The McVictim Syndrome Could Kill Us

Call it the McVictim syndrome. Too many pundits, public health experts and politicians are working overtime to find scapegoats for America’s obesity epidemic.

In his latest book, former FDA Commissioner David A. Kessler argues that modern food is addictive. In it, he recounts how he was once helpless to stop himself from eating a cookie. In a paper in this month’s Journal of Health Economics, University of Illinois researchers join a long list of analysts who blame urban sprawl for obesity. In November, former Carter administration advisor Amitai Etzioni argued that it’s so hard for Americans to keep weight off that adults should simply give up and focus attention on the young instead.

The peak of the trend: A recently released Ohio study, using mice, suggests “fine-particulate air pollution” could be causing a rise in obesity rates.

How long before we’re told that the devil made us eat it?

The McVictim syndrome spins a convenient — and unhealthy — narrative on America’s emerging preventable disease crisis. McVictimization teaches Americans to think that obesity is someone else’s fault — and therefore, someone else’s problem to solve.

The truth: In the vast majority of cases, obesity is a preventable condition. So those of us in the medical community must be candid with overweight patients about the risks they face and the rewards of better health choices. But it’s also time for American policymakers to show the same level of candor.

All things being equal, the simplest explanation is often the right one. And the simplest explanation for the dramatic rise in obesity rates — roughly doubling as a percentage of the total population in just a quarter-century — is the surge in our daily caloric intake. Excess food now, excess weight later. And Americans won’t make better choices if the McVictim syndrome provides a convenient excuse to carry on as before.

Obesity is preventable, but its consequences seem difficult to avoid. Consider that the cost of treating resulting conditions such as diabetes is about 7% of all U.S. healthcare spending — and a significant drain on federal and state budgets. Obesity is a national security threat because it severely limits the pool of military recruits; in 2009, the Pentagon indicated that since 2005, 48,000 potential troops had flunked their basic physical exams because they weighed too much. Most important, obesity is a human threat, destroying otherwise healthy lives and increasing personal health costs, all for the sake of a few daily moments of instant gratification.

For these reasons, there is a role for government to play in attacking obesity. Public policy can help. School lunch programs shouldn’t push our children toward obesity at taxpayers’ expense. We should stop subsidizing agribusinesses; many are using taxpayer dollars to produce and market unhealthful foods. We should promote insurance reforms that support preventive medicine.

But we must also launch a direct attack on the philosophy behind the McVictim syndrome. Policymakers must accept the fact that a poor diet is almost always a poor personal choice.

Yes, it’s fair to say that many Americans try to choose better — and fail because they’ve chosen quack drugs or crash diets as the solution. Yes, it’s fair to say that losing weight solely for appearance’s sake isn’t a healthful choice. Yes, it’s fair to say we shouldn’t crush the self-esteem of those who’ve tried, and failed, to keep off excess weight. In other words, our society makes healthful choices tougher.

But even so, encouraging Americans to cut their dietary health risks is a responsible act of citizenship. And it’s absurd to pretend that Americans are helpless to make that choice — or that it’s too late for them to reap the benefits. Contrary to claims like Etzioni’s, even a modest, voluntary improvement in the average American diet could pay huge dividends.

Just as a little more weight causes more damage over time (to joints, to cardiovascular systems, to organs), a little less weight can produce dramatic health benefits. To take one example, a study cited in the Journal of the American College of Cardiology found that obese patients on a program of mild weight loss and modest exercise cut their odds of getting diabetes by as much as 60%. Imagine the benefits that would flow from keeping millions of future Medicare recipients from ever needing an insulin prescription.

The McVictim syndrome is far too prevalent, which promotes the notion that regulations and laws are the primary solution to the problem. But governments can’t micromanage your waistline for you. Even if governments could magically walk you to work, ban food advertising, regulate sugar out of food and suck those fat particles out of the air, in a free society you would still have the power to drive to the nearest restaurant, shake your salt shaker and order a second piece of pie.

That’s why understanding — and rejecting — the McVictim culture is crucial to obesity reduction policy. And the first step in that process is to reject the temptation to find an easy scapegoat

David Gratzer, MD, is a senior fellow at the Manhattan Institute. His research interests include consumer-driven health care, Medicare and Medicaid, drug reimportation, and FDA reform. The late Milton Friedman, Nobel Laureate in Economics, wrote that Gratzer is “a natural-born economist.” Gratzer’s most recent book, with Foreword by Milton Friedman, is The Cure: How Capitalism Can Save American Health Care (Encounter Books, October 2006).

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57 replies »

  1. I love how everyone’s debating healthy choices… in McDonald’s.
    If you’ve got a car to drive to McDonald’s, surely you’ve got a car to drive to somewhere else? The whole notion of people in sprawling cities being helpless to eat anything but McDonald’s is predicated on the delusion that no one will drive any distance to buy food – yet most families have cars in America, regardless of income. And I’ve seen dozens of medically obese friends jump into their car late at night to drive five miles to the nearest 24hr McD’s for a 1,500 calorie “snack.” Ask them to drive half that distance to buy enough healthy food to last them two days at the same net cost, and the answer will be “forget it.” Not because they can’t. But because they “don’t like it if it’s healthy,” and they don’t know how to cook it, and they don’t want to learn because it’s easier to waste time doing something more leisurely.
    Maybe personal responsibility is the wrong phrase… but anyone who doesn’t factor for personal carelessness or indifference as a major driver of obesity is just kidding themselves.

