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Comment by midoridensha | Hacker News Reader

>One of the greatest failings of our "modern" healthcare system is that there's no plan to address this crisis. Obesity is the gateway to what seems like an infinite amount of health complications

What are they supposed to do? Obesity is caused by American's terrible lifestyle. Healthcare systems can only do so much to compensate for a bad lifestyle. Stop drinking alcohol, and start walking everywhere instead of driving.

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For one, we can start to treat city planning as a healthcare issue.

Limit zoning restrictions that currently make driving everywhere the most convenient choice, stop all freeway expansion projects, and make as many walkable, bikeable, friendly neighborhoods as possible.

If people want/need to go outside and walk or bike to accomplish their daily chores, they won’t need to think about exercise as much because it’ll just be an automatic part of their routine. The best kind of health outcomes are based on societal changes, not personal responsibility (“you need to go to the gym and punish yourself” has been failing us). And people will be happier too, if they are more connected to their community (after the initial grumbling about how “hard” it is). It’s so hard to walk/bike around in the US that I don’t blame people for not doing it more (as an avid walk/run/biker myself).

That doesn’t mean we get rid of all current development and suburbs, but just eliminate the current restrictions which enforce that lifestyle, and let people’s communities start transforming slowly into healthier ones.

That would be nice but I don't see that happening outside of boutique cities like bentonville

you really need to start fresh or force it before hitting the inflection point

When things like tax revenue-per-acre starts adding up, it’ll also be more affordable to live in denser areas.

By removing zoning restrictions, some communities will start becoming more walkable & mixed-use than others. Since it’s more cost efficient, it’ll be cheaper to own a townhome in a dense area than an equivalent townhome in a sprawling area (after the market equalizes & we can keep up with demand, because it’ll be sky-high for those walkable townhomes at first). But if zoning is reduced, supply will start to catch up.

People in sprawling communities will start needing to pay more for taxes for things like road maintenance etc since they have much higher costs per person than a dense area, further starting to push people to favor dense areas. Are people willing to pay the actual cost of living in remote areas like suburbs?

It’ll happen slowly at first, but just removing the current laws that prohibit that sort of development may actually enable those changes to happen automatically

everything's possible it's hard for me to imagine how it would work in some sprawling places like texas eg. houston or austin

I could that happening new/growing suburbs outside of cities like that though like as you say if they commit to a sane design/zoning before it's to late

People will literally rezone entire cities rather than saying we need to eat less food and workout more.

My point was that making it a personal choice seems to be failing us. We’ve been telling people to do that for decades, and they’re not — make it a societal choice so that it’s individuals are automatically enrolled in a system that promotes their health rather than forcing them to sit in a car seat for hours per week

I find it fascinating, from an social science perspective, that in other critical areas of society social shaming is encouraged, but when it comes to human fitness we will invent PhD theses worth of reasons for why that's not allowed.

I 100% agree with you though, the physical structure of (most) US cities makes this difficult if you yourself don't prioritize it, or you can't afford to.

Fat shaming just doesnt work, the only provable outcomes are mental illness and weight gain.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236245/

It's also a huge glaring actor/observer asymmetry issue, you think between the 50's and now human beings innately changed to be lazier, more prone to overconsumption? Why opt for blaming the individual multiplied by 70 million rather than looking at the conditions of their shared environment?

>you think between the 50's and now human beings innately changed to be lazier, more prone to overconsumption? Why opt for blaming the individual multiplied by 70 million rather than looking at the conditions of their shared environment?

Subdivisions basically didn't exist in the US in the 1950s; they were only just being invented then. People lived in smaller towns and cities and walked around a lot more. Even in the 80s, kids were walking around outside a lot, without adult supervision. Now that's basically illegal in most places, so kids stay in their suburban homes all day playing video games.

And, as usual, you can compare to other countries. In other places, there's less of a car culture, people walk around a lot more, and there aren't many obese people.

I'm not certain but I think we're in perfect agreement here. The environment in which people live has changed and I think that should be the obvious first target to change.

