On obesity

Just a photo of a nice croc I saw

I read an article recently about how to best manage obesity as a society. It wasn't a medical journal, though, it was an economics/finance/management report published by the McKinsey Global Institute. It was written by business analysts and economists; which was interesting to me as usually I see these articles about obesity in the context of public health and medicine. And it got me thinking about just how did obesity become a problem. The report is very interesting and I certainly don’t intend to repeat it all; in fact what I’m writing here are merely my own insights and opinions that took this article as a starting point. But if you get the chance, read at least the executive summary of the McKinsey report here.

Food has always been a necessity for us humans, and obesity is not a new thing. The problem is the high prevalence of obesity and the subsequent high rate of health problems for which obesity is a major contributing factor. You then recall times from history like the great depression and wonder how did we overshoot so much that now obesity – an excess – is the problem. The thing is that perhaps the exact same things that brought us out of the great depression brought us to high rates of obesity.

Towards the end of the great depression, a lot of interesting things began to happen. Yes, there was the onset of World War II, which brought about destruction – and subsequently, at it's conclusion, a great need to re-create, produce, manufacture, and re-build the world! Industries soared. Governments and commercial enterprises became really good at economics and business. Extremely good.  And with the end of the great depression, of course, food became more than a rationed commodity, more than a human need, it became a highly lucrative commercialised industry more than it had ever been in our society. The success story of business and industry tracks that of obesity rates. Every strategy that led industry to thrive, also drove obesity rates to rise.

Think about all the strategies that make businesses successful, and then you finally may get closer to finding an answer to the question of how did we as a society let obesity rates rise to the levels they are today. Well, firstly, a great business needs a product that is desirable. What is a more desirable consumable than food? And more than being a desire, it is an actual human need! Food is one of those things that would sell even if it wasn't advertised anywhere.

But food is advertised – and very well; a great marketing strategy is one of the fundamentals of a successful business. The interesting thing is that the food that receives the most advertising is the least nutritious and yet most energy-dense. Unfortunately as a society we developed technologies and became really good at modifying our environment so as to minimize the amount of energy our own bodies expend. Our progress as a society, our advancement, is because we built efficient machines that use external energy to do the hard labour we previously took on. We walked greater distances, lifted more, did more physical work just in our everyday than we do now. And hence the large disparity between the energy content of what we consume (that energy-dense food advertised so heavily) and the energy we expend – with excess energy being stored in our bodies as fat.

Marketing isn't just about direct advertising, though. It even involves exploiting existing societal norms and evolving new ones. What do I mean by this? Actually this concept is the most wide-ranging aspect of how business, and food as an industry, has grown. But let’s take, for example, just two interesting quirks of us human beings: 1) we perceive more as better, and 2) we perceive bigger as better. Have you ever tried to buy just a Big Mac at McDonald’s? Well, let me tell you it costs nearly as much as a Big Mac meal, with the fizzy drink and the fried potato chips included. We all prefer to get more for our money, so we do end up buying a much higher energy intake for just a few cents more. But it’s not just about the big bad fast food giants, even our supermarkets do it.  They sell us even staple foods, but at a cheaper rate if we buy more of it. Why? Not because they think “poor, poor, undernourished people; let them have more food”. No, they do it because we are consumers, and only consumers to them. They sell us more so we pay more (we think we’re making a saving, but the reality is companies never underprice their items even in the “deals” they give us). The concept of portion size is similarly related. And portion size isn't just about how big our meals are, but the fact that because our foods are so energy-dense and our lifestyles for the majority of us are so sedentary, the physical-size of our meals isn't even what we’re really talking about here. And who does know what we are talking about when we say things like “portion-size”, “recommended daily intake”, “calories”, “kilojoules”, etc? Not that many of us! Education about nutrition and its relation to health and lifestyle are severely lacking in our society…

I want to conclude this topic of discussion with a direct passage of recommendation from the McKinsey report I mentioned earlier:

“Education and personal responsibility are critical elements of any program aiming to reduce obesity, but they are not sufficient on their own. Other required interventions rely less on conscious choices by individuals and more on changes to the environment and societal norms. They include reducing default portion sizes, changing marketing practices, and restructuring urban and education environments to facilitate physical activities.”

What do you notice about these recommendations? If you’re like me, then you will have noticed how most of the things suggested that we need to try to do as a society to combat obesity are the complete opposite of everything you need to do to have as great and successful a business as the food industry in industrialized countries is. We became obese not merely because we ate too much, but we ate more than we needed to because the food industry needed to grow its profits. I think in health care we particularly need to take note of this. Sometimes we think we must help individuals (or blame them, as we sometimes do), but the truth is individuals were helped in their demise by large industries and corporations who focused on our consumption/profit value rather than the effect of their products on our health.

On sex and illness

Back in the day, the general thought about romantic partnerships was that the woman had to be dutiful, and part of her duty was to make sure her man was getting sufficient sex to keep him happy. This was prior to the 1960s (though in many cultures and countries this is still a very prominent idea). Back then, men made up the greatest proportion of the salaried workforce, and men’s ideals dominated the media. A by-product of this era that I find particularly interesting is the notion that men (and women) need sex to be happy, and that sex is a necessity to keep relationships strong and lasting.

