People eat more calories than they expend. They gain weight. If nobody is forcing them to eat to excess, then they only have themselves to blame, right?

I harbored this belief for a long time until I read the book The Obesity Epidemic by Dr. Robyn Toomath.^[1] The premise is that too much emphasis on personal responsibility is (1) negating the changing macroeconomic factors that ballooned the population’s weight, and (2) the government’s responsibility (and failure) to regulate the food industry. She makes the case that the food industry acts to addict us in the same way Big Tobacco did in the 20^th century. And one of the clearest ways the food industry does this is in how we shop for groceries.

Supermarkets—drug stores that happen to sell vegetables

Dr. Toomath explains that the development of the global industrial diet is, to a large degree, the fault of supermarkets.

The free market is supposed to empower the consumer, but we hand this power over to multinational companies who in turn create demand (having figured out what sells). Yes, we get to choose this brand of chips over another, but larger forces determine the cheapness of chips and influence our preferences for these over rice or vegetables. 

Price is just one way in which our behavior is manipulated. We’re also influenced by the location of certain products on the supermarket shelves.^[2] People are bored in checkout lines. Stores know this. It’s not a coincidence that impulse-buy candy is located there.^[3]

Supermarkets are implementing the concept authors Richard Thaler & Cass Sunstein describe in their book Nudge.

Nudge: Any choice [made by a decision maker] that alters people’s behavior in a predictable way without forbidding any options.

Where personal responsibility meets subtle manipulation

Back in 2019, my friends and I were in a theater waiting for our movie to begin when an M&Ms ad played. I remember thinking, “what’s the point of ads like this? It’s not like I’ll suddenly be persuaded by this ad to actually get out of my seat and buy M&Ms at the concession stand.” Meanwhile, one of my friends left the theater and returned with newly purchased M&Ms. I was flabbergasted.

Me: “What made you get M&Ms?”

Him: “I don’t know, I just felt like it.”

Me: “So the ad didn’t persuade you?”

Him: “What ad?”

A less obvious nudge than direct advertising is the geographic location that businesses decide to open stores at. In her book, Dr. Toomath notes that:

If a fast food outlet is within a 10^th of a mile of a high school, there [are] 5.2% more obese children in that school than if [the fast food outlet] were farther away.

In the US, an analysis shows that “one-third of schools have at least one fast food restaurant or convenience store within walking distance.” So am I allowed to blame obese high schoolers (whose brains are not fully developed) for consuming what’s in their immediate environment because some business manager decided to open a McDonald’s next to their school? 

Perhaps teenagers, however, are old enough to know that processed foods are not good for them. So let’s turn the clock back and highlight the growing number of adolescents becoming sick. According to the CDC from 2017-2020, obesity prevalence was:

• 22% among adolescents 12–19,
• 20% among those 6–11, and
• 12% among U.S. children 2–5 years old.

Studies have shown that approximately 1 in 5 youths now have prediabetes. They’ll soon join the 38 million American adults living with diabetes. But those kids knew what they were doing when they ate too many dino nuggets and choccy milk, right? And don’t even get me started on the epidemic of obese 6-month olds.^[4] These babies need to learn to pull themselves up by their bootstraps and take responsibility for their health!

Sarcasm aside, reasonable people would say that it’s parents’ responsibility if their children are fat and sick. Okay, but if the children are hooked on processed foods, then they probably learned their eating habits from their parents…who are often just as chronically sick as their kids. And those parents learned their eating habits from their parents. And their parents learned how to eat from theirs, and so on and so on until we arrive at the patient zeros of this epidemic—the first generation of communities when they’re introduced to processed foods.

Patient Zero

Look at the Tokelauan people living in the Pacific islands. A 1982 study showed that 0% of men aged 40-69 years old had a previous myocardial infarction (heart attack) based on EKG readings.^[5] They traditionally subsisted on fish and starchy foods like yams, sweet potatoes, and plantains.

In 1940 they had an approximately 1% obesity rate. By 2014, after a few decades of foreign companies flooding the Pacific islands with processed foods, the Tokelauans became one of the least healthy groups on Earth—90% of their population is either overweight or obese.^[6] And along with the obesity came high rates of heart disease. But I’m supposed to believe it’s their fault, right? A failure of responsibility? It’s not like their community leaders were tricked into accepting cheap foodstuffs that left their people sick and addicted, right?^[7]

Or how about the Innuit? Since time immemorial they’ve lived in the harsh tundra of North America, subsisting on hunting seals and catching fish. Up until 1960, there was little reported incidence of cancer and other non-communicable western diseases. But after being introduced to the S.A.D. (Standard American Diet), the Inuit are now developing chronic diseases at rates similar to the Western world.

