New strategies needed for obesity epidemic

Issue: June 2018

Infectious Diseases in Children asked David L. Katz, MD, MPH, director of Yale-Griffin Prevention Research Center, and founder of True Health Initiative, whether the current obesity prevention methods, including promoting physical activity, eating less fast food and taxing surgary drinks, will reduce the current rate of obesity. Can these methods work for a child who is already obese, and are new large-scale methods needed to address the current rate?

In preventive medicine, we have long expressed to one another in words and at times images, too, how little sense it makes to mop a flooded floor and not turn off the running faucet. No crisis of modern public health better typifies such systemic dysfunction than epidemic, and indeed hyperendemic, obesity in children and adults alike.

In January of this year, a special issue of The Journal of the American Medical Association (JAMA) was devoted to this seemingly intractable problem. The culminating reflection by one of the journal’s editors was a commentary titled “Reimaging Obesity in 2018.” The imagination in question encompassed some applications of policy, such as a soda tax. There was, perhaps predictably, a particularly clinical emphasis, with hope vested in refinements of bariatric surgery, and the personalization of dietary prescriptions informed by metabolic, genetic and microbiomic data.

The irrepressible response in my own imagination was that scene of a flooded floor, dutiful mopping and relentlessly running water. There was little if any attention to children, per se, and the word “family” did not appear. Nowhere in that reflection was the blunt assertion that clinic and culture should not be at cross-purposes, the one working to fix a problem the other works to create. That, however, is the current state of breakfast (as well as lunch and dinner) in America, and the principal cause of the obesity impasse.

Over a decade ago, a four-part expose in the Chicago Tribune highlighted the collaborative effort of food- and tobacco-industry scientists to engineer the addictiveness of their respective products. How that memo failed to evoke outrage when first delivered is bewildering. More bewildering still is the perpetuation of that same cultural apathy when the same message was delivered again, courtesy of a New York Times Magazine cover story by a Pulitzer Prize-winning author. Invoking an infectious disease analogy: It’s as if we knew of companies willfully spraying flu virus into the air, even while relying on clinics to dispense vaccine, and everybody just took it in stride.

Pediatricians, and clinicians in general, should certainly be in the vanguard of obesity prevention efforts. The clinical role is greater still when addressing established obesity with empowering information, enabling programming and as warranted, even pharmacotherapy. In both cases, the clinician can and should alleviate the stigma of obesity by noting the pervasive causes in the modern culture and environment, and by differentiating personal involvement in the solution from personal responsibility for the problem. An emphasis on family-level approaches, rather than the isolation of an “obese child,” is also warranted. After all, we tend to “diet” alone but live together, for good or for ill, and with the strength only unity ever accords.

To date, no evidence anywhere in the world that clinical intercession, however imaginative or well-informed, can effectively oppose the population-level consequences of a willfully obesigenic culture that places corporate profits before the health of children.

As pediatricians help lead families toward a solution, they also should consider leading toward outrage that is long overdue. America runs on and profits from obesity in children and adults alike. Until we confront that, the water is running- and mopping the floor is an exercise in relative futility.

References:
Callahan P, et al. Where there’s smoke, there might be food research, too. Chicago Tribune. Jan. 29, 2006. http://www.chicagotribune.com/chi-0601290254jan29-story.html
Katz DL. Childhood Obesity. 2011;7:1-3.
Livingston EH. JAMA. 2018;doi: 10.1001/jama.2017.21779.
Moss M. The extraordinary science of addictive junk food. The New York Times Magazine. Feb. 20, 2013: https://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html

Disclosure: Katz reports no relevant financial disclosures.