The Weight of Society

Unless you’ve been hiding your sizable corpus under a very large rock, you are likely well aware that our country has a bit of a weight problem. People smarter than I have studied the interaction of health outcomes and excess weight. What these smarty pantses haven’t been able to figure out is how to reverse, or even freeze, the obesity rate at the population level. There are so many facts about nutrition that we know, but no matter how many times you explain that instead of KFC you could simply eat a plain boiled chicken breast and lose weight, it doesn’t seem to work. All this food education is beside the point entirely. People don’t struggle so much to lose weight because they lack cool facts about vegetables; weight loss is hard because hunger is painful, food is social, and the disconnect between the costs and benefits of weight loss is vast.

The pain of hunger is, of course, hard to measure and subjective, but its very real! We evolved in a situation where it was advantageous to eat while we could, and something so innate is pretty difficult to override. It is reasonable to believe, likely for both environmental and genetic reasons, that different people experience this pain differently and have varying tolerance thresholds for hunger pain.

I am reminded of a business ethics class I took in grad school where the instructor was also a doctor who had an all-consuming hatred of overweight people (a terrible problem that could be the source of another entire essay.) He complained of this patient who ate a Big Mac meal and an entire bag of Halloween candy and wondered at how a person could be so lacking in nutrition education. I imagine that, assuming this poor man is real, the amount of painful hunger he would have to experience to get down to a 2,000 calorie diet would be overwhelming. Meanwhile his healthcare provider was completely unable to empathize with him; the doctor just assumed that this poor man must lack his intellect and education. Personally, I find it hard to feel high and mighty over someone who compulsively does something that I couldn’t even force myself to do if I wanted to, nutritional knowledge notwithstanding.

Pain management is rarely an explicit discussion in the weight loss discourse, but its there around the margins if you look. A lot of fad diets promise you can eat as much as you want, ie you can soothe your hunger pains, as long as its only meat or grape fruit or cabbage soup or zero points plus. The secret to gastric bypass and the first generation of actually effective weight loss drugs is that they make the hunger pains go away, or even reverse the direction of the pain to where eating too much is what hurts.

The fact that pain management is rarely directly addressed as a component of weight loss is an indictment of the weight loss industry and public health apparatus. It shows that condescension and shaming are no substitute for empathy and listening when such an obvious root cause goes unremarked upon, and it’s no wonder that a public health campaign oblivious to something so apparent has failed.

In addition to the pain of hunger, there are social and cultural costs to dieting that are difficult to navigate and rarely acknowledged directly, but again the issue is, obvious, and seeps into the margins of the discussion if you’re paying attention.

As celebrities from Jamie Oliver to Michelle Obama can tell you, people do not react well when you tell them that their social sphere has been going about eating all wrong. It’s easy to dismiss these people as close-minded hicks, ignoramuses, or even Republicans, but food is such an integral part of culture that it’s no wonder that an outsider saying a group’s food is bad causes backlash. Foods often come to define cultures, from soul food to street food. Towns and regions have local specialties that they show off. Immigrants bring food traditions from their home countries to add to the great American palate.

Food is family. Recipes are passed down from generation to generation, even as food scarcity and daily manual labor were not. Aromas can trigger memories of Sunday dinner at your grandparents’ house, or making Christmas cookies with your mom, or learning the exact right way to season a pork chop from your dad. Baking a pie can mean “I love you” while enjoying said pie means “I love you, too.” Even if you can’t quite remember those cooking recipes, you can buy a memory that’s almost as good, and the “lite” version isn’t going to cut it.

Food is social. The quintessential form of socializing is grabbing a few drinks with the guys or some work friends or the cute dude you met at the dog park. However, if you are counting carbs or calories, most drinks are a no go. Other major ways of socializing also seem to focus on food: meals at restaurants, movies with popcorn, church potlucks replete with mayonnaise salads, etc.

Food is also comfort when socializing isn’t an option. Wine and chocolate can ease heart ache. The isolation that can come from bullying can also be soothed by a tasty treat—a bitter irony considering who tends to get bullied.

Successful weight loss promotion has to teach people how to navigate social events where calories are abundant and at the same time acknowledge that those events are meaningful and special. Giving up your food culture is a significant loss, and reluctance to change it is not a frustrating sign of stupidity. I don’t know how to walk that tight rope, but acknowledging what is being lost and letting people know when and how often they can say yes is a good first step in the right direction.

There is a cost and benefit to losing weight. I work as an accountant, and in accounting we have this principal called “matching” where a business tries to match an expense to the period when its used; e.g., if a business pays $500,000 for a building, it’s not all an expense in the current year, because the company will benefit from the building for decades to come, so accountants depreciate the cost, assigning a portion across several periods.

Human psychology does not have a great way of incorporating the matching principal. Over-indulgence in candy doesn’t show up at all at first, but eventually builds up over time. Similarly, it takes months of dieting for significant weight loss; meanwhile you feel the hunger pains and hit to your social life immediately. And the threshold view of weight further exacerbates the problem. It is, from my understanding, a bit arbitrary where the lines are drawn between “normal,” “overweight,” and “obese.” That is, a person with a BMI of 30.1 does not have substantially more health risk than a person with a BMI of 29.9, despite crossing the obesity threshold. But the existence of the thresholds and the way they are talked about works to mask potentially health improving weight loss, and all the work that went into losing that weight.

And the threshold mindset doesn’t allow people to make rational choices about the trade offs to losing weight and figure out how to best manage their health. Losing 50 lbs to meet BMI standards may be simply too painful for a person to endure, but what benefits do they get if they can lose 5 or 10 lbs? That doesn’t come up in the national discussion.

The NIH even defines successful weight loss as losing 10 percent of one’s weight and keeping it off for a year, so a 300 lb person that loses 30 lbs is considered a success story on the one hand, but still doesn’t escape the “obese” category. For the people who don’t have or don’t care about the context, our 270 lb weight loss hero will still be subject to all the scorn that the worst and dumbest people think that heavy folks deserve.

At the end of the day, weight loss is easy. All you have to do is endure pain and renegotiate most of your social relationships, and several months in the future, you may start to notice some changes. Given the scope of the problem, it is no wonder that the public health efforts around obesity have not worked.  This failure has been exacerbated by widespread misunderstanding in the public sphere of what a person has to go through to lose weight. We need fewer facts about vegetables and less shame while we help people manage pain, navigate social situations, and evaluate trade-offs if we want to make any progress on public health.

Or maybe Ozempic will save us all and we’ll never have to talk about this topic again.