  2. Well, Nate’s brain needs loads of glucose from somewhere for all these comments …

  3. what increasing food portions? Thanks to the food nazi’s I can’t get a Super Size Coke at McDonalds any more. The social stigma as forced me to take my excessive eating to the shadows. Where I use to be able to go to one fast food joint and order now I have to go to 2-3 per meal to avoid being judged. Society needs to take a long look in the mirror in regards to how they treat big eaters.

  4. Nate, my last comment was in response to this statement of yours: “I don’t read prevalance studies every week but I don’t recall seeing any reduction in smoking amoung the poor, and issue that has always annoyed me.”
    You claimed that it “always annoyed” you, which sounded very much like you believed the data showed no decline in smoking among the poor. That is wrong. Smoking has declined over the years among the poor. The new Gallup poll you cited was a snapshot, not a time series, so irrelevant to that point.
    I must have mixed up income with education as the target of your point, but it doesn’t matter which is chosen in this regard.
    As for the comment about using race as a proxy for income and education, I was going from memory about a comment some months ago where you wanted to explain away the poor performance of the South (on education I thought) by pointing out that there are a lot of black people in the South and the effect disappears when you look at whites only. I thought you had done something similar before that as well. I may have been wrong, because I couldn’t find it after a quick googling.
    Ironically in light of your last response to me, I did find this, though:
    “I just tore apart a gallap poll last week, There is nothing scientific about what they do. They push a political agenda and try to pretend they can support it with fact.”
    Anyway, we’ve reached the point of diminishing returns…perhaps long ago.

  5. Nate – The Fruit and Yogurt Parfait at McDonald’s is essentially all sugar (21 g) and will to little to fill you up because it is only 160 calories with almost no fat/protein. No way that satisfied an average person if they are hungry.
    ‘Salads’ at McDonald’s even worse than eating the a double cheeseburger in some regards because they have even more calories, sodium, and fat if you include dressing.
    Personal responsibility is an issue in the weight debate and no I don’t think there should be class action lawsuits against fast food companies or other food manufacturers. I just get tired of hearing the simpleton libertarian/conservative excuse that fat people are fat solely because of the choices they make. That’s BS. It is much more nuanced than that and doesn’t work like that.
    One of the huge things that hasn’t been discussed here on which there is a huge amount of sociological and anthropological data on how Americans prepare food has radically changed in post WWII America. It wasn’t uncommon that the average family (almost exclusively women) spent over 2+ hrs a day preparing food and cooking. That has radically diminished for several reasons and simply isn’t a luxury available today to most American families.

  6. I don’t know if Alzheimer’s is more expensive than chronic diabetes. But looking only at the costs only tells you half the story. The other half is what that person contributes to society.
    A person who is obese at 25, has severe diabetes at 35, has an amputation at 45, and dies at 55 is unlikely to have done much with his life. It is unlikely that such a person had a high-paying job or paid much in taxes. It is likely that the person was a burden to his family or to the taxpayer. On the other hand, a healthy person who has a productive career, starts a company, helps a lot of people, and then dies of Alzheimer’s at age 85 provides a much more useful service to society. His medical costs might have been higher, but his lifetime contributions are higher as well.

  7. Margalit and rbar –
    Margalit – While obesity rates are higher among the poor than the middle class and wealthy, they increased for all groups over the last 30-40 years. Moreover, according to the Food Research Action Center, the gap in the obesity rate narrowed between low and higher income people, especially for children.
    In addition to the increased prevalence of fast food restaurants and larger portion sizes, contributing factors could include the following: (1) Fewer people in the workforce are doing physically demanding work. The manufacturing sector in particular shrunk dramatically over the last 30 years. Even for those still working in the sector, more mechanized equipment, including robots, made many of these jobs less strenuous than they once were. (2) Plenty of middle class people now hire others to do chores they once performed themselves. For example, 30 years ago, most of the people in my neighborhood, including myself, mowed our own lawn. Now, most of us hire a lawn service. Instead of shoveling snow manually, we use a snow blower. (3) Children spend a lot more time in front of computers instead of running around outside playing. (4) Even getting off the couch to change the channel on the TV was eliminated by the remote control.
    rbar – While I agree that CABG and joint replacements are expensive, as Nate notes, they are one time episodic expenses. By contrast, the average price for a year of nursing home care is now about $75K according to the AARP while in major metropolitan areas like NYC and Boston, it can be well north of $100K. New York’s Medicaid program is the most expensive in the country by far at approximately $50 billion including the federal share. Approximately half of that sum goes for long term care, including home health care. I know that care related to CHF can mount up as patients bounce back and forth between the hospital and home or a long term care facility when fluid builds up to dangerous levels, but I don’t know how many of those cases are related to diabetes. Expensive end of life care most typically relates to cancer in the hospital setting and Alzheimer’s and dementia in the nursing home setting. While I’m not looking to kill anyone off, I agree with your comment about smoking and alcoholism.

  8. joint replacement is a one time treatment, once the surgery is done the expense is gone, and the cost of knees and such aren’t that expensive if not done in major metro areas.

  9. Barry, if I find any empiric data, i let you know, but I think you are plain wrong. All the conditions/problems that I have listed – joint replacement, kidney failure, CAD are very costly ones – I don’t know why you list yourslef as an example as you are not diabetic (the CABG is I believe somewhere between 60 and 90 K, and stents, don’t know, maybe 10 or 20? So that’s already a lot money). Don’t forget that diabetes is a risk factor for dementia (there is reasonable evidence that stroke risk in mid life correlates with dementia risk), probably because of vascular dementia (most dementia is actually of mixed type, pure Alzheimer is less common than previously thought). If you want to let people die before retirement age, alcoholism and smoking probably works best.

