Dollars and Cents, Obesity and Sense

Let’s continue to explore the many ways in which our children, if allowed to become obese, could potentially be blamed and shamed by society. Those possibilities are all too likely. However, at least presently, they are not old enough to vote, and cannot yet be blamed for the measures that state and federal governments put into effect. We as adults, however, can be and are blamed by people who believe that the government should take no part in paying for people’s GLP-1 medications or anything of that sort.

Some critics with a specialized viewpoint do not believe that tax dollars should be used for that particular purpose, while others with different priorities would prefer to see those revenues utilized for purposes that they themselves can benefit from and exert control over. Such motivated citizens have strong opinions, like the anonymous social media critic who, early last year, claimed that “fat people are the costliest component of healthcare.”

Adjudicating that particular claim is better left to others. For our purposes today, it is enough to acknowledge that obesity as a national health problem already costs a lot of money and could grow even more. The notion that people who receive government assistance might get anti-obesity meds for free is repugnant to many Americans. They are totally against the idea that just for being overweight, without any life-threatening condition caused by that obesity, someone could qualify for special treatment.

The basic question concerns responsibility, which is just a softer word for the assignment of blame. But really, is obesity always and only the fault of an individual? What about genetics? What about environmental factors like “food deserts”? How about the inability to pay for good, nutritious food, even when it is available?

And what about the fact that parents are the ones who have the car and the money, and sole responsibility for deciding what a young family eats? Can children be assigned any blame at all when Mom and Dad buy, bring home, and prepare the food?

But shouldn’t motive be taken into account? So many parents are impoverished and unable to do anything meaningful for their children if there is a price tag. Can’t they be forgiven for buying cookies instead of carrots? It is huge, complicated, and in many respects an ugly problem.

Check in with experts

About a year and a half ago, Medical Economics published an article by Dr. Harith Rajagopalan, examining a situation that really has not changed much since then. It starts off with a bang:

Few public health issues have more devastating health consequences — or higher economic stakes — than today’s obesity epidemic… Without aggressive intervention, the number of people living with obesity or overweight [in America] is expected to rise to 260 million by 2050.

Already, he notes, almost three out of four adults in the U.S. are obese or overweight. And guess what proportion of the children? Around one in three.

No offense to the good doctor, but what if things are supposed to be this way? Couldn’t we just say, “Times change, populations change, things evolve, the world changes…” After all, the ancestors of humans didn’t used to walk upright, and yet we consider ourselves to be an improvement over them.

Maybe universal obesity is supposed to be where everything is heading, for evolutionary reasons that we do not yet understand. Maybe obese humans will turn out to be better able to withstand extreme climate change and ever-increasing pollution.

Okay, let’s get serious. When the people in Washington first posited, then ditched the idea of having Medicare and Medicaid pay for people’s GLP-1 drugs, plenty of constituents on both sides were angry for opposite reasons. But one of the problems is that two years in, only one out of every four patients still adheres to the weight-loss drug regimen — and not because they don’t need it.

Please consult the article for the fancy math involved, but the bottom line presented here is:

Unfortunately, the reality is that adherence rates are low. Without ongoing treatment, patients are back to square one: all therapeutic benefit and financial investment evaporate.

Dr. Rajagopalan lays out some of the cold, hard facts of the case:

[S]tandard GLP-1 therapy costs about $550 per month, but after two years, only one in four patients remains on the drug. This means for every 100 patients starting therapy, the total cost over two years reaches $845,625. When divided by the 25 patients who are actually adherent and continue treatment, the true cost per long-term user soars to $33,825…

[T]he total cost to prevent just ONE cardiovascular event based on the results of the trial exceeds $2.2 million.

Of course, no price should ever be set on any human life. But there it is, one of the as-yet-insoluble dilemmas of the case.

Your responses and feedback are welcome!

