Because hyperendemic obesity and epidemic diabetes have proved intractable thus far, there is a prevailing notion that they constitute a complex problem. Depending on the magnitude and direction of forces applied, a heavy rock may prove quite intractable to lifting. This does not make rock lifting complicated; it just makes it hard.
A similar case may be made for the scourges of modern public health, obesity, and chronic diseases—diabetes salient among them—conveniently abbreviated here as diabesity. That neologism is now a fairly well-established entry in the lexicon of epidemiology, and for good reason. Obesity is on the causal pathway to most of the chronic diseases prevalent in the modern world [1] but is most indelibly linked with type 2 diabetes. Epidemic diabetes, overwhelmingly type 2, is presaged in adults and children alike by the prevalence of obesity.
Exotic theories are, at times, invoked to account for the steep rise in obesity over recent decades, from changes in our microbiome, to endocrine disruptors in the environment and food chain, to genetic polymorphisms, to certain viral exposures. Each of these and others like them may be valid. But they likely account for a vanishingly small part of the diabesity epidemic, since so much of it is so readily explained by far more expedient means: we eat too much and exercise too little.
The evidence is reliably in hand that modern living is associated with increased access to ever more palatable calories and an attendant increase in energy consumption. Evidence is similarly in hand that modern living invites more reliance on labor-saving technologies and an attendant decline in energy expenditure. That such a shift in energy balance would not result in widespread weight gain, and whatever metabolic derangements result from it is nothing less than implausible.
We may note that diabesity rates have grown over a span of recent history during which human physiology and genetics have changed negligibly if at all. During this same span, obesigenic cultural and environmental changes have been diverse, potent, and on obvious display. They include, minimally, such factors as increased reliance on the automobile, suburban sprawl, fast food, changes in family structure associated with reduced home food preparation, the reduction or removal of physical activity from the school day, a proliferation of energy-dense processed foods, an equally vast proliferation of labor-saving technologies applied in every aspect of life, and hectic schedules that often preclude or seem to preclude routine physical activity. When we ate natural foods and used our muscles every day, obesity and diabetes were rare. Diabesity now prevails because we have, in essence, engineered it into existence.
In rare cases, that engineering has been willful. Investigative journalists have been telling us for years and with increasing stridor that junk foods are often carefully designed to be irresistible and, for all intents and purposes, addictive. Foods designed to minimize the expense of production and maximize both profit and the number of calories it takes to achieve satiety are a willfully engineered cause of diabesity.
In most cases, however, the engineering has been inadvertent, the unintended consequence of Homo sapien ingenuity. Our species has long been subject to hunger and the high demands on muscle use imposed by the exigencies of survival. We set out to solve the age-old problem of food supply instability, and for a growing portion of the global population (but importantly, not everyone [2]), we have solved it far too well. We are now drowning in a sea of constant caloric excess. We set out to attenuate those high demands on our muscles and solved them comparably too well; we now have trouble finding reasons, means, or time for putting our muscles to any work whatsoever.
Having engineered our way from a world where calories were relatively hard to get and physical activity was unavoidable, into a modern world where physical activity is scarce and calories are unavoidable, we invented diabesity as an unintended consequence. This characterization is sobering, perhaps even disturbing, but it is redolent with promise as well. If we engineered the problem of diabesity into existence, we ostensibly have the prowess to reverse the engineering and orchestrate its exit. If we are prone to obesity and diabetes mostly because we eat too much and do too little, fixing it may be hard but need not be complicated.
However, it will be hard, much like lifting that heavy rock, because here, too, heavy lifting is required. We have propagated cultural inclinations that revere wealth but often denigrate health. We have, for good reason, long considered calories per unit of currency the measure of food value, and we maintain this anachronistic tendency even when calories are excessive rather than deficient. We have long relished opportunities for elusive rest and maintain this tendency even when it is exercise that is elusive. Efforts to combat the forces of diabetes are efforts to oppose the cultural inertia of 15,000 years of human civilization as well as 6 million years of evolutionary biology [3].
The job, however, can be done. As with overcoming the mass of a rock and leveraging it out of its hole in the ground, it simply requires an adequate application of force, artfully directed. In this case, the ends are eating better foods and fewer calories and engaging in routine physical activity. While some might invoke personal responsibility as the sole means, the choices people make are subordinate to the choices people have. Minimally, before people can take responsibility, they must be empowered, and engineering can empower us.
