Obesity Be Dammed!: What It Will Take to Turn the Tide
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Katz: Obesity...Be Damned!
Obesity…Be Dammed!: What It Will Take to
Turn the Tide
David Katz, MD, MPH, FACPM, FACP
I
n the United States, obesity is not only (BMI), at least 15% (over 9 million) of
epidemic, but arguably the gravest and children aged 6-19 in the population at
most poorly controlled public health large are considered overweight.12,13 The
threat of our time.1,2,3 Some 65-80% of prevalence of overweight among some eth-
adults in the US are overweight or obese, nic minority groups is higher; over 23%
defined as a body mass index (BMI) at or of Mexican American children aged 6-19
above 25kg/m.2,4 The increasingly global are overweight and approximately 20%
economy has rendered obesity an increas- of 6-11 year old and 24% of 11-19 year
ingly global problem, with the United old non-Hispanic black children are over-
States the putative epicenter of an obesity weight.12 The prevalence of overweight
pandemic.5,6,7 Rates of obesity are already among Native-Americans has been esti-
high and rising in most developed coun- mated at 30%.14 Overall, the number of
tries, and lower but rising faster in coun- children who are overweight has tripled
tries undergoing a cultural transition.8 In over the past two decades.15
China, India and Russia, the constella- The health consequences of obesity
tion of enormous population, inadequate are potentially dire in children and adults
control of historical public health threats alike. Obesity in adulthood has been asso-
such as infectious disease, and the advent ciated with increased incidence of cardio-
of epidemic obesity and attendant chronic vascular disease,16-18 type 2 diabetes19,20 and
disease represents an unprecedented chal- most cancers.21,22 More than two thirds of
lenge.9-11 children 10 years and older who are obese
Since the 1970’s the number of children will become obese adults and it is reason-
in the United States who are overweight able to assume that they will suffer from
has increased dramatically.12 Despite a similar consequences.23 In fact, obesity
conservative definition of overweight in in children has been linked to higher risk
children based on the 95th percentile for of developing hypertension,24,25 hyper-
age- and sex-adjusted Body Mass Index cholesterolemia,26 hyperandrogenemia,27
David L. Katz, MD, MPH, FACPM, FACP, is Adjunct Associate Professor in Public
Health, and Director of the Prevention Research Center at the Yale University
School of Medicine. Katz is board-certified in Internal Medicine and
Preventive Medicine/Public Health. Twice recognized by the Consumer
Research Council of America as one of the country’s top physicians in
Preventive Medicine, Katz is an internationally recognized authority on
obesity and weight management, nutrition, and the prevention of chronic
disease.
Vol. 7, No. 2, Fall 2006 135Health Highlights
gallstones,28 hepatitis29,30 and other disor- more chronic disease and premature death
ders. Adults who were obese as children from eating poorly and lack of exercise
have increased mortality and morbidity than from exposure to tobacco, drugs,
independent of adult weight.31,32 Obesity and alcohol combined (http://www.cdc.
during adolescence increases rates of car- gov/nchs/data/series/sr_10/sr10_216.pdf; ac-
diovascular disease,17,33-35 and diabetes33 in cessed 5/04).
adulthood in both men and women. In The link between obesity and mortal-
men, obesity in adolescence is also associ- ity has been a matter of discord.55-57 Until
ated with increased all-cause mortality and rather recently, data from the Centers for
mortality from colon cancer.33,36 Disease Control and Prevention were used
The incidence of type 2 diabetes in the to support the assertion that as many as
pediatric population parallels the increase 400,000 premature deaths each year in the
in pediatric obesity.37 One in four over- US alone could be ascribed to overweight
weight children between the ages of 6 and and obesity.58 This has since been refuted,
12 has impaired glucose tolerance38 and defended, derided, and debated without
childhood obesity is associated with an in- evident closure.59
creased risk of hyperinsulinemia26 and in- The resolution of this matter is that it
sulin-resistance, a prediabetic state.27 Chil- cannot be fully resolved with current data,
dren aged 5-17 who are above the 95th and it doesn’t truly matter. Obesity very
percentile for weight are 13 times as likely rarely, if ever, causes death directly. To the
to have hyperinsulinaemia when compared extent it contributes to premature death,
to children above the 85th percentile.39 it does so by contributing to chronic dis-
Obese children also suffer psychoso- eases, such as diabetes, heart disease, and
cial consequences from being overweight. cancer, that generally manifest over years
Obesity diminishes children’s quality of to decades. Thus, attribution of death
life severely, to levels of children diagnosed to obesity is nearly always inferential and
with cancer, as indicated by questionnaires readily overlooked, because the causal
validated to capture health-related quality pathway involved is lengthy, and obesity is
of life.40 Many have poor self-esteem41,42 a distant, ‘upstream’ factor.