Source: “Obesity’s $250 billion problem,” MedicalEconomics.com, 04/16/25
Image by biker_becca/Pixabay

Chasing Stigma Through the Ages, Part 11

Anyone vulnerable to being stigmatized by the larger society — for instance, an obese person — will probably not feel the same about their condition throughout the course of a lifetime. It can go different ways. She/he/they may start out by feeling very “other,” but then at some point encounter a group of similar individuals and seize the opportunity to spend time amongst them and, to all intents and purposes, feel normal.

Or the person might be in circumstances that include no others who are afflicted by the same drawback, and suffer years of feeling estranged from humanity. Even if the individual finds an affinity group with whom to comfortably meld — he, she, or they might change, causing him or her to want to leave and seek other circumstances.

And yet, even if their prospects for finding plenty of similarly obese people to hang out with are abundant, still it is to be hoped that no parent actually aspires to have an obese child.

This is the last of a series of posts examining the work of Erving Goffman, author of “Stigma: Notes on the Management of Spoiled Identity,” and what really does not need repetition is that the author knew what he was talking about.

Ups and downs, ins and outs

In the course of a lifetime, sometimes a person fits in, and sometimes does not. What causes a good fit is often what Goffman calls the special opportunities for in-group participation. Since the beginning of time, that has often implied a consciousness of being somehow superior to the rest of humanity.

An affinity group of musical geniuses might be quite justified in that conviction; a group of people who never bathe, not so much. A mob that burns down a house is an affinity group. Affinity does not necessarily or automatically imply worthiness or any other virtue.

Human nature is subject to ebbs and flows, about which Goffman says,

There will be “affiliation cycles” through which he comes to accept the special opportunities for in-group participation or comes to reject them after having accepted them before. There will be corresponding oscillations in belief about the nature of his own group and the nature of normals.

Each affiliation cycle implies “shifts of participation and belief.” Each such shift involves a change in relationship between the individual and her or his community, whether that is an informal group of hangout buddies, or an official organization dedicated, for instance, to the concept of fat acceptance.

However, all “acceptance” avenues do not lead to the same place, nor do they start out in the same place. Membership in the NAACP, for instance, includes, of course, anyone of any race whose beliefs line up with the principles of racial justice, civil rights, voting rights, education, economic opportunity, and equality — along with a preponderance of people who were born and will remain Black.

Members of an organization centered on fat acceptance (or even fat encouragement) tend to mainly be actual obese individuals, with a welcoming attitude that could be expressed as, “If you’re one of us already, stigmatized in the same way we are, well, come on in. It’s a big tent.” There is room for all, especially if they lean on a moral principle like the basic human right, possessed by everyone, to remain overweight if such is their desire. Or if they like to pretend that they really are without an option.

But for most people, that choice is very much within the realm of possibility. They have it in their power to remain overweight, or to change. Many members could, in theory anyway, slim down to normal-range weights; yet still decide to remain in the organization that encourages acceptance of those who have not committed to the quest for a smaller body.

Another angle

But what, actually, is wrong with having such a positive attitude? Or with believing that we are in excellent health, and could not possibly be happier? If the others join us, they too will experience health and happiness.

What is the problem? Goffman wrote,

In reviewing his own moral career, the stigmatized individual may single out and retrospectively elaborate experiences which serve for him to account for his coming to the beliefs and practices that he now has regarding his own kind and normals.

Basically, anyone with the motivation to remain obese can also find the justification. Nobody should have to go through this kind of moral dilemma, this nightmare of struggle against the self — and eventually, the tipping point will come. Goffman points out that a turning point may occur in the case of…

[…] an “isolating, incapacitating experience, often a period of hospitalization, which comes later to be seen as the time when the individual was able to think through his problem, learn about himself, sort out his situation, and arrive at a new understanding of what is important and worth seeking in life.

Someone might say, “Wait a minute, I think about my problems all the time. That is in fact one of my problems.” To sum up, as parents, we don’t want, or should not want, our kids to ever have to face this sort of existential crisis. What can prevent such a struggle? Not letting them grow up to be obese adults. And what can, in turn, prevent that eventuality? A firm resolve to not let them become obese children.

