Wednesday, December 22, 2010

And if you're fat and failing, you're extra-special!

Early December gave us a pair of headlines that on the surface seemed unrelated but at a deeper level are unmistakably linked to one of the more unfortunate story lines given us by SHAM. First came word that a 10-member FDA advisory committee had recommended the agency loosen the belt on its guidelines for Lap-Band bariatric surgery, lowering the body-mass threshold required for the surgery to be deemed medically appropriate. Lap-Band manufacturer Allergan (which also makes Botox and Latisse) unsurprisingly framed the vote as a historic victory for the 12 million American adults who, though obese, aren't quite obese enough to meet existing clinical guidelines for the procedure. Less enthused, no doubt, are the health insurers who, pending FDA approval, will have to foot the bill for all those additional procedures, which cost between $15,000 and $30,000 a pop. (Of course, those costs ultimately will be passed on.)

A few days later we learned of the nation's latest humiliation in the Programme for International
Student Assessment. The PISA tests compare basic academic skills among 500,000 15-year-olds in some 65 nations; U.S. participants upheld an inglorious tradition by finishing well off the lead in reading, math and science. Notably, U.S. students came in 25th in math, tied with Portugal and trailing Estonia and Hungary, among others.

Despite their differing topics, both stories are mile markers in an ongoing movement that seeks to detach individual behavior from individual responsibility, then spread the resultin
g literal and figurative costs to society-at-large. These days, we seldom force people to toe the line. Instead we move the line to where the people already happen to be standing. The late, brilliant Sen. Daniel Patrick Moynihan referred to this phenomenon as "defining deviancy down": We act as if the best way to eliminate a nonconforming behavior is simply to normalize itto drag it under the tent of orthodoxy.

As veterans of this blog know all too well by now, ever since the 1960s, when the forefathers of modern pop-psychology began lamenting the wounded inner child and related forms of dysfunction, America has approached few tasks as diligently as creating new classes of victims and entitling them to redress/recompense. In the bargain, we have not only undercut time-honored standards but also wiped away the consequences for falling short of same.

Take primary education. Beginning in the '70s, "enlightened" educators championed the (arbitrary, baseless) notion
that lousy students were actually victims of low self-esteem. Working from the premise that improving a child's self-image would improve his or her schoolwork, teachers morphed into cheerleaders, while schools everywhere softened grading criteria and implemented other measures designed to buck up fragile young psyches and protect them from further damage. Curved grading became the norm; teachers were encouraged to weight overall grades toward effort rather than absolute results. Many school districts embraced "social promotion," which keeps an underperforming student with his age-appropriate friends despite his lackluster grades. Some districts prohibited teachers from making corrections in red ink, lest F-level work be observed by others in the class and the failing student be forever stigmatized and unable to go on...

Today, self-esteem-based learning is repudiated even by some of its loudest erstwhile advocates. An almost unbroken 30-year downturn in uniform test scores, highlighted since 1997 by the nation's dismal performance in PISA testing, has helped educators see that accommodating failure does not motivate success; it merely makes students comfortable with failure. Meanwhile, it's clear that the "I CELEBRATE MYSELF!" climate that accompanied early confidence-boosting assembles and workshops is correlated with feelings of entitlement that do not end at the school gates.

Too bad that acknowledgment of a mistake doesn't magically erase its after-effects. The teeming hordes who dep
arted the great American self-esteem mill were unprepared for the rigors of traditional college coursework, so colleges too found it necessary to flex their standards. Grade inflation metastasized throughout the university system. More recently, colleges began weighting curricula toward easier electives and away from the more challenging core competencies whose mastery one rightfully might expect of a college graduate. None of this bodes well for U.S. competition in the global marketplace.

