Transcript
Speaker: There's no pill for poverty. There's no prescription for a history of exposure to racism. In many ways, a lean and healthy body in adulthood is a privilege of wealth and race and class.
Speaker: Is your neighborhood unhealthy? I'm going to talk here about obesity and the factors that drive it, some of which are well beyond the control of any patient. So um a debate has raged for decades now on what to do about obesity and the well-known observation that obesity is higher among lower income groups of people in America and in Europe and Canada and associates with histories of racial discrimination, exclusion, health injustice. But there is no pill for poverty. So in certain ways, obesity is a policy choice that societies make, often unaware that they are doing exactly that.
Speaker: About 15 years ago, a debate was hot within the American Medical Association about whether obesity should be classified as a disease, and if not, was it just a careless lifestyle choice and a bad personal choice? Obesity clinicians, like my former Boston University colleague, Dr. Carolina Povian,
Speaker: had been strongly advocating for that disease classification for decades. She sees impacts ah for patients of all ages in her clinical practice, and so she's very familiar with obesity in the clinic. Several model systems reveal that metabolic signaling is abnormal in obesity, and that's very strong evidence of a disease state. So, in June 2013, the AMA officially recognized obesity as a disease, but overriding um an internal committee that had recommended against doing exactly that. On the other hand, some antagonistic viewpoints have argued that medicalizing obesity by declaring it a disease would render about a third of Americans as ill and could lead to more costly drugs and reliance on surgery rather than lifestyle changes, and the potential financial outlays for health insurance corporations could be astronomical. One of the challenges in considering obesity as a disease is that the definition relies entirely on body mass index, or BMI, that's defined as the weight in kilograms of an adult divided by the square of their height in meters.
Speaker: If the BMI is 30 or higher, that person meets the definition of obesity. However, metabolism is a much better measure of health, and there are underweight or non-obese adults who have unhealthy metabolism, high cholesterol, high insulin, high lipids, inflammation, and then consequently have higher risks for type 2 diabetes, and stroke, and heart attack.
Speaker: Conversely, there are very high BMI adults who are quite healthy, such as American football linebackers or Japanese sumo wrestlers. These are big guys, and their blood values are generally great because they are in an intensive physical training program despite this high BMI.
Speaker: Problems that begin typically once they retire and cease training. Retired sumo wrestlers are well known to die quite soon after retirement due to rapid onset of diabetes or strokes or heart attacks. It's a sad fact of retirement from sumo. However, all these factors are working at the level of the individual.
Speaker: Physical activity, diet, genetics, family and cultural factors also play a major role. For example, the risk of obesity in children increases fourfold if one parent has obesity, but 13-fold if both parents have obesity.
Speaker: And that means that obesity travels in families and in family systems. A child at the dining room table has very little choice in the matter. Much larger forces in neighborhoods and societies also play a powerful role in obesity and disease risks.
Speaker: For example, population scientists, geographers, urban planners, have long used the term food desert. This was first used to describe a populous but nutritionally deprived area of Glasgow, Scotland, where there was little or no retail food available. This characteristic of neighborhood deprivation has been extensively discussed and debated.
Speaker: Food deserts closely overlap with racially diverse or historically neglected neighborhoods in Boston, in Baltimore, in New York, and san diego atlanta all over and they strongly associate with high rates of obesity and cardiovascular disease in association with low income.
Speaker: Racial segregation, too, has also led to significantly lower quality of the built environment and the natural environment in black neighborhoods in the United States. White neighborhoods have lower levels of traffic exposure, for example, higher quality drinking water, fewer dilapidated buildings, more single-family homes, more green space, and more tree cover than black neighborhoods. Furthermore, census tracts with higher proportions of ethnic and racial minorities have lost more green space over time.
Speaker: So what does green space have to do with obesity? While more green space means more walking, more physical activity, which always works well to combat obesity. Research shows that in addition to the food aspects of the environment, and there are aspects of the built environment like places to exercise, these are strong modifiers of obesity and they can be used as sources of intervention. Once we grasp the major importance of these structural factors, individual agency and choice on the part of any one patient begins to look different and somewhat more complex. We can only change so many things about our life and our neighborhood. Many people who live in low-income neighborhoods would be delighted to move out into a better neighborhood, but can't afford to do so, for family reasons keep them there. Many people would love to see more trees in their neighborhood, wherever it is. This is a citywide political discussion.
Speaker: but you see, we're a long way now from the obesity clinic. The standard of care for many metabolic and cancer specialties was developed for privileged patients who are free from the co-morbidities of living in an underserved neighborhood. This standard is not well suited to address the needs of vulnerable patients who actually have the greatest urgency for the care that we're going to provide. So whatever you might have thought about obesity before, i hope you've come to see that it's complex. It's not simply a matter of overeating or under-exercising. Our political will to address obesity is caught up in political differences about opinion of the importance of individual agency,
Speaker: and neighborhood structure and these factors that are be beyond the control of any one person. So as I noted at the outset, there's no pill for poverty. There's no prescription for a history of exposure to racism. In many ways, a lean and healthy body in adulthood is a privilege of wealth and race and class.