  10. from a cost perspective i rather pay for an amputation then any of the degenretive diseases associated with old age. That is a short hospital stay compared to someone that is not capable of caring for themself and needs daily care till death.

  11. Margalit –
    Determining the cost of treating diabetics is complex. While there are, supposedly, more than 24 million people with diabetes in the U.S. today, millions of them have their condition under good control with inexpensive medication. For those with, say, CAD and hypertension as well, did the diabetes cause the latter two or was there a genetic pre-disposition instead? If, for example, just within the Medicare population, we looked at the cost of caring for 10,000 people with CAD and hypertension but not diabetes vs. 10,000 with CAD and hypertension plus diabetes, how would the costs compare? I have no idea. My sense, however, is the cost associated with complications from diabetes such as blindness and amputations are not all that high in the scheme of things, but again, I don’t know. Kidney failure (Stage 5 kidney disease) does cost a lot of money to treat and about 44% of the 300,000 cases in the U.S. stem from diabetes. I wonder how this compares to other developed countries as a percentage of the population.

  12. ” You like to look at race as a proxy for income and education,”
    Please link to an example of this? I clearly said income and didn’t assign it to one race or the other so why do you choose to bring in the race strawman? Poor white people smoke just as much as poor black people, you might have to factor in chew, but they are pretty close.
    This took 2 seconds to find, wonder why you didn’t link to income like I was talking about
    clearly shows people who supposedly can least afford to smoke do so the most.

  13. “Recent legislation in the health reform bill, which has been the law in NYC for some time now, will require restaurants with 20 or more stores to post the calorie content of everything they sell. That’s a step in the right direction, I think.”
    Barry, there is already evidence on the effectiveness of this. Turns out it had no impact for most fast food purchases. The only place it had a (modest) impact was in higher end joints that seem to attract a wealthier or more health-conscious consumer. I believe there was a modest impact on healthier choices at Starbucks, for example. Information can be a small part of the solution, but seems to help the most for those people who need help the least.
    Nate, smoking rates have basically dropped in half nationwide over the last 50 years. You like to look at race as a proxy for income and education, so note that smoking rates declined nearly as much for Blacks as for Whites.
    Here’s another one, this time breaking out prevalence by education (table 6 here). Unfortunately, it is very old data, but the trend is the same: declines for all education levels (except the least-educated women, who had the lowest smoking rates of all to start, and still had the lowest smoking rates at the end).

  14. Barry, I have a small problem with your math. You are looking at lifetime costs for an individual, but shouldn’t you be looking at population costs at any given time? For example a population consisting of 2 Alzheimer’s patients, 2 cancer patients and 1000 diabetics, will be spending most of its resources on the treatment of diabetes.
    “The fact that obesity rates in the U.S. are now far higher than they were 30 or 40 years ago cannot be ascribed to genetic changes in the population.”
    No, it cannot, but isn’t it equally implausible to ascribe it to sudden “character” changes in the population?
    The low prices of energy-dense highly palatable foods is what caused McDonald’s to proliferate, particularly in poor neighborhoods. I would have to drive 5 miles, pass a WholeFoods, a TraderJoe, a couple of very well appointed supermarkets and a variety of “organic” little stores to reach the closest McDonald’s. On the other hand, once you reach the McDonald’s, there are a dozen other equally unhealthy outlets within walking distance and no fresh produce in sight. For the vast majority, what you eat pretty much depends on where you live.
    It’s not about ice-cream, it’s about white bread, potatoes, soda and fatty meat.

  15. Peter –
    For food purchased in supermarkets and convenience stores, drug stores, etc. as opposed to restaurants, there is already plenty of nutrition information on the label that informs people about calories, fat grams, sodium and sugar content as well as fiber. The information is there to allow people to make healthy choices. With all due respect, I don’t think we need to be vegetarians to live healthy lives.

  16. Peter and rbar –
    As I’m sure you both well know, the really expensive care relates to hospitalizations, surgeries, long term custodial care (especially for Alzheimer’s and dementia) and specialty oncology drugs. It’s not physician visits and it’s not non-specialty drugs. In my own case, despite never smoking or being overweight, I have CAD which required a CABG in 1999 and a stent in 2005. The five drugs plus baby aspirin that I take to manage the condition would cost a bit over $2K a year if I had to buy them myself at Wal-Mart. The one branded drug (Plavix) out of the five accounts for 85% of the total cost of all five and it will lose patent protection in 2012. A single course of cancer treatment which, except for lung cancer, generally cannot be prevented can easily approach $100K.
    Peter, it’s the high cost of treating Alzheimer’s, dementia and cancer which are all more prevalent among the elderly that can result in higher lifetime costs even for patients who were largely healthy when they were younger as compared to the shorter lifetime cost of care needed by diabetics and smokers. Very few people are healthy for most of their life and die suddenly and quietly in their sleep.
    The fact that obesity rates in the U.S. are now far higher than they were 30 or 40 years ago cannot be ascribed to genetic changes in the population. When I think back to my own time growing up in the 1950’s and early 1960’s, fast food restaurants were virtually non-existent. McDonald’s wasn’t even founded until 1955. When I was in high school, we probably had one McDonald’s in our entire county of over 400,000 people. Now, fast food restaurants from McDonald’s and Burger King to Dunkin Donuts and Starbucks are everywhere. Even in Asia where obesity rates are one tenth of ours, are starting to rise among young people as fast food restaurants spread there too. Separately, according to a news report I saw a year or so back, portion sizes in restaurants have increased considerably since about 1990. Recent legislation in the health reform bill, which has been the law in NYC for some time now, will require restaurants with 20 or more stores to post the calorie content of everything they sell. That’s a step in the right direction, I think.

