Your own fault, fat belly, hips and thighs?

The question keeps coming up more and more: should we actually reimburse obesity medication or not? As a lover of innovation in healthcare (and that's much broader than medication alone) I am of course biased. So let me start by playing devil's advocate: every pound you carry went in through your mouth, and the Dutch, often Calvinist, national character says: "Your own fault, fat belly, hips and thighs?". Just eat less and move a bit more, and why on earth should we spend our premium money on injections for people who can't control their gluttony? If you really want to, you can do it!

I hear this reasoning more and more often, even from healthcare professionals, and I'll just say it plainly: I don't agree with it. If only because part of the obesity patient population has an underlying condition (for example a metabolic disorder) that caused them to become overweight, or a genetic predisposition. This only concerns a small percentage of the population, but still. On top of that, this typically Dutch way of reasoning completely overlooks three things: the medical side, the behavioural side, and the societal context of obesity.

Medically speaking, it is still the case that obesity isn't always recognised as a disease. We only wake up once someone, after years of living with excess weight, develops diabetes, vascular disease, ruined knees, a ruined liver, or cancer. Or simply collapses on the spot from a heart attack. But a lump of belly fat that has effectively become a hormone-producing organ in its own right — we still don't quite see that as a difficult-to-reverse disease process. So why would you treat it?

What irritates me most is the denial of the behavioural side of obesity. We still like to believe that our choices are a conscious, rational process, in which the individual always has full control over their own actions, their own impulses, and their instincts in general. An outdated view of humanity from the 1970s, and a splendid example of human arrogance. Just as a bull reacts to a red cape, and a cat to a dangling thread, a human reacts to tasty food. There are food marketers and supermarket owners who spend at least 40 hours a week thinking about the question: "How do we get the public to consume as much junk as possible?". And nowadays those food marketers are extremely good at it. You can even graduate with a degree in food engineering; among other things, you learn to find exactly the right mix of sugar, salt, fat, flavour and colour to trigger the highest possible endorphin spike in the consumer the moment they taste the newest snack.

“Just as a bull reacts to a red cape, a human reacts to tasty food.”

And then there's the societal context: it is riddled with contradictions and outdated ideas. If the economy fails to grow for two quarters, we call it a recession; everyone panics. If a lot is being consumed, that's considered a good thing. Good for the economy. But the moment an obesity pandemic emerges, with extremely high societal costs, everyone shrugs it off a little. Your own fault, fat belly, hips and thighs? If Coca-Cola went bankrupt, it would be big news. But if Tommy Tomato went bankrupt, nobody would bat an eyelid. Tommy who? Exactly.

The moment someone proposes taking measures against all that unhealthy junk, the most peculiar excuses come out, such as "personal choice!" and "no to the nanny state!". I've already debunked the first one, but the second one remains odd. If there's fipronil in the eggs, all cartons must be pulled from the shelves immediately, and all the chickens culled, because someone might conceivably die of it. As far as I know that has never actually happened. Yet shelves upon shelves of soft drinks are allowed to stand in the supermarket. Metres and metres of shelving.

The most ill-considered argument put forward by opponents of food regulation is, in my view, the poverty argument: "If we make unhealthy food more expensive, the poorest in society will no longer be able to do their shopping". That may well be true, but it's still not a strong argument for keeping unhealthy food cheap. Firstly, because it means you are consciously letting the poorest in society eat unhealthily. This contributes to the health gap, and only makes all the misery worse. My proposition: make unhealthy food significantly more expensive AND make healthy food cheaper. And for that small percentage of the population who would still be unable to buy healthy groceries, we arrange something so that they too get the healthy food they need.

You'll have already guessed it; I'm a fan of obesity treatments. But I think more is needed. The more I think about it, the more radical my ideas become. I would start by banning all soft drinks and diet drinks. Simple as that: let's all just drink nice tap water.

I think the real solution to the obesity pandemic lies in the supermarket, at school, at the sports club and at the kitchen table. In the habits and reflexes we pass on to our children. My family and I lived in England for a year, and there the children were only allowed to drink water at school. Two weeks of moaning, and after that it was fine. This also works in Japan; it's the only prosperous country in the world where obesity isn't a major problem, and where childhood obesity is actually declining. Why don't we embrace this good example?

“We've been fattening up the population, and now the bill has arrived.”

As long as we are not willing to teach the next generation healthy eating and drinking habits, and as long as we are not willing, out of fear of an economic recession, to protect citizens and consumers with a ban on polluting food and drink, I fail to see why we should deny those same citizens and consumers an effective treatment. We've been fattening up the population, and now the bill has arrived. Your own fault, fat belly, hips and thighs?