Episode #4 – America’s Tragic Normalization of Obesity

Seven out of ten Americans are overweight or obese, and the numbers have been growing. Janis Powers considers obesity to be the greatest challenge to the American health care system. Obesity correlates to every major chronic disease. It negatively affects qualify of life, drives up costs and impedes worker productivity. Worst of all, it has become culturally accepted. Powers takes a serious, critical perspective on how, societally, we must change our views on being overweight and obese by separating the condition, which is severely problematic, from the person, who deserves support and compassion.

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Welcome to The Powers Report Podcast. I am your host, Janis Powers. The show brings you candid, unique and data-driven perspectives on the health care industry. I believe that any solution that is going to positively impact the American health care system has to satisfy two major criteria: financial viability and behavioral incentive alignment. In other words, access to high quality care can only be achieved if we can afford it, and if we behave in ways that optimize our health. These are major themes that will be discussed in each podcast. Please subscribe to our show on i-Tunes or on your preferred podcasting platform and connect with us on social media. Again, this is Janis Powers, and welcome to The Powers Report Podcast.

In this episode, I will be talking about what I consider to be the greatest challenge in health care: obesity. Obesity is the biggest issue impacting the health care system for a number of reasons. First, it’s a precursor to so many chronic diseases, so it makes people unhealthy, lowers their quality of life and drives up costs; obesity impedes worker productivity, so it affects the entire economy; and critically, probably most disturbingly, it’s culturally accepted, which means it’s extraordinarily difficult to eradicate. We can’t bring down the cost of care and we’ll have less money to pay for our high cost system if we don’t reverse our public perceptions about being overweight and being obese.

So let’s talk about what we mean by overweight and obese. A standard metric used to qualify the healthiness of an individual’s weight is Body Mass Index or BMI. BMI is simple calculation. It’s your weight in kilograms divided by your height, in meters, squared. You’re considered overweight if your BMI is 25 to 29.9. A BMI of 30 or over is considered obese. Now, this is not the be-all, end-all definition of obesity. Different people have different bone structures, body types, etc. But for the most part, BMI is a good indicator of whether an individual is overweight or not.

That said, I want to make sure that listeners recognize an essential nuance in this particular show. I will be criticizing the condition of obesity, not the people who are obese. This podcast isn’t about fat-shaming. Fat-shaming is a form of bullying and ridicule. Fat-shamers, who are cowards, are intent on making those individuals who are overweight feel bad about who they are, both inside and out. Any remotely sensitive person recognizes that one’s outward appearance doesn’t determine one’s intelligence, spirit of kindness, sense of humor or capacity to love. This is why fat-shaming is cruel.

The problem we’re having is that some of the defenders of the bullied, those who seek to defend victims of fat-shaming, are, in many cases, emphasizing the wrong thing. It’s quite all right to tell someone who’s obese that they are a wonderful, amazing person. It’s another thing altogether to tell someone who’s obese that it’s OK to be overweight. It’s not OK to be overweight. It’s not OK to be obese. It’s unhealthy. And there’s nothing good about that.

Why is this so important? Because it affects so many Americans. Approximately seven out of ten Americans are either overweight or obese. 40% of Americans are obese … and the numbers have been rising.

That means that when we look around, most people we see are overweight. Being overweight is now normal. Not healthy, but normal because that’s what most people are. The actual incidence of being overweight in America has become a problem in itself. We are so used to seeing people as overweight, that we’ve become conditioned to think that there isn’t anything wrong with it.

Normal behaviors can be good. It may be normal for our neighbor to get up every day and run three miles before work. That’s what she does all the time, so when we see her do it over and over, we think it’s normal. Getting exercise every day is great for one’s mental and physical health. People who regularly engage in positive health behaviors like this serve as role models for those around them – for their family members, neighbors, co-workers, friends. It creates a positive behavioral cycle.

But normal behaviors can also be bad. Think about the cycle of abuse in a family. A child that grows up being abused is conditioned to think the behavior is normal. Abused children are more likely to grow up and abuse their own children because those are the norms they have been conditioned with. It’s a tragic cycle that’s really hard to break because it’s psychological.

We are at the point where we’ve been exposed to so many overweight Americans for so long that the condition of obesity has become normalized. This is borne out in some disturbing data that spans the past 15 years or so.

