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Comment by ipnon | Hacker News Reader

It seems public healthcare is not feasible in the United States while the majority of Americans are overweight and a third are obese. It causes too many expensive health problems that are preventable by maintaining a healthy weight. Perhaps the government should simply pay people to keep their BMI under 25.

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> Perhaps the government should simply pay people to keep their BMI under 25.

The problem is we are doing the opposite: We pay people (subsidize) their unhealthy food (corn, sugar, and beef).

We should just make healthy food cheaper.

But it's not the kinds of food you eat that make you fat. It's how much food you eat. Remember the Twinkie diet?

What you eat and how much you eat don’t seem to be strictly independent from each other, especially when applied over long periods.

There's more to being healthy than being not fat.

Sure, but this article is about obesity in particular.

Is there? Because the evidence for weight loss to improve health is consistent, abundant, and overwhelming. And the evidence for all the other stuff seems to reside mostly in the realm of unverified "common sense."

Weight is a proxy for all sorts of related diet issues. You can lose weight on a Twinkie diet and not be metabolically healthy at the same time.

A healthy diet requires more than just the appropriate caloric intake. Although that’s a great starting point.

I'm not saying people should actually follow the Twinkie diet because they want to lose weight, just that a handful of people have done it as an example to prove it's only CICO that matters. Besides, anyone with the discipline to follow the Twinkie diet could easily follow a healthier diet too.

metabolically, puh, what's that even mean?

“Clinically speaking, metabolic health is defined by optimal levels of five markers: blood sugar, triglycerides, high-density lipoprotein (HDL) cholesterol, blood pressure, and waist circumference—without using medication.“

Things like a high sugar Twinkie diet will expose you to diabetes risk independent of calorie intake.

I was being sarcastic — but genuinely thank you.

You don't eat only for energy, you also eat for nutrients - and they are a lot more varied and complex than the standard list of protein, carbs, fat, vitamins.

To use an extreme example so that it's easier to relate to: You can eat only sugar and nothing else and far exceed your energy requirements, but you will still have lots of appetite despite already having eaten too much in just energy.

Food composition matters - and optimizing for energy (counting calories) is a losing battle. Of course, this also requires that people have had experience with various foods. Kids grown on mostly just fast food, pizza and coke probably won't be able to develop healthy habits no matter what.

Yes it is technically possible to force a body to remain slim by counting calories. It also is either very cruel or, if you manage it on your own, requires an absurd amount of discipline to constantly battle your desires. Yes some people have a huge appetite for the obviously wrong kinds of foods, like more pizza and more ice cream and no water please because it "does not have taste" but coke or some other industry-made drink. When the body was "mis-trained" it can't magically desire the right stuff that it never learned about. The environment matters too, it's probably a lot easier to not eat terribly in Japan than in some US mid-west town.

I know eating healthy food for non-caloric nutrients is important. But don't most people already eat at least some healthy food? Couldn't most obese people get back to a healthy weight just by cutting out junk food, without adding any more healthy food to replace it?

They're usually poor and the junk food is subsidized. The us has underground cheese bunkers to keep the dairy industry running, you won't be seeing a nutritionally complete tempeh salad on the dollar menu.

Is there literally any straightforward evidence that diet composition affects mortality?

> affects mortality?

Why would you only care about mortality?

I had some unfortunate experience with heavy metal poisoning (university clinic diagnosed - mercury, shown by lab tests). There was zero danger of dying and I doubt it took away any of my life expectancy. But it SUCKS and especially the brain works at a substantially lower level. I did not understand even simple sentences even after reading them several times at the height of the problem. I wrote Internet comments that made no sense when I read them again the next day, but at the time it felt perfectly alright and logical (sentence structure was weird too).

(Just an aside) And you know what? I had to end up with a senior researcher doctor at a university clinic before getting diagnosed. Because most doctors were a little like your question: They looked at the vitals and found no obvious disease and sent me home "it's all in your head". Which is funny because it's largely true - mercury being a neurotoxin, but for some reason the brain being the product of physics and bio-chemistry not registering with the oh so "science and evidence" based doctors, who seem to have a strangely meta-physical and esoteric view of it.