However, as bad as all that was (and remains), the nadir of America's culture of victimization would have to be the so-called disease model of behavior. Codified in 1965 when the American Psychiatric Association formally pronounced alcoholism a disease, this mindset conceives people as helpless against shortcomings that once were labeled vices or personality flaws. Further, having been applied to a given fla
w, the disease metaphor is reinforced and extended in every way imaginable. Such is the case with the FDA advisory panel's vote on the Lap-Band: We say that such steps are necessary because obesity is a national epidemic, as though it were smallpox or typhus and the sufferer's own behavior played no role in his condition. I don't know about you, but I find it fascinating that a remarkable 64 million U.S. adults, or roughly one-third of the total adult population, have somehow contracted a disease to which their counterparts in other industrialized nations, like France and Japan, remain virtually immune. (For the record, 134 million adults are classified as either overweight or obese. That is two-thirds of the total adult population.)

But here's the killing irony: Whethe
r or not it's true that a troubled childhood or other environmental circumstances predestine a flawed adult, the point is finally moot. Social theorists who urge indulgent handling of all these victims overlook the fact that penalties clearly are integral to the "cure." Absent such correctives, the undesired behaviors may continue unabated.*

No, we don't want to play political or word games with health. Obesity is a serious problem and must be addressed. However, history underscores a simple truism: You get the behavior you reward. Maybe it's overstating to imply that better access to bariatric surgery encourages people to get fat, but it's also beyond dispute that such access provides little incentive for people to develop healthier eating habits. Telling Overweight America that it's entitled to free surgical intervention isn't that different from telling schoolkids that they're special and brilliant despite their inadequate work. It's not your fault if you're fat. It's not your fault if you fail.

Is it so unthinkable to contemplate a return to that quaint time when moderation, self-denial and personal responsibility were considered virtues?

This is also an aspect of determinism that many people misconstrue. The mere knowledge that life is predetermined is no excuse for failing to try to change unpleasant or unproductive behaviors.


Mike Cane said...

Here's a bit of trivia you might find very interesting. Google's new Ngram feature will compare frequency of words throughout the corpus of Google Books.

I think comparing use of heredity vs. genes says much.

Interesting how genes predominate yet are divorced from inheritability!!

roger o'keefe said...

This is brilliant, Steve, one of your best. I agree wholeheartedly even though I could stand to lose a few pounds myself. And I feel like I'm reading "the old Steve Salerno" from his SHAM days.

Tyro said...

On the self-esteem topic, the "All In The Mind" podcast had an episode about self-esteem and what, if any, connection there may be with performance. What I especially liked was their cross-cultural studies and comparison with Asian societies. Well worth a listen if it's not on your subscription list already:

Not to destroy the suspense but they found asian kids tended to have much lower self-esteem which then triggered the question: was this because it is considered impolite to brag or elevate yourself or did they have a more accurate view of themselves? Was this "healthier" or more productive? Interesting questions and it's not clear that the answers are settled.

As for personal accountability, I agree that it's a very important value of mine and I think it has helped me enormously. I do wonder what society's role should be in encouraging (or forcing!) it in others - who benefits the most, who suffers the most? Are the obese or drug addicted already paying enough and would society improve enough to justify coercing them? Kids seem obvious - we already assume a duty to pass on societal values and to build a foundation for a healthy, productive future - but once they become adults it seems less clear. I'm open to arguments either way.

It reminds me of a recent speech by Adam Savage of Mythbusters talking about failures. Not the "each failed experiment taught me one more way this doesn't work" thing (which is a good thing, don't get me wrong) but in a much stronger, self-accountability sense. It's a great talk with some memorable phrases, quite unlike the Mythbusters persona - if you haven't seen it, it's worth listening to:

Good stuff Steve, thought-provoking as ever.

Steve Salerno said...

Tyro: Thank you. Despite our recent dust-up on QM and such (to which, make no mistake, we will return), I happen to think that the degree of scientific illiteracy among today's American youth is deplorable. We can all agree or disagree with certain theoretical models, but it would be nice if at least we all had some fluency in the most basic scientific concepts--like, say, the fact that gravity is what keeps us anchored to earth. I saw one study wherein some absurd percentage of HS students (over 50%) did not understand the role of gravitation in the conduct of daily life. I wish I could link to it, but I couldn't find it off-hand.

Tyro said...

