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AUGUST 21, 2009 6:21PM

Let's Keep "Personal Responsiblity" in Perspective

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 Off and on during the current health reform debate, politicians, leaders and pundits have raised the issue personal responsibility. For instance, take these now infamous comments from the John Mackey, the CEO of Whole Foods: 

            …many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.”          

          That is a refrain many of us who think about and discuss American medicine are used to hearing.  In fact, I wrote an article over a year ago in Salon emphasizing the role of individuals and incentives in taking care of their own health. 

           That being said, though, the view doesn’t take into account the socio-economic factors that pressure many Americans into chronic illness.  

            Let’s look at obesity as an example that illustrates this.  Almost one-third of adults and children are obese, a problem that costs us $100 billion dollars a year.  In California, where I live, our State Controller estimates that "the economic cost to California of adults who are obese, overweight and physically inactive is equivalent to more than a third of the state's total budget."           

          Those are the facts, and as Mackey so obviously says, a proper diet and exercise can help to prevent obesity.  But for many, that’s not so easy.  

            To illustrate what I mean, about a year ago, I decided to take a trip to the grocery store with $40.  I spent half of that money on fresh, healthy foods and the other half on processed foods.  I took my grocery bags home and counted up the calories per dollar that I spent on both types of foods.  For the healthier choices, I got 140 Calories per dollar; for the processed foods, I got 370 Calories per dollar.             

          That little experiment has real-world implications when you think about middle class families, with two (or one or zero given our current unemployment numbers) working parents, trying to make ends meet.  Even people living paycheck to paycheck know what food choices are good for them. But if you're one of the millions of families just scraping by, popping a couple of DiGiorno pizzas in the over for dinner is cheap and calorie-laden enough to soothe your hunger pangs. It also leaves one less battle to fight with your kids between getting them to finish their schoolwork and getting them ready for bed.            

        Add the consequences of my little experiment to some other factors, like the lack of access to fresh foods in poorer communities (Mr. Mackey, do you have any stores in low-income areas?), or a lack of safe places to get out and exercise, and you can see that prevention has as much to do with class, income, and communities as it does with personal responsibility.    

 

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Obesity is not a simple problem. The equation is simple: Calories in
Um... I had a rather long comment that got lost when I posted it. Is OS having software problems?
Certainly I think we should be tolerant of others' failures. (I've taken excellent care of my body, but I have plenty of failures in other departments.) It's not my business how much someone else weighs. It becomes my business if they want me to underwrite their weight loss surgery when there is much better & cheaper remedy available -- exercising and eating less. As I pointed out in my essay "Big Fat Lies," the safety and effectiveness of this surgery is not a great as some people may think, but I think I'd be more scared if it were safe and effective. It scares the Hell out of me that some of my fellow citizens feel no shame in saying, "I just can't/won't control myself -- cut me open and slice out part of my digestive tract." What has happened to us?
Thank you Rahul , you make some good points. Living in Arkansas, I'm surrounded by low income, rural realities. It almost seems like obesity begets obesity. When I was in the bay area in CA it was a lot easier to be healthy-- the population demanded it-- and it seemed there was a health food store on every corner. While limited organic food supply is beginning to be available at grocery chains, when a person is making minimum wage, food isn't a priority when the electric bill is due. And when the only entertainment is the TV promoting fear and consumption, while outside it's 110 degrees heat index you can see why the average joe sits in his easy chair in the air conditioning, snacking on potato chips--I guess. It's the path of least resistance. I'm sure, intelligence and education play a factor too.
I'm curious as to how building Whole Foods' stores in lower-income areas is going to give people more access to "fresh" (it often isn't) produce? They can't afford to buy it anyway. Most of us with higher incomes can't/won't either.
I'm guilty of trying to stretch the food $$ by getting frozen pizzas when they're on sale even though I know that fresh non-processed foods are healthier. It got to be a habit when I was laid off for a few months. Fortunately there are (many) grocery stores in my area and I also try to keep fresh fruit and healthy snacks on hand, but I agree with Emma about the foods best for our health are hard on the pocketbook.
Building sidewalks and bike paths would go far, too. I spent some time in Maine, where I saw plenty of obese people and lots and lots of newly built homes on busy roads with no sidewalks. I almost never saw anyone walking anywhere (except in Portland, where there are sidewalks) nor did I see many roads that were bike or pedestrian safe.
Excellent post. It's difficult for Americans in the middle and upper classes to understand what it's like for the lower classes if they haven't been there. It's very easy to say, "calories in/calories out", but when you can buy 8 boxes of macaroni and cheese for the same price as a single raw hamburger patty, the choice is simple for people struggling to buy food.
The movie "FOOD, INC." also illustrates this point. If people saw the way our food system worked, they would demand change. Demanding change is the only way things are going to change...and that's kinda hard to do when you are living on a shoestring budget, balancing time, work, and raising kids.
I work at Whole Foods so that I will get a 20% discount on good, wholesome, healthy food. But I know not everyone has that option/luxury.
I hope more movies like FOOD come out so more people will get the message.
As an "obese" person who used to be "morbidly obese" but still isn't apparently small enough to be treated like a human being (at least not by pundits looking for an easy scapegoat) I'm more than a little sick of having the state of our greedy, profit-driven health insurance situation blamed on me.

