**7. Medical research and moving beyond individual behaviors**

Structural constrains on individuals can be medical as well as societal. Not only socioeconomic class but personal medical profiles may reveal the limits to individualistic prescriptions. Biological propensities include a mix of factors that make some children more vulnerable to obesity and its correlates. Specifically, a child's "inflammatory profile" may indicate varying levels of severity of obesity and likelihood of developing Type 2 diabetes [8].

Whereas certain individuals become obese on limited food intake, their experiences are rarely creditable, because ideas of individual accountability suggest that they must be consuming more energy than they report. Research articles with revealing titles such as "Do unsuccessful dieters intentionally underreport food intake?" [55] conclude that shame in a culture that blames obesity on the obese prompts underreporting.

Well‐studied human populations provide illustrative examples of genetic and molecular mechanisms that couple energy intake and expenditure to obesity in ways that are not strongly associated with individual‐level behaviors. The Pima aboriginal population of the states of southern Arizona in the United States and northern Sonora in Mexico are highly genetically similar and share evolutionary origins. The Sonora cohort subsists on a more traditional Mexican diet, whereas the Arizona cohort consumes a calorie‐dense US diet. The Arizona cohort experiences some of the highest rates of obesity and diabetes in the world, whereas the Sonora cohort is less obese and much healthier. Consensus medical opinion holds that these differences are related to genetics and metabolic pathways, not primarily to differences in individual willpower on either side of the border.

New studies are being proposed, to learn more from these populations about the mechanisms linking obesity and health outcomes. With chronic inflammation as a central explanatory mechanism, new types of data become relevant. For example, the nationally representative US National Social Life, Health, and Aging Project, 2005–2006, was used to investigate why older black men have worse metabolic outcomes than older white men, ages 57–85 years. Research at the intersection of social science and medicine finds that health behaviors do not explain the difference [56]:

"Instead, these outcomes seem to derive more consistently from a factor almost unexamined in the literature—chronic inflammation, arguably a biological "weathering" mechanism induced by these men's cumulative and multi‐dimen‐ sional stress. These findings highlight the necessity of focusing attention not simply on proximal behavioral interventions, but on broader stress‐inducing social inequalities, to reduce men's race disparities in health."

The insight that obese individuals who are relatively metabolically healthy (*e.g*., no Type 2 diabetes despite obesity) lack many local (in adipose tissue) and systemic (in blood) biomarkers of chronic inflammation was important [57]. The impact of such insight into medical screening and treatment protocols is surprisingly low inasmuch as many clinicians, whose training is a journey through avowedly meritocratic institutions, do not readily see beyond individual accountability for health outcomes. There is still strong medical opinion that avers that obese individuals must be both in charge of their own obesity and at risk of their somewhat deserved if unfortunate outcomes. Indeed, obesity was only recognized as a disease by the American Medical Association in 2013, over considerable opposition among professionals.

What is interesting from a translational medicine approach is that these findings meet resistance in promulgation into care management and public policy. One reason appears to be that there is a robust faith that obese people must be, to some significant degree, "responsible" for their own obesity and unhealthy as a consequence (or even, more subtly, as a punishment or cautionary tale). The possibility that some obese people might not experience high risk of comorbidities like diabetes and cardiovascular disease, whereas some lean people may in fact experience elevated risk is a provocation and a challenge to long‐held understandings. This provocation might be greeted as a bold new way to direct healthcare dollars into more carefully evidence‐based treatments of obese and lean people [53]. However, these insights run against the grain of cultural beliefs. Dominant ideas like meritocracy traverse societal domains. It is as likely that deeply held views of merit‐based outcomes prevail in the workplace as in the clinical setting.

Overall, the role of unresolved, chronic inflammation [57] in understanding childhood health risks [8] and racial disparities [56, 58] is gaining attention. The quest to characterize structural factors in addition to individual behaviors requires a shift in mindset. Individualism is defended by the corporate actors who benefit most from the current economy. Fresh perspec‐ tive is needed precisely at a time when the idea of individual accountability is gaining global traction. Individual accountability is a fundamental tenet of neoliberal capitalism and its financial institutions, which are only getting stronger [59].
