The future of obesity treatment

Posted on June 3, 2019

(Last Updated On: February 12, 2020)

Obesity has proven to be one of the toughest diseases we’ve come across. In terms of widely known ailments, others I can think of on par with it are dementia, depression, chronic pain. These are ailments we’ve made essentially zero progress in treating.

-> People who work in these domains may be sensitive to that comment, but I’m talking widespread change. These diseases cannot, in any way, be compared to say, the progress in infectious disease (think vaccines).

Yes, heart disease and cancer kill the most people, but we’ve made a lot of strides in treating those.

It’s trendy to shit on big Pharma, but basically, if we don’t find a drug, maybe a surgery, for a disease, we have trouble treating it.

That is, obesity, and most of the hardest to treat diseases, we have not found them amenable to silver bullet interventions.

However, we DO know how to treat obesity -behavior modification- but if nobody wants to, or is capable of making the behavioral change, then have we really treated it? I’d argue no.

After 10 years of being a personal trainer, I’ve easily resigned to voluntary behavioral change -“move more; eat less”- will never work. I don’t think it’s impossible, but the odds are so against it I’d never put much money on it happening.

Smoking has been heralded as an example that widespread behavioral change is possible:

It’s inspirational, but faulty aspirationally.. The desire for humans to minimize metabolic cost (movement) and eat to excess is way more deeply rooted in our DNA than the desire to have a cigarette.

After all, look how quickly smoking went down after we learned the negative effects. Meanwhile, obesity is still going up, and many other related trends are worsening.

For instance, people are progressively NOT realizing they’re overweight, because being heavy has become so normal. We assess ourselves based on how we look in relation to others. Thus, when the average person is overweight, other overweight people now think they’re normal. We don’t even know what overweight is anymore. The importance of this can’t be overstated. One of the first ways towards widespread societal change is education. We’re losing that battle.

I see three plausible realities for the future of obesity.

  1. The miracle silver bullet does happen
    1. Gene therapy may be it; machine brain interfaces to re-circuit your appetite could be another one. Point being, while nothing on the immediate horizon, there are theoretically plausible avenues still not fully explored
    2. But please remember in some ways we do have a silver bullet with obesity -bariatric surgery…still doesn’t work well!
    3. We do have some drugs too, eh em, cocaine, but the side effects are so negative they don’t qualify.
  2. Heavy government involvement

With 2, we’re thinking something like government regulations around weight. Maybe tax penalties for being too heavy. This is a dark view. Politically, this will not be tenable unless things get very bad. Furthermore, the “skin in the game” approach basically hasn’t worked anyways. Paying people to go to the gym, reduced health insurance rates, I mean shit, obese people pay more for food to begin with. Human nature is such that people are willing to pay a lot of money to be heavy. I don’t think making it even more will matter much, unless it was truly oppressive. Think dental care prices. (Though still, most people don’t take the best care of their teeth.)

My personal vision at this point is 

3. The reconstruction of our environment

We’re trying to tackle obesity largely from a willpower standpoint.

“Try harder!”

“Fight those cravings!”

“Take the stairs instead of the elevator!”

We have to stop this and make the treatment invisible to people’s daily existence. Examples will drive this home easiest.

I lived in an apartment building with one entrance. The moment you walked in, the elevator was 30 feet in front of you. Clear as day, that’s where it is.

The stairs? No signs for them. You had to walk at least another 100 feet to find them, if you found them at all.

This is backwards. The way it should be is the stairs are right in front of you. The elevator should be the pain in the ass to get to, which will make people more likely to take the stairs; and at least make people walk a little more if they do want the elevator.

Parking lots- something like no cars within 50 yards of the entrance. If you want to park close? There will be a special area for bicycles only.

More advertisements like this:

Cities will implement more and more days where you can only drive to say, within 2 miles of the city center. You want to go closer? You ride a bike or walk.

Cities will more and more just not have parking lanes in favor of bike lanes.

This is already being proposed in various ways in different places.

  • New York City is getting ready to implement congestion pricing i.e. a tax on driving during certain times.
    • London and Stockholm have already done this
  • Paris is experimenting with only letting certain cars drive certain days (based on your license plate having even or odd numbers)
  • Norway got rid of 700 parking spaces in favor of benches, bicycle docks and other uses for the space
    • The only remaining spaces are mainly for handicapped and business deliveries

Airports will make you pay money if you want to charge your phone, or, you can ride a bike and use the electricity generation from that to charge for free.

Escalators will cost a dollar, or be banned.

Standing desks will become more normalized, and probably to some degree walking desks.

New homes will be built with gym equipment hooked up to the electrical grid, so people can produce some electricity with their movement, lessening their monthly bill.

You get the idea.

For some, this will sound like the Black Plague. Or, “what about the handicapped!!!” To which I respond, what about the OVER 70% of overweight / obese people??? You can’t please everyone maximally. Does it suck the wheelchair person has to roll an extra 100 feet to get in an elevator? Yeah…but the motorized wheelchair life for an extra 100 feet ain’t exactly a concentration camp.

-> You could also give handicapped people a card, allowing them use e.g. elevators for free. While everyone else has to pay money. There are various ways around this.

Others will merely shake their heads in agreement with this. It’s obvious. Plenty of cities do versions of the above, intentional or not. New York City being the prototypical American example. Driving is such a bitch; parking so outrageously expensive; the subway is so repulsive to many, tons of people decide walking is the best option.

A lot of Europe is amazingly friendly to cyclists. Boston is a super friendly American city for cyclists. In some areas, you can get around faster on a bike than in a car.

Of course, this is only the “move more” side of the equation. The “eat less” aspect is another ballgame. Oppresively taxing certain foods would be one approach. Banning certain commercials is already being looked at, such as with ads running during children’s shows.

The gist though is we have to start looking at this as an environmental problem, rather than an individual choice problem. One person you don’t run into much is the person who wants to be obese. And one thing you don’t run into much in a hunter gatherer society is a person who is obese.

People haven’t suddenly become interested in being heavy. It’s their environment has made it awfully easy to be that way.

We have to make people’s default behavior more conducive to a healthy lifestyle. Squatting, bench pressing, deadlifting, lunging, yeah, those can be helpful, but damn man, we just gotta get people to walk more.

When it comes to one on one help, there will always be a place for personal trainers, but I don’t see a world of e.g. personal trainers being paid for by insurance and most people using them on a weekly basis. Most people who currently pay out of pocket still don’t show up for their sessions. (And the gym business makes more money when you don’t show up!)

When it comes to truly treating the obesity epidemic, the future belongs to government officials, civil engineers, architects.

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