I didn't see the survey you're talking about but there's a wealth of other examples. In 2009, there was a scientific literacy survey which showed that:

About 4 in 5 adults think science education is "absolutely essential" or "very important" to the U.S. healthcare system (86%), the U.S. global reputation (79%), and the U.S. economy (77%)

Paradoxically (ha!) it also showed:

* Only 53% of adults know how long it takes for the Earth to revolve around the Sun.
* Only 59% of adults know that the earliest humans and dinosaurs did not live at the same time.
* Only 47% of adults can roughly approximate the percent of the Earth's surface that is covered with water .(*)
* Only 21% of adults answered all three questions correctly.

Sometimes these surveys ignore subtleties and science understanding is so much more than reciting facts but this is pretty elementary.

What's worse, this makes it difficult to improve in the future. It's hard enough to relate scientific theories with a shared knowledge base but when the gap is so wide it's almost impossible. Newton said that he saw so far because he stood on the shoulders of giants and that process of building on the past is even more extreme today. I don't know how anyone could hope to really understand or appreciate theories without first learning about some of the plausible but false ideas which preceded them but this takes a lot of background. Without this, "science" just because a string of statements to be swallowed without understanding so it's no wonder so many people treat science like a modern priesthood.

And then there's the media which seems to only report science as "big mystery: scientists baffled" or "amazing new discovery: everything we thought before is wrong!" These narratives may sell papers & magazines (even New Scientist has fallen into this trap) but they are grossly misleading at best.

We can all agree or disagree with certain theoretical models

I guess that depends on what you mean by "theoretical models" :)

Steve Salerno said...

Come to think of it, I remember a Jay-Walking segment on the Leno Show in which he pressed some poor dumb schmuck on the concept of gravity.

The questioning began something like, "What keeps your feet planted on Earth?"

"My legs?"

"No, but I mean, why do you stay firmly on the ground instead of just floating off into space?"

"I dunno. Because I'm heavy?"

"OK, but what is it scientifically that makes you heavy?"

"I dunno. I eat too much?"

"So the scientific concept that gives you weight is called...?"


It was hilarious, though also, in another sense, very sad.

Cosmic Connie said...

While I agree with the basic premise of this post, Steve, and emphatically don't think that free bariatric surgery is an inherent right, I still think you may be being a bit tough on obese people. The obesity rate has crept steadily upwards in the past few decades in some areas of the developed world but not in others. Certainly lifestyle factors -- the conscious choices people make, in other words -- play a large (no pun intended) part. But I also wonder about genetic factors, as well as food additives that, either intentionally or unintentionally, interfere with the delicate systems that control our appetite*, and I even wonder about the adenovirus (AD-36) that many researchers believe plays a part in obesity. Could AD-36 be more prevalent in some populations than others?

I think there has to be a happy middle ground between looking at obesity as a moral failing (a view that was more or less universally held in the US and elsewhere in centuries past), and viewing every case of overweight as a disease deserving "special" treatment. I may just be reading this wrong, Steve, but sometimes it seems you err a little on the side of that moralistic view of obesity.

As for the disease model of alcoholism, I agree that this too has been carried too far, but I do feel certain that thinking of my own alcoholism as a disease was what saved me from the self-destructive spiral on which I found myself many years ago. Physical addiction of any kind may not be a "disease" in the sense of the germ-theory model, but it sure feels like a disease when you're in the throes of it.

I couldn't agree with you more about the whole self-esteem/education (or lack thereof) mess, though.

* Almost certainly the food industry in the US is contributing in devious ways to the problem of obesity, and I'm not just talking about the aggressive marketing by McDonalds. Again, people's lifestyle choices regarding both diet and exercise can make a difference, but unless you have the money to go all-organic/no-additive, or the ability to grow all of your own food, it's hard to escape the chemicals.

Steve Salerno said...

Conesta: (Don't know where that came from; I just felt like calling you that today) As usual you take the high, well-considered and compassionate, road. And look, I can't really argue with much that you say, especially when you drift into regions of personal growth. It's just that over the past 50 or so years, and with the notable exception of the prison system (and some would argue even there), we have totally lost sight of the penalty component of addressing nonconforming behavior. I say in the post itself that we can't just write off America's fat people, especially since they now constitute an incredible 67% of all adults. (I still can't get over that stat.) It's just that at some point, we have to begin reminding people that they're responsible for themselves, and that the rest of us can't just keep picking up the tab for every conceivable personal demon that gets rationalized or redefined. Or else nothing will ever change (unless it gets worse).

