The following article in the BMJ this week. References may be of interest, too.
well wishes,
Kate

-------- Original Message --------

http://bmj.bmjjournals.com/cgi/content/full/331/7531/1545?ehom

Obesity: the elephant in the corner
David Ogilvie, MRC fellow1, Neil Hamlet, locum consultant in public health
medicine2

1 Medical Research Council Social and Public Health Sciences Unit,
University of Glasgow, Glasgow G12 8RZ, 2 Forth Valley NHS Board, Stirling
FK8 1DX

Correspondence to: D Ogilvie d.ogilvie@...

In 2055, everybody knew that obesity was a problem, but what did they do
about it?

The year is 2055. Socrates is discussing the history of the western obesity
epidemic with Panacea, the goddess of healing.

Socrates: Do you recall the days when people were still allowed to smoke?

Panacea: Indeed, Socrates. It seems unthinkable now. Of course in those
days smoking was the leading preventable cause of chronic disease. It is
remarkable how times have changed.

Socrates: In the past 50 years, obesity has come to account for more health
problems than any other single factor. I can't help thinking, Panacea, that
something could have been done to prevent this. What on earth was going on
at the beginning of the 21st century?

Panacea: Well, it was common knowledge that more and more people were
becoming overweight. Obesity was well established as a risk factor for all
kinds of diseases. There was even talk of epidemics and time bombs.1 2

Socrates: So why were people becoming obese?

The rational prescription

Panacea: Surely that's obvious. They were consuming more energy than they
were expending.

Socrates: It was that simple?

Panacea: Absolutely.

Socrates: I suppose this was a recent scientific discovery?

Panacea: Oh no, Socrates. Even in the 20th century, the concept was well
understood.3

Socrates: Is the human body not designed to regulate itself?

Panacea: Indeed. It has sophisticated mechanisms for controlling hunger and
appetite.

Socrates: So why did some people not achieve a balance between their energy
inputs and energy outputs?

Panacea: Well, Socrates, it was all to do with their lifestyle choices.4

Socrates: Some followed a lifestyle of gluttony?

Panacea: Or a lifestyle of sloth. Or both.

Socrates: Your explanation implies a very neat, rational prescription,
Panacea. If people consume more energy than they expend, they will gain
weight, and if they are told to adjust their intake to suit their needs,
they won't gain weight.

Panacea: Indeed, Socrates.

Socrates: Didn't your disciples take this message to the people?

Panacea: Oh yes! They offered all manner of diets, drugs, operations,
healthy living campaigns... One could hardly avoid being exposed to the
information.

Socrates: These measures helped people to lose weight?

Panacea: Sort of. Well, some of them, anyway.5

Socrates: Presumably, then, the weight of the population as a whole went down?

Panacea: No, Socrates. The weight of the population as a whole went up.1

Socrates: People ignored all the diets, then?

Panacea: No, Socrates. Many people tried many diets.

Socrates: I see. So much for controlling energy intake. Can we also assume
that people were expending too little energy?

Panacea: Conceivably, Socrates. The television demanded many hours of
attention each day. The more advanced citizens even managed to watch TV
while simultaneously eating high energy snacks to support their cerebral
activity.6

Socrates: Couldn't people have chosen to do other things in their leisure time?

Panacea: They were very busy with their computers and TVs. They didn't have
much time or inclination for activities like walking.7

Socrates: To recap, then, if people consume more energy than they expend,
they will gain weight, and if they are told to adjust their intake to suit
their needs, they won't gain weight?



Panacea: It didn't seem to work like that, Socrates.

The obesogenic environment

Socrates: So, Panacea, your rational prescription is found wanting. Tell
me, what do the scientists tell us about human instincts?

Panacea: That human beings are inclined to conserve energy whenever possible.8

Socrates: What sort of environment would suit that kind of organism?

Panacea: One where food was scarce and people had to use large amounts of
energy hunting and gathering.

Socrates: And where were people hunting and gathering at the turn of the
21st century?

Panacea: In places where food was abundant and they could get hold of it
with little effort—especially if they could find a convenient parking space.

Socrates: An environment designed to encourage energy intake and discourage
energy expenditure?

Panacea: Indeed, Socrates. Some of my disciples began to describe it as an
obesogenic environment.9

Socrates: Intriguing. How did they respond?

Panacea: Surely that's obvious. They did what they were trained to do: they
described it, measured it, investigated it, published their findings...

Socrates: Yes?

Panacea: Well, then they said it should be modified.

Socrates: What was the idea behind modifying the obesogenic environment?