Or what about the Australian Aboriginal people who, as documented in That Sugar Film, went from healthy to chronically sick within a generation?

Time and again, the Western industrial global diet conquers a new community, turning into a war zone of non-communicable disease and death. Wait a second, those are the four horsemen of the apocalypse! It does make you wonder…

Cruel Optimism

When people fail to sustainably lose weight, they often feel as though they only have themselves to blame. This leads to a term I recently learned called cruel optimism.^[8]

Cruel Optimism: When a small solution fails for an individual, they blame themselves for their lack of willpower and grit, rather than acknowledge the colossal system that overwhelmingly stacks the odds against their success.

Never mind the fact that food scientists, like Barry Smith, are hired to make processed food as addicting as possible:

Initially, companies would come to [Smith] asking how to reduce the salt and sugar in their products without compromising flavor. But over time, [he] said companies became more interested in enhancing food to make it irresistible to the point where people feel they can't stop eating it.

Never mind the fact that Coca-Cola executives are sitting around discussing stomach-share (which is the percent of your daily calories they want to come from their products) while pretending like they’re trying to help the consumer address the obesity epidemic.

Never mind the fact that a former Coca-Cola executive once admitted that:

He achieved peace of mind by simply not allowing himself to think about what he actually sold.

He changed his mind abruptly on a business trip to Brazil in 2001. [His] marching orders from Coca-Cola were simple. Find the best way to push Coke on poor Brazilian kids living in the ghettos.

After that eye-opening trip, [he] tried for 4 years to change Coke from the inside. Unsuccessful, he left the company, unable to stand the relentless marketing to the poor and Coke addicted a moment longer.

Forget about all that! The poor food industry didn’t do anything wrong. I’m told that you are to blame if you’re fat & sick. It’s not as if the food industry lobbies governments around the world and spends billions of dollars to keep food labels purposely vague with things like “% of Daily Value.” It’s supposedly your fault that you don’t understand the purposely vague “% of DV” instead of the easy-to-interpret traffic light labels of red, yellow, and green to indicate the nutritional value of a food product.^[9]

Dr. Toomath summarizes the situation with this:

Placing responsibility for weight control on individuals suits the food industry, which claims that their responsibility with regard to the obesity epidemic extends no further than providing choice. And it suits governments, who like to avoid putting in place regulations that restrict the free market. [Let’s face it], the drivers of obesity lie outside the control of individuals.

What can a single mom who works two jobs to barely afford to put food on the table do against multinational conglomerates that control the global food supply chain who conspire to addict her and her children to their product? She doesn’t have the privileges I do—the disposable income to purchase higher quality foods, and the free time to pour 300 hours into learning about nutritional biochemistry through consuming dozens of books, professional lectures, and PubMed articles in order to build mental constructs to dodge the nutritional landmines in our modern food environment. Per usual, the poor and undereducated folk get fucked over.^[10]

Dr. Toomath, after having studied this issue for decades, made a dismal concession:

I realized that asking people to lose a significant amount of weight and keep it off was about as useful as asking them to change their eye color. No other therapeutic strategy employed in medicine has such poor results, so why was I continuing to prescribe it? Not only was the treatment I was recommending ineffective, but it was my patient who was invariably left with the sense of failure. So, years ago, I made the decision to stop asking patients to lose weight.

Instead she encourages people seeking advice for their weight-related medical problems to optimize their health irrespective of weight.^[11] On a sociological level, she believes that:

Eating healthy food and getting enough exercise should be the default, not something we have to battle for.

And currently it’s not the default. This study reports that “less than 7% of the U.S. adult population has good cardiometabolic health.”^[12] Meaning that 93% of Americans now have compromised metabolic health.

Research suggests that "~80% of people who shed a significant portion of their body fat will not maintain that degree of weight loss for 12 months" and that "dieters regain, on average, more than half of what they lose within two years."

Obesity and related chronic diseases are systemic issues. They'll likely only be solved through systemic means rather than via the determination of individuals trying to stand against the system that's intent on keeping them fat and sick.

My point is not that individual people shouldn't try to improve their health. It's that, ultimately, people are a reflection of their environment. And the environment we've created over the past 100 years is killing us.