  17. “That all said, I know that I love ice cream and I used to eat it every day. I brought it into the house and I ate it. When I stopped bringing it into the house, I ate a lot less of it because I had to make it a point to go out and buy it if I really wanted it. So, the less unhealthy food we bring into the home, the less we will consume. That’s a matter of personal responsibility and discipline.”
    Barry, there’s a lot of difference between personal responsibility for cake and ice cream and highly processed, high salt/fat/sugar “foods” sold as regular meals. People need to eat something and need to bring it into the house, when an entire industrialized food industry is geared for subsidized cheap high calorie foods it doesn’t give enough of a fighting chance for people to eat better. I don’t know when the Nates of this country will recognize an epidemic (http://www.cdc.gov/obesity/data/trends.html) and when it needs serious action, but then Nate thinks the solution to everything is to just adjust his risk tables then price his healthcare options to suit.

  18. Let’s see, healthy people, who don’t need medical care, cost the system MORE money while sick people needing medical care cost the system less????? The reasoning is that healthy non-sick people live longer (without sickness and not needing medical care) while unhealthy people die sooner with sickness???? Sounds like healthcare Reaganomics.

  19. Barry, I believe the jury is out whether healthy people “cost” society more or less … I believe I read some major modeling studies proving either. But let’s focus on diabetes: the people with obesity I encounter are going strong with 35, OK with 45 and beginning DMII, and with 55, trouble starts with complications (CAD, stroke, severe DJD, kidney disease). They will get into medicare and SS, and even if they expire at 68, they will need a lot of care and don’t have an enjoyable last 1-2 decades. Maybe that arguments works with smokers, but I don’t believe it applies to obesity.

  20. As I read this post and comments, I feel like I’m in a Chinese restaurant and I need to choose one each from columns A, B, C and D.
    It’s certainly true that some people gain weight more easily than others even if the types and quantity of food is held constant. Also, some people don’t get the signal from the brain as quickly as others telling them that their full. When you understand how hard and long you have to exercise to burn 400 or 500 calories, it’s a lot easier to just not take in the calories in the first place. But, for many people, that’s easier said than done.
    Fiscal policy counts for something as well. We could indeed subsidize healthy foods more and unhealthy foods less. When it comes to healthy food, it’s not as available in poor neighborhoods as in middle class and wealthy neighborhoods and, to the extent that it is available, it costs more.
    That all said, I know that I love ice cream and I used to eat it every day. I brought it into the house and I ate it. When I stopped bringing it into the house, I ate a lot less of it because I had to make it a point to go out and buy it if I really wanted it. So, the less unhealthy food we bring into the home, the less we will consume. That’s a matter of personal responsibility and discipline.
    Finally, as Nate notes and studies done in the Netherlands and elsewhere show, smokers and obese people die sooner than healthy people and probably cost the healthcare system less over their lifetimes. Heart attacks kill quickly. People can live with Alzheimer’s, dementia, Parkinson’s, etc. for 10-15 years and need expensive custodial care for much of that time. Cancer is also much more prevalent among the elderly than the under 65 population, and it’s expensive to treat as well.
    At the end of the day, when it comes to obesity, genetics matter. So does how we apply taxes and subsidies to food, cigarettes and alcohol. Personal responsibility is a relevant issue. But, if you’re significantly overweight, at the population level, you will probably die sooner than your healthy counterparts and you will likely cost the healthcare system less money over the course of your lifetime.

  21. “It amazes me that people don’t grasp when to large a population stops contributing and just sucks resources you will eventually kill the host.”
    Agreed 100%, although you probably have the suck-ers and the suck-ees mixed up….

  22. Patients should take responsibility for their weight. However,their are far more Factors than just patient accountability. Processed Foods are just as deadly as fast food. It not surpising how little the Health Profession understands about the manufactoring of food and their liberial exercises of manipulating food to meet demand and /or create demand.Also, genetics,Mental Health etc, plays a large factor in this arguement. Again ,something the medical field and insurers are clueless about and More likely can care less about.
    These organizations are so driven by demand for profits. They fail to recognize the entire cycle of prepared foods and the excessive uses of ingredients,Pesticides,Herbicides and Agriculture practices that contribute to Health Hazards. It is so much easier to shame patients than to offend a industry that share the same ends. Placing profits above Health!
    Largely,people are victimized by their beliefs,perceptions,arrogance and somtimes ignorance.I think it is important to explore all the facts and not simply expound on the obvious. It is Not that SIMPLE.

  23. Well Nate, you can say it’s all about personal responsibility and wash your hands of it, but all those non-responsible people are costing us all a lot of money. At least we can tax them to help pay the costs so that they’re not just sucking our resources. If that changes habits then that’s good too.

