The political perils of “obesity prevention”

Sounds odd, doesn’t it? My title I mean. How can prevention be a peril in any sense, whether political or otherwise? And what do I mean by using the phrase in the context of the arthritis diseases?

Clearly, if we have the power and capacity to prevent disease --- any disease, be it diabetes, heart disease, cancer, arthritis, or whatever ----- we should exercise that capacity and, surely, “prevention” in that context would constitute what Martha Stewart would indubitably term a “good thing.”

I certainly agree. But “prevention” is a complex, multi-dimensional component of the disease continuum and we need to be clear about what we mean when we use the word. And we also need to remember that the word is charged with different meanings and subtexts and that sometimes the concept of “prevention” can be over simplified or cited to justify agendas that do not serve to advance the real interests of patients.

I venture to suggest that if you asked an ordinary member of the public to define their current understanding of what constitutes “disease prevention”, the answer would probably be as plain as the other chin on your face and it would centre around the “war on fat”. Obesity has become the new health enemy --- the new smoking, if you like. And a virtual jihad against junk food has now been declared.

A confession here … I used to smoke. But as smokers became progressively socially isolated and vilified, and the places where they could light up became ever more rare, I quit. I couldn’t stand the social opprobrium or the cost, so I kicked the habit.

But what I noticed on the path to ‘nicotine cold turkey’ was that the absence of smoke in my office air allegedly made my office air officially clean. But I wasn’t breathing clean air. Indeed, I worked in a hermetically sealed office building where the air quality was actually simply dreadful. The rugs and furniture all leaked formaldehyde and toxic rug shampoos regularly used there gave off the very same chemical odours one encounters in a dry cleaning establishment. And what was more worrisome from the health standpoint about my office air was that once it was declared to be ‘smoke free’, other measures of air quality ceased to matter and complaints about bad air fell on deaf ears. Indeed, the air exchangers in my smoke-free building were now switched off every weekend and evening to save money, making the office air more foul than it had ever been when people smoked and the ventilation system was in constant use. Many people (including airline staff) have noted the same phenomena on aeroplanes, where overall air quality has declined with the loss of good (but expensive) air ventilation once considered necessary to clear the air of smoke. Smoke-free air is not necessarily clean air, although it suits many different agendas to pretend that it is.

I mention this example because it is often the case that one-dimensional fixations concerning the underpinning elements of good health --- particularly those fixations that serve to shift responsibility to the shoulders of the patient --- can serve to shut down intelligent analysis and informed debate over good preventative health care and play to a political agenda that is actually antithetical to patient interests.

Those of us who work in the arthritis field also know that our diseases are not well understood by politicians and health policy formulators and we are therefore particularly vulnerable to caricature and stereotyping. The “blame game” is just sometimes too readily at hand to justify neglect when it comes to securing timely and effective treatments for arthritis diseases.

Okay. Everyone agrees on exercising and eating responsibly. But does saying ‘no’ to that Krispy Kreme mean one is saying ‘hello’ to good health? Are overweight people really just thoughtless irresponsible slobs who expect the health care system to rescue them from the consequences of their own lack of will power? And what is government’s role in the obesity equation?

The plain truth is that we actually know very little scientifically about why we Westerners are becoming fat. Inactivity and overeating are obviously part of the equation, but only a part it seems. Bacteria may play a part. Genetic inheritance and ethnicity appear to be factors, as are economic and social class origins. Agricultural subsidies that have seen high fructose corn syrups enter hundreds of food products, along with growth hormones and antibiotics may play a part. Selective plant breeding to increase shelf life of vegetables while stripping them of vitamin content may play a part. Schools with subsidised Coke machines, made necessary by other budget cutbacks may help to inculcate bad eating habits among the young. Indeed a multiplicity of factors appear to be involved in creating obesity and until we know a whole lot more about causal factors, let us refrain from condemning the overweight and making cheap moral judgements about individual will power. And clearly, solving the problems associated with obesity is likely to compel governments, as well as individuals, to look for long-term solutions. Attempting to dump the burden of obesity solely upon the shoulders of the individual at the fast-food take-out window is both dishonest and doomed to fail.

Food after all is not tobacco. None of us needs to smoke but we all need to eat.

And yes --- being too heavy may make it more likely that a person with Osteoarthritis may need new knees. But perhaps the weight followed the bad knees and not the converse? And for those of us with one of the inflammatory arthritis diseases, nothing is more frustrating than to find ourselves on the receiving end of not so subtle suggestions that we have somehow assisted the onset of our disease by indulging in too many Krispy Kremes.

Recently, I attended the funeral of a dear colleague who had waged a courageous lifetime struggle against Rheumatoid Arthritis. At her service, a series of slides from her life eloquently illustrated the precise period when her disease made its presence known through her sudden acquisition of a cortico-steroid “moon face” and a thickening of her waist and hips.

The ignorant might have called her obese at that point; her friends, who shared her horrible burden of disease, knew better.

Dedicated to the memory of Elizabeth Hipson, a friend and colleague in the Patient Partners in Arthritis program.