BOOK REVIEW: 'A Big Fat Crisis': Dr. Deborah A. Cohen Says It's Not Your Fault -- Entirely -- If You're Fat

Deborah A. Cohen, M.D. in her groundbreaking "A Big Fat Crisis: The Hidden Forces Behind the Obesity Epidemic -- And How We Can End It" (Nation Books, 272 pages, $26.99) argues that the obesity epidemic is the product of two forces:

(1) Immutable aspects of human nature, namely the fundamental limits of self-control, the lazy decision-making of the brains non-cognitive system, and the automatic and unconscious way that we are hard-wired to eat; and

(2) A completely transformed food environment: all of the food-related elements of our surroundings, including food stores and restaurants, prices, portion sizes, the types of food available to us, and food marketing and advertising.

I have problems with many of Dr. Cohen's positions, including her flat out statement that "Diets don't work." I'll explain my own experience with losing weight -- almost 30 pounds since May 2013 -- later in this review; meanwhile, I'll present Dr. Cohen's arguments as fully -- and as sympathetically -- as I can. I'm doing this because I agree with so many of her positions.

To arrive at the above two forces behind the obesity epidemic, Dr. Cohen used her own research at the RAND Corporation, as well as the latest insights from behavioral economics, psychology, cognitive science, and the social sciences to demonstrate to her satisfaction that we as a nation must take action to standardize food portion sizes, limit impulse marketing of candy and other foods that make us fat and run counter advertising like that on tobacco products and alcohol with warning labels on junk food.

These are among the many suggestions Dr. Cohen makes in her argument that it's not your fault that you're fat -- it's those darn candy displays at the checkout counter at your pharmacy. She argues that willpower can only take us so far, that advertising, among other forces, makes it much too easy to access the kinds of low nutrition, high calorie junk food that leads inevitably to obesity. To this I would argue that life is a series of decisions, that you can decide if you want to smoke or drink or pig out, that you are not a robot lacking willpower.

In Chapter 8, beginning on Page 109, Dr. Cohen writes how laws against open sewage and waste in the streets and yards of England reduced epidemics of cholera and typhoid in the crowded industrial cities of the early 1800s. This is a fascinating and educational chapter, but I think it's a big leap to link sanitary regulations to legislating against junk food, the way outgoing Mayor Michael Bloomberg did in New York City. 

Or maybe not: Warning labels on cigarettes have greatly reduced smoking and pregnant women tend to avoid alcohol because of labels.

In Chapter 13 -- the book's conclusion -- Dr. Cohen discusses (Pages 197-198)  New York City's "Children Can't Fly" campaign.

She writes how, In the hot days of the summer of 1972, the New York City Health Department investigated an unusually high incidence of deaths among toddlers who fell out of tenement windows.

Just as wide-body people -- the kind we see waddling around in TV programs about obesity -- are blamed for their condition,  mothers and caregivers were blamed for not being alert, not properly supervising children, or simply neglecting naturally curious toddlers and adventurous young children who leaned out of apartment windows, or crawled onto fire escape stairwells to try to cool off. If you've visited NYC in the summer, you know what it's like in a place where the majority of people are renters.

After an investigation, the health department launched a campaign, “Children Can't Fly” and offered free window guards to families in tenement buildings. The next summer, there were no falls from buildings that had the new window guards.

Dr. Cohen argues that this story from 40 years ago is an apt analogy for the problem and the solution to the obesity epidemic. Just as children are born curious and may wander to an open window even if (or because) we tell them to stay away so too all of us were born with the capacity and inclination to eat more than we need.

In a world where there is too much food, Dr. Cohen argues that -- currently -- we have no constraints that limit our natural tendencies to automatically eat what is readily available.

Sections of the book that deal with our couch potato lifestyle I can agree with wholeheartedly. Dr. Cohen explores the importance of exercise -- even if it means just getting up and walking around, as I do periodically after a computer session (I'm doing it right now…hold that thought)….OK, I just came back from the patio, where it will be another beautiful late December day in south Texas, with temps in the 70s. It felt good. Dr. Cohen wants exercise breaks for cubicle dwellers especially, since much of our work-life these days is of the sedentary kind.

Modifying urban design is another way to reduce obesity, Dr. Cohen argues. On Pages 172-173, she cites a study she conducted with her RAND colleague Roland Sturm on the impact of urban sprawl. The study revealed that people who live in places like Atlanta, where the average person drives four to five miles to a supermarket, have more health problems -- including obesity -- than people in San Antonio and Pittsburgh, where it is much easier to walk to a supermarket. 

In another RAND study examining the expansion of the light-rail transit system in Charlotte, N.C., researchers found that light rail users increased their physical activity and reduced their risk of obesity.

In a trip to Portland, Oregon a few years ago, I found this to be true: Portland has an excellent transit system, with light rail tied in with buses. I didn't need a car to get around and I noticed that Portlanders tend to be less obese than people living in cities that lack decent public transportation. I live in a small city in Texas, but if I had to pick a city to live in, Portland would be high on my list.

Now about that statement from Dr. Cohen that dieting doesn't work, we jump to Page 180 and following pages, where she makes her points. This is in Chapter 12, "In the Meantime: What Individuals Can Do."

Maybe what I did to drop from 247 pounds in May 2013 to a relatively svelte 219 (svelte given my large frame 6-1 body; my goal is about 200, but I seem to be stuck on 219, so maybe that's my ideal weight)  wasn't technically dieting. Maybe I changed my lifestyle, but not so much. I still need to exercise more, but I've continued my practice of not parking close to stores, choosing instead to walk more. My portions are smaller and I've mostly eliminated pasta and bread. No more cheese, either (and I love cheese, especially a good grilled cheese sandwich).

As I said at the beginning, Dr. Deborah A. Cohen has written a groundbreaking book on obesity. It should be read by everybody.  

Dr. Deborah A. Cohen

About the Author

Deborah A. Cohen, MD, is a senior natural scientist at the RAND Corporation. Santa Monica, CA. Cohen received her BA at Yale University, MPH in epidemiology from the UCLA School of Public Health, and her MD from the School of Medicine, University of Pennsylvania. She has served on several advisory panels for the National Institutes of Health (NIH) and was a Fulbright Senior Scholar in Brazil. She lives in Santa Monica, California.

Publisher's website: www.nationbooks.org