A question us health professionals often overlook when consulting our patients is the importance of sex to them – they are, of course, human beings just like us and therefore have the same interest in it that we do. There was a time when we were all being urged to tell our cardiac patients to abstain from sex for a certain period of time after a cardiac event or surgery – and the message got through to us and them. We became good at dishing out advice to patients that sex after heart problems is a big no. Patients, motivated to obey as they didn't want to suffer complications from what is a very serious health issue, listened and took this very seriously too. A lot of us, however, forgot to frame anything but the negative to our patients and advise them that sex is OK too, and bar a few restrictions, it was OK to resume it. It was like as if as health professionals we thought that patients are sex-crazy insatiable beasts that cannot resist the urge to have sex straight after having (often) extremely painful chest surgery and/or losing a large amount of physical endurance. The reality we were forgetting is that very often after cardiac events, people (yes, patients are people too) become depressed, and with depression often comes an actual loss in libido. Suddenly after a major health scare we are faced with the realisation that our life isn't infinite, that our risk of dying is a lot higher than we once thought, and that we now have a chronic illness that you just can’t shake off and pretend like nothing ever happened. Our patients’ whole lives change, priorities change, relationships are tested and adjusted – and there we are as health professionals thinking that our patients actually want to have sex after considering all this! Yes, some do, but the majority probably also would benefit from being reminded that once they’re ready, sex is OK.

Another interesting scenario is sex in the context of cancer. I mean specifically cancers that affect tissues that we traditionally would associate with sex: breasts, prostate, testes, etc. As an example, let me consider women who have the most common type of breast cancer, those which are hormone-related/responsive. Treatment of their cancers often involves surgery, scars, and sometimes very marked deformity. All this in areas of their body often thought of as very intimate, sensitive, and defining of one’s sexual identity. Radiation treatment does similar, and sometimes making an area that was once so sensitive in a positive way, extremely tender.  Medically, to achieve remission of their cancers, these women often have to be put in a state of sudden menopause. And then come all the effects that go with menopause: vaginal atrophy, loss of libido, low mood, hot flushes, etc. You put all of this together and can you imagine how hard it is not only to think of sex, but to actually enjoy it in the way these women once did. Now think of the effect this has on a relationship if we aren't being open and honest on what people with these types of cancers are going through.

It’s no big leap of the imagination to conclude that a lot of relationships often become sexless after cancer affecting what we predominantly think of the sexually-defining features of our body. For those who are not in a relationship at the time of diagnosis, entering or re-entering a relationship is equally as daunting and is often delayed by many many years. Now, as an example (because I have seen this scenario a few times in my own practice), consider a heterosexual couple where the woman becomes diagnosed with breast cancer. Initially, both partners become concerned about the physical well-being of the partner affected by the cancer. The couple shares common goals: for the woman to survive the cancer, and for her to tolerate the treatment as best as possible. Of course, despite our best personal support networks and the best-meaning friends, family, and health professionals, cancer diagnoses and treatments are very isolating. Everyone may know what you’re going through, they may care about you and want the best for you, but only you are going through it in mind and body. It’s a sad fact of life, that at times no matter who’s around you, you feel very alone. The cancer treatment begins and ends for the woman, but the emotional adjustment takes a lot longer. Sometimes it takes a very long time, and though couples never forget the cancer, they sometimes forget to speak of the less “heavy” things of life, things like sex. And more than simply not speaking of it, sex during and after cancer becomes taboo. I mean, such greater things are in question when the cancer diagnosis came up: mortality, strength, survival, endurance, support – who can think of the mundane things of life like sex? But time passes and life and relationships continue once the acute cancer story is done with.

And, yes, we do think of sex. Not just the partner who hasn't been sick, either! We know that the person who has survived cancer has all that physical and emotional stuff to deal with, scarring, pain, deformity, loss of libido, low mood, etc. How can you possibly have sex again? Unfortunately, this same information is often locked up inside with shame, fear, and the desire that if we just ignore the issue it will all just go away. If we return to the example of the woman with breast cancer, the partners of these women often do not know her struggle beyond the acute cancer story. No one talks about it. And so they wonder what they’d done wrong, what did they do during the woman’s struggle to turn them off them sexually still so many years down the track? Can they ever undo this and how? Is this it; is this just how it is after cancer? Does a sexless marriage mean a loveless one? Is it wrong to still be sexually attracted to the woman she is despite her body changing? Has this got nothing to do with the cancer? Has it really got nothing to do with it at all, and the only reason the woman isn't leaving is because she’s grateful for his support during her cancer battle? Is gratitude enough to continue a seemingly loveless marriage? These thoughts are very emotionally painful – and I think very important to talk about. Similarly, I've known of men who won’t approach their partners sexually after cancer treatment for fear that she won’t want it, can’t have it, and just not knowing (and unable to ask?) how it will be different for her. Women may react to this in the way that, ‘hell, not only did I just go through cancer, now my partner doesn't even want to touch me or know me sexually’. And so the cycle of sexual abstinence continues…

And what do I conclude? That we talk about sex. That it becomes neither an expectation in relationships nor a forgotten burden. That health professionals to their patients about it, but more importantly, that couples talk to each other about it. And that we be allowed to form our own conclusions as to the importance of sex in relationships.