“Increasingly, I think that civil unrest may be the only way to fix obesity.” — Dr. Toomath

Challenging the mainstream narrative of personal responsibility

I was playing pickleball with this guy last year and the topic of obesity came up. Our conversation went something like this:

Him: “It’s pathetic that people can’t stop eating crap all the time. Just have some self-respect, stop cramming Twinkies down your throat, and buy a fucking vegetable every once in a while.”

Me: “I know how you feel. Although, have you ever considered if it’s not their fault that people are overweight? That other forces could be at play?”

Him: “How could it not be their fault? Who else is putting junk food down their throats?”

Me: “Larger macroeconomic factors and a capitalist society hell-bent on profit over the general welfare that exploits our evolutionary tendency to consume energy-dense food that is made incredibly accessible and is designed in labs to be as addicting as possible.”

Him: “...what?”

1. ^{^}

   She’s the clinical director of general medicine at the Auckland Hospital, the former president of the New Zealand Society for the Study of Diabetes, and the founder of Fight the Obesity Epidemic.

2. ^{^}

   Some research indicates that up to 90% of the food displayed at a child’s eye level in checkout lines is unhealthy.

3. ^{^}

   Last week in a grocery store, I watched a lady in front of me become bored, she started looking around her, and began loading her cart with candy bars until it was her turn to check out. Had the grocery store not designed it that way, she probably would have been spared that extra ~1,000 calories. But you may argue, “Yes, but what if she really wanted that candy?” To which I would reply, “Then she could have gone to the candy aisle—an entire section of the grocery store devoted to ultra-processed foods.”

   I’m not judging this woman. In fact, I’m just as indulgent, but specifically for video games (I’ll easily play 10-15 hours straight when I have access to them). But the difference between us is the accessibility of our indulgences. Earlier this year I sold my TV and video game consoles. Without them, I no longer have the desire to play. But what can a person who has a weakness to processed food do? I don’t have to play video games, but everyone has to eat. There are practically fast food joints on every corner. And supermarkets lace 80% of their product with sugar—they’ve become drug stores that happen to sell vegetables. There’s no escape.

4. ^{^}

   A 2010 study by researchers at the University of Texas Medical Branch at Galveston found that 16% of infants as young as 6 months fit the study's criterion for obesity.

5. ^{^}

   Wessen, Albert F (ed.), Hooper A, Huntsman J, Prior IAM, Salmond CD. Migration and Health in a Small Society: The Case of Tokelau. New York, Oxford University Press, 1992, p.361

6. ^{^}

   "23% of the population is overweight and 67% is obese" for a combination of 90%. See page 8 of this pdf from the Tokelau National Statistics Office.

7. ^{^}

   From Dr. Robert Lustig’s book Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease, he explains that: 

   Caffeine and sugar are injected in our energy-dense highly processed food-like substances. It’s scientifically proven that both are addictive. Evolutionarily, sweetness was the signal to our ancestors that something was safe to eat because no sweet foods are acutely poisonous.

8. ^{^}

   Originally from Johann Hari’s book Stolen Focus.

9. ^{^}

   The traffic light proposal is one initiative that Dr. Toomath supports to curb obesity. The country of Chile has tried this, but has not yet seen positive results in the decade since introducing the initiative. “Experts say that it can take decades for obesity rates to budge.”

10. ^{^}

    To add insult to injury, they disproportionately live in food deserts, which affects an estimated 13 million Americans.

11. ^{^}

    She acknowledges that behavior change is hard. Rather than focusing on taking away certain foods, she recommends people add more nutritious foods to their diet. As a clinician, she never blames people for their circumstances—the stigma produced from judging a patient can increase their stress levels (which may lead them to cope by eating comfort foods). 
    
    At a wedding recently, I got to chat with a nurse. I asked her how she advises people dealing with obesity and related metabolic diseases.

    Her: “I tell them to eat less and exercise more.”

    Me: “And do they follow your advice?”

    Her: “No, but I’m legally required to tell them that unless I want to invite negligence lawsuits when they inevitably keep getting sicker.”

12. ^{^}

    “Researchers evaluated Americans across five components of health: levels of blood pressure, blood sugar, blood cholesterol, adiposity (overweight and obesity), and presence or absence of cardiovascular disease (heart attack, stroke, etc.). They found that only 6.8 percent of U.S. adults had optimal levels of all five components as of 2017-2018.”