  24. is smoking reducing becuase of taxes and indoor bans or because the consiquences are more clear? I don’t read prevalance studies every week but I don’t recall seeing any reduction in smoking amoung the poor, and issue that has always annoyed me. You would think the poor would be the most cost concious but it hasn’t solved the problem of people that supposeduly can’t afford to live without public assistance smoking at such a high rate. My recollection is the more affulent(those that can afford the taxes) and educated have started smoking less and that would lead me to believe it is responsibility, i.e. if I smoke I will most likly die sooner then if I don’t.
    I would find it hard to believe the ease of having a baby out of wedlock and as a teen compared to 40 years ago has not contributed substantially to the willingness of teenagers to engage in activity that leads to pregancy.
    What do you mean unprotected sex is cool? I have never heard anyone brag how unprotected is the cool way to do it, does it feel 1000% better, now that is a valid argument.
    evolved or devoled Margalit? We do some incredibly cruel things to people in the name of humanity.
    I would argue the economic fallacy of poor diets costing us money any day. A heartattack at 50 is substantially cheaper then cancer or alzhimer at 80. If you want to worry about cost then you would be stuffing people full of transfat like patte then giving then a pack of cigs after. Living is far more expensive then dieing, especially if your talking about offing the non working aged.
    Is it possibble one of the main reason things are as bad as they are and continue to get worse is becuase we aren’t in the life yourself by the boot strap would we use to be? It amazes me that people don’t grasp when to large a population stops contributing and just sucks resources you will eventually kill the host.

  25. “and FYI there has never been a pure responsibility model in the past 100 years”
    Yep. Somewhere along the way humanity evolved away from a pure Darwinian model.
    Nobody said anything about “forcing restrunts to sell ceretain types of food and baning them from selling others”.
    If there was an issue raised here, it was about spending tax payers’ money to subsidize sugar, grains, fats and cruelty to animals, and subsequently complain that folks that can only afford cheap food are picking the foods that we make cheap (and tasty), only to become obese and cost us all unsustainable amounts of even more tax payer money. All because cheap food turns out not to be good for you. Some interesting unintended consequences….
    As an aside, perhaps we should think twice before promoting cheap health care and “fast” health care venues in every corner….

  26. “Yet or your ok listening to the endless duldrum that people are victums and don’t have any ability to change their sitution?”
    I think that stuff is equally off base, but who says that, really? It’s not what we get in pop culture media. What we get is more like Oprah and Dr. Phil, who are very much about changing your situation. It’s true that there is often a desire to avoid having people get down on themselves by focusing on self-blame–out of the belief that this blame easily becomes counter-productive, not because they believe there is no personal responsibility or people can’t change their ways with the right inspiration, social support, public policies, etc.
    Those who say there is no responsibility are fringe dwellers (I’ve seen some obesity “advocates” simultaneously say they can’t help it and that being fat is good), or people who latch on to the latest study seeking simplistic explanations (like “the fat gene” or “the addiction gene”). I really don’t see them as dominating the discussion, but for the record I believe they’re full of it.
    You’re “you people” comment is ridiculous. Why do I have to agree exactly with what anyone else says just because I’m to the left of you, and why does my failure to do so indicate that we people keep shifting? Of course I speak for only myself, and no one else here.
    You ask for an example: I’d say public policies to reduce smoking by making it more difficult and expensive have been quite effective for a highly addictive substance. There is solid evidence of decline as a result of restrictions on where you can smoke and higher taxes for cigarettes (higher taxes have the largest effect in deterring younger people who are not yet addicted).
    Finally, just because insisting on personal responsibility alone doesn’t usually work, that doesn’t mean that any old intervention will work. I agree labels by themselves rarely achieve much (recent data from NYC supports that). I don’t want to prejudge the evidence. Both abstinence programs and condom programs leave a lot to be desired. On the other hand, increasing the income and education of teens, having parents who are in a stable and loving relationship and having few peers engaged in unprotected sex (so that it’s “uncool” rather than “cool”) are all better predictors of what the children will do. Note that a sense of responsibility may play a role in several of these factors, but we are emphatically not in the lift-yourself-by-the-bootstraps world that libertarians keep leaning towards. Behind almost every successful person there are lots of other people who held your bootstraps at one time or another….and those people could have been family, friends, government employees like teachers, or a state government that helped your parents through a rough spot when they lost their jobs so you could stay in school.

  27. IMHO, we have 2 rather extreme positions where the “liberals” want to blame conditions/society almost exclusively, while the “libertarians” focus on free will and state that options for cheap healthy eating are plentifold and only choices matter.
    I think the truth is in the middle (it usually isn’t, usually the libertarians are wrong — just kidding). Conditions matter, and the fact that fatty fries and sugared drinks do taste better, which likely has evolutionary reasons as someone pointed out already. I’d suggest to do both at the same time: emphasize that there are choices to be made, but introduce policies that support good choices. That’s also the best attitude to treat addictions: it is a problem of choice and willpower, but it is also a problem of policy, in order to to create conditions that allow coming off the addiction or to prevent it from developing in the 1st place … or are most libertarians suggesting to drop age limits as well?

  28. and FYI there has never been a pure responsibility model in the past 100 years so your claim about their effectiveness is conjecture and nothing more. Just say no didn’t force moms to pay for their own bills, they still have a social saftey net, drug abuse still comes with countless free programs and assistance. LEts apply your same standard to the liberal soltuons to these problems, how have they performed?