My health is pretty darn good, thanks for asking. Blood pressure is at a healthy level, cholesterol is healthy, no real persistent health issues other than my continued wrestling with post-surgical endometriosis, which is a good thing, since I haven't been able to afford medical insurance for more than a year; not since I dumped Kaiser's insane self-employed rates, enjoyed a year of domestic partner benefits while my sweetie worked on "Coraline" and, once the movie was complete, we both became uninsured.

Other than the endometriosis, which ain't weight-related, I've had a gall bladder removed (might have been weight-related but plenty of skinny people have them out, too) and I died 3 times in a car accident that was supposed to leave me in a wheelchair if not dead. I probably survived that wreck DUE to my weight, in fact.

So, if the sanctimonious asses who think they'll live forever because they ride their bike more often than I do and they filter their virgin picked juice before taking it as a high colonic would back the hell off and start directing their advice where it belongs -- at the insurance industry itself -- maybe we could accomplish something.
Calories in/calories out is the way priviledged people see the equation. A more realistic way to look at the problem is as a power struggle over your time. If you regularly work 12-hour days (your boss says: "I work 12-hour days, you work 12-hour days," not remembering that his salary is triple yours, or more!) or unscheduled/unpaid overtime, or two jobs, when, precisely when, and I'd like you to map it out for me, are you supposed to make the time to prepare healthy meals for your family?

Especially on days when there's no help from the spouse (again, those 12-our days or the THIRD job), heaven forbid that our son has an extra-curricular activity. On those days, it's straight to McDonald's or Papa John's. And we ARE vegetarians. And I don't eat that food. I would rather not eat than eat junk food or fast food, but what am I supposed to do for a busy, growing nine-year old?
DarkLady, Right On.

Doc, this is as close to a soft approach as I could imagine and you still get this blowback. Shows the complete and total naivete many would be intellectuals blabber incessantly. There is now a Whole Foods in Hawaii, in Kahala, our Beverly Hills. There is also an outlet not far from Lake Merrit in Oakland, CA. I challenge anyone who is actually interested in broadening their horizons to find their way to 98th and International and board a bus- see what its like to get just a few miles to get ripped off by Whole Paycheck, then, with your fancy-dancy custom re-cycle canvas grocery bags, you take the bus back and get off and begin to get some idea why we need fresh produce in the hood- all hoods- just try and find anything fresh in the ghetto grocer, maybe cherries once in a while, thats about it ... and republicans suggest kids there just bootstrap! Ketchup as a vegetable and other such rot!

