One Against the Many: Time to Take a Broader Perspective
Posted: 03 Mar 2009 05:52 PM PST
By Barbara Berkeley
Yet another disappointing weight loss trial.
On February 26, the New England Journal published the results of a study of 881 adults being treated for obesity with varying food plans. The purpose of this study was to determine whether certain nutrient combinations were superior to others in promoting weight loss. Patients were assigned to one of four diets and followed for two years. The length of the trial was unusual because very few weight loss studies extend past one year.
At the end of the day, all the participants were basically in the same place. The media went into their usual frenzy, reporting that these results proved that no one diet was any better than any other. But a closer look at the data showed something very different.
First, the study showed that, yet again, people lost weight and then began to regain it. Second, it proved that even under monitored conditions, people were unable to stick to precise ratios of fat, carbs and protein. In the end, participants could not sustain diets that required detailed counting nor could they really sustain calorie reduction. The average subject on any diet had lost about 13 pounds at 6 months. By two years, and despite group and individual counseling sessions, losses averaged only 7-9 pounds and weight regain was continuing in a seemingly inevitable upward path. Granted, these results are better than no intervention at all. At least the average participant was still at a lower weight than where he or she had started, yet the curve suggested that this situation was not to be long-lived.
Writing in an editorial in the New England Journal, Dr. Martijn Katan commented, “The inability of the (study) volunteers to maintain their diets must give us pause…Even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic…Evidently, individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices.”
Dr. Katan then suggested a paradigm shift. He went on to describe a total–community approach that was tried with great success in two small towns in France. Called EPODE (a French acronym for Together Let’s Prevent Obesity in Children), the program used multiple fronts to bring down obesity levels in kids.
“Everyone from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government joined in an effort to encourage children to eat better and move around more. The towns built sporting facilities and playgrounds, mapped out walking itineraries, and hired sports instructors. Famillies were offered cooking workshops and families at risk were offered individual counseling.”
Within 3 years, the prevalance of overweight in children in EPODE areas was 8.8% whereas it had climbed to 17.8% in neighboring communities. The program is now in place in 200 European towns.
Dr. Katan concluded:
“Like cholera, obesity may be a problem that cannot be solved by individual persons but that requires community action…The apparent success of such community interventions suggests that we may need a new approach to preventing and to treating obesity and that it must be a total-environmental approach that involves and activates entire neighborhoods and communities. It is an approach that deserves serious investigation, because the only effective alternative that we have a present for halting the obesity epidemic is large-scale gastric surgery.”
This assessment rings completely true to me. Day after day I read about the successes of people like you who follow this website. But day after day in my medical practice, I deal with the realities of endless numbers of patients who can’t make permanent change work. These are sincere, determined people who very much want to change. But they can’t. Why not?
I believe that it is because the modern environment is leaning on them like a crushing weight. It leans on most of them so heavily that they can’t be successful. Permanent maintainers are an unusual group in that they have found ways to shelter themselves from this pressure. This takes a certain unique level of determination, imagination and interest, and an ingenuity that may not be available to the majority. Even the most determined may be crushed when life circumstances divert their attention and make them more vulnerable. Unless one’s healthy lifestyle has become utterly ingrained, it is apt to be obliterated when a parent gets hospitalized, a child goes through a crisis or a divorce threatens.
It’s clear that the individual approach to permanent lifestyle change is not working, but that doesn’t say much about either the approach or the individual if we haven’t given that person a fair chance. After all, how can we expect someone to climb a mountain when they’re saddled with a thousand-pound environmental back pack?
As Dr. Katan suggests, let’s think about lightening the load.
1. Let’s have the new administration turn the tide by lobbying for new initiatives that would make taking care of your health “cool.” Bring back the Presidential Physical Fitness tests and awards that were part of every gym class during the Kennedy years. Appoint a Wellness Czar who would start nationwide health challenges and set an agenda for clear health goals we want to accomplish.
2. There is a lot of talk about being more responsible. Banks, investors, mortgage holders and big business all have suffered from going beyond their reach; consuming too much. The same can be said for Americans regarding their health. Besides reorganizing our insurance industry, we need to call on our citizens to become responsible about their health. That means setting national standards and trying to get there. Responsibility is “in.” We should extend the message to taking care of our bodies. That, much more than electronic medical records, will ultimately have the greatest impact on the cost of health care in the future.
3. We should reduce the amount of food stimulation in the environment by getting rid of food ads for kids and by running nutritional information in a crawl at the bottom of the screen over food ads for adults (as they do in France). Cigarettes have a warning and so should many food ads.
4. Our stimulus package spending should include the building of bike paths, walking courses, community fitness facilities and other wellness related projects.
5. We should move lots of people (the community at large) toward wanting to take better care of themselves. If everyone wants to do something, no one person is an outlier. I believe the way to do this is to incentivize healthy behaviors. That might mean giving insurance discounts, bonus pay or other perks to people who keep their weight stable from year to year, or to those who can prove they have attended exercise sessions, or to people who are successfully keeping off at least some of the weight they have lost.
6. Having just worked on a project that created six weeks of menus for a magazine, I can tell you that I was amazed at the calories in most of the foods we eat. We could make it a lot easier for people if all restaurants were required to post calories next to their menu items.
7. And what about one of my favorite ideas (although most people don’t like it): the food-free workplace. Food in the office would have to be confined to designated eating spots like break rooms or cafeterias. Second-hand food exposure is a major environmental “lean” for people who are trying hard to control weight. Like second-hand smoke, the presence of food where it’s not wanted triggers all sorts of brain and gut responses. Since obesity causes as many deaths a year as smoking, why don’t we take it equally seriously in the work environment?
I believe that creating a healthy America will ‘take a village’. At a time when bold new projects seem to be in vogue, there couldn’t be a better moment for action.