obese man sitting on stairs 2000 x 1125
Photo source: iStock Photos

It used to take an adult lifetime to accumulate all the disease risks associated with the modern American lifestyle. High cholesterol, pre-diabetes, diabetes, hypertension, heart disease, obesity, and more.

Now, many of these health problems are being diagnosed in children, some at a shockingly young age. Screening for Heart Health risk factors, such as hypertension, is no longer limited to adult primary care, pediatricians have had to add these task to their workflows as well.

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.

The problem with Body Mass Index

Obesity is often defined as falling into a range of Body Mass Index (BMI) scores above what the CDC considers “normal.” This definition of obesity has its own limitations. 

One drawback of focusing on BMI is that often escapes scrutiny is the way that this calculated number becomes its own measure of success. Many people believe that if you 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.

The myth of personal responsibility

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. The belief is if you accept responsibility, make the necessary changes, then the results should speak for themselves.

And, indeed they do. Upwards of 95% of dieters fail to sustain their new programs for 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.”

The social context of heart disease and obesity are complex

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 that weight/girth is an insufficient proxy for heart health. This is because putting the onus for change on individual patients is a sociologically-disguised way of treating symptoms rather than the disease.

The social context in which patients of all ages develop heart disease and obesity are more complex than we historically have allowed. That complexity makes it hard to assign blame to the individual for failure to get and remain fit. It also makes it difficult tol applaud successes.

Being sedentary is becoming the norm

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

Kids are anchored to school desks for 18 years. They are awash with both educational and entertainment activities that oblige them to remain seated, often engaged with computers or cell phones.

Adulthood promises more of the same, as the Internet and screen time 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. In fact, they look more and more like the result of irresistible inertia.

We’ve come to depend on something that is slowly killing us.

The case against individual accountability for heart disease

Since the risk factors for cardiovascular disease and obesity are legion. Further, the social forces driving them are broadly distributed amongst the population. So 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 of the auto and the human body. But, if avoiding the accident was a simple matter of stepping out of the way, who wouldn’t have tried doing that instead of being struck and injured?

Research is ongoing, but the latest data shows that childhood cancer rates are on the rise. It also shows that the increase correlates significantly with birth weight. This doesn’t necessarily correlate with maternal weight gain during pregnancy. Now, 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. As is the approach that caregivers take in confronting and addressing patients on these issues.

But there is little chance that this approach will gather sufficient momentum to reverse the trend. When something becomes the top cause of mortality for an entire population, it can no longer be considered primarily a personal responsibility issue.

The bottom line

Patients, as well as providers, should strive to better understand how much an individual’s behavior contributes to trends in population health. And how much is related to changes taking place at the population level. Are sedentary lifestyles or diets revolving around fast foods solely a personal choice? Or are they driven by changes in societal norms driven by much broader socioeconomic forces?  

I believe that the idea that personal responsibility is at the heart of every solution to every health problem can be safely abandoned now. Only in that way will we be able to focus our efforts on the much harder work of affecting cultural changes that can improve the health of populations as well as individuals.

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