As we are overcoming the COVID-19 pandemic, the obesity pandemic is worsening. The United States is the most obese country in the world. Is it time to admit defeat in this 30-year battle against obesity?
Source: Organisation for Economic Co-operation and Development (OECD) (click for full-size figure)
Only 1 in 122 mildly obese people with a primary care physician will achieve a normal weight, according to a large study in the UK. The study included a multidisciplinary team of dietician, personal trainer, and doctor — likely an unsustainable and expensive weight-loss program.
As a primary care physician at a loss for effective weight-loss methods, I sometimes resort to alternative measures. I’ve started scheduling video appointments on patients’ lunch breaks to see their meals. One patient dumped out a soda for me on video, vowing to never drink one again. I make grocery lists with patients. Admittedly, when I have run out of time, I play parent and tell patients they are not allowed to eat dessert. I supplement my diet counseling by brainstorming with the patient on what new hobby they can start.
Efforts in primary care clinics will continue, with varying success. But the harsh reality is that reaching our goal of slowing obesity cannot occur within the sphere of primary care or public health.
Psychologist and author Maria Konnikova warns, “The more we have invested and even lost, the longer we will persist in insisting it will all work out.” It is human behavior to stay the course, but that distracts from considering alternative perspectives.
Targeting Culture, Not Lifestyle
The root causes of obesity are usually social and cultural, and diet and lifestyle counseling doesn’t address culture. The CDC recommends involving the community and targeting children for prevention efforts, since obesity in toddlers often leads to obesity in adulthood. These recommendations are still lifestyle modifications at the community level and do not address culture head-on. As University of Michigan physician Charles Burant, says, “Don’t get heavy in the first place.” This requires a paradigm shift.
Finding Cultural Habits and Fixing Them
The hardest part of changing culture is changing deep-rooted habits. The best way to change a habit is to replace it. Without alternatives to the current food culture, we will not win the fight against obesity.
Bad habits baked into our food environment, value systems, and media seem inaccessible to public health efforts. Dopamine surges from fast foods and normalized obesity make reinforcing obesity as a medical diagnosis quite difficult. Further, we have a consumer culture that favors excess over moderation. Too often, the unhealthiest foods are subsidized by the government.
When humans consistently behave in a way that is deleterious to public health, the government sometimes intervenes to influence that behavior. For example, governments may use mechanisms such as the so-called “sin taxes” on cigarettes and alcohol. But sin taxes may not be very effective at reducing soda consumption, because a tax doesn’t offer a replacement to drinking soda. The US drinks the second-most soda per capita in the world. Sugary drinks are sometimes cheaper than (bottled) water!
Food Environment
The government shouldn’t subsidize a food environment that is unhealthy for the people it serves. Consumers must press the food industry to change to focus on offering products that benefit customers’ health, not their addictions. Perhaps we, as a culture, can encourage a return to eating local foods, replacing grocery stores with farmers’ markets. Some might even garden themselves and realize the benefits of cultivating their own food.
How We Value Food
Our relationship with food has morphed into a supersized obsession. We commonly use unhealthy foods as a source of happiness when we celebrate small events and as a crutch when we are depressed. The ceremonial opening of a bag and the ‘ding’ of a microwave have replaced the pleasures of cooking. Exorbitant portion sizes have regrettably become an American culinary signature. How can we change the way we interact with our food? Our zest for food should be fuel for our zest for life.
Admitting Defeat Could Help Us Move Forward
I am not offering solutions to these cultural woes, but rather arguing that they are the primary cause and outside the domain of primary care. Physicians should sound the alarm, admit defeat, and make space for outsiders who can act as problem solvers in the fight against obesity. Health experts and physicians must stop giving false hope that these cultural problems can be fixed through health care. This false impression creates a barrier for society changing its culture.
In his book Range, author David Epstein focuses on a radical way to approach problem-solving: recruiting people outside of the domain in which a problem appears to exist. He says:
The outside view probes for deep structural similarities to the current problem in different ones. The outside view is deeply counterintuitive because it requires a decision maker to ignore unique surface features of the current project, on which they are the expert, and instead look outside for structurally similar analogies. It requires a mindset switch from narrow to broad.
If we don’t invite people outside of primary care, science, and public health to help solve the problem, what will the obesity pandemic look like in 20 years?
Corey Meador