Preventive Medicine Column
Dr. David L. Katz
Historically, doctors have either neglected the topic of weight management, or wagged an admonishing finger. That admonishing finger is useless only at best. At worst, it is overtly harmful. I have long joked, ruefully, that a judgmental approach to obesity by doctors has done nothing to help with weight control, but has made patients feel about an inch tall. Reduce height without changing weight, and body-mass index goes up.
A new study just out in the Journal of Experimental Social Psychology builds on this basic theme suggesting that, among young women at least, exposure to anti-obesity bias actually fosters less thoughtful eating in the short term. In a modern world of ubiquitous calories, many of them packaged into processed foods essentially engineered to be irresistible, hunger is perhaps among the less common motivations to eat. Stress, boredom, frustration, and low self-esteem can all be treated with the comfort of feel-good foods. Such foods prove to be bad medicine over time, conspiring against weight control, physical health, and mental health alike.
In this context, efforts to engage physicians in constructive and insightful weight management counseling are welcome. A new era began when Medicare statutes were changed to allow for medical coding of obesity, and reimbursement for weight management counseling. Many private insurers have followed suit. There are ever more apps and technologies enabling more constant information flow between patient and clinic. And with considerable fanfare, the A.M.A. recognized obesity as a disease in 2013, in a further effort to establish its medical legitimacy.
I have long been in this space myself, in the good company of many others. Colleagues and I have studied clinical weight management counseling and published our findings. I have taught nutrition and obesity management to medical students, nursing students, medical residents, and colleagues around the country. I have published several editions of a nutrition textbook for use by physicians. Colleagues and I developed an on-line program to train clinicians in weight management counseling, based on years of research, and offer that program for free. And, I have helped develop a weight management program that empowers patients while establishing a role for clinicians without burdening them excessively.
Such efforts and trends are all for the good. But at best, doctors reacting to established obesity will be addressing a weighty problem, with no option other than administering pounds of cure. Lifestyle is the best medicine, both for the prevention of chronic disease and the management of weight, and overwhelmingly, it is cultural medicine, not clinical medicine. Opportunities to be physically active and eat well every day are closely related to how and where we spend those days, and have little to do with clinics and hospitals. Culture is the right medium for lifestyle as medicine, for that is where the ounces of prevention best reside.
Before resuming a discussion of ounces and pounds, let’s digress to talk about miles and light years, and invoke the proverbial example of a space mission going awry. If you are at mission control directing the flight of a spacecraft, and practice good and vigilant prevention, you note the first minor deviation from the flight plan. You make a very minor correction- no heavy lifting- and all is set to right.
But if instead you are at mission control and fall asleep for a decade or so, and wake to find your spacecraft in the wrong solar system- you at best have a job that involves a great deal of heavy lifting, and at worst have a job that simply can’t be done. You may be looking at a failed mission.
Weight management is much the same. Physicians reacting to obesity can potentially offer counseling, drugs, and surgery. But the best approach to this problem is far less clinical. It’s a cultural devotion to healthy living that carries us all along in its currents. Its doing what’s necessary in schools and worksites, supermarkets and food courts, to make eating well and being active a path of lesser resistance rather than a route so seldom taken.
If you are struggling with your weight, as so many are, your clinician is either part of the solution, by providing constructive and compassionate guidance, or part of the problem for failing to do so. But the growing focus on engaging clinicians and making obesity a disease may be subject to a societal tendency to over-medicalize. Do we really need doctors much involved to eat more salad and go for a walk?
We can commit to such ounces of prevention as individuals, and families- and they would add up to a formidable defense. And they would spare us the heavy burden and high costs of quite so many pounds of cure in the clinical setting.
Dr. David L. Katz