AUWE
Does Whole Foods accept WIC vouchers?
Thank you all for sharing your thoughtful responses!
Some great points here.
I keep wondering if there is more to healthful living than diet and exercise. What about the cleaners (both household and personal) that we use that are filled with chemicals? What effect do the endocrine disruptors contained in personal care products have on our health? I daresay the impact of these chemicals is significant and probably causes more health problems that anyone will admit.
This article is right on. There aren't too many average citizens at the neighborhood Food Coop - and if they were, many who shop there would look down their noses at them. I'd like to point out also that there are people in higher income brackets with no excuse for their overeating or unhealthy eating habits. Lots of well to do fat people who make the choice to eat out rather than eat right. Really no excuse whatsoever for them! And no exercise!

Tolerance is important - but ignorance is bliss. If some of our tax dollars were spent educating people with children or limiting what could be purchased with food stamps or WIC vouchers (i.e. NO sugar waters, soda, fat meats - which could be done via scanner codes) it would be tax dollars well spent - saving much on the other end of things... so to speak!
When I visit the USA, I usually don't have cooking facilities, so unless I live on fruit I have to buy prepared foods. Usually, after an hour in the supermarket I still find nothing where sugar is not a major ingredient, and fall back on apples. (Oranges have been bred for oversweetness even with no added sugar.) The typical restaurant is worse. Avoiding sugar is far harder than avoiding meat, and requires far more rejection of offered food: you have to seem an antisocial nutrition wonk.

I do not understand how anybody in the USA is _not_ obese.
Scribblenerd,

There's a new policy here. Anyone who thinks it's cute or clever to begin a post with "Um..." is automatically rejected.

Stymie
I hope everyone who feels strongly that John Mackey is an elitist, with a disconnect to how the majority survive in this country, is boycotting Whole Foods. There is not much we can do as individuals to impact the current imbalance in the distribution of health care resources. But as a group we can effect change. We can as a group register our displeasures with a conglomerate. John Mackey as CEO of Whole Foods, wields extraordinary power and influence. We should not support any corporation that does not have the best interests of the common man at heart. That everyone needs healthcare is a no brainer. Unless one person's life is more valuable than another person's life, in a country as wealthy as our own, everyone should have access to the healthcare they need. Period. I will not shop at Whole Foods. What about you?
rated. Very good points all around. Down here in Los Angeles, our city council is trying to legislate away fast food restaurants in lower income areas. Last year they signed a one-year moratorium on any new fast-food restaurants in a 32-square-mile area south of I-10 and offered incentives to grocery store owners a healthier restaurants.

http://www.nytimes.com/2008/08/09/us/09ban.html
Eating healthy, or as I like to emphasize, Eating in your best interest has far reaching global ramifications but they can not come any where near filling the voids we have carved out of individual esteem and human value that are now being filled with unhealthy calories.

Though the choice of fresh & organic may be basically more expensive as you have so aptly pointed out, it can be done on a very tight, fixed, small income. I am living proof. The almost instant benefits are worth every penny. The outcomes will save each person's living expenses like medical, dental, eye sight, time off work, productivity... Not to mention the tremendous results possible when you "feel" good.

The more dollars we each spend on organic, fresh, non-processed foods, the more demand, the less they will begin to cost. In season, buying local, fresh, at farmers markets, etc. is far less expensive as well and becoming more and more available in urban society. Growing your own in pots if there is no ground available is also cheap and fun and a great learning experience all around.

There are several keys to healthy outcomes and none of them have to do with "will power," or blame, or failure. Our society has blamed "overweight, obese, fat" people for their own plight for long enough. The focus on being thin in our society and the blame we throw toward those who aren't is far more problematic. The #'s on the scale or clothing rack are not the problem, they are the symptom.

Eating healthy is a "choice" that needs to become "the next big thing." But NOT with "blame" or "guilt" or disdain at the core of the message.

The good news: You must EAT to be healthy and happy and not eating or DIEiting will not only kill you but make you FAT. It is NOT eating, that is one of the biggest culprits in our "obesity epidemic."

