Is it possible to mount a public health campaign against obesity?

Forget the recent flap about fat people wanting a right to extra seats on airlines. The real issue, which has been heating up in medical circles for several years and is about to start spilling into the media arena, is alarm about the health consequences of being overweight. Whether it's a conference in Charlottetown, an article in The New England Journal of Medicine, or almost any gathering to talk about diabetes, health care workers have been viewing the "epidemic" of obesity with growing alarm.

It's not only that more Americans are grossly overweight than ever before. It's not only that obesity in the young is a growing problem. It's that obesity is endemic among Samoan islanders, Bedouin tribesmen, aboriginal Canadians, peoples everywhere who have recently adopted sedentary lifestyles with high-calorie food intake. For people all around the world, junk food has become what alcohol was in centuries past: dirt cheap, ubiquitous, a source of instant gratification, and dangerously addictive.

That significantly overweight people are likely seriously to damage their health is beyond argument. Obesity has all sorts of bad consequences for cardio-vascular systems, metabolism, joints, and most indices of well-being. Having an academic interest in the history of diabetes, I frequently attend conferences where the rapid increase everywhere of type-II or late-onset diabetes is viewed with deep alarm. After giving their learned lectures on the molecular biology of the type II variety, which is 90% of all diabetes, experts in the field usually agree that the disorder is mostly a problem of obesity -- of too little exercise and too much eating.

What is to be done? How can people be persuaded to be more temperate in their eating habits and more vigorous in their physical routines? Our most current model of a public health campaign against an unhealthy habit is the war on smoking. It's gradually being won, thanks to the efforts to increase the habit's cost, decrease its accessibility, punish its purveyors and stigmatize its victims. Can similar strategies be mobilized in a war against obesity?

Schemes to tax french fries and ice cream, regulate their sales (no fries to anyone under 12), and sue fast-food chains for causing heart attacks all sound more than a little ridiculous, not to say offensive. It's likely, though, that slightly less silly strategies, such as targeted health taxes levied on fat purveyors, may gradually enter public policy debates. We will probably see a new wave of pressure on governments to rev up campaigns against sloth and junk food. Son-of-Participaction will surely be born in the next couple of years, and there will be much talk about restoring compulsory physical education in the school. Five years from now, there will be debate about putting warning labels on chocolate bars and mounting campaigns against eating those disgusting fatty, greasy foods.

In fact, in an almost complete reversal of the older values of hungry societies, we have been socially stigmatizing obesity for the last several decades. As with the rejection of smoking, the well-educated and health-conscious have long since signed on to appreciating thinness, good eating and exercise. Indeed, we now disapprove of chubbiness so thoroughly that we've created a serious backlash, especially among women. Part of this backlash is a reasonable reaction against the ideal of the frenetic female toothpick, part a hugely misguided and dangerous counsel to the effect that fat is OK. As well, it's hard in today's super-tolerant, non-judgmental society to tell people that they really are responsible for their eating and exercising habits, their appearance and their health.

Discussing these issues with a group of scientists and physicians at a recent Toronto Diabetes Association function, it was discouraging to find consensus that so far there's no likelihood of being able to induce the behavioural changes that would reduce the problem of obesity. Many scientists feel the only real hope is pharmacological -- drugs that will alter genetic or hormonal functions, or perhaps effective fat substitutes. For the very obese, surgical interventions to reshape the stomach are becoming more common. Most physicians, indeed most sensible people, shake their heads at these prospects, knowing how miserably the idea of a quick fix for obesity has failed in the past, knowing that it's no kind of answer to create an underclass who truly are emotionally and medically disabled.

There are no easy approaches to an issue that we are all going to hear a lot more about. If we take the idea of improving the public's health seriously, we have to come to grips with the problem of overeating and under-exercising. The dilemma of modern societies is that it's easy to have your cake and eat it too and then just have some more. The ultimate contradiction of affluence is that we have to learn to push ourselves away from the heavily laden table.