Panacea: To increase the availability of healthier choices, of course.4

Socrates: So you're now saying that people are exposed to a set of hazards
that you call the obesogenic environment, and if that environment is
modified to increase the availability of healthier choices, then people
will adopt a more appropriate energy balance?

Panacea: Yes, Socrates.

Socrates: Was anything actually done to modify the environment?

Panacea: Oh yes! Cycle lanes were painted on the roads.

Socrates: Presumably there was a huge increase in cycling after road space
was reallocated so effectively?

Panacea: Sadly not. But other things were done too. Soft drinks companies
were banned from putting their brand names on vending machines in schools.10

Socrates: Soft drinks were banned from schools?

Panacea: No, Socrates, you must have misheard me. If children demanded soft
drinks, companies had the right to supply them. It was only fair.

Socrates: So, these changes to the obesogenic environment... they were
quite ambitious?

Panacea: Well...

Socrates: They sound more like tinkering to me. Let us recap again,
Panacea. People are exposed to a set of hazards that you call the
obesogenic environment, and if that environment is modified to increase the
availability of healthier choices, then people will adopt a more
appropriate energy balance. It's that simple?

Panacea: Well, perhaps with the benefit of hindsight, it wasn't quite that
simple.

The obesogenic society

Socrates: So, Panacea, your environmental modifications are also found
wanting. I can't help wondering why people didn't design an environment
that would enable them to achieve a more appropriate energy balance?

Panacea: A splendid idea, Socrates.

Socrates: So, this obesogenic environment—who designed it?

Panacea: I'm not sure that anyone deliberately designed it. It just happened.

Socrates: Spontaneously?

Panacea: No, Socrates.

Socrates: Very well. Where did it come from, then?

Panacea: I suppose the people made it, Socrates.

Socrates: Accidentally?

Panacea: Yes, I suppose so.

Socrates: Tell me, Panacea, why do people eat?

Panacea: Well, people need food to provide fuel for their activities. And
some people see eating as an important social activity.

Socrates: So why were people being "accidentally" exposed to so much fuel?

Panacea: Because the producers were paid to make too much, and the food
companies had to sell the food to someone.11 12

Socrates: These food companies—presumably their aim was to provide food of
the highest nutritional quality to the people?

Panacea: I suppose so.

Socrates: You sound unsure. Had they some other aim?

Panacea: I believe there may also have been a profit motive.

Socrates: Ah yes—you refer, of course, to the heady days of consumer
capitalism?

Panacea: Indeed, Socrates. Everything had become a commodity.

Socrates: What was the primary objective of society at that time?

Panacea: To be honest, Socrates, it sometimes seemed as if the primary
objective of society was for people to keep buying things.13

Socrates: This was in people's best interests?

Panacea: Oh yes! People loved shopping.

Socrates: And some found they could profit from everyone's love of buying
things?

Panacea: Indeed! Everyone knew that the pursuit of economic growth was the
key to success, prosperity, happiness, health...

Socrates: Presumably there was evidence to this effect?

Panacea: Ah...14 Well, money was very important, Socrates.

Socrates: So the people had made unconstrained economic growth their
highest priority?

Panacea: Indeed. No government could get elected on any other platform.

Socrates: I see. Was it possible to sell other things to the people?

Panacea: Oh yes! Exercise, for example.

Socrates: So the ways of using up energy had also become commodified?

Panacea: Indeed, Socrates. There were tremendous business opportunities in
health clubs.

Socrates: I don't understand. Why couldn't people take exercise by walking
or cycling to work, or playing in the park?

Panacea: They were too busy earning money to pay for all the things they
were told they wanted to buy—and worn out from driving in heavy traffic to
get to work. In any case, how could anyone make a profit out of such
mundane activities?

Socrates: Bicycle manufacturers, perhaps?

Panacea: True, Socrates. But the more the people used cars, the more they
were told that cycling was dangerous.15

Socrates: So it was better that people should drive to their health club
and pay for their exercise there?

Panacea: Indeed. Or better still that they should just pay their membership
fees and not actually turn up. They didn't really have time.

Socrates: I suppose everyone benefited from this consumerist society?

Panacea: Absolutely. Everyone had more choice, and of course if the range
of available choices is increased, then obviously...

Socrates: People will take the healthier choices?

Panacea: Well, if choices aren't offered, how can people choose a healthy
option?

Socrates: You don't think offering all this choice might have encouraged
people to eat too much?16


Panacea: Well, I think people wanted to make up their own minds.

Socrates: That might have been reasonable so long as people could afford to
go and exercise the "right" choice.

Panacea: Ah. Well, it's true that it was easier to buy healthy food in some
places than in others...17

Socrates: And perhaps it might also have been easier to exercise safely if
one had the right money or the right address?

