Weight Loss Advice: It Doesn't Have to Be So Hard

An Expert Interview With David L. Katz, MD

David L. Katz, MD, MPH; Laurie Scudder, DNP, NP


September 27, 2013

In This Article

Strategies for Primary Care

Medscape: This is a pretty sobering assessment. So what can be done in the busy primary care setting? Are there strategies that are practical, achievable, and workable in that setting?

Dr. Katz: It is a really important question, and I am going to answer it in 2 diametrically opposed ways. Yes, absolutely, there are practical strategies in primary care. And no, we should not think that primary care really has much to do with the solution at all.

Let me first provide the practical strategy. I am currently writing the third edition of a textbook called Nutrition in Clinical Practice. I wrote the earlier editions as a clinician doing primary care committed to leveraging lifestyle and, in particular, nutrition to the advancement of the human condition. I wanted my patients to be beneficiaries, and in order for that to work, I believed that clinicians needed information about how to apply what we know about nutrition in primary care.

What are the crisp messages that pertain to patients' concerns if you have a patient who is dyslipidemic or hypertensive or diabetic or trying to lose weight? What can you do in the span of those notorious 15-minute encounters? The book was written to be a resource in that situation, and it is extremely practical.

Beyond that, my colleagues and I at the Yale-Griffin Prevention Research Center have been studying the adaptation of best behavior modification models in the primary care setting for roughly 15 years. My motivation there was personal.

I was a primary care doctor. My training is the product of sequential residencies in internal medicine and preventive medicine. For the first decade of my career, I was doing primary care internal medicine, but I was trained in preventive medicine and I wanted to leverage lifestyle and diet. I was seeing patients in a busy clinical schedule and fully understood the constraints of primary care, and as much as I appreciated other effective models of behavior modification, such as the transtheoretical Stages of Change model, there was just no way to get our arms around it and deliver it in the span of a few minutes.

So I developed a behavior modification construct called the Pressure System Model, which simplified everything to 2 opposing forces: motivation for change and resistance to change. I developed intervention trials based on that, and published those as well. The goal was to assist clinicians in delivering effective behavior modification with a particular emphasis on weight in increments as short as 2 minutes. (Editor's note: The Online Weight Management Counseling Program for Healthcare Providers is available through the Yale School of Medicine.)

I think we are either part of the solution or we are part of the problem. We should certainly not be part of the problem. We should not ignore obesity. It is not helping our patients. That is really the reason why they have multiple health problems and we never talk about it.

On the other hand, when we do talk about it, we have to be both constructive and compassionate. I have long joked about the fact that a patient who is fat knows they are fat, they know you know that, and they know you know they know they are fat. And we just wag our fingers at those patients. It makes them feel about an inch tall, and we've then reduced our patients' height but not their weight. Their body mass index actually goes up, and that is counterproductive, so we have to be compassionate and constructive.

The second half of my answer is that weight really is not a clinical problem. Essentially, getting fat in modern culture is the norm, and the modern culture is the problem. We live in a profoundly obesigenic environment. We have a vast proliferation of foods that are not only junky, but are literally designed to maximize the number of calories it takes to feel full. When the food industry told us that you can't eat just one, they meant business. They have done their homework and have willfully engineered foods that are all but impossible to stop eating.

I don't think the playing field is level. We are asking the average consumer, the so-called soccer mom, to control her own intake of calories and her family's intake of calories and get energy balance under control, while we have PhDs in nutritional biochemistry and neuroscience and physiologists using functional MRI to examine what stimulates the appetite center in the hypothalamus and conspires to maximize the number of calories it takes for her to feel full. This has to be fixed at the source. We need improvements in the food supply. We need improvements in information about food. Everybody needs to be given clear indications about overall nutritional qualities.

At my center, we built an algorithm called the Overall Nutrition Quality Index (ONQI), which is an algorithm designed to generate a single, summative score for the overall nutritional quality of a food on the basis of its micronutrient and macronutrient composition and several other of its nutritional properties. We need systems such as that. We need physical activity engineered into the workday and the school day, so it is really part of the cultural norm. We need to do something about the aggressive marketing of junky foods, in particular to children. Essentially, there are large companies profiting massively by contributing directly to the epidemic of childhood obesity and diabetes. I don't think our culture should put up with that.

So ultimately, for lifestyle to be the incredibly effective medicine it can be, we need it to be cultural medicine. Then the job of the clinician is primarily to treat people who get sick, which is really what we are trained to do, and to be effective cheerleaders and play a supporting role in directing our patients to good information, good advice, and good programming. But first, we need that good programming to populate our culture, and until that happens, I fully understand why my fellow clinicians are very frustrated by the issue of obesity and don't want to talk about it. If we are left to deal with it alone -- if we try to make this a clinical solution -- we are likely to fail, because it isn't really a clinical problem in the first place.


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