and are subjected to teasing, discrimina- This doesn’t matter for several reasons.
tion and victimization and may be socially First, it may be that obesity is not caus-
excluded outside of the home.43,44 In third- ing premature death to the extent once
grade girls, BMI was shown to be associ- thought because medical advances so ef-
ated with depressive symptoms.45 These fectively prevent such deaths. These ad-
psychological factors can jeopardize chil- vances do not prevent disability and dis-
dren’s ability to perform in school.46-48 ease, however, which leads to the second
Projections are uncertain, but include issue: regardless of the number of years
the prospect of our children living less obesity is taking out of life it is indisput-
long than we as a direct consequence of ably taking life, and quality of life, out
epidemic obesity.49-54 More reliable are of years. There is little if any dissent re-
statistics suggesting that children growing garding the associations between obesity
up in the United States today will suffer and cardiovascular disease,60,61 cancer60,62
136 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
and diabetes.63,64 And since these consti- ing sedentary when circumstance permit-
tute leading causes of death in the United ted was a prudent conservation of energy,
States,65,66 it seems rather far-fetched that and doubtless a welcome indulgence.
obesity can be entirely exonerated of lethal Thus, one may suggest that human be-
influence. We needn’t wait for unanimity ings, adapted to withstand exertion and
on the body count to assert this, any more the threat of starvation, have no native
than we should wait for Oklahoma to be- defenses against caloric excess. Nature
come beach front property before accept- never tested us with this problem before.
ing, and confronting, the reality of global Furthermore, we have no native defenses
warming.67,68 against the lure of the couch, either. Ani-
mals in nature run after what they want
to eat, and away from what wants to eat
A Rationale for Irrational them. There is little running otherwise.
Behavior Exercise is a modern concept, invented for
a world where physical activity in the form
We may, then, reasonably make the case of work, and mere survival, is increasingly
that as individuals, a population, and even expendable.
a species, we are ostensibly eating ourselves Human beings in a modern world of
to death. Less contentiously, we are over- fast food restaurants, vending machines,
eating ourselves- and under-doing our- elevators and video games are as out of
selves- into states of chronic disease. Why place as polar bears would be in the Sahara
would a putatively intelligent species do Desert. Our adaptations are to a world of
such a thing? scarce calories rather than scarce warmth,
Because we can. There are many ex- and thus it is food energy we soak up and
planations one might invoke, from the retain with noteworthy efficiency. Trans-
low cost of food, to its energy density, to port us from our native savannahs to the
stress, hectic schedules, technology, and modern suburbs, and we find ourselves
advertising. But it all comes back to the floating in a sea of tasty calories. And in it
most fundamental explanation of all. Ani- we continue to soak up and retain food en-
mals- including we- tend to get fat when ergy as we have always done. But whereas
circumstances allow. Circumstances have it always fostered our survival before, in a
never so generously allowed for obesity as world of caloric excess it threatens if not
they now do. our survival, at least our health.
Our ancestors adapted to a world of The modern epidemiology of the Pima
scarce calories, and high levels of physical Indians serves to illustrate this point. The
activity.69-72 The anthropology literature Pimas are a tribe of Native Americans in-
consistently refers to the cycles of ‘feast and digenous to the 4 corners region of Ari-
famine’ that characterized most of human zona, New Mexico, Colorado, and Utah.
history. In such a world, eating when palat- The American Pimas branched off from
able calories were available made constant the mother tribe in Mexico some 1500
sense for calories were very inconstantly years ago, and have been living in the
accessible. Similarly, in such a world, be- desert ever since. Their native lifestyle in-
Vol. 7, No. 2, Fall 2006 137Health Highlights
cluded walking long distances across the more decades. The differences in suscep-
desert for water, and subsisting on the low- tibility to obesity and its sequelae between
calorie, low-fat, low-sugar, high-fiber flora the Pima Indians and the population at
of the desert, including mesquite and the large are of degree, rather than kind.
tepary bean.
Until roughly the middle of the 20th
Century, the Pimas’ health was unremark- Epidemic Obesity:
able. Around that time, new government Complex Simplicity
programs brought them indoor plumbing
and access to the typical American diet. The persistence and progression of the
The Pimas quite rapidly went on to devel- obesity epidemic despite control efforts
op the highest rates of obesity and diabetes may suggest an underlying complexity that
of any population on the planet (having need not be invoked. Human beings store
since been surpassed by one or two oth- body fat as a survival mechanism; it is a
ers).73,74 The change in their health was way of using excess calories available today
so extreme that a branch office of the Na- as fuel tomorrow when calories may not be
tional Institute for Diabetes, Digestive & available. Since we now have an excess of
Kidney Diseases of the NIH was set up in calories available every day, we accumulate
Arizona to study the Pimas. fat that is never burned as fuel. The result
Decades of research culminated in rath- is obesity. We gain weight when calories
er self-evident conclusions. The Pimas are ‘in’ exceed calories ‘out.’ The disturbance
a uniquely fuel-efficient people. Specifi- in energy balance responsible for obesity is
cally, they have a very low resting energy fundamentally simple.
expenditure, or basal metabolic rate. Calories in are, of course, quite straight
This was a foregone conclusion. Only forward; they come exclusively from the
the most fuel-efficient people could sub- food we ingest. Calories out are more
sist on mesquite and tepary beans while complicated. We burn calories as fuel for
walking long distances each day. Only the physical activity, and to support growth
most fuel-efficient people could grow and and development until physical maturity
reach adulthood under such circumstanc- is reached. We waste some calories as heat
es. And only the most fuel-efficient could (referred to as the thermogenic effect of
possibly procreate under such conditions. food), because energy utilization is never
And since those who do not procreate completely efficient. And we of course use
make notoriously poor ancestors, we may calories to sustain basic body processes, or
be confident that today’s Pimas are all the basal metabolism. This is referred to as
offspring of highly fuel-efficient stock. Resting Energy Expenditure (REE). REE
Suddenly plunged into a sea of calories accounts for 60%-70% of total energy ex-
and technology, the Pimas fuel-efficiency penditure, physical activity and heat gen-
turned against them, subjecting them to eration roughly 15% each.75-77
epidemic obesity and diabetes. The gen- Weight regulation, admittedly, involves
eral population has now achieved a rate of a great deal of complex physiology. Liter-
overweight of 65% or more over several ally dozens of genes have been identified
138 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
that play some role in weight regulation, But for it even to be plausible, we must
and hundreds are under investigation.78-81 first overcome a confederacy of dangerous
An intricate array of neurochemicals com- diversions. Prominent among these has
municating among fat cells, the hypothal- been a parade of fad diets, offering quick-
amus, and the gastrointestinal tract regu- fix weight loss promises to desperate adults.
late appetite, and satiety.82-84 But nothing First, scientific evidence that fat restriction
fundamental in human physiology, and offered compelling health benefits85-87 led
certainly nothing fundamental in the hu- to a national preoccupation with ‘cutting
man genome, has changed over just the fat.’ Many turned form high-fat, high-cal-
past few decades during which epidemic orie, nutrient-poor foods, to low-fat, high-
obesity has emerged. Human physiology calorie, nutrient-poor foods, perhaps best
is substantially the same as it ever was. represented by ‘Snackwell’ cookies. As a
The modern, and obesigenic environment population, we cut dietary fat in a rather
is the same as it never was before. In the dysfunctional way, and grew ever fatter.
span of less than a single century, we have This created a great opportunity for
gone from a world of no cars, to one that iconoclasts who could claim that fat re-
enjoys digital photos sent via satellite from striction had been a mistake all along
rovers on Mars. Is it any surprise culture, (rather than acknowledging we had gone
let alone genes, have failed to keep up? about it all wrong). Reviving a low-car-
The US produces some 3800 calories a bohydrate diet he espoused in the 1970’s,
day, after export, for every man, woman, Dr. Robert Atkins rose to the head of this
and child in the country; and elaborate class with the publication of his “New Diet
marketing effectively peddles these excess Revolution” in 1992. The “low carb” era,
calories to us. the continuous advent of which seems now to be waning if not ex-
new technology continuously reduces the piring outright88-90 recapitulated the follies
necessary energy expenditure of a typical of low-fat history. Rather than turn from
day. Powerful forces thus conspire to cre- sugar and white flour to more wholesome,
ate the energy imbalance that propagates less processed foods, the population turned
obesity. from low-fat, high-calorie processed foods,
to low-carbohydrate, high-calorie pro-
cessed foods. A case of “déjà vu, all over
Simple, But Not Easy again” was concurrent with ever rising
rates of national obesity.
The basic simplicity of obesity regret- Sequential preoccupations with the
tably does not imply an easy solution to elimination of a macronutrient class may
the crisis. On the contrary, all of human have delayed more productive responses to
evolutionary biology, the profit incentive the worsening epidemic of obesity. Eat-
of large companies, and the basic momen- ing well for sustainable health and weight
tum of technological advance all conspire control never has been, is not, and never
against us. Accounting for obesity is any- will be about deciding which of only three
thing but complicated. Controlling and main nutrient classes (carbohydrate, pro-
reversing it will be anything but easy. tein, and fat) to abandon. Eating well for
Vol. 7, No. 2, Fall 2006 139Health Highlights
lasting health and weight control, for all • Increase micronutrients
members of a family, always has been, is, • Control portion size and total
and always will be about making good calories
choices within each nutrient category. • Increase physical activity
This very position is rather explicit in the (Katz DL. TIME Magazine / ABC News
2005 Dietary Guidelines for Americans.91 Summit on Obesity; Williamsburg, VA:
Yet another diversion comes in the June, 2004)
parsing of nutritional fine points by aca-
demics. Perhaps the most salient example Another potential diversion forestalling
of this has been defense of competing di- an all-out effort to control obesity through
etary pyramids.92,93 The Harvard Medical lifestyle change is the perennial hope for a
School, for example, offered up a ‘Medi- wonder-drug. This is driven in part by the
terranean’ food pyramid as an alternative recognition that whereas all diets work for
to the both venerable and much maligned short term weight loss, no diet to date has
USDA food pyramid,94,95 which itself has worked with any consistency for long term
since evolved.96,97 Obscured by this com- weight maintenance.101
petition was the widespread consensus Pharmacotherapy is certainly warranted
among nutrition experts about fundamen- for managing certain cases of obesity, and
tals of healthful eating. Namely, there is advances in drug therapy may offer greater
little debate about the merits of a diet rich benefits. But the notion that obesity can
in whole grains, vegetables, fruit; moder- be reversed at the population level through
ate in fat and protein; restricted in satu- phamacotherapeutic advance seems a mis-
rated fat, trans fat, salt, sugar, and refined guided fantasy. First, the prospect of most
starch. The typically much-hyped discord adults and a large percentage of children
among academic nutrition experts has taking drugs routinely and perhaps perma-
always discouraged a dedicated commit- nently to control weight is somewhat dis-
ment to healthful eating by a public that tasteful. Second, the costs would almost
can then claim, disingenuously or not, to certainly be prohibitive. Third, the history
be confused about what healthful eating of pharmacotherapy for obesity has been
means.98-100 Some tips for healthful eating quite disappointing, and this may be a pre-
that are subject to minimal controversy cautionary tale.
among reputable nutrition authorities are: But fourth and finally, obesity is un-
like most conditions treated with medica-
• Reduce trans fat tions. A body gaining weight when excess
• Reduce saturated fat calories are available for consumption is
• Reduce sodium behaving normally. Efforts to curtail such
• Increase fruits and vegetables weight gain with drugs are not efforts to
• Increase whole grains correct an anomaly in human physiology,
• Reduce refined starches and sim- but rather to deconstruct and reconstruct
ple sugars its normal operations at the core. Advanc-
• Replace “bad” fats with “good” es in pharmacotherapy, like advances in
• Increase fiber surgery, will serve the weight management
140 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
needs of individual patients. But looking cally active. This apparent double stan-
in this direction for a population-level so- dard is a barrier to the effective cultivation
lution is ill advised. of population-level commitment to the
fundamentals of healthful eating, a dietary
pattern supported by a robust confluence
When the Going Gets of evidence.104,105,107,111,129,131-136,72,137,138
Tough Scientific reviews of dietary intake for
optimal health do not necessarily demon-
There is little argument that regular strate complete agreement on all points at
physical activity is vital to both health and all times, but the consensus about funda-
weight control. Yet there has never been a mentals is really quite convincing. Diets
definitive, randomized trial to prove that rich in fruits, vegetables and whole grains;
assignment to differing levels of activity restricted in animal fats and trans fat from
predicts variation in weight and health. processed foods; limited in refined starches
Nor is such a trial likely, or needed. In the and sugar; providing protein principally
aggregate, the evidence supporting a role from lean sources; and offering fat princi-
for physical activity in both health and pally in the form of monounsaturated and
weight management is quite convincing. polyunsaturated oils are linked to good
Rather than debating ‘whether’ or ‘what,’ health.102-104 When it comes to diet and
we are left to wrestle with ‘how,’ and ‘how optimal health, legitimate debate really is
much.’ limited to variations on this basic theme,
Oddly, although the evidence charac- not departures from it.
terizing fundamentals of a healthful94,102-111 Modern scientific study of optimal hu-
and weight controlling87,112-129 diet is also man nutriture and anthropological esti-
abundant and convincing, we have thus mates of our native intake levels, have con-
far failed to acknowledge consensus in a verged with remarkable consistency69,144,145
way the public finds persuasive. Instead The implication is that until or unless re-
of focusing on ‘how’ to make a healthful, search methods answer all our questions,
weight-controlling diet more accessible to our native diet is a robust model for filling
all, we have continued to debate the rela- in gaps. The dietary pattern that results is
tive merits of different diets- including shown in Table 2. This constitutes a basic
fad approaches at odds with mainstream ‘theme’ of healthful eating on which there
thinking.7,130 This would be rather like re- may certainly be practiced some reason-
fusing to commit resources to the promo- able variation. But to deny the theme is no
tion of physical activity until alternatives more reasonable than to refute the health
to physical activity had been assessed for benefits of physical activity.
comparable benefit. It seems unlikely that
any who favor studies of diets at odds with
the consensus view on healthful eating Actions & Accountability
would favor studies of all the ways there
are to be sedentary to see if, perhaps, one At the International Congress on Obe-
of them is as good for us as being physi- sity in Sydney, Australia, in September of
Vol. 7, No. 2, Fall 2006 141Health Highlights
Table 2. Recommended Dietary Pattern for Optimal Health & Weight Control
Adapted from: Katz DL. The Way to Eat. Sourcebooks, Inc. Naperville, IL. 2002
NUTRIENT CLASS/NUTRIENT RECOMMENDED INTAKE
Carbohydrate, predominately complex Approximately 55-60% of
total calories
Fiber, both soluble and insoluble At least 25 grams per day,
with additional potential
benefit from up to 50 grams
per day
Protein, predominantly plant-based sources Up to 20% of total calories
Total Fat Types of Fat Not more than 30%, and
preferably 20-25% of total
calories
Monounsaturated Fat 10% of total calories
Polyunsaturated Fat 10% of total calories
Omega-3 and 1:1 to 1:4 ratio
Omega-6 Fat
Saturated Fat & Trans Ideally, less than 5% of
Fat (Partially Hydrogen- total calories
ated Fat)
Sugar Less than 10% of total calories
Sodium Up to 2400 mg per day
Cholesterol Less than 300 mg a day
Water 8 glasses a day/64oz/2liters
Alcohol, moderate intake if desired Up to one drink a day for women
Up to two drinks a day for men
Calorie level Adequate to achieve &
maintain a healthy weight.
See Resource 9 for details.
Physical Activity / Exercise Daily moderate activity for 30 minutes
Strength training twice weekly
142 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
2006, it was announced that for the first sponsibility” and others of “environmental
time in history, there are more overfed determinism.” We would be well served
than hungry Homo sapiens on the planet. by measures that tell us who is sufficiently
The implications for obesity management empowered to take control of their weight,
are both clear and compelling. A univer- and who is not. If responsibility comes
sal, preventive approach is warranted, as with power,146,147,148 the corollary is that
the entire population- indeed the species- empowerment is prerequisite to taking re-
is in the ‘at risk’ group. sponsibility. Divisive rhetoric all too often
The challenge of obesity control is not conceals the middle path of reasoned con-
about ‘what;’ it is about ‘how.’ How can sensus from all concerned.
we enable an increasingly overweight pop- For example, we cannot expect a hard-
ulation to resist the obesigenic forces con- working single parent earning minimal
spiring against it? wage in a city neighborhood to have the
There are two reasonable approaches. same potential to manage her weight
One is to reengineer the modern environ- through “personal responsibility” as a high-
ment so that its obesigenicity is attenuated. ly educated, well paid suburbanite.149,150,151
The second is to better exploit native hu- The playing field of opportunity is not
man intelligence and resourcefulness, and level, and that calls for policy interven-
empower individuals and families with tions. Many reasonable approaches have
knowledge, skills, and strategies necessary been espoused.152-155
to resist fixed obesigenic elements of the We should also acknowledge the hypoc-
modern landscape. risy in telling children to eat well and be
These approaches are both achievable active, then sending them to schools that
to some degree and will likely both be re- provide vending machine junk food, but
quired. There is a limit to how far either not physical education.156,157 Those who
can go alone. Some environmental reforms contend that parental or personal respon-
seem much more plausible than others. sibility should carry the day despite these
We may, for example, construct sidewalks environmental temptations might consider
more consistently in neighborhoods of the the implications of generalizing the prin-
future. It seems improbable that having ciple. Perhaps children should be encour-
devised snow blowers, leaf blowers, and aged, but not required, to attend school
tractors, we will ever renounce them and and tempted each morning by alternatives,
return to rakes, shovels, and ploughs. such as buses to the circus, zoo, or beach.
How much can be achieved through a Were we to treat what we feed the minds
focus on the environment and how much of children as we have treated what we feed
through empowering individuals is a mat- their bodies, this might well be the prevail-
ter worthy of dedicated attention. To ing standard.
strike the right balance will require rec- School policies are rapidly evolving
ognition that the approaches are comple- across the nation to raise nutrition stan-
mentary, rather than competitive. Current dards158-161 and a number of promising
opinion tends to be divisive and polarized, programs are emerging to teach children
with some proponents of “personal re- about nutritional health and weight con-
Vol. 7, No. 2, Fall 2006 143Health Highlights
trol.162-166 Multidisciplinary programs in- provided courtesy of the hypothalamus,
clude physical activity, but school officials where specialized cells respond to specific
are still prone to lament the lack of time taste categories. When eating shifts from
for physical education due in part to the salty turkey to sweet pecan pie, a new ap-
stipulations of the ‘No Child Left Behind’ petite center is activated, and hunger re-
legislation.167 But if the school day is a sumes.
round hole and time-honored approaches This is of profound significance in a
to physical education a square peg, surely world awash in highly processed foods.
human resourcefulness is up to the task of First, a wide variety of foods is available
redrilling the one, or whittling the other. almost constantly. Second, a variety of
For example, perhaps elementary school flavors is designed into individual foods,
teachers could be trained to guide their perhaps as a willful attempt by the food
classes through a 5-minute aerobic routine industry to manipulate appetite. Com-
during each session of the day.168 Such mercial breakfast cereals routinely contain
an approach might serve to dissipate the nearly as much salt as salty snack items.
native restlessness of young children, en- Sauces, dressing and condiments that taste
hance the behavioral environment in the salty routinely contain sugar in quantities
classroom, and improve academics, while to rival dessert items. Processed foods of
allowing for the accumulation of 40 min- every variety contain artificial flavor en-
utes or so of fitness-enhancing activity for hancers. Efforts by the food industry to
student and teacher alike over the course combined flavors for maximal effect on the
of the day. appetite center were described in an expose
There is comparable opportunity to published in the Chicago Tribune in Janu-
empower individuals and households ary of 2006 (http://www.chicagotribune.
through innovation. Simply noting that com/news/specials/chi-oreos-specialpack-
the challenge of eating well is more about age,1,7094476.special?coll=chi-news-hed).
‘how’ than ‘what’ may be of some use.169 Many other food industry practices, and
Of potentially greater utility is the de- cultural patterns, that influence dietary in-
tailed elucidation of little known barriers take are addressed in a recent book.171
to weight control, and the strategies that Viewed dispassionately, epidemic obe-
serve to overcome them. sity is the perhaps inevitable consequence
One example is sensory specific satiety, of a veritable flood-tide of obesigenic fac-
the very well researched tendency to be- tors that have accumulated and converged
come full faster when flavor varieties are to make an abundance of calories con-
limited, and to stay hungry longer when stantly and temptingly available, while
flavors are available in greater variety at reducing ever further both vocational and
any one time.170 The most universally fa- recreational physical activity. To hold back
miliar representation of this phenomenon flood waters requires a complete dam. No
is feeling stuffed at the end of a holiday one sandbag, brick, or branch will make
meal, but still finding room for dessert. any discernible difference at all. But every
Rather than the proverbial hollow leg or dam begins with a first sandbag, brick, or
extra stomach, this extra room actually is branch, and could not accomplish its in-
144 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
tended purpose without them. This, in than elevators the social norm. We need
part, explains why epidemic obesity has to overhaul the food supply and eliminate
thus far proven intractable. A defense the category of ‘junk’ food. We need to
commensurate with the threat has not yet subsidize the sale of fresh fruits and veg-
been constructed. etables. We need truth in advertising and
What would be the anti-obesity ana- controls on food marketing to children.
logue of the Hoover Dam? A compre- We need to educate families about how to
hensive system of reforms in knowledge, practice good nutrition, and good physical
behavior, policies, and the environment. activity together. It should once again be
We need schools that provide nutrition possible for children to walk and bike to
education, serve only food that conforms school. And while a place in our barricade
to what is being taught, and make a place may be reserved for bariatric surgery and
for physical activity as a part of every day. drugs such as rimonabant, it must be in a
The remedy for the native rambunctious- small and isolated corner.
ness of children is recess, not Ritalin. Accountability for these actions is
We need clinicians trained to provide shared. Many anti-obesity policy initia-
weight management counseling that is ef- tives warrant and require government in-
fective, efficient, and compassionate; and tercession. These include policies related
an insurance system that will reimburse to the built environment; food marketing;
those who use behavior modification sci- public sector insurance benefits; school
ence to counsel artfully. We need physical food standards; food subsidies; and more.
activity breaks to be a standard part of the The academic community should accept
work day- and perhaps financial incentives responsibility for separating debate about
for the pursuit of health when it is not, nutritional fine points from the expression
alas, its own incentive. of consensus about fundamentals. The
We need food labels for dummies that clinical community should establish and
enable consumers to know, at a glance, enforce basic standards in lifestyle counsel-
what choices are best, and when to step ing. And ultimately, as more useful poli-
away from the box so no one gets hurt. cies are adopted and more resources are
Every neighborhood needs to provide rec- made available, individuals and families
reational facilities and sidewalks, and new must accept responsibility for making use
neighborhoods should be designed so that of them. The control of obesity will ul-
it makes sense to get around them by foot, timately require a balance between public
rather than car. We need social engineer- policy, and personal effort.
ing to give us back time to prepare food at
home, or ways to eat out that offer good
nutrition at low cost. We need new-age Conclusions
tools, such as www.healthydiningfinder.