Panacea: Conceivably, Socrates.18

Socrates: I see. Correct me if I'm wrong, Panacea, but your disciples
treated the obesogenic environment as a hazard imposed on the population
from outside, and tried to tinker with it. But actually that environment
was the inevitable result of a much more fundamental problem: society had
chosen to prioritise the wrong values in life?

Panacea: Yes, Socrates, I believe that is so.

Conclusion

Socrates: So, Panacea, let us summarise what we have learnt about Western
society at the beginning of the 21st century. It was a society with an
abundant food supply...

Panacea: In which people were actively encouraged to eat too much...

Socrates: In the pursuit of economic goals...

Panacea: And in which simple physical activity like cycling was seen as
positively dangerous...

Socrates: And if people did want to resist these forces, it helped to have
money to pay for safe exercise and nutritious food...

Panacea: Yes, Socrates, that about sums it up.

Socrates: A society that had got its priorities out of order?

Panacea: An obesogenic society.

Socrates: Well then, Panacea, your disciples in those days were fond of
phrases like "primary prevention" and "going upstream." Did they never come
up with a serious challenge to the obesogenic society?

Contributors and sources: This article is an abridged version of an
original dialogue jointly written and illustrated by the authors and
performed at public health events in Scotland and northern England in 2004
and 2005. The dialogue was written to stimulate further debate about the
conclusions of a community of inquiry into the causes of obesity in
Scotland, originally published at www.obesescotland.org.uk and subsequently
in abridged form in Public Health News (15 November 2004). The members of
the community of inquiry were Karen Budewig, Fiona Crawford, NH, Phil
Hanlon, Jill Muirie, and DO, who all contributed equally to the thinking
that inspired this article. Funding: None.

Competing interests: None declared.

References

1. Obesity: preventing and managing the global epidemic. Report of a
WHO consultation. World Health Organization Technical Report Series
2000;894: 1-253.[ISI][Medline]
2. Storing up problems: the medical case for a slimmer nation. London:
Royal College of Physicians of London, Royal College of Paediatrics and
Child Health, and Faculty of Public Health, 2004.
3. Egger G, Swinburn B. An "ecological" approach to the obesity
pandemic. BMJ 1997;315: 477-80.[Free Full Text]
4. Department of Health. Choosing health: making healthier choices
easier. London: Stationery Office, 2004.
5. Asp N-G, Björntorp P, Britton M, Carlsson P, Kjellström T, Marcus C,
et al. Obesity—problems and interventions. Stockholm: Statens beredning för
medicinsk utvärdering (The Swedish Council on Technology Assessment in
Health Care), 2002.
6. Ebbeling C, Pawlak D, Ludwig D. Childhood obesity: public-health
crisis, common sense cure. Lancet 2002;360: 473-82.[CrossRef][ISI][Medline]
7. Department for Transport. Transport statistics bulletin: national
travel survey 2002. London: Stationery Office, 2004.
8. Peters J, Wyatt H, Donahoo W, Hill J. From instinct to intellect:
the challenge of maintaining healthy weight in the modern world. Obes Rev
2002;3: 69-74.[CrossRef][Medline]
9. Swinburn B, Egger G. The runaway weight gain train: too many
accelerators, not enough brakes. BMJ 2004;329: 736-9.[Free Full Text]
10. Day J. Scottish schools ban food adverts. Guardian 2003;24 Dec.
http://media.guardian.co.uk/advertising/story/0,,1112620,00.html (accessed
27 Jan 2004).
11. Neroth P. Fat of the land. Lancet 2004;364:
651-3.[CrossRef][ISI][Medline]
12. World Health Organization. Diet, nutrition and the prevention of
chronic diseases. Report of a joint WHO/FAO expert consultation. Geneva:
WHO, 2003.
13. Cable News Network. Transcript of President Bush's address to a
joint session of Congress on Thursday night, Sept 20, 2001.
http://www.cnn.com/2001/US/09/20/gen.bush.transcript (accessed 27 Jan 2004).
14. Hamilton C. Growth fetish. London: Pluto, 2004.
15. Department for Transport. It's no joke. www.cyclesense.net (accessed
10 Jun 2005).
16. Lean M. Prognosis in obesity. BMJ 2005;330: 1339-40.[Free Full Text]
17. Ellaway A, Macintyre S. "5-a-day" may be harder to achieve in more
deprived areas. J Epidemiol Community Health 2004;58: 892.[Free Full Text]
18. Ellaway A, Macintyre S. Play areas for children. J Epidemiol
Community Health 2003;57: 315.[Free Full Text]

(Accepted 14 October 2005)


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