A nation of diabetics?

I am waiting to board a flight to Europe with my family. As we wait, my adult son, Adam, whispers to me, “I can pretty much tell who is an American here and who comes from other countries. At first I wasn't sure how I could tell the difference; but then I realized . . . Americans are really fat.”


And so we are. We are really, really fat. And while other nations are starting to catch up to us, when we travel abroad, we cant help but notice how we stand out in comparison. Jowls and dewlaps dangle from our chins; our stomachs bulge over our belts; we waddle, not walk. And the food we eat? An endless stream of burgers, fries, doughnuts, nuggets are required to make us a nation of Sumi wrestler wannabees – without the athletic ability.


During the current round of health care reform debate, much has been made of “personal responsibility” in the rising cost of health care. After all, if only Americans would eat less and exercise more, fewer would get heart disease or diabetes – diseases that drive up the cost of care for everyone.


In fact, while obesity is a very serious and costly issue, it is a smaller contributer to soaring heath costs than factors like the enormous administrative waste, or our fee-for-service payment system which encourages lots of unnecessary (and sometimes harmful) care.


But, for the purpose of this discussion, let's put aside the cost issue and explore why Americans are so obese and what can be done about it.


Obesity – a problem of individual responsibility or a public health issue?


If we are we are serious about addressing the obesity epidemic, we had best treat it as a public health issue. As satisfying as it may feel to blame others for their personal bad choices, that is not an effective strategy to get people to change their eating habits or get more exercise. (Besides, do you ever notice how some of the people who shout the loudest about taking personal responsibility are themselves 50-100 pounds overweight?)


Having set aside the blame game for the moment, we can consider obesity as a public health problem. Treating obesity as a problem to be examined and solved – just as we do epidemics or spreading infections – allows us to identify the causes of this epidemic and find solutions.


Our weighty history.


A hundred years ago; even 50 years ago, Americans were not unusually fat. But starting in the 1950's and accelerating steadily through the subsequent decades, we began to balloon. What changed to make this happen?


Essentially, two things changed about America. First, in the post-WWII era, how we travelled was transformed. In 1945, Americans travelled over 90 billion miles on rail. By 2000, this figure had declined by over 80%, even as the U.S. population more than doubled. Even more dramatic was the sharp decline in the availability of urban public transportation. People who once depended on mass transit to shop and get to work, now relied on automobiles for the same activities.


My own family's story nicely demonstrates the shift:

In the 1940's, my family lived in an apartment in Chicago near the two stores my father owned and managed. But raising three kids in a brownstone apartment and shlepping them (and strollers, toys, etc.) up and down three flights of stairs every day was not at all easy. As the business grew and my parents had more disposable income, they, along with millions of other Americans of that era, decided to move to suburbs. The first house they moved to in 1950 was five blocks from a transit stop and my father walked to the platform every morning and took the train to his store. It required a couple of transfers but he could usually get there in 45 minutes. My mother, meanwhile, had the family car.


But, after World War II, U.S. transit was in the midst of a death spiral. Ridership fell as people purchased cars (and as General Motors purchased urban rail systems and tore up the tracks). As ridership fell, transit systems went out of business, which made it more difficult for the remaining riders to get around. Not surprisingly, in the early 1950's, the transit system my father took to work went bankrupt. There was another railroad company in the same area; but it was not within walking distance. So for the next several years, my mother drove my father every morning in the family car to the station where he boarded the train. But, without all of the connecting routes, he had to take a taxi from the train station to his stores.


Finally, in 1960, the famous interstate highway system envisioned by President Eisenhower came to Chicago. Our family could now do the unthinkable – buy a second car - and my father could drive to work every day. No trains, no waiting on platforms, no transfers, door-to-door service. What could be more convenient?


Only it wasn't. A ride that previously took 45 minutes on the “El”, now took 35 minutes . . . or 45 minutes . . . or an hour and a half, depending on traffic. The expressways that accelerated the death of mass transit encouraged more and more Americans to move to distant suburbs, which meant more people used the freeways, which led the cities to build even more freeways, which led to . . . well, you get the idea. It sounded like a good idea; but once implemented created new problems to solve.


But there was another, more subtle outcome from these transportation changes. Remember, how my family got a second car in the 1960s? My father, who previously walked a quarter mile to the station each day and then another quarter mile to his stores, now only had to walk 25 feet to his car for the long drive to the city. Similarly, millions of other Americans lost their walks that had been previously built into their daily routines.


And remember how my mother schlepped 3 kids and strollers down three flights of stairs and then walked to the park eight blocks away? Even in her final years, she complained about how horrible that experience was and how grateful she was when they moved to the suburbs where she could pop the kids in the car (without seat belts in those days) to go anywhere she liked. That was an enormous and desirable shift which, along with washing machines and dish washers, improved the quality of her life.