Socialized medicine is one thing. But socialized pathology, where all the costs of each person's given maladjustment is borne by all the rest of us? I don't know about that one...

Cosmic Connie said...

Conesta...isn't that a prescription sleeping pill? Wait, that's *Lunesta*. I rather like "Conesta," though.

I do agree with you that "socialized pathology" (I like that term) sometimes seems to be the direction in which we're headed.

RevRon's Rants said...

"obesity as a moral failing (a view that was more or less universally held in the US and elsewhere in centuries past)"

Centuries? How about mere decades? And I think that our collective reaction to said prejudices has played a key role in the excessive pendulum swing away from personal responsibility that has characterized the current mindset.

For many years, the relative morality of behaviors varied widely according to who was exhibiting the behavior. Nobody would dare think badly of a wealthy person, just because they were obese, yet an obese member of a less affluent class would often be considered slovenly or lazy. Adults were generally assumed to be faultless in any kind of confrontation with a child, and as a result, most instances of child abuse were simply not spoken of, much less, addressed. Then, the pendulum began to swing - widely, as is typical - resulting in excessively harsh judgment rendered toward previously unassailable individuals, countered by swelling the ranks of supposed "victims," some of whom were "empowered" beyond anything resembling reason. Now, a kid can ruin an adult's life with even a completely unfounded accusation, and people who gorge themselves at the buffet can claim that they are victims of some insidious outside (or organic) influence.

My perspective is that the pendulum swings are inevitable, but that it is their nature to swing in ever-decreasing arcs in their movement toward some place of equilibrium. We can always complain about the excesses, but in the larger context, they do serve a productive purpose. It would be wonderful if we as a species were capable of learning lessons without over-reacting to them, but I fear that for the time being, at least, such is the nature of the beast. In time, we'll quit lap-banding the gluttons, and the kids will learn the core lessons of personal responsibility. For now, however, we'll likely continue to be opportunistic assholes, demanding everything as being "rightfully ours," while abdicating any responsibility for our own actions. Kind of a schizophrenic approach to the process of maturing emotionally, but it's what seems to have been our way for time immemorial. And we ain't quite done yet.

Tyro said...

This socialized pathology reminds me of an interesting, controversial proposal I read about in a Vancouver newspaper.

As background: there is a clinic called "Insite" which offers a safe injection facility for homeless intravenous drug users (Vancouver has the highest concentration of drug use in Canada). Insite has helped to reduce the spread of several diseases, reduce the overdose rate and provide targeted health care for a vulnerable population. There was a lot of debate about the ethics (essentially: "what message will it send to the children?") but its health benefit has been clear and strong. What's more, it has resulted in a net savings to the provincial health care so there are ethical and practical reasons for support. (The provincial conservatives have still tried to shut it down several times but because of the clear benefits, the BC Supreme Court has ruled that it must remain open. I know, whacky commies.)

The new controversy arises with new proposals from the University of Victoria to deal with the alcohol abuse problem in these poor communities. Some people have been drinking (and sometimes stealing) mouthwash and hand sanitizer because the alcohol is so much cheaper (it doesn't have the high taxes meant to deter youths from drinking). These people suffer from any number of associated health problems as you could imagine.

The proposal is that the province should provide free alcohol to the homeless (reasoning they're evidently beyond deterrence and they pose a health and ethical problem) while raising the taxes on rotgut and other dirt cheap booze to deter everyone else.

Apparently it has been tried in other provinces and resulted in less street crime (and so less police work), fewer health problems in the homeless (so reduced hospital costs) and fewer street fights.

Of course, if giving out needles was controversial, I can only imagine what reaction this would create. Still, it does raise interesting questions. Even if we say that alcoholism isn't a disease (and I think that is a ridiculous, harmful idea), we can agree that it does have societal consequences on health and crime so how should we respond? Is there a point at which self-inflicted harm becomes pathological and deserves a health care response?