I think this urge to blame people for the effects of their environment seen in the one of the parent post is an example of a very dark part of our attitude toward change. It is very easy and tempting to short circuit into ridiculing positive changes in favor of instead attempting to fix it by punishment/shaming ("People will literally rezone entire cities rather than saying we need to eat less food and workout more")

The "you are beautiful no matter how you look" social campaign probably doesn't help here. There are literally visual cues that you 're doing something in excess and your doctor tells you to lose weight but Instagram says it's ok to be obese. I wonder if there's a limit to it, is it still ok to be twice your normal weight overweight?

Do you live in the US? Fat people are routinely discriminated against in employment and healthcare. A few Instagram influencers and ad campaigns don't negate that.

I have never met a fat person who wasn't aware they are fat. I do know two people who have failed to lose significant weight even after bariatric surgery physically restricted how much they could eat.

After even the most extreme medical intervention fails and you are still obese, what can you do? Stay inside your home forever so that thin people are not forced to look at you? Never eat a piece of cake in public? Never go shopping, never date, never dance?

Of course not. In the end the only choice is to live your life anyway, in spite of your reduced opportunities and the judgment you receive from others.

If you're brave, you might even dare to post photos of yourself on Instagram.

> I have never met a fat person who wasn't aware they are fat.

"Today, 7 in 10 Americans are obese or overweight, but only 36 percent think they have a weight problem. In other words, close to half the people who are overweight or obese don't think they're overweight or obese."

https://www.washingtonpost.com/news/wonk/wp/2016/12/01/nearl...

I live in Europe. For employment that demands physical stamina it makes sense that fat people would not be favoured at the extreme level of obesity. My healthcare provider differentiates between overweight and obese and you can't treat triage as discrimination. There's a whole lot of middle ground between staying in your home not eating cake and promoting yourself on Instagram. Date and dance as you see fit.

The kind of discrimination I am talking about is refusing to hire fat people for desk jobs (or not promoting them, or paying them less) because of stereotypes that they are lazy or lack self-discipline or simple distaste for the way they look. [1]

Categorizing a patient as overweight or obese is not discrimination. Dismissing their health concerns or providing lower-quality care because they are fat is. [2]

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853419/

[2] https://journalofethics.ama-assn.org/article/weight-bias-hea...

When you say "we've been telling people to do that for decades" I'm assuming you're referring to the accumulated scientific wisdom that says eating healthily and getting exercise is good for your health, and not the trillions of dollars spent advertising addictive sugar water, alchohol, cigarettes, sugar coated cereals for kids, subsidized beef and corn syrup and attacking every health recommendation as lies if it threatened someones profits?

It might actually be worth telling people to eat healthily and excercise as a consistent message before we abandon the idea.

Exactly this. Not sure how much of the scientific messaging reaches the lower socioeconomic subsets of society either, I don't think kids' obesity is because they 've tried everything to lose weight and can't help themselves or rather their parents don't really understand the intricacies of how processed food works. There's something that defies intuition about a 50g mars bar having the same calories as a 300g potato even if most people vaguely understand that 'sugar is bad for you' but can't really put it in perspective, what does that mean in practice? The dosage makes the poison.

Working out more and eating less is a pain. Rezoning and rebuilding is fun!

Jokes aside, an environment that softly pushes people towards better choices has a far, far better chance to push them towards these choices than an oppresive self-discipline regime. In the long term, only the former works.

On the contrary, people have been saying we need to eat less food and work out more for decades. The "just educate people and they'll make better choices" approach has not worked.

Has worked for me. I find the UK food labels on most products quite informative as a rule of thumb. I remember initially being very surprised at some food contains when I started paying attention and how very small things like Mars bars can have so many calories comparatively of course. I think there's something sinister about not wanting the consumer to know what your product contains.

Libertarians are fighting for 'food freedom' and escape from these authoritarian rules forcing sellers to inform consumers:

https://reason.com/2022/06/18/mandatory-menu-labeling-still-...

This thread is full of people commenting along the lines of "I have been able to manage my weight successfully, so other people must be fat because they're lazy idiots."

