COMMENTARY

Inspiring Weight Loss: What Works?

Yoni Freedhoff, MD

Disclosures

June 20, 2019

"It has to be harsh. If it's not, nobody's going to listen."

Linda Matzigkeit, vice president of Children's Healthcare of Atlanta, was describing the childhood obesity campaign, "Stop Sugarcoating It, Georgia," in response to criticism of bus shelter posters of children with captions like, "Chubby isn't cute if it leads to type 2 diabetes," "Big bones didn't make me this way, big meals did," and "Fat kids become fat adults."[1]

The campaign ads were well intentioned, meant to inspire change. I have no doubt that many physicians today are hoping to do the same when they talk to patients with obesity about their risk for diabetes, dying young, or not walking their children down the aisle one day.

Yet, despite decades of these well-meaning public health efforts and clinical office chats, rates of obesity keep rising. To date, the bulk of public health efforts have focused on the individual, with the general drumbeat being some combination of blame, shame, or fear designed to motivate a person to take greater personal responsibility.

These are odd tunes to play, however, because doing so implies two things: (1) that somehow, the world has seen a global epidemic loss of willpower, and (2) that blame, shame, or fear is able to successfully motivate permanent changes to a person's forks and feet (ie, food and fitness) for their purported betterment.

Of course, these are not true. And to that point, not only are blame, shame, and fear unhelpful, but some research[2] suggests that they're harmful, making change more difficult and worsening obesity and health disparities.

What Has Worked?

Hearteningly, it seems that public health efforts geared at changing the food environment as a whole are starting to roll out. Chile led the way by implementing an 18% sugar-sweetened-beverage tax; placing black warning labels on food packaging to call out items high in sugar, salt, calories, or saturated fat; removing cartoon character mascots; and banning toys from food sales (think Happy Meals and Kinder Eggs), school-based junk food, all infant formula advertising, and junk food advertising between the hours of 6 AM and 10 PM.[3]

We already have a 'nanny'—it's the food industry, and its job is to protect and promote profits, not health.

Now, countries around the globe are beginning to address the food environment through legislative and policy changes. And although we lack conclusive studies confirming that countrywide efforts at regulated approaches designed to affect diet and lifestyle provide durable and beneficial effects,[4] studies of smaller communities' initiatives geared at changing the food environment and culture are encouraging.

Take, for instance, two small French towns, Fleurbaix and Laventie,[5] with a combined population of 57,819.

  • In 1992, schools in these two towns were recruited to teach children about healthy living, with lessons that were implemented throughout the entire curriculum. Teachers received training from dietitians and cross-promotional programs, including cooking classes and supermarket tours. In addition, dietitian-led school-based family breakfast programs were launched.

  • In 1999, two dietitians were recruited to give presentations to town councils, committees, and other meetings. The town councils then built new sporting facilities and created walking school bus (chaperoned walk-to-school route) programs, and local stakeholders—including physicians, pharmacists, shopkeepers, and cultural associations—made healthy family living a focus and organized activities to support and encourage it.

  • Finally, in 2002, 5% of the residents of those towns received a free home-based healthy living checkup, and those deemed at risk were offered dietitian-led advice. If necessary, they were also referred to a physician to address specific health issues (including childhood obesity).

The local media was also involved: 212 articles appeared in local newspapers, 190 in the medical press, and 208 in the national press, along with 25 television stories and 75 radio reports.[5] By 2005, childhood obesity rates in the control towns had reached 17.8%, compared with 8.8% in Fleurbaix and Laventie.

Changing the Food Culture

More recently, a different success story came out of what was once described as "America's fattest city" (though it's possibly just regression to the mean). Huntington, West Virginia, was the subject of an intervention of sorts: The celebrity British chef, Jamie Oliver, chose Huntington for his 2008 reality show Food Revolution, which was designed to help the city change its food culture.

Since the show's filming, Huntington's adult obesity rates have dropped from 45.5% to 32.6%, while rates in nearby cities have remained the same.[6]

What happened to potentially explain the drop? Perhaps consequent to Oliver's show and efforts, Huntington tackled the issue not by way of simple public health messaging that encouraged healthier choices, but with interventions in schools, churches, food stores, and the mayor's office, where healthy choices were enabled through programs and projects to make their undertaking easier and more accepted.

If we want to see changes in the prevalence of diet-related chronic diseases, we need to make changes to our food environment and food culture.

And to be clear, there's much to change, but pointing at a singular intervention (like soda taxes, for instance) and criticizing it on the basis of it being unlikely on its own to change the health of a nation demonstrates only the critic's ignorance of the issue. Complex problems don't have simple, singular solutions.

And for those who wish to speak up against the "nanny state," realize that we already have a nanny—one who sets such things as portion sizes, front-of-package health claims, use of cartoon mascots, prices and discounts, and marketing. It's the food industry, and its job is to protect and promote profits, not health.[7]

When it comes to obesity, if any amount of shame, blame, or fear worked, the world would already be quite slim.

Plainly, it takes a village. If it didn't, we'd already be there.

Follow Yoni Freedhoff on Twitter: @YoniFreedhoff

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