Simply: 1. by prioritizing your grocery purchases to get the most bang for the buck - protein, fiber, valuable nutrients and putting white sugar, white flour, processed food at the bottom of that priority list with little to NO emphasis on "calories" one can improve their health, and happiness ten fold. 2. by changing ones own mindset, not to a DIEit mentality but to a LIVEit mentality will dramatically switch one's "why we eat" focus. 3. by rejecting our societies superficial goals for our "weight loss," "be thin." and adopting one's own personal, valuable and experientially measurable goals we loose the "self bashing" and begin to "feel" results rather than measure. "Feeling" trumps weighing and measuring every time. i.e. getting dressed, moving, going out in public, looking in the mirror, fitting in a booth at the restaurant or being able to lower the tray table all the way on the airplane, or being able to walk and not chafe your inner thighs because they aren't touching... (we each have our own set of these more valuable goals) 3. by putting the emphasis on eating, what we eat, eating enough, eating less but more often, not skipping any meals... we can all be healthier and happier. No hype, no cost for the best advice, just trust yourself and treat yourself the very best possible in every way!
Please check out http://www.waytoliveit.blogspot.com for all the details and good news. It is FREE! Not selling anything just trying to get the word out about the guilt free way to change your life.
I should follow that up with saying that I don't think the government needs to step in and solve all of our problems, but much like your bring up in the past paragraph of your your essay, if people don't have access, that makes it a lot more challenging for them to take personal responsibility. Also, we zone things like bars and strip clubs; why not fast food places?
Plastic baby bottles and lifetime fat

I'd like to see some research into the role that endocrine disruptors play in obesity. As I understand it, they often imitate and increase estrogen levels, and estrogen plays a role in stockpiling fat.

The book, "Our Stolen Future: How We Are Threatening Our Fertility, Intelligence and Survival," by Theo Colborn, Dianne Dumanoski, and John Peter Meyers (1995) summarized considerable research that points to an environmental factor to obesity (and increasing estrogen sensitive cancers).
...For the healthier choices, I got 140 Calories per dollar; for the processed foods, I got 370 Calories per dollar.

If you want to buy calories, you can get 460 calories per dollar from raw processed sugar or hard candy. The issue isn't the price of calories, but how many you consume. Buy all you want, but it's always your choice to eat it.
I'm about 10 pounds overweight - because I am no long able to spend three each 3-hour sessions riding 50 miles on my bicycle. I can / could lose that 10 pounds pretty easily - and probably will.

I also have worked at a grocery store: what people say about the relative cost of "health foods" is quite accurate. Even with a 10% employee discount, I could not afford to feed myself if limited to "health foods." The whole idea of "health foods" has become another ugly joke - since the corporations are naturally over-pricing that which they know will be bought by... people who can afford it.

Looking at the overall picture, one has to ask if the idea of purposely eliminating the large scale production of food is even possible since we have twice the population we had when I was in high school. Anyone who wants to can tell us how to feed 300 + million people (affordably) with "good old fashioned organic farming." I'm sure we're all drooling with anticipation for an answer to that one.

Oh, I do agree that there're too many overweight people. I witnessed a man about 6 feet tall standing at the meat counter who (apparently without thinking) pulled up his shirt to scratch his belly. What I saw was almost indescribable: lets just say his abdomen was a "waterfall" of fat hanging 3 inches over the waist band of his shorts.

Anyway - just show us where / how we're going to get the time and money to "pursue healthy lifestyles." Some if this mantra is ridiculous, some of it is simplistic. "Quit smoking" - yeah, fine if it weren't for the fact that nicotine is as addictive as crack cocaine. THERE IS NO WAY to cure even 50% of addicts of their addiction.

