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

Environmental Obstacles

Medscape: How can these strategies by adapted to the population most affected by this epidemic: the urban poor with lower resources, who live in food deserts, and have limited access to public parks? Is it even less of a clinical problem in those communities than it is in middle-class communities?

Dr. Katz: The challenges here are domain-specific, in terms of environmental obstacles to eating well and being active and consequently achieving weight control and good health. We can think of specific barriers in terms of resources, such as having access to fruits and vegetables. Then we can think of problems related to the flow of information and knowledge.

When dealing with a middle class that has resources for physical activity accessible to them and access to healthy foods, it may very well be that one of the limiting things in the pursuit of health and weight control is information. If that is the case, clinicians can do more because we can be teachers. We can be reliable sources of good information, assuming we ourselves are well informed -- and in the area of nutrition, that is not always the case. But that is at least a fixable problem.

However, when we are dealing with populations that have essentially no access to what they most need, giving them good information about physical activity when there is no place to get it is very unlikely to work. Giving people advice about eating more fruits and vegetables where they have no place to buy them is unlikely to work. So we could make the case that the obesity and chronic disease related to it are hardest to fix where there is the greatest need for cultural and environmental change and the least opportunity for clinicians to do anything other than address problems after the fact and apply the truly clinical interventions that tend to occur late in the game.

I would argue that really the solution is predominantly cultural in both cases. Even the middle class are mostly getting this wrong. They are mostly buying a lot of foods that are junky. They are vulnerable to the marketing of food that they and their kids should not be eating. They have schedules that conspire against daily physical activity. If we are going to turn the tide, then they, too, need programming in the community -- in places where we live and love and learn and work and play and pray as opposed to just those places we go for clinical care once every 6 months. This is my professional mission.

I have long likened the problem of epidemic obesity and dependent chronic disease to a flood -- a flood of obesigenic and morbidogenic factors. The solution then may be likened to a levee. An important thing about the levee is it doesn't work until it is comprehensive. It doesn't work until all of the sandbags are stacked up to a height greater than the flood waters. It doesn't matter how much work you have done, how many places you have done work -- if the water is higher than the levee, it is going to fall right over.

On the other hand, you construct the levee one sandbag at a time. We can incrementalize the problem of epidemic obesity. We can incrementalize the solution. We can think about what can we do in supermarkets, schools, work sites, churches, shopping malls, and suburban neighborhoods, as well as with the Internet, gaming, and media -- all of these different elements of modern culture. All can ideally be part of the solution, or they remain part of the problem. Similarly, clinicians have a role to play by both providing good information in treating complications and in directing patients, whatever their environment, to the best resources available to them.

The last thing I will say about juxtaposing the challenge of the middle class and the challenge of urban poor -- or for that matter, the rural poor, who face the same basic issues -- obesity rates continue to rise and there is no access to supermarkets, fresh produce, or opportunities for physical activity, and there are real deficiencies in information. Many people are off the grid and not on the Internet -- those kinds of problems. One of the ways to fix obesity in those challenging areas is to get involved directly there.

For instance, what about church kitchens as a place to teach healthy cooking and turn the kind of church meals that everyone is used to into healthier meals? Hand out recipes. Make better use of the resources that are available even in those most challenging areas.

The other thing we can think about is that if we can mobilize the middle class, then clinicians can play a role in making their middle-class patients care passionately about the fact that food is one of the most profound influences on health -- the construction material for the growing bodies of the children we love -- and junk is simply not an acceptable option. If we can rile up the middle class, then the middle class can exert its will at every checkout counter in the country. When the big food manufacturers can no longer keep the customer satisfied any way other than by offering higher-quality food, they will offer higher-quality food. And if that becomes the norm, it will spill over and become the norm, even where it is harder to raise the standard, so everybody could potentially benefit.

So some solutions can be customized to specific populations and locations. In some cases, I think we must think more globally about improving the food supply at large. Then everybody benefits, even those in the most difficult places.


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