Just weeks into his tenure as CDC Director, Dr. Thomas Frieden is already preaching moral improvement to the American public.
Yesterday, according to an Associate Press report, Frieden sermonized that “obesity and … diabetes are the only major health problems that are getting worse in this country, and they’re getting worse rapidly.” Now, Dr. Frieden heads the agency that collects data on illness and calculates disease rates; presumably, he knows that many conditions are either increasing now or have risen to high levels from which they have not retreated — MRSA, Lyme disease, injuries in certain occupations, and foodborne illness, to name just a few.
But as Dr. Frieden’s campaigns in New York City against trans fats, unprotected sex, and TB sufferers who didn’t take their meds revealed, when there is a moral battle to be fought the facts just get in the way.
The impetus for yesterday’s obesity sermon was a study by investigators at RTI who had determined that “obesity-related diseases” account for over 9 percent of U.S. healthcare costs. Most people who suffer from most of the so-called obesity related conditions are not actually obese. Even diabetes, the one most commonly associated with obesity in the popular mind (and, apparently, Dr. Frieden’s) occurs more often among people who are not and have never been obese than it does among those who are obese. So the study was really showing that obesity accounts for much less than 9 percent of healthcare costs.
But that wasn’t the only problem. While the RTI study found that obese people spend 40 percent more than comparison “normal” people on health, most of the increase in spending was related to pharmaceuticals. So one might ask if it was obesity that was increasing expenditures, or the price of certain drugs.
Furthermore, there’s no way to know whether being fat was causing the obesity group in this study to be sick in ways that cost more money, or if they were fat because they were unwell in the first place.
In fact, the study wasn’t designed to test whether becoming obese led to an increase in medical expenditure — which might have shed some light on the question of whether obesity causes higher costs. Many people in the study had no expenditures at all for certain types of healthcare costs. But the researchers weren’t interested in finding out whether obesity sometimes costs nothing at all, so they used an adjustment technique to allow them to relate obesity to predicted expenditures.
Finally, the estimate of percentage of total healthcare costs attributed to obesity-related expenditure was based on the assumption that obese people who return to “normal” weight suffer no consequences of their weight loss — an assumption that is well known to be false.
So it’s a falsehood to state on the basis of the RTI findings that obesity is accounting for a tenth of American healthcare costs — although AP, Reuters, and other media outlets so claimed in covering the Frieden sermon.
In fact, a lucid assessment of the findings would ask why, if obesity is supposedly up 37% among Americans and if two-thirds of Americans are now overweight or obese, obesity would account for only 9% of costs? Surely if obesity is so bad, increasing its prevalence by more than a third would be swamping the healthcare industry with fat people.
But the whole appeal of a sermon is that it isn’t based on fact or lucid assessment of the present reality. It’s based on suppositions about the future with a steadfast moral foundation. Frieden has the supposition and he has the moralism. His religion is that it’s up to the “community” to perfect itself.
As Shirley Wang at WSJ Health Blog reports, Dr. Frieden believes that increasing availability and decreasing price of healthy foods, while decreasing availability and increasing price of unhealthy ones, “is likely to be effective.” He claims that the decision to adopt such a strategy “is a political one.”
But of course it isn’t political in its essence; it’s moral. When the community is told to perfect itself it rises to the occasion by looking to the usual moral suspects: women, especially pregnant women or mothers; the uneducated; the poor. Last fall, Frank Furedi discussed the moral underpinnings of British authorities’ removal of fat children from their parents’ homes. And we can hope he’ll have something to say about what’s happening in the U.S., where the community policing can be even worse: a few days ago, a South Carolina mother was arrested and charged with neglect for having a son who weighs over 500 pounds. Other states have contemplated other methods of dealing with parents who violate the community standards of parenting. Not by hitting their kids, starving them, or forcing them to work — but by allowing them to get fat.
Obesity is offensive, it seems, in just the way that sexual license and intemperance with alcohol have been found offensive by some. And just as the problem with sex and drinking has been found in the environment — in “peer pressure,” the “latchkey phenomenon,” TV advertising, Hollywood, and the decline in “family values” — so it is with obesity. “We did not get to this situation … because of any change in our genetics or any change in our food preferences,” Frieden adumbrated. “We got to this stage of the epidemic because of a change in our environment and only a change in our environment again will allow us to get back to a healthier place,”
It isn’t obvious what to do when appetites produce offense — so it’s handy to claim that the environment is at fault and then to hand the problem to public health. Because for certain health officials, it’s always clear what to do: Take the moral high path, clean up the offending elements, urge the community to police itself better. If more parents are arrested… well, perfection has its price.
This entry was posted on Tuesday, July 28th, 2009 at 6:25 pm and is filed under Behavior, Disease, epidemics, Health Professions, Myths, News, obesity, public health, Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.