illness, like multiple sclerosis—something that happens to you by virtue of an impersonal fate. To be obese is simply a physical description that leaves open the question of how you became obese in the first place.

An accompanying editorial in The Lancet lamented the fact that, in Britain, the number of people undergoing bariatric surgery had fallen by 10 percent in the last year, despite the number of people with obesity (another locution the journal favors) rising over the same period. Bariatric surgery has proved effective in reducing very fat people’s weight and in correcting their metabolic imbalances, the editorial declared; in fact, about a 30th of the population would benefit from the procedure. So why, the journal asked, has the number of operations performed on obese people declined?

But is the idea implied by these locutions—that obesity is a disease like any other—correct? Based upon a growing number of considerations, it has some initial plausibility. Genetics undoubtedly influence the propensity to obesity and its opposite: even allowing for similarities of diet, fatness and leanness run in families. My father’s family was notably more inclined to fatness than my mother’s; and the difference was not all attributable to what, or how much, they ate. A genetic condition exists—Prader-Willi syndrome—characterized by, among other things, excessive appetite and gross obesity. Certain endocrine disorders, such as Cushing’s disease, also lead to fatness. If obesity is sometimes of pathological origin, why should it not always be of pathological origin? As one of The Lancet articles puts it: “The assumption that severe obesity is a behavioural or social choice, which can be reversed with a determined patient’s effort, is simply incongruous with medical fact.”

The process of growing fat is clearly a physical one, with a well-understood physiology and biochemistry. The neurophysiology of appetite has also long been well understood. I remember as a student of physiology 45 years ago learning about rats that ate uncontrollably—and became enormously fat as a result—after part of their brains had been ablated. And it is all too easy to suppose that physiological explanation implies or automatically entails personal exculpation for whatever is thus explained.

The increase of obesity in the last few years is more pandemic than epidemic—it is a global phenomenon. Americans are the fattest people in the world, followed closely by the British, but the prevalence of obesity is increasing even in countries such as France, where only a third as many people are extremely fat as a percentage of the population as in America. For the first time in history, obesity is associated with poverty—relative poverty, that is—rather than with wealth; and for the first time in history, great masses of people are able to eat more or less ad libitum. It was statistical regularities such as these that led the great French sociologist Émile Durkheim, studying suicide, to conclude that human behavior, which seems so dependent upon individual decision making when viewed from close up, is actually subject to impersonal forces, of which individuals may not be aware, and which explain that behavior better than considerations of individual psychology.

What would be those forces in the case of obesity? A currently fashionable explanation is the change in the nature of the food that we eat. The principal culprit is the fructose with which the food industry increasingly laces its prepared products. According to Robert Lustig, a pediatric endocrinologist with a special interest in childhood obesity, such sweeteners are addictive in the literal sense: an ever-increasing quantity is necessary to produce the feeling of satiety that tells people it is time to stop eating. This theory neatly explains the observation, recently published in The New England Journal of Medicine, that children who are obese when entering kindergarten are very likely to be obese as adults. Overfed as young children, often with sweetened drinks as part of their diet, they continue to overeat because their satiety level has been recalibrated, and they crave fructose as addicts crave heroin. Thus, the theory holds, these fat adults are not responsible for their condition. Moreover, one can point to an economic locus of responsibility as well: one reason that food companies add so much fructose to their products is the government subsidies given to farmers to produce corn, from which the corn syrup is made. It is even conceivable, though unlikely, that in the future an occult virus causing a change in human metabolism will be found to account for the obesity pandemic.

The medical consequences of obesity have been so widely publicized that I hardly need to rehearse them here. Because of widespread obesity, life expectancy may actually fall for the first time in many decades. The financial burden on society will surely be great: in British towns and cities, it is common to see people in early middle age confined to battery-powered wheelchairs, provided at public expense, because they are too fat to walk farther than a few paces. Hospitals now have special machines to weigh the obese and special operating tables to accommodate them.

Yet none of these considerations can quite extinguish the suspicion that obesity is not just something that happens to you, like multiple sclerosis. Obesity is as much something you have done as something you have. At the very least, there must be contributory negligence. After all, no group exists of whom it can be said that every member is fat. Even 53 percent of children who are obese at kindergarten stage do not grow up to be obese—and these are the people probably least responsible for their subsequent physical condition. Even if it were true that fructose is addictive (and largely responsible for the obesity pandemic), no substance is so addictive that it is impossible for people to give it up. It seems that people give up addictive substances in proportion to the difficulties, legal and other, in obtaining them. Fructose is now harder to avoid than to find; and even in good restaurants, one notices a tendency to the sweetening of dishes, presumably in response to changed public taste.