Anyway, back on topic:

I find this obsession with the binary outcome "death / no death" strange. Before death, your extremely parallel structure (not just your own trillions cells, each cell itself has lots of independently working parts, and then there are even more bacteria and other organisms occupying your insides and the outside who all contribute and are often affected too) does a poorer job of bringing the "you" into being. See your body like a computer running the software that is "you". The quality of the simulation drops if the hardware is impacted (you are the activity of your parts - a brain without activity is not "you", you are not there if the hardware does not run the "you" software). But the life expectancy may not be impacted at all.

Surely, if you provide far from optimal fuel you can expect the quality to suffer too, not just when you are poisoned or otherwise restricted.

So, it is a question of what version of "you" do you want to be? Is mere existence enough?

It's not that I object to any of that, so much as it's just that mortality is a lot easier to measure.

These subsidized 'unhealthy' foods are highly calorie dense. While in-theory, you can eat less, you will not feel full like you would with low calorie dense food.

For example, an Apple weights 200g and is 110 calories. Whereas a double cheeseburger at McDonald's is 173 grams but 450 calories.

We also outlaw health plans providing discounts to those who lead healthy lifestyles.

We also have car centric city planning, which is going to take untold amounts of time and capital to shift away from.

https://www.flickr.com/photos/carltonreid/4646637491

Good thing then that exercise (while healthy in other ways) burns relatively few calories.

We have had a car culture for far longer than we have had an obesity problem

Cars are not the reason this nation is getting fatter

Right. The argument for why they're bad is straightforward, but the rankings don't line up. [1] [2]

[1] https://en.wikipedia.org/wiki/List_of_countries_by_vehicles_...

[2] https://en.wikipedia.org/wiki/List_of_countries_by_obesity_r...

Miles driven per capita would be a better comparison. Americans drive more than any other country.

https://www.thecarcrashdetective.com/americans-drive-more-dy...

You'd want to measure butt in seat hours since the problem isn't the distance but being sedentary.

OK, but they cause a lot of death and injury quite apart from their effect on weight. Societies that drive more miles have higher mortality rates. When you compare health care in the U.S. to other Western countries you have to consider how much we drive, how fat we are, and how many of us overdose.

This is a topic about obesity not how cars do not do not contribute to other health concerns.

This subthread was actually about the feasibility of public health programs in the U.S. And that's a topic that needs to account for those 3 areas in which we are outliers, especially if, as inevitably happens, people get around to drawing comparisons between the U.S. and Europe.

This is like saying we’ve had the Internet a lot longer than we’ve had social media addiction.

Obesity rates started rising with the introduction of drive-in food, which wouldn’t exist if it wasn’t for car culture.

Well if I have to choose between Car Culture, Fast Food food, and Obesity, or giving up those things.

I choose FAT... every day.

Thankfully that is a False dilemma, and we can keep our car culture and rollback obesity at the same time

Most of the people focusing on "car culture" do not really care about obesity, it is a proxy war for Climate Change, and opposition to Rural America.

I will never accept high population density, and electric cars will resolve the climate change issue

This is probably sensible.

The current article suggests obesity is the top modifiable dementia risk, which suggests that there's other risk factors that are more important and not modifiable.

It might be tricky to actually reward healthy lifestyles via health plans, since people generally need more care as they get older.

The people farming the healthy food are not a big enough voting bloc for this to happen.

Frankly, you are trendsetters, not the odd exception. You are just ahead of the curve, but the rest of the world is following you.

I am 44 and I am aghast at how fat some of the youngsters here in Czechia are. Middle-aged people are, too, much fatter than when I was young. This isn't a common grumbling of an aging person, the trend can be measured fairly well.

I am not sure how our public healthcare systems will cope 20-30 years down the line. Aging (greying) of the population plus chronic metabolic diseases caused by obesity, treatable but not yet curable, will be a double whammy.

“For people aged between 65 and 69, around 2 in every 100 people have dementia. A person’s risk then increases as they age, roughly doubling every five years. This means that, of those aged over 90, around 33 in every 100 people have dementia.”

https://www.alzheimers.org.uk/sites/default/files/pdf/factsh...

So, as more people live longer, the odds of getting dementia increases greatly.

Maybe we should spend the money to cure the disease?