Your responses and feedback are welcome!

Source: “Stigma: Notes on the Management of Spoiled Identity,” WordPress.com, 1963
Source: “Social Change and Status Protest,” Phylon, 1949
Source: “Cycles and Turning Points,” essay in “Men and Their Work,” Free Press of Glencoe, 1958
Image by pinterastudio/Pixabay

Chasing Stigma Through the Ages, Part 10

Is it even possible that there could be more to say about how different groups of people have either suffered under, or dealt out to others, the crushing pain of stigma? Relax, there is plenty more malice in the pot, without even needing to scrape the sides yet.

How people cope

Erving Goffman made a distinction between normalization and normification. The difference is real, and sometimes crucial to the point of threatening the person’s survival. To normalize is to actually change, which an obese person can do by losing weight. A gay individual, however, can’t voluntarily change their nature.

To normify, however, denotes “the effort on the part of a stigmatized individual to present himself as an ordinary person, although not necessarily making a secret of his failing.” In the midst of society, gay people can pretend to be straight by adopting the appearance and behavior that is not natural to them.

It is a move that in some eras and places can be a life-saving deception. However, obese people, if they are actually present on the scene, cannot really pretend to be otherwise. These points have a lot to do with what kind of stigmatization a person is expected to put up with, how they deal with it, and a great deal more besides.

Another reason for not wanting our children to become obese

Back when Goffman studied the effects of obesity within society, science held that “obesity is rarely reversed,” and it seemed unlikely that a young obese person would become any less so over time. Today, however, a new phenomenon has arisen, to form a world in which dealing with the consequences of constant and ongoing dependence on weight-loss medications could turn out to be as much a burden as the obesity those substances were designed to prevent.

Yes, the new meds might slow aging and extend the lifespan, but what will take place within those extra years? It will be a long time before our science can really grasp the full implications of such a dependent lifestyle, and financial expense is of course a major factor in that prediction. To continue affording their meds, men might prefer not to marry, and women might choose to forego motherhood.

The new normal?

Maybe a best-of-both-worlds lifestyle will evolve, in which the eventual agreement to marry will imply that both participants have decided to “let themselves go,” and to accept whatever that implies in their partner. But isn’t this pretty much what most of the population have been going with all along, and the premise of 1,001 banal sitcom jokes? The standards might stay higher, for a longer period, but eventually just about everybody gives up. It becomes a case of “Love me? Love my thinning hair, my wrinkles and my 50-inch waistline.”

And if someone decides to stick with the meds until the bitter end? She or he would be a true “anti-hero,” refusing to give up the skinny pills far beyond some arbitrary and generally agreed-upon time limit.

In the slightly younger age bracket, among those who had caved to the inevitable and let obesity take over, some of its members would rant against the refuseniks, although, perhaps, while secretly envying their courage and determination. Contention over the appropriate time to abandon all subterfuge, and surrender to a corpulent old age, could become just one more major divisive issue in a society that already suffers from so much dissension.

Another literary genre is heard from

Among the Slim Forever crowd, some would have worked hard for years to make sure they could continue to afford their prescriptions. What a noble life goal — not! A screenwriter could easily imagine a criminal mastermind who must continuously steal in order to stay with the anti-obesity meds. Even at age One Hundred and Slimmity-five, even on crutches, Howard is slim. Yellowtart isn’t giving up her Lululemons any time soon.

They must constantly generate new ideas about how to get their hands on plenty of money and, ta-da! There is a whole series of cinematic comedies starring geriatric drug dependents who refuse to give up.

Your responses and feedback are welcome!