  29. “don’t preach about the primacy of responsibility in a void of evidence.”
    Yet or your ok listening to the endless duldrum that people are victums and don’t have any ability to change their sitution? What evidence do we have that posting nutriuonal info or giving out condoms works? Actually we know that with those measures taken the problem still gets worse.
    Your also ignoring the fact that Peter, MG, Margalit with their typical hyperbole were wrong. You start with an argument that there are no options then when that is disproven now the argument is the number of options. Your arguments, like your idelogy, are so fluid its impossible to argue anything with you people, you just change it as it is disproven.
    Jonathan if youw ant to talk stupid lets talk liberal solutions, you claim pure responsibility doesn’t work, no one is arguing people shouldn’t be offered nutrional information or offered assistance, what we are saying is trans-fat shouldn’t be outlawed. We shouldn’t be forcing restrunts to sell ceretain types of food and baning them from selling others. Bad logic and bad science is trying to force people into a lifestyle, that is unamerican and dumb.

  30. Nate, there is a trade off to eating the fast food salad over a burger and fries and that is the calories needed and that satisfied feeling. Fast food joints get to choose the size of salad and it’s make up. They’d prefer you order the burger and fries. I was referring to grocery stores and the price of fresh fruits and vegetables and unprepared starches over factory prepared and fast food crap. My wife and I have been vegetarian for the past 5 plus years but it was a change in cultural mindset, education and time allocation to make food taste good and get the proper variation. We used to typically eat slab-o-meat plus frozen veggie and pre-prepared starch. I have started back on some meat, once in a while, but only organic and humanly raised, but that stuff is very, very expensive. When the food culture trains you from childhood, especially with toy give-aways, fun cartoon characters and lots of sugar, it’s hard to rewire the brain to do the right thing. Yes, price does matter and our ancestral survival mode genes also work against good eating habits. Of course conservatives think all problems can be solved with a simple-minded one liner.

  31. The lack of cheap healthy and tasty options in most of the country when eating out is simply a fact. Wendy’s has many artery busting items for every healthy one. I know that it is way cheaper for me to get a nutritionally horrible breakfast on my way to work than a healthy one. I work in Manhattan, so food carts, fast food and delis are all over the place. There are a couple fruit trucks that allow me to get a fast-food cut fruit breakfast for $3.50 minimum. There are many more standard sidewalk carts and delis that will sell me pastries for as low as $1.00 (including a very large cinnamon role that I confess to eating too often). Quantity of options and cost of those options matter.
    But let’s say Nate is right that it is equally easy to get cheap healthy food when you go out to eat. How does that help the case that we should spend all our time blaming individuals and none on policy interventions to make it easier to do the right thing? It doesn’t.
    David Gratzer doesn’t like the blame game, and yet he is playing it. He chose the individual as the locus that bears the brunt of the blame, instead of genetics or society or the subsidy and tax policy or food-science advances, etc. This is not a wisdom that breaks out from the finger-pointing loop, but instead is just another part of the circle of blame. It is wiser to allow that multiple factors matter, and to focus on what is effective rather than what fits your preconceived ideas of responsibility. You do want to get results, right? Then show me what works, don’t preach about the primacy of responsibility in a void of evidence.

  32. Yes Margalit every where but your liberal utopia where no one takes responsibility it is that simple. When you order the McDouble instead of the Fruit and Parfait it was as simple as making a bad decision. And yes as the links show the salads are just as cheap as the burgers and you can get fancy salads for the same price as the fancy burgers.

  33. “Another conservative making flip comments for which they don’t have any kind of real research besides cheap and largely generic antedotes.”
    How does that foot taste MG, hope its low fat.
    I know you liberals with your poor education don’t really understand science but looking at the menu and doing the comparison generally is not considered cheap and largely generic antedotes.
    “On what fast food menu is a salad cheaper than the $.99 double cheeseburger?”
    The thing I love most about liberals is your so stupid you make my point for me. Well lets see how about the same dollar menu the $.99 cheesburger is on?
    You can order salad or fruit and parafe…..how is that foot MG?
    “In how many fast food restaurants are apples or bananas readily available in lieu of chips besides Subway?”
    Well lets see Wendy’s has mandarian oranges. McDonals has apples Burger King has apple fries, I could go on MG but I think it would be quicker for you to find a fast food restruant that doesn’t then it would be for me to name all that do….oh how was that foot tasting?
    You were saying something about conservatives making factual and accurate statements while liberals make flip comments or something?
    Maybe you fat city dwellers should walk your fat asses to the grocery store then if prices are that much higher, read a book while on your way and maybe you wont make so many slip statements and suck so much foot.

  34. I hope everyone understands that what we’re doing here is philosophy, specifically ethics with a helping of political philosophy.
    Any generalization you can make about human behavior will have exceptions, and so it is never strictly possible to point to (say) some self-destructive behavior and show that people couldn’t do otherwise. Some do, even in the same circumstances. Some people born to fat parents who were fat as kids decide to change their lives and have BMIs under 25. Some people born in the ghetto with no family members who graduated from high school graduate from an Ivy league college and have successful careers.
    In that way, there is always room, conceptually, for the libertarian, hoist-yourself-by-the-bootstraps type to say: see, people can do otherwise. We should hold them accountable and not let them blame anyone else.
    So it’s not incoherent to take that approach. It’s just dumb. And it’s dumb because we have data, lots of it, about the effect of various policies and social norms. Even though it is all statistical and about trends rather than laws of nature, some pretty consistent things emerge. Pure responsibility approaches have tons of limitations, and in fact I’m not sure they are effective by themselves at all. “Just say no” as a policy whether written into law or preached on TV and in schools, doesn’t work. It didn’t work for drugs, or abstinence and teen pregnancy, and it won’t work for overeating and obesity.
    A policy of responsibility when conjoined with various supportive paternalistic measures to “nudge” people works far better. Make it easier to do the right thing, recognizing that people have tendencies to fall into traps of reasoning and seek short term pleasure over longer term gain, etc.
    It reminds me of Reagan’s old dictum: Trust, but verify. In this case: Hold people responsible, but recognize that they are weak or irrational in reliable ways and use that knowledge to shape policy. Treat them like they are responsible and irresponsible at the same time. Maybe not at the same instant, but in the same conversation.