HN is full of people who will accept nuance and complexity in technical discussions. Why not in this area as well, where individual biology, cultural expectations, economic incentives, and environmental factors intersect with personal choice?

There's plenty of victim blaming on technical topics too.

Any negative impact of tech on people will have comments saying “well they should have just..."

Look at this video with fragments from England and Ireland 120 years ago.

https://twitter.com/bo66ie29/status/1565100701755314180?s=20...

How many fat people you see?

Do you think human biology changed a lot the past 120 years?

I think just a bit of movement each day and eating healthy food is enough for 99% of people to prevent getting overweight.

The very point I'm trying to make is that human nature has not changed in the past 120 years. What has changed is the social and technological context in which we live.

Take a group of people from the 1900s and drop them in to the US in 2022, they would likely experience obesity at similar rates.

It's not that people made more virtuous choices in 1900, it's that food was scarcer, less palatable, and more nutritious, and physical activity was a part of daily life.

A busy suburban parent in a 2-income household did not need to squeeze in time to make a home-cooked meal and a Peloton workout around a 9-5 desk job with an hour+ car commute.

The whole concept of "workout" is absurd considering how much effort and energy we spent in removing any physical challenge from our day-to-day life, especially considering how bad for the environment (global warming) the consequences are. I am not saying that people should have to work hard for the simplest things in life, but just designing cities around short walking distances and cycling vs. driving even the shortest distances would mean better health and nicer and healthier cities.

I think you should really think about the connection between public infrastructure and public lifestyle choices. If you think that infrastructure cannot both positively and negatively affect its populace then I'd find that a very interesting opinion on a board of primarily engineers.

This dismissal would be more compelling if it was actually clear that most cities are zoned well.

Rezoning entire cities also has environmental benefits.

> and start walking everywhere instead of driving.

This sounds nice until you actually look at most of America. Cities are designed around cars. I'm in a rather walkable city and the nearest grocery store is a mile away. That's not too bad, but other places I've lived it is 5+. Buses are bad (hour+ between pickups) or non-existent. It gets difficult to do all kinds of chores, visit the doctor or whatever. Even using a bike my grocery store shopping becomes a multi-hour experience that I have to do more than once a week where a car is 30 minutes and once every week because I can carry more. The experience is completely different in a city where I would rather actually walk than take a car. I don't think this is an uncommon experience either. What I'm trying to say is that it isn't great to just tell people to start walking but rather to recognize the design and incentives places by that design. The burdens that it creates. If you want people to walk more for their commutes then you need to design cities for walking. I've lived in many places in America where sidewalks are non-existent. If you live in these places and walk you either have a death wish or a DUI. But rather, build it and they will walk.

You can walk/bike/bus to a store and then order uber back to carry all the bags.

Have you visited the U.S.? Suburban sprawl has made it a 1-2 hour walk one-way to a grocery store in many places (if you can walk there at all). In many places there isn't even a sidewalk.

I lived in CA, AZ, NV, NC, FL, NJ and NY, and visited a dozen of other states. There was always a large grocery store I could walk or bus to.

Visit middle America. Specifically, visit The South. You'll find that many regions in The South do no have sidewalks. If you're also only visiting major cities then you are likely not to see these differences in architecture. It is easy to form a selection bias. No one here is saying that there aren't plenty of walkable cities in America, but we are saying that you'll find a substantial overlap between non-walkable cities and obesity. If you don't visit rural America, you won't see what we're discussing. Or don't attempt it.

Since most people are familiar with California I'll provide this reference which breaks it down by county. First graph is adults, second is low income children 5-19, and third graph is low income children 2-4. You will notice how the high obesity rates highly correlate with regions that are difficult to walk around in and are more rural.

https://www.researchgate.net/figure/Percentage-of-Adults-in-...

As another analysis, Not Just Bikes talks about this topic quite a lot. Here's his episode on strodes: https://www.youtube.com/watch?v=ORzNZUeUHAM

Sure I've being to rural America and I know what you are talking about. But only one in 5 Americans lives in rural communities, vast majority lives in an urban setting. I was just suggesting in my comment that one can use uber to haul groceries.

