Are the Treatment and Prevention of Obesity Different Problems?
When I visited the Pacific island of Nauru in the early 1980s it was populated by the kind of human mastodons who have since become extremely common in the United States and elsewhere. Half of the Nauruans were diabetic, the reason being a combination of genetic propensity, physical inactivity, and a taste for sweet drinks such as Fanta and Chateau Yquem, which they drank in vast quantities. Life expectancy was very low.
A recent edition of the New England Journal of Medicine is largely devoted to the relation of sweet drinks to obesity. It reports, for example, a controlled trial in Holland in which children were divided randomly into two groups, those who received sugar-sweetened drinks and those who received non-calorifically sweetened drinks. The children were aged between 4 and 11, and the parents gave their consent, the children their "assent," to the experiment, which lasted on average 18 months.
After 18 months, the children who had drunk sugar-sweetened drinks had put on a kilo (2.2 pounds) of weight by comparison with those who had drunk similar quantities of artificially sweetened drinks. Those who had drunk the sugar-sweetened drinks had grown slightly but statistically significantly taller than those who had drunk the artificially sweetened drinks (the Dutch, incidentally, are now the tallest people in the world); when adjusted for the difference in height, the sugar-sweetened drinks accounted for 0.8 kilos (1.7 pounds) of the weight gain.
These results are important for the United States, because the quantities of sweet drinks consumed in the Dutch trial were far lower than those consumed, on average, by American children. They will give some comfort to Mayor Bloomberg in his campaign against sugar-sweetened drinks.
Another trial in the NEJM reported the apparently contradictory failure of the restriction of sugar-sweetened drinks to lead to weight loss by children who were already obese. This suggests that the treatment of obesity and the prevention of obesity might be different problems. Indeed, it would not be surprising if this were so: it is true of most conditions.
Public health is not the only good, however, and the idea of the government interfering in our diets, telling us what we may and may not eat and drink, raises fears of totalitarian nannying. How long will it be before it tells us what we must eat and drink?
An editorial in the NEJM deals with this question by arguing that administrative restriction of unhealthy products is already within the constitutional competence of states. And, unfortunately, there is no simple principle that allows us to draw a clear line between legitimate and illegitimate interference. We cannot demand of nature that it divides phenomena into the neat categories that would make our lives much easier.
We would expect the government to forbid drinks destined to be drunk by children that contained amphetamines, for example, even if the children liked them very much. But how harmful does something have to be, and how immediate the harm, before the government has the right and indeed the duty to step in? It is a question of judgment rather than of principle.
The German novelist Juli Zeh has recently published a novel, The Method, in which health is the last totalitarian dystopia. In the health-totalitarian state, citizens are required to keep themselves healthy and to turn in regular blood results to the health authorities. Sensors in their homes and offices keep track of their heart rates and rhythms; toilets automatically analyse the composition of their excreta. But not every slippery slope has to be slipped down to its bottom.
Fashions in medicine change, partly because new information becomes available. The Dutch trial of artificially sweetened drinks did not consider the possibility that the artificial sweeteners might one day prove to be unhealthy. All that could be said was that 18 months’ consumption of them did not appear to do any harm.
In the last analysis, life is a bit of a risk.
Related at PJ Lifestyle from Theodore Dalrymple: