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 actually goes up, even as self-esteem goes down.
The humor I apply to this scenario is only rueful, and overlays a very intimate sadness about it. I have seen many patients over the years with antipathies and aversions to all of medicine for the beratings they have suffered because of nothing more meaningful than a surplus of pounds. Frankly, whoever first mistook a bathroom scale as a device for measuring human worth should be tried and convicted of crimes against humanity.
I have seen patients who avoided medical care, for years at times, to spare themselves the addition of more insults to such injuries suffered. And before I saw my first patient, my maternal grandmother was one of these victims, and in her case, the toxicities of ill-informed judgmentalism proved lethal. Harassed about her weight at each encounter with a doctor, she simply chose to avoid doctors altogether. The result was a breast cancer that came to attention only when it was far too late to do anything constructive about it. My grandmother died in her 50s.
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. Harsh judgment does not teach, in other words; it taunts.
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, of course, conspiring against weight control, physical health and mental health alike. But they do provide quick if transient relief. Judgmental reactions to weight by clinicians and our culture at large may thus propagate the very problem they are purportedly seeking to ameliorate.
In this context, efforts to engage physicians in constructive and insightful weight management counseling are welcome, and if anything overdue. 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 since followed suit. There are ever more apps and technologies enabling more constant information flow between patient and clinic, empowering patients and unburdening providers of some of their historical frustrations and futilities. And with considerable fanfare, the AMA recognized obesity as a disease in 2013, in a further effort to establish its medical legitimacy.
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I have long been devoted to advancing this agenda 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 online 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 and their families to lose weight and find health, while establishing an important 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 are most readily exchanged.
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. New guidelines provide relevant parameters for such interactions.
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But clinical counseling and treatments for obesity are applied once obesity has developed. Sustainable reversal of obesity is certainly achievable, but notoriously challenging. Counseling may prove insufficient, inviting use of drugs with common side effects, or surgery with attendant costs and risks of complications.
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. It's 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. Empowering programming could be offered in schools and worksites, supermarkets, restaurants, and churches. We could confer on everyone the skillpower to lose weight and find health, and impart to everyone an array of supportive resources and programming in all of the settings we spend our time; the places we live, and love, and learn, and work, and dine, and pray, and play.
Of note, the places around the world where people are the healthiest, longest-lived, leanest and happiest – the so-called Blue Zones – do not attribute such blessings to the frequency of good clinical care. They attribute them to the fundamentals of their culture that obviate the need for much of the clinical care we accept as customary in our culture. There is an important place for lifestyle in medicine, with clinicians providing constructive and compassionate guidance. But there are even greater gains attendant on lifestyle as medicine, with culture rather than clinics the principal medium of dissemination.
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. You deserve the former, and should seek out an enlightened clinician who can provide it. But the growing focus on engaging clinicians and making obesity a disease may be subject to a societal tendency to over-medicalize. Obesity need not be a disease to be medically legitimate; it need not be medical to be important or effectively addressed. Do we really need doctors much involved to eat more salad and go for more walks?
Ounces of prevention are famously commensurate with pounds of cure. We can commit to such ounces of prevention as individuals, families, communities and culture – and they would add up to a formidable defense against obesity and an array of related chronic diseases. Addressing obesity before it develops, relying on culture to dispense the requisite medicine, would spare us the heavy burden and high costs of quite so many pounds of cure in the clinical setting.
[Read: Finding Health and Losing Weight: Is It That Complicated?]
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David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine. He is the author of “Disease Proof: The Remarkable Truth About What Makes Us Well.”