OTH - No one, regardless of age, should be permitted to "start smoking." This should be federal law. Those already smoking should at least be required to register as subscribers to tobacco companies and those companies should be in charge of "curing" the addiction of their subscribers. Failure to either find such a cure or find a safe alternative to tobacco within a specified time should be punishable by life imprisonment.
I'm in my 50's and 50 pounds overweight, have NO issues medically. I eat just the way you all propose because I can afford to. We don't eat sweets, focus on fruits and vegetables with whole grains and appropriate amounts of high quality protein daily. My average caloric intake is 1700 per day. I exercise, although not as much as I'd like because I'm desk bound for 12 or so hours each day; much of my exercise is in 5 minute bursts as I get up at least once per hour and dance around or run up and down stairs. My husband who is of normal weight, plays tennis, bikes and so on is the one on medication for hypertension and other ailments. So go figure - but stop judging. There is much more to being unhealthy than simply being overweight.
Just to play devil's advocate, brown rice, black beans, and corn (in season right now) are CHEAP! I got 2 ears of fresh corn at the grocer's for 74 cents. Throw some salsa on there, add a salad and some cheese if you like, and that is a healthy dinner - and very yummy.
There is not just one solution, but for many, the solution is a matter of priorities. Do you want to spend your money on fancy cell phones, cable service, high speed internet, designer shoes and handbags, new cars, outragiously expensive basketball shoes.....or do you want to buy fresh (or frozen, available anywhere) fruits and vegetables? Do you want parenting to be easy....or do you want to face the challenge of teaching your children to do the right things for their bodies? Do you want to lose weight....or do you want to eat another potato chip? Do you want to watch TV and munch....or do you want to find another way to entertain yourself, such as read a book, have a family game or monopoly, or take the family to the park. Responsibility in perspective means those who can do something do. Don't make excuses for them.
When it comes to cost and health care and what an individual can do, it is interesting to note that " While HR 3200 ostensibly prohibits illegal aliens from receiving benefits . . . . Moreover, another section says the states may consider "only the income of the applicant" in determining eligibility.

It is becoming increasingly clear that this smokescreen is deliberate. While not admitting that illegal aliens would be covered, the proponents have designed language that allows such a use of funds.
_____

How about going after the corporations who hire the "illegals" (I'm certain you can detect who they are just by looking: they're always brown) in order to undercut the minimum wage, and the Republican corporatists who righteously claim that they're for immigration reform, but only, in fact, to stir up the racists and deliberately misdirect their rage at the pawn -- the "illegal" -- in the game?

Summative response: Being stupid isn't smart.
Your article is excellent as it relates to socio-economic contributors to obesity. However, obessity is a symptom of two unmentioned factors -- depression and food addiction, both of which need medical support. As you are a physician, I hope you will devote at least equal time to these very important factors.
Vicki Hurst
Brooklyn, NY
What a simple, compelling calorie computation. Income does play a major role in obesity. But not all poor people are obese and many affluent people are. Our culture needs to address the problem with empathy, understanding and outreach--qualities in short supply in our current medical paradigm. Weighing 50% more than the normative range for any age, gender, height, etc. is not "normal." I see a system that is blind to the dynamics of obesity, but punitive toward the "sin" habits such as tobacco. Certainly no empathy there. The government loves sin taxes, but won't tax junk food to pay for health care. This is a failure of tax policy, but more than that, a failure of will to confront the food manufacturing industry and a portion of the root causes of the runaway costs of heath care.
While obese people in general have more health problem and incur more costs per year; it turns out that they actually incur LESS costs over their lifetimes, precisely because they die sooner, before they get old enough to have the usual dementia/Altzheimer type debilitation and other age related degenerative diseases. Read this study here:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0050029
So, being thin and fit is certainly good for health, but let's not equate that as being cheaper for the society as a whole. Indeed, if you add up the savings from social security payouts, fat people are SAVING us money by checking out early!
One of ht problems facing the poor is that they often don’t have access to a real grocery store with fresh produce, Whole Foods or no. Big chains don’t like to build in low-income areas, so the poor wind up relying on mom-and-pop stores, who often carry few if any fresh veggies and fruits. If you want produce you have to hop a bus to a nicer area, which means you can only carry a few things home, provided you even have the time to hop that bus. So they wind up making do with the frozen pizza because that is what is available to them at the corner store and it’s cheap.

Then they get a lecture about personal responsibility for being overweight from some middle class twerp who has 5 groceries stores with 2 miles of their house.
The title to this post says it all: "Keep it in Perspective."

