Against the view that keeping ourselves healthy means making responsible choices, there is little convincing evidence, beyond the example of smoking control, that people who change their diet or lifestyle actually do live longer or have more quality of life than people who ‘live and let live’ and make no real attempt to live healthily. Consider a hypothetical example: an epidemiological study shows that vegetarians live longer than meat eaters. Such a study normally proves very little. This type of study usually falls well short of being a randomized controlled trial, the closest thing we have to a controlled ‘experiment’. The vegetarians may differ from the meat-eaters in many ways other than their choice of diet, e.g. religious beliefs, use of alcohol, social support. A second issue is that a statistical association between two variables such as a vegetarian diet and longevity never proves causality or allows a prediction about any particular individual case. A vegetarian could still die of stomach cancer and becoming a vegetarian will not necessarily lengthen the life of any specific person. Epidemiology is purely statistical science – it can never tell individuals what will happen if they do X, Y or Z, but only provide a statistical or probability statement.
Yet the assumption that we must ‘live well to be well’ is prevalent in contemporary society. The moral aspect of this assumption also leads to victim blaming. If people get ill it is often seen as ‘their own fault’ because they smoke, drink, eat a poor diet, fail to exercise or use screening services, do not cope with stress in a healthy way by joining a gym and so on. Health policy is run through with the blaming and shaming of individuals for their own poor health. The ‘smoking evil’ has been replaced by the ‘obesity evil’. A person who smokes, eat fatty foods, drinks alcohol and watches TV for many hours every day is represented as a ‘couch potato’. Fitzpatrick compares disease with sin, and health with virtue. Medicine is thereby portrayed as a quasi-religious quest gluttony, laziness and lust. Diets are seen as moral choices, in which a ‘balanced’ and healthy diet is a moral im perative.
We may like to believe in the fiction that we are free agents with self-determination. To what degree the people who are the targets for healthy eating campaigns have the resources to choose what they eat is a matter of concern. The majority of human activity is influenced by the social and economic environment, role models among family, friends or in the mass media. The herd instinct is as strong in humans as in bees, birds or sheep. Christakis and Flowler report evidence that there is a person-to-person spread of obesity. They evaluated a database containing a social network of 12,067 people from 1971 to 2003 and found clusters of obese persons at all time points, and the clusters extended to thee degrees of separation. A person’s chances of becoming obese was increased by 57 percent if he or she had a friend who became obese in a given interval. Network phenomena appear to be relevant to the biologic and behavioural trait of obesity, and obesity appears to spread through social ties. Social imitation in social networks seems to be as an important determinant of health as any individual decision to live a healthy life. A successful approach, social cognitive theory, is based on this assumption
The built environment, the sum total of objects placed in the natural world by human beings, is equally important to the social one. The ‘toxic environment’ propels people towards unhealthy behaviours and causes large amounts of mortality and illness. People become overweight and obese because they inhabit an obesogenic