Out of misplaced delicacy, perhaps, certain factors that promote obesity in our societies are seldom emphasized or even mentioned because they refer to the lifestyle and choices of those who become fat. In the course of my work, I would often visit the homes of the kind of people most prone to obesity: those on long-term welfare, whose unhealthiness, consequent upon obesity, was a further impediment to any employment for which they might otherwise be suitable. In such homes, I rarely detected any sign of real cooking having taken place, despite the oceans of disposable time for it. The only tool in culinary use was the microwave: there was no table at which members of the household, often with an unstable membership (particularly of adult males), could have eaten together. Surveys have shown that a fifth of children in Britain do not eat with other members of their household more than once a week, a figure in keeping with my own observations; at this end of the social spectrum, it was probably much more than a fifth. It was obvious that children in this environment foraged for industrially prepared, fat- and fructose-rich food, found in the refrigerator whenever the mood took them, which was often, and which they ate distractedly, while sitting in front of the giant flat-screen television on the wall, which was never, in my experience, extinguished, except maybe in the dead of night. Eating, the most elementary of social activities, had become in these settings solitary, almost solipsistic, having lost all connection with anything except the appetite of the moment: and appetite grows by what it feeds on. All this, again, in circumstances in which no pressure of time could explain or excuse such behavior.

No statistical regularities can explain highly complex human conduct, such as the mode of preparation and consumption of food, or prove that individual choices and decisions have nothing to do with the production of those same regularities. All individual choices are made in definite (and constantly shifting) circumstances: Indeed, what could choice possibly be if it were made in the absence of all circumstances? Can one imagine a life without circumstances? And so it is hardly surprising that statistical regularities occur: minds, not necessarily great ones, often do think alike. I hesitate to quote Karl Marx, but he was surely right when, in “The Eighteenth Brumaire of Louis Napoleon,” he wrote: “Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past.”

This truth, however, which is so obvious that it ought to be, if it is not, a cliché, does not mean that choice does not exist. The inevitable existence of circumstances does not mean absence or abrogation of choice. To know the circumstances of a man is not also to know his future actions.

Why, then, is the element of individual choice generally avoided in discussions of such social problems as obesity? (I disregard the unconventional wisdom that obesity is not a problem; conventional wisdom is sometimes right.) I think there are three main reasons. The first is that those who emphasize poor choices as an explanation often do forget the circumstances in which choices are made, and therefore underestimate their importance. Where individual choice is emphasized to the exclusion of all else, it can blunt human sympathy and betray an unfeeling and unattractive censoriousness.

Second, the element of personal choice suggests that we can never have a society so perfect that good behavior or self-control will no longer be necessary. Thus, the scope of politics and role of bureaucracy necessarily have limits, and this is not flattering to the self-esteem or self-importance of the providential class—those people who feel that, without their detailed guidance and legislative direction, society is doomed to permanent ignorance, sickness, vice, and disorder. And this is a serious loss for an educated cohort for whom politics has replaced religion or culture as the source of personal meaning and significance.

Third, and most important, is the false and sentimental belief that, in taxing people with even partial responsibility for their downfall, you must thereby be withdrawing all sympathy from them. To tell a drug addict, for example, that he is not ill but rather is behaving foolishly or badly, is on this view to deny him understanding or assistance. This does not in the least follow, however; though the type of understanding and assistance you will give him will be different from what you would give if you regarded him as solely a victim—say, a dweller of a coastal area devastated by a tsunami.

It is sentimental—and, in the last analysis, condescending, dehumanizing, and even brutal—to regard people with self-destructive habits as simply victims of circumstances, who contribute nothing to their unhappy situation. It is to regard them as animals at best and as inanimate at worst, and also to assume a locus standi to interfere compulsorily in the smallest details of their lives (indeed, the previous government in Britain considered installing video cameras in the homes of bad parents to monitor what was going on there). Ordinary people therefore can only be innocent victims, for if to blame them, even partially, for their own condition is to lack all sympathy for them, then to exculpate them totally is to exhibit maximum sympathy for them. Those who are not victims are then divided into two classes: the perpetrators and the saviors.

The saviors, I need hardly add, soon become professionals in the redemption business. Poor things! the saviors think, they can’t help themselves. They need my help. As for the poor things themselves, such is the nature of human weakness that this is precisely what they, or at least some of them, want to hear, for it means that their misfortunes are not attributable to themselves. The solution lies elsewhere, and in the meantime, they can continue their pleasurable bad habits without guilt or self-blame. To adapt Luther’s famous declaration, they can say to themselves, “Here I eat, I can do no other.” It is likely that the effort that people make in any endeavor is proportional to how much they believe that they influence its outcome.