If all the fat haters out there had their way and could "officially" blame the overweight and obese for costing too much, how long before we go right down the slippery slope to "Well, if you have a chronic, inheritable condition, you shouldn't have kids. Here, have some sterilization, you know, to keep costs down." And with full approval of the "healthy living" fanatics, I feel certain. (Who, let's face it, are often, as somewhere here pointed out, middle class (or upper class) twerps who have never gotten outside the gated community long enough to know the Real World.)

Seriously. We ALL pay for the drunk drivers, the firebugs, the people who don't take care of their kids...how is providing medical care much different than paying for other public services, some of which are co-opted by idiots who are careless and heedless? But the vast majority of which are services we all need and use?

And to the boob who started up about the illegal aliens....do you think "those people" don't have jobs, or don't pay into SS and Medicare? Think again. Many of them do, and will never collect that money. So in a sense, they are subsidizing YOU.
Your use of the term experiment is wholly inacurate. A true experiment has controls and is double blinded. Your forray into the grocery store was hardly unjaundiced. It was with typical liberal bias that you drew any conclusions regarding your "experiment". Once again we must empathize with the poor. If what you say is true than is it not also true that the poor would not be so poor if they had made the choice to become educated enough to eat healthy foods. In the end it is not hardly my fault that poverty exists. The impoverished our rosponsible for the austere lifestyle they have inadvertantly chosen. Yor "experiment " only confirms my belief that liberals stoke the fires of class warfare. To those standing in a line at McDonalds I say if you want grilled fish and salsd then get a better job.
John E Moore MD
Dr. John Moore- you seem to be having a bad spelling-typo day. I have them, too!

I have seen several PhD level scientist lose their jobs without warning in this recession. Are they are not educated enough? Many were undercut by overseas workers. Many worked very hard. Are they to blame?

How fortunate for those who are healthy enough to take advantage of available educational opportunities. How fortunate when they have these educational opportunities. Hard work is important, but it is not a cure-all for circumstances.

It is fortunate when a person is lucky/healthy enough to work. The fact that luck plays such a large part in a person's standing in the world strikes many people as heresy. They perceive it as denying their worth while elevating the undeserving and inferior.

How can our current system not incite class warfare? The middle class is losing it's jobs and healthcare, or being priced out of them. Only the very lucky and wealthy will be able to have healthcare soon. If you have no fear of losing your healthcare you are lucky to have medicare (socialized medicine) or your are very well politically connected and wealthy.

While it is not our fault that poverty exist; it would behoove us to remember that we are not divinely immune from poverty. Poverty -perhaps the fifth horse of the apocalypse after- Conquest, War, Famine, and Death. It can certainly be the catalyst for the original four.

If you want class warfare in the US there are no better fire-starters than the neo-cons. Their policies have made life more and more difficult for the middle class, working man, and the working poor, while entitling and engorging the rich. They disseminate misinformation and stoke the fires of regional and secular/religious divisions. If a revolt occurs these faux conservatives are to blame.
Your points are well taken and articulately expressed. I quite aggree about the neocons but still you are missing my essential point. Misfortune in this country is rampant even amoung college professors. However it is how we deal with misfortune that defines us. The government has no responsibility to feed starving college professors. It is however incumbent upon the professor to pick himself up by his own bootstraps and re-vitalize his carreer. What doesn't kill us makes us stronger.
I also concur that there has been a dissolution of the middle class. however to atribute that to the neocons is both iresponsible and outright wrong. Bush did not cause the destruction of the middle class. Bush in fact wanted to regulate the mortgage industry in 2005 but was thwarted by liberal ichons and conservative pariahs Barney Frank and Chuck Schumer. Mark my words history will be much kinder to Bush and the neocons than it will to the arbitrary and peicemeal destruction of the US economy brought on by the democratic party against strong Republican resistance. Back to the point. The dissolution of the middle class was a result of the the steady efflux of jobs overseas. And that was a direct result of unbearable and unreasonable union demands. The neocons played no role in eroding the middle class. That distinction belongs to the unions and their bedfellows in the democratic party.
Your comment that work does not solve all problems is patently uninsightful and very dangerous. That is precisely the conundrum of liberal logic(oxymoron). They would first have the government support a man rather than help him get a job. I am not unsympathetic to misfortune I just see the role of government more clearly than you. You would have the government --the taxpayer----me support the professor who lost his job. Whereas I see the governments role to help him get another job. If you give a man a fish you give him one meal. If you teach a man to fish you feed him for a lifetime. Wouldn't it be nice if the government helped those who helped themselves rather than dole out my hard earned money to the droves of the lazy and ignorant. Social security disability is tantamount to dumping money in a hole. Instead of giving the desperate fools a living why not work on getting them a job. I am working the ER tonight and I have a patient but I am thoroughly enjoying this exchange as I am learning alot gotta go