Yeah, go watch the Not Just Bikes video and you'll see that what he's talking about isn't rural. But of course, you won't really see the issues unless you try to walk. When I was 19 I was living in Orange County (CA) and my car was in the shop. What was normally a 15 minute drive to work turned into a 3hr bus ride. I probably would have saved 15 minutes by walking, but these are the design differences. You probably wouldn't notice the difficulties unless you actually attempt to walk.

Anecdote time: I currently live in Texas, the closest grocery store is a hour walk. While living in Colorado it was a hour and a half, and in Florida it was 2 hours, all of these where easy 5 minute trips by a car and an excursion by foot.

Not to mention that all three of those states have major portions of the year where being outside that long can actually be dangerous. Either through dehydration and heat stroke (especially considering that on pavement temperature is higher) or through freezing temperatures (and potentially frozen over sidewalks).

Americans are so delicate. Frozen sidewalk oh my G-d! Tell that to Finns.

If it was a 2 hour by foot, assuming an average of 3 mph walking, that's 6 miles away. For that to be a 5 minute trip by car you need to drive 72mph.

Reasonable on the interstate but as your driveway (nor the store entrance) are directly on an interstate, there has to be at least some stretch of slower driving bringing the average down, so the speed on the interstate section would have to be much higher to bring the overall average speed to 72 mph.

You're assuming a straight line and constant speeds. While this is naive for both situations the error will not average out.

Let me give a direct example. I pulled up google maps and what is a 10 minute car prediction (2.8 mi) is also a 54 minute walking estimation (2.7 mi) and a 17 minute bike estimation (2.8 mi). Also, 33-43 minutes by bus fwiw

> I pulled up google maps and what is a 10 minute car prediction (2.8 mi) is also a 54 minute walking estimation (2.7 mi)

That does change the numbers; 10 minutes by car being 54 minutes on foot sounds a lot more realistic than 5 minutes by car being 2 hours on foot.

>This sounds nice until you actually look at most of America. Cities are designed around cars.

Right, and that's the problem. These cities are a product of choices that Americans have made over many decades, and now they're paying the piper.

>If you want people to walk more for their commutes then you need to design cities for walking.

No, Americans need to choose this for themselves, but they don't and they won't. They don't move to places like this, they don't demand it of their elected officials, they instead just buy big SUVs and move into subdivisions. Americans have chosen this lifestyle, and now it's costing them dearly.

For starters, they could stop encouraging unhealthy eating (cough food pyramid cough). We should be be eating like our grandparent's grandparents (or as I call it: 'A real food' diet) but instead they tell us to shun meat but feel free to eat all the heavily processed carbs with HFCS and canola oil foods you want. Don't eat red meat, but pizza and fries are just fine!

This is true. There are also, though, other environmental factors that make it harder to maintain healthy weight in postindustrial countries than it was in the past, even if you eat no processed foods, cap your calories and work out regularly. Pharmaceutical and industrial waste in the water supply, Roundup in the grain supply, pesticides, hormones in the meat. Personally I'm swayed by the argument that these are at the root of other issues too, like gluten intolerance.

I'm all for encouraging people to eat healthier but some of this is beyond what an average person can control unless you grow your own food and drink from your own well.

Agreed, my suspicion is our problems are 'multi-causal' which is why it makes it so difficult to pin it down to just one thing.

> unless you grow your own food and drink from your own well

there was a post a few days ago about Australia: home-farmed eggs have 40x more lead than the industrial ones, because of unchecked pollution in non-agricultural areas...

I was under the impression that that "40x" argument" largely speaks to pollution in cities and suburbs. Curious how the rural/urban breakdown relates to that number.

> eating like our grandparent's grandparents

Is there any science showcasing exactly what that was?

Michael Pollan advocates for this in his book, "In Defense of Food" [1], and to a lesser degree in "The Omnivore's Dilemma". The big take-away for me was (paraphrased) that ethnic cuisines worldwide built and supported civilizations over many generations. It's only been over the past couple generations that we've been able to deviate from traditional cooking, with the globalization and industrialization of our food supply, and that's led to poor eating habits. It's especially pronounced in the US because we have a pretty short and heterogeneous cultural history and identity. He basically advocates choosing an ethnic cuisine and sticking with it.