  35. Nate – Next time you to a big city, go to a corner bodega and price a half-gallon milk vs. your suburban supermarket. You will likely be shocked how much more expensive the milk is in the corner bodega.

  36. “The salad on most menus is as cheap or cheaper then the big burger.”
    On what fast food menu is a salad cheaper than the $.99 double cheeseburger? In how many fast food restaurants are apples or bananas readily available in lieu of chips besides Subway? That isn’t the case in just about any sandwich shop I would walk into in Philly.
    Another conservative making flip comments for which they don’t have any kind of real research besides cheap and largely generic antedotes.

  37. “crap food is too cheap and good food too expensive.”
    Water is usually free yet people still order the soda. The salad on most menus is as cheap or cheaper then the big burger. Its BS argument that obseity is cost driven, there are cheaper alternatives to junk food but people choose not to order it. An apple or banana is cheaper then a bag of chips. Examples go on for ever.

  38. As with any issue, there isn’t one single dominant overwhelming factor that is influencing this trend and it isn’t a US-based problem either as many third-world nations are experiencing rapid rises in obesity-rates too.
    If you want to most directly address this problem, you would address it through the agricultural bill that passes through Congress every 5 years. The problem is that you have huge vested corporate interests in preventing this.
    You also have huge access problems to high-quality food in both many rural areas and urban areas in the US. Many elderly people who live at home don’t have the means to go to a store on a regular enough basis and many who live in urban areas don’t have a supermarket that is within reasonable distance from their house via walking/public transportation.
    I amazed at just ignorant most Americans are regarding how food is grown, processed, transported, and ultimately sold in the US. Most Americans simply assume that there is fairly easy access to food. That simply isn’t the case especially if you don’t drive and/or have a car.
    Corner bodegas are a poor substitute in many cases (high cost, limited selection, poorer quality) and there has a general trend the last 30+ years for local butcher/grocery shops to go out of business because they simply generate enough businesses from local customers to keep their doors open given their higher input costs.
    The other main issue besides access is the cost of food too. There are alot of people who simply struggle with food ‘insecurity.’ Nearly 1 in 4 people in Philly either cut back voluntarily on food/go hungry on a weekly (miss at least 1 meal/day) on a regular basis and you have to fairly creative to feed yourself and your kids on a limited basis.
    Hell, in order to feed yourself a healthy diet on food stamps ($1.50-2/meal/day for a person) you have to eat to buy dried beans/rice or other grains in bulk, buy organ meat which is almost always cheaper than regular cuts, and look for deals on produce but mainly stick to root vegetables which are almost always cheaper & easier to buy in bulk. It isn’t easy to accomplish this for multiple reasons especially the access side of buying healthier carbohydrates staples in bulk at cheaper rices.

  39. Of course the liberal cannot accept that obesity is one more “irresponsible” character trait.
    To accept this would be to accept there is no government solution to impose on the obese. And no liberal will ever belive that.

  40. Well, yes. Obesity may be a disease for some, and a manifestation of poverty and lack of education for others, and finally an inability to put down that extra brownie for the rest.
    I don’t think obesity is socially acceptable though. Most obese folks would prefer to not be obese, and most non-obese folks do not look with envy or happiness at the very large person about to board the same flight, for example.
    I think obesity is a byproduct of so many objective factors that it cannot be dismissed as just one more “irresponsible” character trait of the masses, which seems to be the answer to every misfortune nowadays.

  41. “They are all irresponsible slobs…”
    Ah. Push an argument to its extreme version, then refute the strawman. Why “all”? Did the writer say “all”? Why not “most”?
    I say this as a middle aged man struggling with a middle aged waist line: if you are too fat, it’s your own fault, and the solution is within your power.
    The “answer”? “Solution”? Why does “society” need to come up with an “answer” for my calorie count? Am I a ward of the state?
    McVictims, indeed.

  42. Maybe you are right re. the label “platitude”.
    But I feel strongly about 2 issues:
    -it is a huge issue and (apart from all the suffering it causes) able to break medicare.
    -I feel it is a mistake just labelling obesity a disease or a condition society alone is to blame. We need to enhance the notion that obesity is harmful and unproductive and that the affected individuals need help. (as a side note I am unsure whether child abuse was a good example, but there are plenty others that you will be able to identify youerself; if you restrict an issue to law enforcement only (and don’t think that societal disapproval is necessary), you have a policy that will not succeed, like e.g. prohiobition).

  43. rbar, I am a bit surprised. Child abuse is a crime. It should be curbed by prosecution. Alcoholism, I thought, was shown to not be exactly elective.
    As to obesity, I find the epiphany in this article more of a platitude than a unique insight:
    “And the simplest explanation for the dramatic rise in obesity rates — … — is the surge in our daily caloric intake.”
    So we are fat because we eat a lot, and we are drunk because we drink a lot, and we are fit because we exercise a lot, and we are rich because we make a lot of money and conversely we are poor because we don’t.
    These are not answers or explanations. This is just rephrasing the original assertion. Wouldn’t it be more interesting to ask why do people eat a lot? Why do they eat more now than 50 years ago? Sure, food is plentiful, but we are not all obese. Why are some people obese and others are not? Do most obese people have something in common?
    I guess the McVictim label holds the implied answer. They are all irresponsible slobs, and the fact that not everybody can afford arugula & endive infused in a light balsamic vinaigrette, and may not even know what that means, is because these are irresponsible (already established) lazy bums anyway.

