All this week I have been writing about issues of health in the United States. Americans are less healthy than our counterparts in other wealthy countries, for a variety of reasons. But the two biggest reasons are poverty and culture.

Poverty can be dealt with using the bluntest of methods: throw money at it. It works. Food stamps, welfare payments, and other programs have been effective at poverty reduction, despite the bad press they have received and constant harping by conservatives that such initiatives only create generations of government dependence. This is viewed as a moral hazard, even though one would expect that producing a growing, impoverished underclass would present a hazard to a society’s long-term stability. Minimally, a balance between such concerns could be sought, rather than the gradual erosion of useful programs that we’ve seen over the past few decades.

But poor health is not simply a consequence of poverty. Poverty makes it more likely, but Americans are less healthy across the board, regardless of income. Cultural and environmental issues are responsible. Addressing them is complex, to say the least.

Obesity is often pointed to as the cause of Americans’ poor health, but it too is a symptom. Efforts to combat it tend to focus on weight itself as the primary concern, as if shedding pounds, in and of itself, dramatically improves health. In fact, research shows that weight loss alone has either very limited benefits, or is actively harmful. It is medically beneficial for rather narrow slices of the population, but in others it has either no positive effects or is detrimental. For most patients, then, a focus on weight is counterproductive.

Nevertheless, obesity is part of an overall complex of ailments that have resulted from two major shifts in American behavior over the past several decades: caloric intake and activity reduction.

While I had long been aware that Americans’ caloric intake had increased dramatically, I did not know how this fit into a historical context. CDC information describes the overall trend in caloric intake:

During 1971--2000, a statistically significant increase in average energy intake occurred ([Table](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm#fig1)). For men, average energy intake increased from 2,450 kcals to 2,618 kcals (p<0.01), and for women, from 1,542 kcals to 1,877 kcals (p<0.01). For men, the percentage of kcals from carbohydrate increased between 1971--1974 and 1999--2000, from 42.4% to 49.0% (p<0.01), and for women, from 45.4% to 51.6% (p<0.01) ([Table](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm#fig1)). The percentage of kcals from total fat decreased from 36.9% to 32.8% (p<0.01) for men and from 36.1% to 32.8% (p<0.01) for women. In addition, the percentage of kcals from saturated fat decreased from 13.5% to 10.9% (p<0.01) for men and from 13.0% to 11.0% (p<0.01) for women. A slight decrease was observed in the percentage of kcals from protein, from 16.5% to 15.5% (p<0.01) for men and from 16.9% to 15.1% (p<0.01) for women.

Both raw quantities of calories increased, and their sources changed. Americans, in fact, eat about as much meat now as we always have–but we eat a lot more sugar, in various forms. High-fructose corn syrup is sometimes held up as the “true” cause of Americans’ weight gain. I haven’t seen enough research to say either way–it’s certainly not conclusive. It seems much more likely that the amount of sugar consumed, regardless of its source, is the bigger issue. Our caloric intakes have increased significantly, at the same time our levels of physical activity have decreased.

Changes in our physical activity weren’t necessarily deliberate, of course. They resulted from broad, coincidental trends. The advent of television and its penetration into our lives likely helped us develop preferences for staying in and on the couch. Children spend much more time indoors than in the past, when they were more likely to play outside. This is frequently blamed on children becoming preoccupied with screen time, though the trend really began in the ‘80s (if not a bit earlier) in response to panics over kidnappings and crime. Parents started to keep their children inside. Such children, for want of other activities, often turned to television and video games. Once a habit has been formed, it becomes difficult to break–and now we have a multi-decade trend.

It has also been found that much of our inactivity can be traced to the workplace. Jobs today are less physically demanding, and more likely to require you to sit at a desk, or at least not move around all that much. Such persistent lack of physical activity is also a major factor in hypertension and heart disease, both of which increase mortality and reduce lifespan. Likewise, obesity is higher in rural areas, where food portions are often larger and physical activity is more limited than in urban environments due to a necessary reliance on motor vehicles instead of walking, cycling, or public transit.

