It used to take an adult lifetime to accumulate all the disease risks associated with the 20th century American lifestyle: high cholesterol, pre-diabetes, hypertension, etc. Now, we see these issues becoming apparent—even acute—in younger and younger children. Heart health is no longer an age-specific screening consideration or care priority.

The range of specific cardiovascular problems afflicting a greater share of the population is often overshadowed by the familiar, accessible, and prolific issue of obesity. While there is very frequently a strong correlation, the heart health gamut is harder to simplify and quantify than obesity, which is essentially just the name applied to a certain range of Body Mass Index (BMI) scores above what the CDC considers “normal.” This definition of obesity has its own limitations, but one that often escapes scrutiny is the way it becomes its own measure of success. Improve the BMI score—and, by extension, escape the classification of “obese”—and you are a modern success story: Willpower and determination overcoming the foibles of comfort food and laziness.


Getting too personal

The manner in which lifestyle-related diseases are measured and attributed may well be contributing to their spread and severity. On the one hand, it has been long accepted, even advocated, that personal responsibility is the key to making the critical changes necessary for improved health. Diet and exercise are implicated in most cardiovascular conditions; clearly, patients need to make the choice to incorporate more movement and better eating. Accept responsibility, make the necessary changes, and the results should speak for themselves.

And indeed, they do: Upwards of 95% of dieters fail to sustain their new programs within 18 months; most end up regaining any weight they lost. For patients who opt for invasive bariatric surgeries in support of weight loss, more than half continue to exhibit disordered eating behaviors even after shedding the culprit pounds that had them branded “obese.” And despite a multi-billion dollar weight loss industry asserting itself in the lives of everyone, obese or otherwise, heart disease remains the single-most prolific killer of Americans.

The cumulative data would seem to indicate not only that weight/girth is an insufficient proxy for heart health, but that putting the onus for change on individual patients is a sociologically-disguised way of treating symptoms rather than the disease. The social contexts in which patients of all ages develop heart disease and obesity, as well as diet and exercise, are more complex than we historically have allowed. That complexity makes it harder to assign either blame or failure to get and remain fit, as well as to applaud successes.


A different sort of accounting

Basically, American culture advocates personal accountability for undoing the damage it collectively exerts. Nominally, Americans are passionate about eating nutritious meals and making exercise a priority. Economically, we’ve married sedentary lifestyles to many of the best-paying and most numerous careers. The rat race of running to stay in place has become a rat trap: Surviving the modern economy tends to entail desk-based work that undermines our ability to do what we know is best for our health.

Kids are anchored to school desks for 18 years, and awash with both educational and entertainment activities that oblige them to remain seated and engaged with computers. Adulthood promises more of the same, as the Internet and the screen account for more and more of productivity, creativity, social connectivity, and modernity.

When viewed through this lens of economic necessity and social normalization, the trend in obesity and heart disease looks less and less like a personal choice, and more and more like irresistible inertia. We’ve come to depend on something that is slowly killing us.

If the risk factors are legion as they are, and the social forces distributed among the population, then how can accountability be laser-focused on individual patients and their doctors? It makes almost as much sense as blaming a pedestrian for being hit by a car; certainly, there were some personal choices that led to the collision, but if it were a simple matter of stepping out of the way, who wouldn’t have tried doing that in the first place?

Research is ongoing, but the latest data shows that childhood cancer rates are on the rise, and can be correlated significantly with birth weight. This doesn’t necessarily correlate with maternal weight gain during pregnancy—and we can’t rationally blame the fetus for putting on unhealthy extra weight. But something has to be causing fetal weights (and disease risk) to gradually be increasing.


Recasting the lead roles

Obviously, personal choice can at least mitigate, if not entirely prevent or repair, obesity and risk for heart disease. To that end, the doctor-patient relationship is still meaningful, and the approach that caregivers take in confronting and addressing patients on these issues matters. But there is little chance with this approach of gathering sufficient momentum to reverse the trend. When something becomes the top cause of mortality for an entire population, it is no longer personal.

Patients, as well as providers, could stand to integrate more understanding and discussion of the individual’s role in contributing to population health. From candid conversations about vaccinations and antibiotics to engaging with research and policy news, the exam space can expand its reach beyond the individual, while keeping the individual at the center of the relationship. More than that, though, the notion that personal responsibility is at the heart of every solution to every problem can be safely abandoned so that the hard work of affecting cultural change can be taken up in earnest.



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