We could make everyone a nutrition expert by putting an objective, evidence-based, at-a-glance measure of overall nutritional quality on display everywhere people and food come together and thus close every loophole to marketing distortions. Among the many virtues of more nutritious foods is that they reduce the calories it takes to feel full; they thus directly oppose the diabesigenic manipulations of willfully addictive food.
We could attach to such a metric a system of financial incentives so that the more nutritious the food is, the less it costs. The incentives would not constitute a new cost but rather an opportunity for savings. They would be paid by the entities that currently pay the costs of disease care—insurance companies, large employers, and the federal government. Very few coronary bypass or bariatric surgeries need be prevented to cover the costs of healthful food incentives many times over.
If the modern lifestyle is a square peg to the round hole of physical activity, engineering can reconcile the two. Schools can implement reimagined recess and physical education programming that allow for the recommended daily dose of physical activity while preserving or enhancing academic achievement and actually increasing teaching time. Comparable programming could be applied at the worksite, and programming in schools and worksites could be complementary and funded in both cases by the entities most likely to benefit financially. This would allow sustainable, health-promotion programming to exert its influence at the basic level of cultural significance: family.
Church kitchens could be configured into adult education centers, applied to teach cooking skills to congregation members even as they maintain the tradition of shared meals and solidarity. Incrementally, we could do the requisite hard work on the built environment so that every neighborhood and building encourages rather than discourages self-powered locomotion. This would cost money in the short term but save both money and lives over time. In the interim, we could provide those in acute need access to the oases of comprehensive health promotion that already exist.
Every school could teach children and their parents the skills required to identify and choose more nutritious food. Every cafeteria could be designed to encourage, without coercion, better choices. Guidance to nutritious restaurant meals, wherever they are available, could be at the fingertips of all.
Robust economic modeling could be conducted to guide biomedical research so that it translates most efficiently into measurable and meaningful improvements in the human condition. Every clinician could be trained to be an expert in lifestyle counseling and serve as an effective agent of health-promoting behavior change.
Policy and regulation need not be heavy-handed but could be applied strategically to favor healthful eating and activity as prevailing defaults. We could shift subsidies and marketing from foods with the longest shelf lives to foods that extend the shelf lives of the people eating them.
Were we to commit ourselves accordingly, nearly all obesity and roughly 90% of all diabetes could be eliminated, in conjunction with comparably stunning benefits across the full spectrum of chronic diseases [4]. Such efforts would advance our health in conjunction with benefits to the environment, improved sustainability of resources, protection of biodiversity, and enhanced economic opportunity.
There is, admittedly, heavy lifting to be done. But engineering has long mastered the application of levers.
For Further Reading
- D. L. Katz. (2012, Apr. 10). Is obesity cultural? Eat & Run Column. U.S. News & World Report. [Online].
- (2014, Jan. 20). The Oreo, obesity and us. The Chicago Tribune. [Online].
- M. Moss. (2013, Feb. 20). The extraordinary science of addictive junk food. New York Times Mag. [Online].
- D. L. Katz, V. Y. Njike, Z. Faridi, L. Q. Rhee, R. S. Reeves, D. J. Jenkins, and K. T. Ayoob, “The stratification of foods on the basis of overall nutritional quality: The overall nutritional quality index,” Am. J. Health Promot., vol. 24, no. 2, pp. 133–143, Nov.–Dec. 2009.
- S. E. Chiuve, L. Sampson, and W. C. Willett, “The association between a nutritional quality index and risk of chronic disease,” Am. J. Prev. Med., vol. 40, no. 5, pp. 505–513, May 2011.
References
- (2012, Dec. 12). Global Burden of Disease Study, 2010: Executive Summary. The Lancet. [Online].
- World Food Programme. (2014, Jan. 20). Hunger. [Online].
- D. L. Katz, “Culture, evolutionary biology, and the determinants of dietary preference,” in Nutrition in Clinical Practice, D. L. Katz and R. S. C. Friedman, Eds., 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2008, pp. 423–433.
- D. L. Katz and S. Colino, Disease Proof. New York: Hudson Street Press, 2013.