But something got lost in the process. And that something, was physical movement and exercise built into the daily routine. Before 1960, very few people (except the very wealthy) worked out at athletic clubs, in part because their days were full of movement and exercise. They may have viewed all this movement as time-consuming drudgery; but it had the effect of burning calories and toning muscles.


This process of removing physical activity from people's lives has continued unabated. I grew up in the 1960's where it was a given that I walked or rode a bicycle to school. Because we lived in an old, pre-Interstate highways suburb, I could ride my bike to the town center to shop, take music lessons, and visit the library. But, if I were to live in a remote suburb where all the stores were located in a distant mall, that would not be an option. I would have to drive (or be driven) to the mall to do the same kinds of activities.


Today, fewer children routinely walk to school. Often, the lack of sidewalks and pedestrian-friendly intersections make that nearly impossible. So they are driven to school, losing the source of daily movement that was simply part of life in previous generations. Today, over 30% of school age children are overweight or obese and many are now saddled with diabetes – a serious, lifelong chronic disease that shortens lifespans and increases the risk of heart disease, blindness and loss of limb. No child should have to deal with such things.


Corporations make you fat.


There is a second chapter to this story of how we became so obese.


In the late 1950's, my father heard about a brand new restaurant in Des Plaines, Illinois. This amazing diner had brought the industrial revolution to dining. Food was prepared with minimal human interference – allowing a faster, safer and cheaper product to be made.


We went to the diner and we were both entranced. A Ford-like assembly line took a pre-made patty of beef on a conveyor belt, through a grill and out the other side. French fries (my favorite) were fried in large vats following a fixed process. The results, while satisfying to us, would be unrecognizable to today's patrons: a 4-inch patty on a small bun and a paper sack containing about 10 fries.


This exciting culinary experience happened at one of the first MacDonald restaurants. While full of fat and cholesterol, this meal was:

1. A rare, one-time event; and
2. The portions were tiny by today's standards.

In this pre-supersize era, fast food was unlikely to make anyone very fat . . . unless they ate amounts that were enormous by the standards of the period.


Much has been written about the industrialization of the food industry, the enormous subsidies for corn and soybeans and the absurd – and dangerous – products that came out of this system. Suffice to say, we now subsidize a food industry that puts out vast amounts of processed food laden with fats, sugars and salt In other words, our food system is designed to kill Americans – quite slowly perhaps – but kill us nonetheless. With both parents working full time, feeding the family on the run may be a necessity – but a necessity that transforms us into a nation of diabetics and cardiac patients.


So, reliance on the car and subsequent suburbanization and loss of daily movement, PLUS the availability of cheap, fattening food have unintentionally created the obesity epidemic.


What to do?


We can and do lecture ourselves and fellow Americans about the need to take personal responsibility by exercising more and eating less. But, by now most people know that they need to eat better and exercise more . . . they just don't. If we want to solve the problem, we need a better plan. In other words, we need public policy and public actions that will undo the conditions that created the problem. A hundred years ago, public health cleaned up our city sewers and taught personal hygiene. Today, we have a more challenging task: we must re-introduce physical activity into our daily routine and we must change the food we eat.


Difficult to do? Not really. The action steps are easy to come by; but the politics are daunting indeed.


But first the easy part – the prescription:


Fewer cars. A few – very few – people have the discipline (or obsessive-compulsive disorder) to exercise daily at a gym and eat only green leafy vegetables. But the vast majority of us just aren't there. And lecturing us about how we should and ought to be there is nice, but not especially helpful. The vast majority of us don't have that kind of discipline and never will. So, if we want to get skinny, we are going to have to change how we live. We'll need to undo urban sprawl, reduce or eliminate freeways, build out mass transit and disperse shopping to neighborhoods. We have to structure where we live so it's easier to walk, bike and take transit than get in the car and drive to the mall. Is this intrusive? Perhaps. But there probably isn't any other way to get us moving again. One added benefit . . . these same changes will also reduce carbon emissions and global warming.


Fewer calories. Does anyone (other than Cargill, ADM or Monsanto) still think we should be stuffing ourselves with fat, sugar and salt as if our actual purpose in life is to emulate a Christmas goose and produce human foie de gras? At a minimum, we must stop subsidizing the production of vast quantities corn syrup, cooking fats, etc. One of the reasons fast food is so cheap is that we, the taxpayers, pay billions in farm subsidies. For those who fear creeping socialism, let me be clear: we already have a government-directed food policy. Only our policy is to spend our tax dollars on the foods that sicken us. At a minimum, we should stop putting fast food on welfare; and at best we should consider taxing the fats and sugars because they cost us our health and economic well-being. If we must subsidize anything, shouldn't it be fresh vegetables and whole grains?