A cure would be great, but it's not something we can just buy by throwing enough money at it. This argument feels like saying to try to find a cure for lung cancer instead of getting rid of asbestos and getting people to stop smoking.

“Top Modifiable Risk Factor”

I think we should dig deeper into the numbers before deciding. I get the feeling we aren’t going to see the same numbers like we do for smoking.

The odds for *everyone* increases greatly simply by aging.

And it’s costing a fortune.

“Costs Associated With Alzheimer’s Disease Reach $277 Billion Annually, Report Finds”

https://acl.gov/news-and-events/news/costs-associated-alzhei...

Well the disease of Aging is the number one killer. We should solve that

I’ll just leave off by saying that some causes of death have a much higher cost to society.

Spending a decade with Alzheimer’s then dying is expensive.

Simply dying quietly in your sleep at the age of 99 after living a healthy life, not so much

Clicking through the submission shows: "Approximately 1 in 3 of ADRD cases (36.9%) in the US were associated with 8 modifiable risk factors, the most prominent of which were midlife obesity (17.7%; 95% CI, 17.5-18.0), physical inactivity (11.8%; 95% CI, 11.7-11.9), and low educational attainment (11.7%; 95% CI, 11.5-12.0)." Interpreting those risk factors as saying x% higher risk than not, i.e. a relative risk of 1.177, it's a far cry from smoking relative risk findings > 20.

I agree that just solving the disease, or at least making its treatment options cheaper (so that it's not a big deal if some people cost a bit more to treat than others), is a lot better than trying to alter levels of service based on BMI. But throwing more money at ADRD directly is probably a mistake, especially given findings like https://www.science.org/content/blog-post/faked-beta-amyloid...

I'm much more in favor of solving aging. Maybe see what happens if you give SENS $1bn/yr. Don't even need to take more public money, I'm sure Alzheimer's researchers won't miss it. (Though even without SENS being better funded, things are looking up; there are more groups, and things have been able to be spun out into startups. It's especially relieving that the Theranos case hasn't completely destroyed the concept of VC-funded health-related startups as a class, since VC money is a lot better than government money dollar-for-dollar. Before his personal drama with SENS recently, Aubrey estimated 50-50 odds at solving aging by 2035. With more funding, that could probably be improved.)

Terrifying statistics considering the age of our leaders in Congress.

Well not to excuse their age, but most of congress goes in with a declined metal state so....

Our system of election is not designed to elect the "best and brightest" and we hardly ever get that option

Incentives are perverse. We reward seniority in office when we really need people to cycle in and out more often. Though perhaps a bit less frequently.

You know that whole trope of "the science/medicine just keeps getting better". For Dementia it is just getting worse. We have a better handle on cancer than pryon diseases. Please spend your money on fusion research instead, it has a better outlook and roi.

They used to cling to statistical fallacies about "keeping an active mind" but now we know no amount of crossword puzzles will keep proteins folding right. Cognitive health just masks symptoms longer.

Woah. My grandmas is 92 and has done the crossword everyday for years. I’m not going to tell her that science shows it isn’t helping her offset dementia.

Explain survivorship bias sometime!

Maybe instead the government should "simply" stop doing everything it can to increase the cost of healthcare. When something is cheap enough (as our tech industry has many times observed), it's not a big deal to leave big factors of inefficiencies on the table and get on with other stuff.

I’d be surprised if paying people to keep their BMI low had more of an impact than the doctors repeatedly and clearly telling everyone who listens that obesity increases the risk of dementia and premature death.

But only a bit surprised.

Agreed. I think one step would be to have public healthcare, but only for people who are at a healthy weight (as determined by body fat percentage).

For example, Type 2 diabetes is a big cost burden for any health system. 70% of people with Type 2 diabetes who are also overweight would be asymtomatic if they lost weight. Why spend money on these people if the best course of action is free? (I.e., eat less food)

Even better: Do what certain Latin Amercan countries did and take the fight against convenience food and the producing industry serious. Tax sugar, reduce max sizes of soft drinks,... You name it. Using public healthcare as a way to punish people seems to go counter the goal of oublic healthcare.

Yes, I think ultra-processed food is a good candidate for being the root of the problem, but it seems only recently that people have tried to do anything about it.