com, to empower our navigation through In a report on the prevention of child-
the challenges of the modern nutritional hood obesity, the Institute of Medicine has
landscape. offered a useful array of policy recommen-
We need to make use of stairs rather dations (Institute of Medicine. Preventing
Vol. 7, No. 2, Fall 2006 145Health Highlights
Childhood Obesity: Health in the Balance. eat less, and the desire of the food indus-
September 30, 2004), while a more recent try to sell more. We will need to confront
report indicates that much of the work is the paradox that obesity, due to its health
still undone (Institute of Medicine. Prog- toll, is objectionable, even though its root
ress in Preventing Childhood Obesity: How causes- an abundance of desirable food
do We Measure Up? September 13, 2006). and the opportunity to be sedentary- his-
There are several reasons for relatively slow torically are not. The greatest obstacle to
uptake of the policy recommendations obesity control is ambivalence.
proffered by the IOM, and others (Nestle Obesity trends will not change appre-
M, Jacobson MF. Halting the obesity epi- ciably until the aggregation of obesity con-
demic: a public health policy approach. Pub- trol strategies is commensurate with and
lic Health Rep. 2000;115:12-24). opposite to the aggregation of obesigenic
First, obesity control requires an array of elements in modern society. This means
coordinated actions, but there is no coordi- that even when actions against epidemic
nating entity. Many of the actions needed obesity are robust, evidence of success will
to contain academic obesity, such as school initially be sparse. Evidence of success is a
nutrition policies, zoning regulations, food potent stimulus to policy reform, whereas
marketing, and pricing incentives fall with- its absence is a potential impediment for
in the purview of the government. Oth- failing to reward investment of effort or
ers, such as media representations, clinical resources. There is thus a need to focus on
counseling, insurance benefits, and social intermediate outcomes, such as changes
marketing are substantially outside the in dietary pattern or activity level, as early
government’s control. Ultimately, the use measures of success in obesity control. Ef-
of information regarding dietary choices fects on weight patterns in the population
and physical activity must be put to use by will be discernible only after a delay that
individuals. While the personal choices of allows for the gradual accumulation of
individuals will generally fall outside the necessary, but independently insufficient,
purview of public policy, the flow of in- contributions to a comprehensive array
formation and resources to empower those of obesity control program, policies, and
choices falls within. The US Secretary of practices.
Health, or perhaps a designated appointee While simple to explain, epidemic
in the position of “obesity czar,” should obesity will be anything but easy to fix.
be accountable for the coordinated imple- We must overcome the propensity of our
mentation of obesity control strategies genes, the propulsive force of culture and
needed to empower individuals. some 6 million years of gathering momen-
For this to occur, we will need to rec- tum. The task is daunting, but possible.
ognize the magnitude of the obesity crisis Each useful policy, program, or strategy
and overcome our general reticence toward implemented will function like one sand-
governmental regulation. We will need to bag in a levee. When we have stacked
acknowledge conflicts of interest that pre- enough strategies together, the flood tide
clude reliance on market forces, such as of obesity will be turned.
the need for an overweight population to
146 Harvard Health Policy ReviewKatz: Obesity...Be Damned!
Acknowledgments 14. Caballero AE, Saouaf R, Lim SC, Hamdy O, Abou-
Elenin K, O’Connor C, et al. The effects of tro-
glitazone, an insulin-sensitizing agent, on the endo-
This work was supported in part by thelial function in early and late type 2 diabetes: a
placebo-controlled randomized clinical trial. Metabo-
Grant # U48-CCU115802 from the Cen- lism 2003;52(2):173-80.
ters for Disease Control & Prevention. 15. Ogden CL, Carroll MD, Flegal KM. Epidemiologic
trends in overweight and obesity. Endocrinol Metab
Review of the manuscript by Dr. Zubai- Clin North Am 2003;32:741-60.
da Faridi, and the technical assistance of 16. Burton WN, Chen C, Schultz AB, Edington DW. The
Michelle Larovera are gratefully acknowl- economic costs associated with body mass index in the
workplace. JOEM 1998;40(9):786-92.
edged. 17. Willett WC, Manson JE, Stampfer MJ, Colditz GA,
Rosner B, Speizer FE, et al. Weight, weight change,
and coronary heart disease in women. Risk within
the ‘normal’ weight range [see comments]. JAMA
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