LizaJane said...

Cosmic Connie -- No offense intended, but if you simply spend a long weekend with an obese person, it will become immediately evident why that person is obese. They eat too much. It's not all that complicated. We eat too much. Yes, obesity "runs" in families -- because the families eat too much. Are they EVER medical reasons for someone being overweight -- sure... and it's usually a long course of steroids (e.g. in the treatment of certain cancers, for example). After the steroids are stopped, the weight, which is mostly water, falls off. Sure, a thyroid problem can have you gaining or losing weight -- but it won't account for the morbid obesity you see rampant all around us. What accounts for THAT is eating too much. And if you want to blame it on "additives" or "fast food," consider that back when a grown-up's hamburger McDonald's burger was the size of today's Happy Meal burger, and a regular bagel was the size of today's "mini bagels," we weren't fat. We just eat too much.

What makes it hard to lose weight is that unlike other "addictive" substances (drugs, alcohol, tobacco, etc.), you can't live without food. You have to learn to regulate your intake. And that can be a terrible struggle -- especially in a society that is OBSESSED with food and thinks that more=better. But that doesn't mean society should pay for surgery so someone doesn't have to do the work of unlearning bad habits. Especially since it's already been shown that even the most extreme bariatric surgeries can be "undone" over time by unchecked overeating.

LizaJane said...

And for the record, I'm very much in favor of socialized medicine. I am also in favor of personal responsibility and agree with you that we are trending toward socialized pathology.

As for science, the problem isn't with a lack of knowledge of basic FACTS (e.g. gravity holds us down, Earth goes around the sun, etc.) it's more that the average American doesn't understand the basic tenets of what science IS. The idea, for example, that a theory is a theory -- meaning it is the best possible explanation, given the current state of research and information, until something that better explains the question is discovered. This is why you can't argue about, say, "Evolution vs. Intelligent Design" with the average American. It's not that they don't understand the facts about evolution, it's that they don't understand the most basic notion that evolution is a THEORY and intelligent design is NOT (i.e. it cannot be disproved). You can't compare them. Never mind which is right and which is wrong.

I think three things should be absolutely mandatory before earning a high school diploma: a course in basic logic (as in philosophy 101), a course on the scientific method, and a course on basic English grammar. Any sort of knowledge of the founding events of our country and the history of the world at large, after that, would just be icing on the cake! At least then more people could make a valid argument, spot a fallacious one, and have the means at their disposal to point both out!

Steve Salerno said...

LZJ: You raise many interesting and (to my ear) worthwhile points, but I must applaud specifically the final paragraph of your second comment. As we gravitate farther and farther from what was always the historic mission of education, such that we allow people even to collect college degrees without a minimal mastery of core knowledge, it becomes clear that the one overarching and incontrovertible failing of modern education is that it no longer teaches students to think critically. Though I would still mourn the death of traditional scholarship, I wouldn't even complain so much if kids didn't know about Columbus and the Magna Carta as long as they at least came out of school equipped to THINK. And that isn't happening anymore. Increasingly, students at the college level are permitted to slide through on the easiest possible track, a track often consisting of an overwhelming number of electives (with which the student is already familiar and "comfortable"); with the exception of specialized curricula like law or philosophy, that student is seldom if ever challenged or required to build a logical case for anything.

No wonder today's politicians are able to attract mass numbers of voters with absolutely the dumbest possible positions and platforms.

We need more math. Lots more math. For everyone, regardless of occupational track. Math is the closest analog to logical argumentation. (At the very least, we should force students to do sudoku.)

Anonymous said...

Too busy planning my return visit to the mall to get into the arguments about why people weigh more than they should. I'm not sure that anyone knows the precise answer to that anyway. It seems to me there are so many complicated variables. What bothers me about this whole topic is the judgmental tone. Steve, in the past you have expressed understanding for rapists and murderers but you are so cold toward "fat people?" And especially LizaJane. No sympathy in this one area for people whose only "sin" is they weigh too much? Shame on you.