None of this is to deny the effectiveness of bariatric surgery. But then the question arises: Who is to pay for it? In a libertarian paradise, everyone would pay for the consequences of his own behavior—the prospect of having to do so moderating that behavior and molding it in the direction of long-term self-interest. However, it is precisely the degree of responsibility of the fat for their own obesity that is in question, and it is probably not susceptible of a definitive answer. Are they 0, 10, 50, or 100 percent responsible? The two extremes are—well, too extreme, especially the 0 percent option. Further, where health care is paid for on the principle of insurance and pooled risk, it seems inevitable that a large element of unfairness and moral hazard must enter. Why should I pay premiums to cover, say, sports injuries if I play no sports? How large or serious a risk does it have to be before it should affect premiums? And what if the risk is genuinely beyond the control of the person to be insured?

The problem is particularly acute in Britain, with its universal and centralized health-care system, almost free to the patient at the point of use. The average cost of bariatric surgery in Britain is estimated to be about $16,000; according to one of The Lancet articles, approximately 2 million people in the country would derive medical benefit from it. The cost of bariatric surgery for all who needed or would benefit from it would therefore be $32 billion, roughly $500 per head of population. Assuming that the costs would be additional to those of the system as it stands, a family of four would have in one way or another to pay $2,000 in additional taxes for the fat to have their operations (also assuming that the government did not raise the money by borrowing, in which case, the costs would be transferred largely to future generations).

One Lancet piece argues that this tax nevertheless would be an economic bargain because the savings on future health care of the obese would outweigh the costs of surgery. Unfortunately, the costs are immediate and the benefits are in the future, even the distant future; and it seems to me to be a common characteristic of cost-benefit analyses of this type that the costs tend to escalate over time, while the benefits tend to evaporate.

Besides, cost is not the only constraint. Bariatric surgery is specialized, and results are better when the surgeon and his team are experienced in this branch of surgery. Such surgeons and teams are not trained in an afternoon; and in a rigid system such as ours, increasing bariatric surgery might mean reducing some other kind of surgery, on people more deserving, in the sense that they have conditions to which their own conduct contributed less. Rationing of such surgery of some sort is inevitable, therefore, but how to arrange it? By need, worthiness, ability to pay, future value of the obese person to society (how many fat unemployed people with IQs of 90 equal one fat professor of engineering)? First-come-first-served, or by lottery, perhaps?

Part of the current formula for rationing bariatric surgery in our system is a Body Mass Index (the weight of the patient in kilos divided by the height, in meters squared) greater than 40—that is, no operations for people with BMIs of less than 40, or 35, if diabetes or severe hypertension is also present. The BMI is a surrogate estimate of medical need. But note the possible perverse incentive: 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.

It is interesting to read the dietary recommendations of BOSPA, the British Overweight Surgery Patients’ Association. These, it says, are the golden dietary rules for patients to follow long-term after their surgery, whether it be gastric band or bypass:


Only eat three meals a day.

Avoid snacking between meals. If you are following your recommended guidelines, there is no reason why you should feel hungry between meals.

Eat solid food. While soft foods may be easier to digest, they usually contain more carbohydrates and fat and make you feel less full than solid foods.

Eat slowly and stop eating as soon as you feel full. Cut your food into very small chunks, around the size of a pencil-top rubber, then chew each chunk 10–25 times before swallowing. Stop eating once you feel a sensation of fullness or tightness in your chest. Overeating or eating too fast could cause unpleasant symptoms such as pain and vomiting.

Do not drink during meals. This can flush food out of your stomach pouch and make you feel less full. Avoid drinking fluids 30 minutes before a meal and for an hour afterwards.

Avoid drinking high-calorie drinks, such as cola, alcohol, sweetened fruit juices and milkshakes. These types of drink will quickly pass out of your stomach and into your small intestine, increasing your calorie intake. Ideally, drink water or zero-calorie drinks, such as diet cola or diet lemonade.

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? What price now The Lancet’s bald and unqualified declaration that “The assumption that severe obesity is a behavioural or social choice, which can be reversed with a determined patient’s effort, is simply incongruous with medical fact”?

Facing up to human weakness is not the same as condemning the weak out of hand or refusing to help them. We are all weak in one respect or other and in need of understanding and sympathy. As Hamlet put it, “Use every man after his desert, and who should ’scape whipping?”

Photo: Some doctors argue that obesity should be considered a disease like any other. (GRAHAM BARCLAY/BLOOMBERG/GETTY IMAGES)

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