We know we’ve gotten heavier. But the ideal size – the ideal weight that we think we should be has also gotten bigger. In about 15 years, our ideal weight has gone up about four pounds. As a corollary, over this same time period, fewer of us think we’re overweight. We’ve gotten heavier, but less of us think we are overweight. And making it worse: less people want to do anything about it. The percentage of people who want to lose weight has dropped eight percentage points in the last decade or so.

This normalization problem is a result of what we see and what we say. Social media is riddled with messaging that inappropriately conflates the celebration of the person, as a human being, who is overweight or obese with the celebration of the condition of being overweight or obese. There is a difference between the condition and the person. We need to recognize the difference and focus on wording that promotes good health, not an acceptance of unhealthiness.

In addition, “newsier” articles and posts that legitimately decry fat-shaming often add caveats in an attempt to explain why some people are overweight and obese.  Doing so gives people who are overweight an “out” because they may interpret these explanations as excuses. They may think they their condition is a result of factors that are out of their control. As a result, they may be less motivated to take on the hard work of losing weight.

Here’s what I mean. Some populations are more susceptible to obesity than others. Those with lower levels of education and lower income have, on average, higher levels of obesity. Someone who’s poor with less than a high school education who is obese may hear this explanation and think that there’s nothing they can do about their situation. It’s like, statistically, they were destined to be overweight. Unfortunately, we can’t fix the educational system or income inequality overnight. These changes will take years, even decades to address. But people who are obese need to lose weight now. They shouldn’t be waiting for anything, and we can’t use explanations as excuses for inaction.

There’s a lot of talk about ‘food deserts”. These are geographies where it’s hard to find a regular supply of healthy food. If you can’t eat right, it’s hard to maintain a healthy weight. But we can’t blame grocery store chains that refuse to set up shop in sparsely populated, low income areas and call it a day.

Those receiving public assistance through SNAP (formerly known as food stamps) can use the allocated funds to buy junk food that includes sodas and chips. That’s a policy issue that should be changed. And there may be a significant gap in understanding what nutritious food really is and what constitutes a good diet. That’s a problem with the effectiveness of public health education campaigns and that, too takes time to modify.

Hands down the most challenging aspect to dealing with the obesity epidemic is getting people to accept that it’s their responsibility to fix the problem. The blame game is dangerous because it puts responsibility on institutions and situations that, in the short term, we cannot control. We need to focus on what we can control, which is behavior.

That said, dieting is easier said than done, and those who are obese may have more to overcome than others.

First, they’ve got to deal with the challenges that all dieters have: changing habits and maintaining discipline. That’s hard for anyone. Further, it is physically challenging for severely overweight people to exercise. They’re more prone to injury, which can kill all the momentum of starting a workout routine in the first place.

Many dieters, obese or not, over-estimate the impact that exercise will have on weight loss. Taking a 30-minute walk may be a significant effort for someone who’s obese. The exercise will drive up their appetite, but it will only burn a few hundred calories. That’s less that what’s in a doughnut.

Then there’s some weird metabolic stuff that goes on in with some dieters, especially those whose weight fluctuates a lot, and it’s been known to impact overweight people. It’s a phenomenon called adaptive thermogenesis. I’m not a clinician, but my simple understanding of this situation is that a reduction in caloric intake actually slows down the dieter’s metabolism. It’s like a starvation reaction. The body reaches this stasis and when calories are reduced, it feels like it’s being starved. So it slows itself down so less calories are burned. That’s got to be absolutely maddening, because it makes losing weight even harder.

There are mental health issues associated with some of the obese which may need to be addressed through counseling. Then there are those with a genetic predisposition to obesity and they may require a tailored clinical program that may include medication and/or surgery.

I bring up these issues to ensure that we have sensitivity to the fact that losing weight, especially for the obese, is challenging. Our job as citizens is NOT to approach strangers and give them weight loss advice. We live in a time where we need respectful, courteous discourse. Instead, we need to be positive and focus on health and personal responsibility.

Sometimes I wonder if some of our cultural acceptance of being overweight and obese stems from the fact that we just don’t understand how bad the problem is. Maybe if more people knew just how severe the situation is, they’d be more motivated to change. So here are some jarring perspectives.

If you’re obese, you increase your chance of getting high blood pressure, high cholesterol, type 2 diabetes, coronary heart disease, osteoarthritis, gall bladder disease, sleep apnea, some forms of cancer, mental illness, dementia and you’ve increased the odds that you’ll have a stroke.