John E Moore
Dr Moore
Apologies. I have not been able to come back to the board in awhile.

I agree that everyone who can work should work. I also know that there are many many people who cannot find jobs at all right now. Highly educated people, PhD's, who produce things (not teachers), people who are willing to perform the most menial of task; they are unable to find pay for their labor. They cannot pull it out of thin air. There is no start-up capital for new ideas. There are no part-time jobs. Lawyers just out of school cannot find work, in law or in food service. If the government sets up more clinics and increases medical record digitization and standardization, this creates jobs, the workers pay taxes.

The middle class is in trouble because the business class decided that sending jobs overseas for short term profit was easier than innovating with their loyal workers to improve quality and productivity. If Big Biz wants less idiotic Unions, don't press the working class to the point that they don't care if their representative institutions are morally bankrupt. How can they tell them from their employers? The mentality of, "I've got to get mine now and the heck with others" has trickled down, if not the money the theory supposed. Our culture has promoted the immorality of the individual thru greed, and hindered the growth of the individual with group-think right and left. There is no deviation/innovation allowed. Only crap compromises designed to trick the 'enemy' and bs the public. If workers have no input into safety, quality, and productivity and less and less compensation, the folks are going to organize. The neocons did not enforce laws against Big Biz hiring illegals (granted - not much enforcement all around) and tried to blame the illegals who were "pulling themselves up by their bootstraps" as best they could. Illegals are leaving because 'there is no work for them.' Hiring them illegally was the cause of the problem. An influx of the willing to work was the result. Hiring illegals and then working them like they are expendable in the fields is more immediately profitable than developing robots to pick tomatoes. And yes, robots can size, grade, and pick tomatoes 24 hours a day. It has a big upfront cost in R and D, so it wont be developed anytime soon.

I would agree vigorously that it is important that people be taught to fish rather than receive the fish free forever. If you starve before you can bait the hook it's a little too late. It is demoralizing to need and accept charity. Where we disagree is that I do see there are times when a person cannot care for themselves and needs assistance. And there are a few that will never be able to care for themselves. Our system is not set up to educate school aged children properly, much less remediate adults so they are employable. There are also execrable social reasons for under-education (it's not cool- the spoilage of the American youth). Therefore India exports scientist and engineers, and imports phone bank jobs. Many folks are intellectually, mentally, and physically unable to work even a partial day, even if they could get hired. They are often overlooked in favor of a person who may not even do they job as well, but is a person without quirks of the mind, body, or intellect.

I have been sent this Whole Paycheck letter by a neocon friend who thought it would influence me. I was irritated because he drinks, eats nothing but garbage, sodas, and never ever moves off his couch or work chair. Obviously he doesn't take responsibility for himself or for the future of his children or he would try to live healthier and longer. I don't automatically agree with a person who calls themselves liberal any more than I automatically agree with people who call themselves conservatives. I want evidence based information.

If these people can become as well as as they possibly can then they are able to contribute to society. This should be the goal of public assistance, including health care, to move people to, or close to, working full time, paying taxes, and participating in society. If there were better preventive care and mental health support then perhaps your ER would not be so full of folks coming in for minor problems, or major problems that could have been treated easily and cheaply a month or two earlier. The economic problems are much like the medical issues of the day. If we can prevent unemployability or illness, we will have to work less on sickness and the unemployed later.

