By the time I was done last week with my (oh-so-restrained) rant on the shameful reasons for relentlessly rising rates of childhood obesity, I had burned through 1400 words, give or take, and that’s more than enough for a single column.
But leaving the matter there was a source of some frustration for me, and perhaps for you, too - because it left dangling that proverbial second shoe: so, now what? I move on to that matter- the remedies- this week.
My assertion on cures is as unsubtle as my allegations about causes: we could fix childhood obesity (at the population level) any time we wanted. The reason we have not fixed it thus far is not because the condition is too enigmatic, not because we have yet to settle on the appropriately recondite theory or mechanism. We have failed to fix the fact and consequences of rampant childhood obesity because…we have never tried.
Sure, some few of us have tried; some few of us have devoted entire careers to the effort. But as a culture, as a society, as the body politic- we have gone the other way entirely, learning to overlook both obvious causes and dire effects under our very noses- or worse, propagating them on purpose and for profit, as addressed last week.
Those causes amount to a veritable flood of factors. We have wave after wave of unltraprocessed, willfully addictive, hyperpalatable and hyper-profitable, betcha’-can’t-eat-just-one incarnations of junk displacing food. The adverse effects of caloric-excess-by-design are much compounded by an endless flow of inventions propagating new exertion-sparing necessities - gadgets, gizmos, and gimmicks to displace all manner of movement that formerly involved the use of our muscles and our native animal vitality. When the great inertia of culture at large is directed at both maximizing calories in, and minimizing calories out, anyone left to think that epidemic obesity is mysterious must feel the same way about getting wet when jumping in the ocean.
So let’s talk about that water. If the factors propagating obesity may be likened to a flood, then the adverse effect on individuals- adults and children alike- may be likened to drowning. I have propounded that very simile, in columns, peer-reviewed journals, and even on the rarefied pages of Nature, for years. Obesity is a form of drowning, not in water- but in a floodtide of obesigenic factors on both sides of the energy balance equation.
That simple analogy immediately suggests the remedy: whatever we do about drowning, we should do for obesity. Let’s dive into that.
Our primary response to drowning is prevention. When resuscitation is required, it is because generally robust and diverse preventive measures are nonetheless imperfect. We do not blame the victims of these failures; we do not debate the need to train health professionals to be adept at resuscitation; we do not, or should not, encounter insurance company denials of coverage. But most importantly, resuscitation is a rare, last resort because we are all engaged in the practice of prevention.
Every parent knows to be, and with rare exception every parent is, diligent about young children anywhere near water. Were we to treat drowning the way we treat obesity, parents would point young children toward the water, and then lose all track of them; society would both sanction, and encourage, such neglect. The anti-obesity analogue would be every parent learning the threat posed to children by junk food and inactivity, and a prevailing, compelling societal standard for parental oversight and protection where these waters roil.
There are fences around pools, intended in particular as protection for children. Were we to treat drowning the way we treat obesity, not only would there be no fences, but there would be cartoon characters on placards encouraging young children to wander in the direction of the pool’s unguarded edge. The anti-obesity analogue here would be to place the protective barriers of distance, disclaimer, and safe defaults between every child and access to ingestible junk.
There are lifeguards at beaches. There are, as well, signs calling out such hazards as riptides, rough surf, or patrolling sharks. Were we to treat drowning as we treat obesity, there would be no lifeguards, and the signs at the beach would deny all perils and espouse a “come on in, the water’s fine!” invitation no matter the weather, surf, tides, or dorsal fins on display. In fact, the encouraging signs would be most populous and emphatic where the dangers were greatest. The anti-obesity analogue to safety at the beach is truth in advertising at every level from mass media to product package (e.g., “this cereal is made with an absurd excess of added sugar and you should buy it as breakfast for your child only at their extreme risk of obesity, diabetes, liver disease, and tooth decay…”); and dietitians routinely patrolling supermarket aisles (surf boards optional) to intervene when they see danger unfolding (e.g., “you are about to choose a really terrible product; let me help you step away from that box and choose a better one, and no one will get hurt…”).
Yes, my tongue is in my cheek- but only just. We really could analogize rather directly from all we do to minimize the risk and rate of drowning to achieve the same for obesity. One strategy is more salient and compelling than all the rest: we routinely teach people to swim. We could, and should routinely teach people to “swim” through the dangerous waters of obesigenic living, too. Adults, and children, could be taught such specific skills as food label literacy at low cost, and high return. I know, because colleagues and I have engaged directly in just such an effort.
There is another simile, closely related and comparably useful. When our aim is to contain flood waters, we need something like a levee. We do not expect any one sandbag to do what only a whole levee can do, nor do we run randomized trials to determine which sandbag in a levee is “the” active ingredient, responsible for the net effect. Were we to study sandbags in isolation, we would find that no one of them stops a flood on its own. We might, on that basis, conclude that sandbags are useless- and never work our way up to the full levee, which belies that misguided reductionism.
In our limited efforts to contain obesity, we have engaged in just such nonsense- asking far too much from small parts of a greater remedy, and finding them wanting when analyzed in isolation. We need an aggregation of component remedies from policies to products; from Farm Bill to food costs; from marketing to mandates; from cooking skills to clinical counseling- commensurate with the vast aggregation of causes. I have made this argument, invoking the levee analogy, for years. I was delighted to see the venerable Marion Nestle make it, too, in a recent commentary in JAMA Pediatrics.
We have not fixed epidemic childhood obesity because at the requisite level of societal commitment, we have never tried. Our children drown not only in dessert for breakfast, junk for food, and diabetes- but in our complacency about all of these as well.
In his poetics, Aristotle calls “an eye for resemblances” the unique genius of poets. He is referring to simile and metaphor, the capacity to see beyond a thing to what that thing is…like. In one of my own books, I argue that same ability is the critical aptitude of every adept clinician, too. Here, I contend it may extend to public health as well. Obesity is like drowning. Our collective efforts to prevail over its menace would be well begun by treating it as such. Were we to do so, at long last, perhaps it would qualify as poetic justice. More importantly, it might actually work.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.