  44. That is the fantastic bunch of information really very appreciable job.I have read your books, heard you speak, and even testify.This means that absent a specific, disciplined effort to limit intake, obesity is the natural state of a world where food is cheap and abundant.

  45. I have to agree with the OP. Just saying that this is an oversimplification is not a valid criticism, IMHO. Even though there may be a complex web of psychosocial and medical factors contributing to obesity, it is clear that there is no obesity without overeating. But how many obese patients state that they “barely eat anything”, or speculate about unidentified metabolic/endocrine conditions, even some who have already seen an endocrinologist?
    My social libertarian leanings end at this point. Yes, everyone should be free to eat, smoke, ingest whatever they want … but if we talk about creating/maintaining a solidarity system of public (or Obamacare mandated corporate) insurance, modifiable unhealthy behavior should be negatively incentivized. The smoker, the obese person (esp. if weight is stable or increasing), and maybe, to be fair, also the, say, recreational downhill skier (I am one of them)should contribute proportionally to the increased risk they carry. And get all the help offered that they need to change the behavior if it is problematic (and obesity is very problematic).
    And in conjunction with what Peter suggests, we need deep cultural change. I believe the epidemiologic data is convincing that obese family/friends increase the individual obesity risk. As much as I hate collective pressure when it concerns neighborhood lawncare (or any other nonsensical conformism), it has some justification in curbing child abuse, alcoholism and – potentially – obesity.

  46. Dr Gratzer
    I have read your books, heard you speak, and even testify. You are a smart guy, even though I dont agree with most of your ideas. Regardless, as a psychiatrist, I am surprised you oversimplify the root causes of obesity and distill it down to personal responsibility as the major cause.
    Either you dont believe a lot of reputable peer reviewed papers released this decade and/or multiple theories as to why 2/3 of our country has a weight problem (you are in the minority here, remember)or you are playing ostrich.
    I dont claim to know the answers, but what I do know is its complicated and we have not come close to figuring it all out. If your answer is, just dont eat the sloppy joe, you will be writing about the McVictim Syndrome long into this century with concurrent soaring diabetes rates and plenty of depressed patients to keep your waiting room busy.

  47. Of course, self control and will power come into play in almost every case. But, as mentioned, cheaper more refined foods are a huge part of it. Modern life which involves less and less physical work plays a role. Not to mention a lack of knowledge by the average citizen on why certain foods are bad. I could go on and on, and I don’t think there is one simple solution. But if we don’t do something, I hate to think where we’ll be in 50 years.

  48. I’m not sure what David Gratzer is saying the solution is? Is it the Nancy Reagan solution – “Just say no”?
    Tom is part right, crap food is too cheap and good food too expensive. I’d say it’s not so much “McVictim, but from corporate America, “McBlameless”. Dr. Gratzer stops at not subsidizing agribusiness but falls short on closing the loop. Subsidize fruits and vegetables and less processed food, ban the marketing of junk food to children, impose a calorie tax to pay for healthcare, and force restaurants to clearly post calorie/fat content in their menu’s. We have a fat culture and only measures working to change culture will this be brought under control. But now with Republicans in full control, don’t look for any of these measures any time soon. Eat on and bloat up America while you enjoy your tax cuts.

  49. A correction:
    The NCQA report lists the percentage of individuals who received a BMI assessment, not the average BMI. 41.3 percent of people with commercial insurance received a BMI assessment. A higher number for this measure is a good thing.

  50. From the 2010 NCQA report, average BMI strata:
    Commercial plans: 41.3
    Medicare: 38.8
    Medicaid: 34.6
    AVERAGES! Conjur in your mind distributions around those (they may not be Gaussian), then pencil in in your mind a vertical line at BMI=26 (the recommended upper limit).

  51. Mr. O’Brien, you should look up Putnam (1999), Food Review 22(3) for an early study on that. Several studies since then have produced additional evidence and looked at other factors that may also affect obesity (such as urban sprawl). As far as I know, the Freakonomics guy has not weighed in yet.
    As for Dr. Gratzer, I am confused as to the point of this article. Yes, obesity comes down to personal choices. But don’t you wonder why people are fatter now than they were 30 years ago? Is it because people now have less self-control than people 30 years ago? Or is it because other factors have changed, and now people need more self-control to keep their weight down?
    It would be a shame, of course, if a patient were to read the article in the Journal of Health Economics and decide, based on the results of the authors’ analysis, that he or she is not responsible for his or her weight gain. Given that journal’s broad readership, that is certainly a danger.
    On the other hand, it is useful to know what public policies we could put in place to help stop the rapid increase in obesity. One would think that would actually make Dr. Gratzer’s job easier.

  52. The answer to this is simple. The reason for the obesity epidemic is that food is too cheap.
    Encoded deep in our DNA is the possibility that some day there will be no more food, and when it is cheap and abundant the lizard brain tells us to stock up – as protection against an uncertain future.
    This means that absent a specific, disciplined effort to limit intake, obesity is the natural state (and predictable outcome) of a world where food is cheap and abundant.
    I’d like to see the Freaknomics guys do the research on this question.
    You could look country by country for the relationship BTW food cost/capita and as % of income vs. obesity rates.
    Tom O’Brien