I do not see 'the poor' as a monolith. I know there are plenty of nasty poor people who perhaps don't deserve of pity. Im not going to feel worry for my friend when he has a heart attack from eating badly. I will worry about his small children. Pity is actually quite useless to anyone. I have the most selfish reasons to want the poor to have healthcare. Public health reasons are to reduce communicable diseases, pandemics, easy immunization access, addiction treatment and prevention, health education (especially prevention of HIV, pregnancy, immunizations ect). I want the ER reserved for emergencies, not clogged with the uninsured or the treatable mentally ill. There needs to be better psychiatric care and support so the public is not unduly endangered by willful or delusional actions. Yes, I want reformed healthcare. I have really good insurance, but I want others to have care for selfish reasons.

Nietzsche saw tragedy as life affirming. He hated Platonism, Christianity, egalitarianism, democracy and socialism. SO I think he would be irritated by us all. He had a psychotic break brought on by a combination of a stroke, mental illness, suspected overuse of medications, possible fronto-temporal degeneration and lived as an invalid with his sister in his later years. He died of pneumonia and stroke in his mid 50's. This was before todays modern medicine. However, if her were alive now, perhaps his stroke could have been treated or prevented by blood thinners among other things. His tendency to take a lot of medications could have been assessed for safety or treated as an addiction. His degenerative brain disorder could have been treated or slowed with medication and proper mental therapy. His pneumonia could have been treated with antibiotics or the like. Nietzsches life could have been improved, his productivity and life prolonged....if he had health insurance. In the end it did kill him. It gets us all in the end, but hopefully with more dignity. I think of N much like I think of Willhelm Reich. Nuts, but with some really ardent admirers.

I take Philosophical and Psychological theories with a grain of salt. Usually they are formulated by one individual and their world-view and perceptions about how other behave and why. It takes time, practicality, and observation to refine the good an practical from the fanciful and idiotic.

Nice talking to you Dr Moore
" Those are the facts, and as Mackey so obviously says, a proper diet and exercise can help to prevent obesity. But for many, that’s not so easy. "

Exactly. And with topics like these, and complex disease states like obesity, oversimplification is dangerous. Mackey's heart is in the right place, and he's a very intelligent man. Whole Foods goes a long way to improve eating habits, but is indeed far from perfect. However, Whole Foods does donate a lot of food to soup kitchens and food pantrys. So while fair criticism is deserved, don't be so quick to condemn them.
"Calories in/calories out is the way priviledged people see the equation. "
Interesting point, Carman.
The fact is, calories in/calories out IS the equation, but its not linear or straightforward - many factors affect this equation. Sleep, stress, overall health, nutrition, genetic background and inherent metabolic capacity, I could go on and on.

Also forgot to mention in my earlier post, that smaller food co-ops and farmers markets are indeed found in lower income communities, and provide the same healthful foods as a larger chain like Whole Foods.
The problem as I see it is our consumerist capitalist greedy nature has essentially set up this situation.

Somebody mentioned 8 boxes of mac& Cheese vs a raw hamburger patty. Neither one of those is good for you, when you can spend a few dollars extra, and buy a whole roasted chicken and canned veggies, and while it may cost more at the time, because there is more of it, it will last longer.

THAT is the problem. What happened to "waste not, want not?" what happened to left overs and preparing a meal that will last for 3 meals?

Even if you go to a fast food joint, you can buy enough to last 2 or 3 meals, and that will save time and money. But, no, we are brainwashed to believe that we have to cook everything and eat everything in one sitting, thus forcing us to eat more later and buy more.

It actually *IS* cheaper to buy a whole chicken or a roast and complimentary veggies that lasts several meals than it is to replace those same meals with fast food for whichyou have to pay every time.

It is our greedy capitalist mindset that is killing us, not the foods or how much we spend on foods, but how much money we spend EATING because we eat more food per serving and have more servings