Obesity: What To Do About It

This is the part I have been dreading; it’s been relatively easy describing the problems and their causes but fixing the problems is another thing. There is good news and bad news about treating obesity (we’ll tackle diabetes issues later). First the bad news- there are no treatment approaches that have been shown to be highly effective and safe over an extended period of time, 5 years or longer. Almost any weight reduction plan will work in the short run; take your pick of diet books, commercial weight reduction programs, or whatever. None really work well for the majority of people, children or adults. That’s not really surprising given the power of the brain appetite center and our way of life.

The good news

All is not lost. It is still possible for people, children and grown-ups, to lose weight or, at least, not gain excess weight year after year as most people do. It does, however, require that a person recognize his or her problem and commit to a solution long-term. Dealing with obesity is no place for the timid.

Where to start: Goldstein’s principles

1. First, I do not really believe in “diets” as most people use the term. In most instances a diet implies some plan to consume fewer calories until whatever weight goal is achieved. Thereafter, most “diets” get a little fuzzy about what to do and inevitably most people (note- I didn’t say everyone) regain all the weight they have lost and then some. I believe the primary reason most “diets” fail is that they do not really give a person a satisfactory way of eating life-long. In fact, there are considerable data showing that the best way to lose weight and keep it off is to lose weight slowly through a new approach to eating that can be sustained long-term. We should stop taking about “diets” and begin talking about healthy eating plans. A healthy eating plan should be the way all of us eat, overweight or not.

2. People who are significantly overweight (BMI >35) need to face their situation squarely in the mirror- literally and figuratively; they are at great risk for serious consequences of their obesity. They have to come to the conclusion themselves. For children it’s a bit tricky and parents need to be very sensitive to the psychological side of their child’s obesity. This is particularly true for teen-age girls. I have encountered many mothers who create enormous stress by continually nagging about their child’s “problem.” The mothers clearly mean well and are genuinely concerned about the short- and long-term consequences of their child’s obesity; many of these mothers struggled with their weight as teens and many are still struggling. Parents must not press too hard, despite the seriousness of the situation. I was told about a recent report on CNN describing a high prevelance of bulimia in teenage girls placed on diets (there’s that word again!).

3. Let’s forget about “guilt trips” and anti-obesity bias. Most people got overweight by just living in a “machines can do almost everything for us” era and by listening to their brain appetite centers. Most people who are overweight are not suffering from serious personality disorders characterized by lack of restraint. It’s not a disease (it could be a symptom of a disease such as hypothyroidism), although over time it certainly can have serious health consequences. Those of us who are lucky enough to have desirable BMIs need to stop looking at overweight people with some measure of distain or even revulsion. It’s an irrational bias that doesn’t often help people who are overweight deal with their situation (our society has the same type of bias against short people- that’s called heightism. We’ll discuss it at another time). Many physicians have trouble working with people who are overweight simply because of this anti-obesity bias and their belief (probably subconscious) that the patient is to blame for his or her problem.

4. Keep it simple. While a very complicated weight management plan might be a great idea for a neurotically obsessive-compulsive person, most people do best with simple, easy to understand plans that are also easy to implement. I already discussed my aversion to “diets” and I especially do not like diets that offer a gimmicks as their draw; usually it’s completely avoiding a certain type of food (e.g., don’t eat anything that is white in color, don’t eat bread or pasta) and often the plan includes purchasing expensive foods or supplements. It’s amazing- just because someone writes a book (or a blog?) people tend to “believe.” Certain diet plans are also trendy and come and go as quickly as the “beautiful people” find they are hard to follow or, as is usually the case, do not work long-term.

I confess that I am being a bit heavy-handed with my criticisms of many diet plans out there but in my experience simple and nutritionally sound eating plans work best.

5. People who are overweight need to know as much as possible about nutrition principles. They need to understand the differences between carbohydrates, proteins, and fats. They also need to know about saturated fats and trans fats. They need to know how to read food labels (maybe we’ll cover that subject in the future?); if whatever food they are contemplating purchasing has 18 grams of fat in each portion and that fat is mostly saturated fat, they need to appreciate what that means for their eating plan (answer- maybe good tasting but not anything very good for their eating plan). Children as young as 6-7 years can be taught quite a bit about nutrition.
Not to be overly critical of physicians, but most don’t have a clue about good nutrition; it is generally not taught at all in medical school or in residency/fellowship training or if it is taught, addressed in a very cursory way. Even though I think I have a better-than-average understanding of nutrition principles, the program I direct for children with obesity (it’s called the University of Missouri Children’s Hospital Health and Fitness Clinic) relies on a pediatric dietitian to help educate patients and their families.

6. Healthy eating plans must be individualized and the specifics depend on the unique characteristics of the overweight person and his or her family. Unfortunately, developing a customized healthy eating plan requires that the health-care provider know a great deal about the overweight person and family; the plan will be doomed to failure unless it takes into account the way the overweight person and family “operate.”

For example, if an overweight child comes home after school and is all alone, maybe a major contributor to the overweight is the afternoon megasnack? Is it a very busy family, always on the run, with many meals at fast-food restaurants (or meals eaten in the car to or from some activity?). Does the family tend to spend many evenings watching TV and snacking? You get the picture? It helps to know a great deal about how the overweight person and family eat and live before trying to fashion a healthy eating plan. Of course, in many instances given the genetic aspects of obesity, the healty eating plan is appropriate for the entire family.

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