Blog | Thursday, June 14, 2012

Obesity, be dammed!

That's dam"m"ed, not dam"n"ed.

A CDC report from the Division of Unintentional Injury Prevention reveals that drowning causes more deaths among children age 1 to 4 in the U.S. than any other cause except congenital anomalies.

This is a terrible, tragic, and obviously extremely important subject in its own right, just not one in which I have any particular expertise.

Since my work doesn't relate directly to drowning--other than having been a lifeguard and swim instructor earlier in life, and having taught all my kids, and many others, to swim--I want to talk about my usual topic, epidemic obesity, because I think the two are more related than most people realize.

The Institute of Medicine recently released its report on what it will take to fix the problem of epidemic obesity. Timed to coincide with the Weight of the Nation scientific conference and mini-series on HBO, the intent--well served, I think--was to draw the nation's attention to the urgency of this issue more forcefully than ever.

The urgency relates to the dire human toll of rampant obesity and its consequences among children and adults alike. I have addressed this topic on any number of prior occasions, and I trust you don't want to hear about it again. There is a point at which doom and gloom simply cause us all to tune out.

The novel elements that figured in the programming this time around included, for one, a new perspective on the price tag--the opportunity to save, or spend, over a half-trillion dollars on obesity between now and 2030. And, for another, a dedicated focus on the solution.

The solution is what the IOM report, "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation," is all about. There are, of course, plenty of particulars in the full report, but the authors distilled the gist down to these five bullet points:
--Integrate physical activity every day in every way;
--Market what matters for a healthy life;
--Make healthy foods and beverages available everywhere;
--Activate employers and health care professionals ; and
--Strengthen schools as the heart of health.

That's pretty succinct, but really could be made more so. The solution to epidemic obesity and its unsustainable toll in both human and dollar costs is: Fix everything.

I don't disagree. We have epidemic obesity for many good reasons. Fundamentally, we have converted a world in which calories were relatively scarce and hard to get and physical activity unavoidable into a world where physical activity is scarce and hard to get and calories are unavoidable.

We've solved the age-old problem of food scarcity by devising, for our part of the world at least, food excess. We've solved the problem of over-taxed muscles by devising technology to do just about everything muscles used to do. We've solved the problem of food spoilage by devising highly processed foods that might literally have a longer shelf life than the person eating them.

And, whereas we relied on people's intrinsic motivation to eat throughout all of history up until now, we have devised an industry dedicated entirely to talking people into eating more. Vast sums of money are exchanged both on marketing the dietary excesses that spawn obesity, and dieting programs that promise to fix it. An intelligent life form from elsewhere looking at this would surely conclude: We are nuts!

But of course, it's not all crazy. Some of it is just momentum. We've spent thousands of years working to overcome the challenges of too little food and too much physical exertion. We got caught up in these efforts and overshot the target! It's hard to reverse 12,000 years of human inertia, but that's what the IOM is recommending.

The IOM and I agree; we need to fix everything. We need physical activity to populate our daily routines once again. We need healthful foods in reasonable quantities to constitute our diets once again. We need time for food preparation. We need to sleep better, and manage stress, so we have the energy and equanimity to eat well and exercise.

But there are problems with a "fix everything" platform, no matter how defensible it may be.

First, no one is in charge of everything: food marketing, farm subsidies, sin taxes, school programming, school food, nutrition labeling, worksite wellness, transportation, and so on. And since no one is in charge of everything, calls to fix everything have the potential to lead nowhere, because everyone assumes someone else should get it all done.

And second, even if we can figure out where the buck should stop, fixing everything can be quite overwhelming. And when we feel overwhelmed, we may not even bother to try. That tends to happen at the individual level, where people who don't feel they can succeed at eating well or being active simply abandon the effort. But it can also play out at the level of policy, where if doing it all is out of the question, the alternative all too often is doing nothing.

Since I have been wrestling with just such misgivings for years, I have settled on a particular view of what fixing everything looks like that I believe can help. Fixing everything is like building a levee.

I like the levee metaphor and have relied on it to guide my own health efforts, personal and professional, for years, for three reasons.

First, the challenges we confront may be likened to a flood. A flood (800,000 items strong!) of highly processed, hyper-palatable, energy-dense, nutrient-dilute, glow-in-the-dark, betcha-can't-eat-just-one kind of foods. A constant flow of marketing dollars encouraging us and our kids to over-consume the very foods that propel us toward obesity and early-onset chronic disease. Wave after wave of technological advance, endowing us with devices that do things muscles used to do at work, and at play.

Second, a levee helps relieve the burden of a daunting task. Holding back a river is a daunting task. But no one person has to do all that! All anyone needs to do is stack a bag of sand. Stack one bag (or more than one) of sand, and you are part of the solution and thus not part of the problem. A levee is achieved incrementally, and so, too, can we turn the tide of epidemic obesity.

And, finally, the levee illustrates a precautionary tale. Imagine the folly of putting one bag of sand along the bank of a flooding river and then asking: Are we dry yet? No one sand bag, no matter how good, can possibly contain a cresting river. No one sand bag can do what the whole levee can do. And similarly, no one program, or policy, or practice will fix obesity and related chronic disease for society. But we tend to think--or at least wish--it would. We are a quick fix, silver bullet, active ingredient kind of society.

But the active ingredient in fixing epidemic obesity is eating well and being active and everything that helps us get there. No one sandbag will do.

What are the sandbags in such a levee? I've written about them before, on more than one occasion, in both the peer-reviewed literature and here; cried out for them from any podium I'm granted; and established a non-profit foundation devoted entirely to making them available.

The levee is more than a good metaphor; it's a method. There are no clear marching orders that correspond with "fix everything." But the marching orders related to levee-building are clear to the point of intuitive. Choose a bag of sand, and set it on the bank.

Which brings us back to the report on drowning. In the case of drowning, it's obvious we should not focus on lotions, potions, or pills. It's obvious we should not focus primarily on better ways to treat drowning when we have the option to prevent it. It's obvious the "fault" lies with an environment that makes drowning possible or likely, and not with the children.

With regard to obesity, we have overlooked all these same considerations. So it's time to start looking over the obesity floodplain we have been overlooking, and build the levee--one sandbag at a time.

And in the interim, we need to recognize we are drowning in a flood of calories and labor-saving technology of our own devising, and willpower does not keep people afloat. Skill power does. Everybody can learn how to swim, and while waiting on the world to change, everybody needs to do just that.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.