I’m not making this up. This is the kind of information that needs to be hammered home. No one should put themselves in a position that increases their likelihood of developing basically every major chronic disease you can think of. This is scary.

Think about the physics of the situation. The human frame, our skeletal system on which everything else depends for support, was only designed to hold a certain amount of weight. When we add too much mass, our bones are weakened, our ligaments tear …our bodies deteriorate. As a result, over half the patients who have joint replacements (like for their knee or hip) are obese. What’s worse, complications in surgical outcomes go up when the patient is obese. There’s been a lot of discussion around requiring obese patients to lose weight before surgery, but none of them have gained formal industry or policy acceptance. We need to think more about how to have these discussions so we can ensure that patients have positive outcomes.

Relatedly, patients who are obese cost more to care for than others. A well-cited study identifies the cost of care associated with the obese to be about $150 billion per year. But that study was in 2008. The percentage of obese Americans has risen and the population has also increased by about 25 million people in the last decade. That means the cost of obesity today is much greater than $150 billion.

Then there’s the economic impact. Obese Americans have higher rates of absenteeism than the general population. Obese people are less productive than the general public, and their wages are typically lower. That means contributions to the country’s Gross Domestic Product are comparatively lower for the obese than for everyone else.

Lower wages, coupled with a poor state of physical condition, also lowers the quality of life for the obese. Improving quality of life should be a major motivator for those who need to lose weight.

It’s become harder for the military to recruit because the population is so unhealthy. According to a recent study about a third of the potential military recruits are disqualified because they’re obese. Enlisted soldiers may become obese. That creates another series of problems because a team is only as strong as its weakest link. Any situation that requires physical exertion can be compromised if soldiers do not satisfy the criteria for appropriate levels of fitness. Further, obesity is responsible for the loss of 650,000 work days by active duty service members every year.

The overall obesity rate in America will likely get worse because the rate of obesity among children is also increasing. Right now, about 20% of kids are obese. Obese children, like obese adults, are predisposed to serious health conditions like type 2 diabetes. They also suffer from bullying and other mental health issues associated with their condition. Sadly, being obese as a child increases one’s risk of being obese as an adult.

Nationally, the data about obesity is grave. Things get worse on the global stage. We can compare ourselves to other countries that are in the Organisation for Economic Co-Operation and Development or the OECD. This is a membership organization of 36 economically developed countries and includes the US, Canada, Mexico, most European countries and also Japan, India, China and Russia. Among this group, the U.S. had the highest obesity rating. Yikes.

Right now, there are over 200 countries in the world, not just the 36 OECD members. So how does the U.S. look compared to everyone in the world? Well, not good. I had to do my own simple analysis to pull together obesity rates because, surprisingly, it’s one of the key data points that is not captured by the World Health Organization. They report on dozens of statistics for all the countries in the world (if they can get the data). I got data from the NCD Risk Factor Collaboration and I excluded countries with a population below 300,000. That cut off is at right below the population of Iceland, an OECD country, so Iceland could be included in my ranking. Other countries, like Monaco with its 40,000 people, are just too small to compare to the US.

The results? We rank as the 7th most obese nation in the world. Here’s some unexpected info about the top ten most obese countries. Belize ranked 5th. Belize has a population that’s like Iceland, at about one tenth of a percent of ours, so they’re almost statistically irrelevant when talking about size. Here are the other eight most obese nations (one of which is a not exactly a nation): Number one is Kuwait. Then it’s Egypt, Qatar, Jordan, 5 is Belize, then the West Bank and Gaza aka the Occupied Palestinian Territory, which has over four and a half million people in it. That’s about the population of Louisiana. They’re 6. We’re 7, and then comes Iraq, Saudi Arabia and the United Arab Emirates.

There is an awesome PhD thesis or book in the making if you think about how alike the United States is to Muslim -majority nations…at least in terms of obesity rates.

Given all of this information, I think the most impactful thing we can do to help address the obesity epidemic in America is to be honest about what’s going to fix it. We are actually hurting people who are overweight and obese when tell them that their physical state doesn’t matter and they should be proud and “own it.” Instead, we need to be supportive and sensitive and encouraging so we can all be as healthy as we can be.

This is The Powers Report Podcast. Please subscribe to our show and please follow me, Janis Powers, on social media. We will be featuring listener questions, comments and suggestions on future podcasts. Please see our website at powersreportpodcast.com to submit questions and ideas on the Contact page. I look forward to hearing from you. Thanks so much for listening!