[1] https://www.goodreads.com/book/show/315425.In_Defense_of_Foo...

We can look at it from the source side, and assume that what gets produced gets eaten (not entirely accurate of course). How have food production, processing, preservation, and distribution changed?

An interpretation of the obesity epidemic and resulting health crisis is that we are now producing a toxic quantity of food.

I think you'd be hard pressed to find a nutritionist that recommends eating a lot of processed food. And red meat is a hazard, even though I agree that it tastes great. If you're not convinced, this YouTube channel does a good job of going over a lot of the science: https://m.youtube.com/watch?v=EtLNHvC4aUw

He also has a 2-parter on plant sourced fats: https://m.youtube.com/watch?v=qInpEKHdjXk

My two of my great-grandparents lived in the house where I was growing up as a kid and teenager. They were both born in 1905, both much thinner than their descendants and both lived to their mid 90s.

Their diet was closer to the food pyramid than mine has ever been. Breakfast every morning was either Quaker oatmeal, Creme of Wheat or a similar cereal, one piece of fruit and coffee. Their lunch and supper was impossibly boring arrangements of sandwiches, meat and potatoes with a vegetable on the side, and the occasional dessert once a week or so.

They didn't "shun" meat per se, but they did live through the depression, WWII rationing, etc, and really weren't used to large quantities of it outside of big holiday dinners.

>Healthcare systems can only do so much to compensate for a bad lifestyle.

And this right here is my problem. Healthcare doesn't only begin when you get to the doctor or the hospital. There's no reason that healthcare officials/leaders/experts/whatever can't recommend baseline levels of fitness for Americans, and provide help for getting to that standard. I don't know, maybe Healthcare plans should include subsidies for gym memberships by law.

This would be a beautiful dream

Imagine what half the population would say if an expert or an authority started telling people to walk more, eat less and eat better.

From what I’ve observed, even with free gym and advice, most of people will still ignore it. It’s simply not convenient, especially for people who haven’t gotten into a routine.

I live in an extremely walkable neighbourhood of a fairly dense city, and honestly speaking, and just walking around to do my daily chores already helps with casual fitness. I do bike, swim and lift, but mostly for “fun” rather than for health. And before consistently working out, I weighed constant amount (+-4 pounds change depended on the season). Honestly, I want to blame the epidemic on cars and the convenience it brings to everyone.

I agree, and that was a glib suggestion of mine. It's a combination of cultural proclivities and the infrastructure. I was in the military, so I lift weights basically every day and either swim or run on the days I don't ... but that's because I've just had fitness culture inculcated in my mind since I was 18. I don't live in a city where I have to walk everywhere to get everything. But my fitness preferences do make me vote in certain ways (for candidates that encourage more public transit, bike lanes, and so on). Politics is downstream from culture, I suppose?

> From what I’ve observed, even with free gym and advice, most of people will still ignore it. It’s simply not convenient, especially for people who haven’t gotten into a routine.

Maybe we should consider stronger incentives.

Such as “exercise passports”, you can’t enter public spaces unless you did 30 minutes of exercise that day. Would solve the problem very quickly.

Or obesity tax is another practical idea.

> I don't know, maybe Healthcare plans should include subsidies for gym memberships by law.

I can only imagine the level of added bureaucracy , certifications for gyms to qualify, and spiraling prices for gym users without healthcare plans through white collar salaried jobs. Just look at health care costs over the past 50 years as lengthier and lengthier laws have been passed in the hopes of shifting incentives and otherwise tweaking the system.

Average amount of exercise has gone up and average amount of alcohol consumed has gone down. Those two factors alone cannot explain the steady rise in obesity starting in the 1980s in the US and other developed nations. This[0] analysis points to environmental contamination, specifically three candidates: animal antibiotics, PFAs, and lithium.

https://slimemoldtimemold.com/2021/07/07/a-chemical-hunger-p...

> Average amount of exercise has gone up

Exercise is not the only thing that matters. If you eat twice as much, but exercise only 1.2x as much, you'll still get fat.