Source: “Stigma: Notes on the Management of Spoiled Identity,” WordPress.com, 1963
Image by Hellio42/Pixabay

Chasing Stigma Through the Ages, Part 8

Regarding a person who is visibly different in any way that might cause others to cringe, the previous post mentioned the constant tension of never knowing how you will be received and perceived by people in the environment. It appears that Erving Goffman’s research unearthed every possible disadvantage that might be experienced by a person who is clearly an Other. One result he confirmed was that someone “grossly deformed need suffer less doubt about their reception in interaction than the less visibly deformed.”

What an advantage! The more messed up a person is, the easier it is to avoid doubt. Imagine giving this advice to a chubby child: “If you seek peace of mind, just go ahead and grow really enormous, because at least then you’ll know for sure that people actually are repelled by you.”

No reprieve

Another psychological discomfort may be felt by the stigmatized person in mixed company (perhaps more by someone with a racial or class difference), which is the inability to relax because, in the eyes of a potentially hostile public, they presumably represent their whole group. In that arena, a “normal” person might compliment you by expressing surprise that you are, in some ways, just like an actual human.

What if a little child stares at or insults a grotesquely obese person? Aside from reminding that child not to be rude, the responsible adult might tuck the moment into memory to be retrieved next time the kid wants some fattening treat. Just say, “Eating that leads to obesity.” Not out loud — the kid won’t respect the logic. It’s a reminder for you, the grownup, to try and protect that child from regrettable consequences.

In public situations, the potential for trouble never ends:

Instead of cowering, the stigmatized individual may attempt to approach mixed contacts with hostile bravado, but this can induce from others its own set of troublesome reciprocations… Each potential source of discomfort for him […] can become something we sense he is aware of, aware that we are aware of, and even aware of our state of awareness about his awareness; the stage is then set for the infinite regress of mutual consideration…

In the 1960s Goffman noted the propensity of people who are “othered” to form action groups for mutual support. This, of course, still happens, and now, media access offers a vast array of possibilities in addition to mere print media. Then, as now, a typical publication aimed to help affected individuals deal with their situation and provided the opportunity to share feelings, grievances, and ambitions, and bond with the similarly affected:

Success stories are printed, tales of heroes of assimilation who have penetrated new areas of normal acceptance. Atrocity tales are recorded, recent and historic, of extreme mistreatment by normals. Exemplary moral tales are provided in biographical and autobiographical form illustrating a desirable code of conduct for the stigmatized.

Interest groups typically address the general public about such issues as terminology. Goffman offered the example of how, decades ago, the New York League for the Hard of Hearing worked to convince the adoption of…

[…] only such terms as hard of hearing, impaired hearing, and hearing loss; to excise the word deaf from their conversation, their correspondence and other writings, their teaching, and their speeches in public… It worked. New York in general gradually began to use the new vocabulary. Straight thinking was on the way.

Apparently, this movement did not spread, or stick, because the accepted definition of “deaf” today denotes partial or total hearing loss, and does indeed seem the most fair and accurate way to describe the total inability to hear. In a way, that particular battle seems to have been misdirected, because plenty of people are actually unable to hear at all. It was a birth defect, or caused by illness or infection, or by an industrial accident, or exposure to loud noise as in wartime; and every possible cause of total deafness has not yet been identified.

Controversy over the terminology pertaining to body weight and size is much more complicated and emotionally charged, and still continues vigorously and fiercely today and is inextricably bound up with the issue of stigma.

Your responses and feedback are welcome!

Source: “Stigma: Notes on the Management of Spoiled Identity,” WordPress.com, 1963
Source: “Deafness,” HealthGrades.com, 11/02/20
Image by Hansuan_Fabregas/Pixabay

Chasing Stigma Through the Ages, Part 7

While obesity is not exactly a curse, at least not compared to some other fates, like life inside an iron lung, it is still not a future anyone looks forward to — especially a parent in regard to a child. The purpose here is not to condemn bariatric surgery, GLP-1 meds, or any other weight loss trend, but to emphasize that, in every instance, the mind and heart need care too. Any sort of extreme change can mess up a person’s life, and in the case of massive weight loss, mental and emotional health must be considered and provided for.