Nobody made things this way on purpose. These circumstances are the culmination of millions upon millions of individual decisions, small and large nudges by government policy and regulation, and much of it came about through pure happenstance. There is a tendency to blame individuals for these outcomes, which is both errant and counterproductive. Such cultural shifts have a dramatic effect on individuals–how much you see the person next to you eating will influence how much you are eating, and efforts to engage in physical activity are more successful if done as part of a group. Humans are social creatures, and deviating too much from the behaviors of those around you earns stigma and suspicion. This makes changes to habits that have become culturally ingrained extremely path dependent.

Changing habits is made all the more difficult by other pressures for one’s time and attention. When two-parent households were more common, and prior to women’s liberation, home-cooked meals were a more reasonable option. They were cheaper and generally more nutritious than what one would find in restaurants. They also had fewer calories. As households where all adults are working outside the home (this would include single parents, as well) have continued to rise, the middle class has been eroded and wages have stagnated in some instances while falling in others. This leaves adults with less time to prepare meals at home, which means turning to cheap (and generally less healthy) sources of nutrition. Fast food is notorious for being high in calories and sugar, especially in the portions typically provided, and it is a popular option for those pressed for time and money since it is readily available and takes little time to procure. This reads like another instance in which poverty mitigation would be a big help, and it would certainly offer benefits, but again: habits, once formed, are very difficult to break.

An individual who never cooked at home for lack of time to do so does not start cooking simply because they have more time now. What if they’ve never cooked? What if they once knew, but have forgotten most of their cooking skills? It is, after all, an activity that must be practiced with some regularity in order to remain effective. Likewise, merely giving people more time to be physically active doesn’t ensure that that will happen, especially not if an individual had little history of pursuing physical activity in the past.

I don’t mention this to be discouraging, but rather to describe the complexity of the issues involved. Public initiatives to improve Americans’ health tend to focus on imploring people to eat less and move more, to send kids outside rather than keeping them indoors. Putting aside the fact that such measures are too simplistic and generally ignorant of the reasons why such habits developed in the first place, merely telling people what to do doesn’t work. People, by nature, do not make whatever decision is most optimal, but usually what is most comfortable, and what tends to be most comfortable is what you’ve always done for comfort in the past. Our brains are wired this way: once an activity has been repeatedly associated with pleasure or enjoyment, we easily feel compelled to continue it, even when we intellectually know it is bad for us.

It took us decades to get to where we are; it will take decades to find our way out. The good news is that we are, in fact, more aware of what activities improve our health and which ones don’t. Medical science is finally catching up to the idea that weight is not the be-all, end-all of health. Many of us are cooking at home more, eating out less, and spending more time outside and engaging in physical activities. Medical research is also helping us better manage our health in general, regardless of how individually healthy (or not) we are. The news isn’t all bad. But there are many others being left behind, with poor access to medical care, with precarious financial situations that don’t permit focusing on one’s physical and mental health, and various environmental and racially-charged issues that produce worse health outcomes for minorities. It can’t be said enough: poverty itself is bad for your health. There is a health disparity between men and women, too. Women face unnecessary risks due to an endless assault on reproductive health rights and access to good prenatal and perinatal care. None of this needs to be happening, and the unique problems faced by various demographics in this country require more attention and more effort to address.

I think there is cause to be hopeful for the future, as much as I describe negative circumstances and trends here. Change never comes fast enough, but I am confident that it will come, especially if we take the time to see the need and work toward it. I will no doubt revisit these topics at some point in the future, but for now, I hope this week’s series has given you some food for thought. If you’ve learned anything here, discuss with your family and friends, and continue to educate yourself, too. Health is often treated as something you maintain just by going to the doctor and taking medications, but it’s so much more complex than that, driven by a host of socioeconomic and policy factors. Once again, we come to what this blog is about–poking around those resilient constructs.

Photo by Moyan_Brenn