It is very dangerous to advocate government prohibiting access to care based on limits they choose. be very wary of unintended consequences, and potentials of abuse

It may sound find and good to impose limits in this way, but I can think of all kinds of ways that could be abused

Type 2 diabetics get fat because of the insulin injections they are using. Not because they are eating more or are more lazy than the average person. The real solution for Type 2 diabetics is a low-carb diet. Doctors in the US, UK, and Australia routinely reverse Type 2 diabetics for their patients using low-carb diets.

It seems quite simple. Just allow insurance companies to charge more for “avoidable” things like motorcycle riding, inactivity, obesity, smoking.

> Just allow insurance companies to charge more for “avoidable” things like motorcycle riding, inactivity, obesity, smoking.

Insurance companies already ask for a subset of this. My health and life insurance asked about smoking (multiple times), and life insurance specifically requires you to get a health exam done at a doctor if you are trying to opt into a high tier of coverage. My life insurance also asked me if I am doing any "extreme sports/activities", with their listed top examples of it being motorcycle riding and skydiving.

None ever asked about obesity or inactivity. I am all for obesity being treated like smoking, but inactivity is a bit of a tough one to filter or screen for.

Oh well thanks for solving the problem there chief. Who knew you only had to pay people to lose weight.

Edit: Downvote me all you want, these are just stupid internet points. But what the guy/gal said was offensive to anyone who’s struggled with weight loss.

Edit 2: Sounds like I should really lose some weight before I interview.

Why? I’ve been heavy. I’ve been light. Burn more calories than you consume and you lose weight. I don’t think it’s fair others should need to pay more for my healthcare if I choose to use my American freedom to be heavy?

That’s not what OP said, they said the government should pay people to lose weight. As if getting a $100 check in the mail each month would change people’s behavior. It just lacks any real understanding of why people are overweight to begin with.

they don’t want it enough

money is a motivator

losing weight sucks because the changes are slow

weekly payments could help with motivation

this would create a dystopian nightmare but people would be thinner

Money is a huge motivator. Aside from the fact that $100 check every month can directly subsidize healthier food choices.

A $100 check is not going to get someone to choose Broccoli over Ice Cream...

for example I have for force myself to eat vegetables, cant stand them, no matter how they are prepared, I have a heightened sensitivity to bitter things. It is not a cost issue that prevents me (and many others I know) from eating "healtly" things, it is fact that to us they taste like crap

and yes I know "how to prepare them", I am actually a pretty decent cook, and tried every preparation method known to man, just my taste buds reject veggies, especially cooked veggies, Salads greens, Spinach, Green Peppers, Tomato's, Cabbages, etc are tolerable and make up the bulk of my vegetable intake

I did what you are doing for years and finally switched to a low-carb diet instead. It works much better for me. I still eat 200g spinach and 150g broccoli a day to get the vitamins I need. It tastes excellent when fried in butter with lots of spices and eggs/meat. I instantly lost 7kg and 9cm around my waist eating the same amount of calories. And my blood results are “superb” according to my doctor. I recommend the “low carb down under” YouTube channel for the science talks.

You're projecting an implementation onto an idea. It seems bad faith. The ability, or physical and emotional investment to lose weight isn't exactly insignificant, so you're right to emphasize that - projecting ignorance and malice on the idea rather than criticizing it's merits isn't helping though? $100 check contingent on nothing does seem like it could go wrong as well as being subjectively offensive, but you are the one who suggested that right? What would work best I wonder. I was lucky in the sense that my life's circumstances forced me to lose all my spare weight.

You’re the one doing the projecting. I only offered one example of a possible implementation as the OP didn’t provide any.

I certainly wasn't trying to, just giving you my impression of your intentions. Are you trying to impune and argue, or is that just me? What ideas are you suggesting besides the $100?

I think it’s just you. I welcome more ideas, but it’s not my job to come up with public health policy ideas.

It’s more complicated than that. If you don’t keep your insulin low then you literally can’t loose fat no matter how little calories you eat. The body will simply down regulate your energy expenditure to match your calorie intake if it can’t access your body fat. So you will be colder, have less energy, be more tired etc.

For the down voter: https://youtu.be/LRHir1k9jmE

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