Better yet, and most of all, an important goal is to convince parents to begin early with ensuring that such drastic measures are never needed. Chronic obesity is the sort of problem much better avoided in the first place than faced later under difficult circumstances.

To put it as plainly as possible, one of our goals is to encourage parents to steer clear of, rather than ever need to handle, such problems. We point out the many disadvantages of being an overweight adult in the modern world, for a reason: in hopes that parents will understand that preventing obesity now is infinitely more valuable than dealing with it later.

Good news and bad news

The science of prosthetics has come a long way, especially thanks to experiences gained in treating patients wounded in needless wars and preventable vehicle accidents, etc. A person can get an artificial leg so well-crafted that an onlooker might not be able to spot it. But no parent who learns about the existence of such marvelous devices would proceed from there to conclude, “Well, if my kid needs an amputation, it won’t be such a bad thing.”

Although that sentiment may be true, it has no place in our minds as long as the best alternative still exists: to do everything humanly possible to make sure that our child never needs a leg replaced. Likewise, as parents and other relatives; as teachers; as medical personnel of every sort: Our energy is better spent in guaranteeing that our children, the ones under our care, for whom we are responsible, don’t get fat!

Roughly one-half to two-thirds of children obese at age seven may still have obesity at 18, and roughly two-thirds may still have it at 25. The available evidence does not support a precise figure at 65 or at death, but the estimated numbers are large. These are population averages, not a child’s destiny.

Early, family-based treatment can change the trajectory, and improvement does not require reaching a “normal” BMI immediately. Health can be substantially improved by preventing further excess weight gain as height increases. Meanwhile, let’s not delude ourselves. To think, “In a couple of years he’ll get interested in sports and the problem will solve itself” is false comfort. This is not a chance worth taking.

Back to Goffman’s findings

Erving Goffman’s book, Stigma: Notes on the Management of Spoiled Identity,

[…] is specifically concerned with the issue of “mixed contacts” — the moments when stigmatized and normal are in the same “social situation,” that is, in one another’s immediate physical presence…

To the person who is unconcealably different, this becomes a problem when she or he perceives — rightly or wrongly — that others certainly do notice the difference and, no matter what they may claim or pretend, do not really accept it. The subconscious mind concludes some version of “I’m not what I should be; I don’t belong in company with this person or these people; they don’t and never will accept me as worthy or equal…”

And on and on into an infinite number of sad and dire possibilities. This is the fertile mental/emotional soil from which shame grows and then transmogrifies into any number of emotions and convictions ranging from simple unworthiness to suicidal intention.

Goffman quotes examples drawn from a large number of sources, like Katharine Butler Hathaway’s memoir detailing the effects of spinal tuberculosis on her childhood years and later life:

I didn’t scream with rage when I saw myself. I just felt numb… I saw a stranger, a little, pitiable, hideous figure, and a face that became, as I stared at it, painful and blushing with shame.

That person in the mirror couldn’t be me. It became impossible that I should speak of it to anyone, and the confusion and the panic of my discovery were locked inside me then and there, to be faced alone, for a very long time to come…

Not surprisingly, Hathaway specifically noted the emotion of shame, along with being “horror-struck” when she did not recognize herself in the reflecting glass. Perhaps even worse, that feeling did not remain in place but…

Slowly and stubbornly my robust persistent illusion of well-being and of personal beauty spread all through me again, and I forgot the irrelevant reality and was all unprepared and vulnerable again… My disguise had been put on me without my consent or knowledge, but it was on me for life.

Quite clearly, the trauma of being unacceptably different does not strike just once but can recur at any time, amongst any surroundings, over and over, many times a day, ad infinitum.

Your responses and feedback are welcome!

Source: “Stigma: Notes on the Management of Spoiled Identity,” WordPress.com, 1963
Source: “The Little Locksmith,” K. B. Hathaway, Coward-McCann, 1943
Image by geralt/Pixabay