It's mostly about diet, not calories burned, unless you're burning a LOT of calories each day.

For most people weight creeps up on them slowly. Losing a lot of weight quickly does require radical changes to diet, but not putting on the pounds in the first place is generally going to be a matter of burning an extra few hundred calories a day.

Also, just not being sedentary all day is associated with a ton of positive health outcomes (possibly mental even more than physical) independent of body fat percentage. So it’s worth it all on its own.

Of course! Nobody can deny the panacea that is exercise. But it's still a widely misunderstood concept. Throughout many of these comments, people are claiming that the remedy to obesity is more exercise, but I hold that indeed a much larger component of combatting obesity is diet, not exercise.

I’d say on a population level exercise (as in more active, less sedentary lifestyles) will be a large factor. Though on an individual level you are right that diet will be the big thing.

Though population level there is also a lot of food policy and incentive structures we could alter to improve diets in general as well.

The way we design our systems is what made this mess, we can also design systems that lead to better health outcomes.

We can also look around and see what other countries are doing right (and wrong).

it’s not a lifestyle problem. neither willpower nor lifestyles have changed much. processed carbs being addictive, however…

medication that treats it like the medical problem it is, instead of berating people for a lack of willpower that they were never missing to begin with, will fix it

https://www.mounjaro.com/

It's absolutely a lifestyle problem. Americans have a shitty car-based lifestyle that causes obesity. Go to Manhattan and see how many obese people you see; there aren't many. Or go to any other country where people walk a lot. This is uniquely a western, and especially American problem.

Correlation is not causation. Manhattan has many thins because thins are more likely to make more money and get better jobs in high-standard-of-living areas due to commanding more respect. (Which they mostly do not deserve, being mainly the beneficiaries of good genes, but I digress) Also, most people move out to the ‘burbs to raise kids, so Manhattan is strongly weighted towards the under-40 set.

> any other country

OK let’s pick Germany. (I’m German.) Most Germans are thin because they don’t eat many carbs at all. Orange juice is expensive and piss-poor compared to sugary American OJ. Breakfast typically consists of unleavened-style breads, mustard, and meats. Gas is super expensive so everybody walks or bikes. But guess what? Obesity is steadily rising there too! Gosh, I wonder why, with all that walking and biking? Wait, I know… They just need MORE walking and biking, that must be it!

Lifestyles haven't changed? Come now, in just my lifetime I've seen kids go from being outside everywhere playing until dark, to being mostly inside all day. And I live in a very active community!

With regards to changes in willpower, that seems like a strong assertion, got any sources on that?

100% agree that our diet (generally) has changed drastically.

But I don't get your jump of why medication has to be the solution? Maybe undoing some of the changes that got us here?

Sure, in many cases where they're already well down the road of obesity and experiencing its negative health consequences - yes medication can be useful. But that's far from the only option at hand here.

> With regards to changes in willpower, that seems like a strong assertion, got any sources on that?

How is it a strong assertion that willpower HAS NOT changed? Isn’t that the null hypothesis? It seems to me that you’d need evidence that it HAS changed

Take a look at your average individual from 100 or so years ago: probably working a manual job, lived through a depression and world war. Life was certainly harder for most in many basic ways. Obviously not true for all, but generally speaking quality of life has improved a lot.

Our culture is light years away from that in terms of the resilience that's generally expected from people.

Yes, I think it's fair to question the assumption that willpower has not changed.

> medication that treats it like the medical problem it is

That was the approach in the 50s and 60s with amphetamines as an appetite killer.

That didn't work out well.

That’s because amphetamines were a piss-poor solution. Meds like Mounjaro, which directly eliminate hunger hormonally in the brain instead of simply being a side-effect of brain overstimulation, seem like a significantly better option to me

Disclaimer: Been on Mounjaro for 1 month and have lost 15 pounds absolutely effortlessly and with zero side effects

Driving is legislated into city design.

They could also try obesity tax, where you're taxed more of you're obese.

Money is quite a good motivator, especially when it's being taken away from you.

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