The American Heart Association recently published a sobering “scientific statement” on severe obesity among children and adolescents in the U.S. in their flagship journal, Circulation. The report, predictably spawning widespread attention in the popular press, suggests that by reasonable criteria, between 4 percent and 6 percent of our kids between the ages of 2 and 19 have severe obesity.
Those percentages probably don’t fully convey how common that makes this ominous condition. Consider that if a typical classroom held roughly 20 kids, there would be one “severely” obese child, on average, in every such classroom in the country. That is stunning, and extremely alarming — particularly given the current trends. Those trends, also noted in the report, indicate that severe obesity is “the fastest growing subcategory of obesity in youth.” Even where overall rates of obesity are leveling off, rates of severe obesity are rising briskly.
Our problems begin with our apparent inability to keep our eye on this ball. All too often, and at our collective peril, we treat scientific research like a Ping-Pong ball, diverting our attention first this way, then that. Media uptake of any given study often gives the impression that it represents the new, final word — replacing all we thought we knew before. But, of course, science is incremental; studies don’t replace one another, they contribute to the gradually accumulating weight of evidence. When we learn that rates of childhood obesity may be dipping slightly in some places, or leveling off among adults, it does not refute everything we knew about the outrageously high prevalence, the grave metabolic consequences, or the run-away increases in the most severe forms.
If virtually all of those vulnerable to obesity — adults and children alike — are already there, we can count on rates stabilizing. But if we are failing to help those who are already there from succumbing ever more fully,we can count on weights rising. It may no longer characterize the toll of epidemic obesity adequately to determine how many of us are overweight; that number may be relatively fixed now. We may need to ask: How overweight are the many of us? The American Heart Association gives us this answer about our kids: very.
This may explain why diabetes rates are rising on a truly ominous trajectory, even as overall obesity rates level off. More severe degrees of obesity are more predictive of metabolic complications and chronic disease, the details of just such associations occupying much of the new report’s verbiage.
But with the pages devoted to the new solutions we need, welcome and appropriate as this attention is, the AHA authors were far too conventional in my view. One of Albert Einstein’s famous witticisms is brought to mind: “We cannot solve our problems with the same thinking we used when we created them.”
We created the problem of epidemic obesity in children, and now hyper-endemic obesity in adults, over the past half century while propagating its causes in our culture and seeking its remedies in our clinics. But scalpels may be a very sorry substitute for the good that might be done in schools; pharmacotherapy may compare quite unfavorably to empowering better use of feet and forks.
Imagine looking at us from without, and assessing causes and cures of severe obesity informed by a dispassionate view from altitude. There would be a role for clinicians, clearly, but much of the relevant medicine would be cultural. Is it symptomatic of our inability to see outside the donut box that there is no mention in the new report, for instance, of aggressive food marketing to children?
The causes of obesity are not so much within us, as all around us. We and our kids are put together much the same ways we ever were, of course; yet the epidemiology of severe obesity is as it never was before. It takes change to produce change, and while our genes and physiologies are fairly constant, our culture is awash in obesigenic changes. Our plight is the predictable consequence.
There is a correspondingly predictable emphasis on drugs and surgery in the new report, and on models of clinical counseling. These are, indeed, appropriate for severe obesity — but they have severe liabilities.Drugs don’t tend to work very well. Surgery does, at least in the short term. But the costs are high; recidivism may be high as well. And surgery is something of a “deus ex machina” approach to obesity, doing nothing to address the factors that caused it in the first place. Surgery requires the skills of a surgeon but imparts no skills to the patient. Benefits we acquire under general anesthesia, whatever their duration, cannot be paid forward.
As for clinical counseling, consider its challenges. A child who is severely obese is generally caught up in a difficult dynamic at the family level. For a clinician to provide family counseling, appointments need to be scheduled for the whole family — a logistical challenge. If these appointments are during business hours, they pull adults away from work (assuming they are employed), and kids away from school. At best, the frequency of such encounters will be modest compared to the scope of the problem, and ill-suited to address some very practical concerns — such as no one in the home having the time, or skills, to prepare a meal.
Such challenges are further compounded by something we likely all know from personal experience, if not from the abundant research literature on the topic: Severely-obese kids are severely persecuted by their peers. When we were young, the “chubby” kid was the object of schoolyard bullying, to the regret of those of us victimized by it, and the shame of those of us who perpetrated it. Now, among kids who are chubbier in general than we were, it’s the severely “fat” kid who gets that daily dose of derision. That addition of insult to injury can lead to depression and despair, putting the behavior change needed for a remedy hopelessly out of reach. Can we really expect a doctor visit, even as often as once a month, to fix all of this?
There is something that can. We can embed solutions to severe obesity into the existing infrastructure of our lives and routines.
So, for instance, just as we have boarding schools to cultivate the talents of the academically gifted, or remediate the difficulties of the behaviorally challenged, so, too, could we have boarding schools for the severely obese, that blend academic rigor with comprehensive weight management. The appeal of such a concept, nowhere mentioned in the AHA report, is that severely-obese kids could get the intensity of treatment they need without stepping out of their lives to do so.
That treatment would almost certainly include behavioral, and psychological counseling. Depression and despair would need to be recognized and addressed by qualified professionals.
It would also include an emphasis on the relevant skills, such as identifying nutritious foods, learning how to choose and prefer them, and learning how to cook. It would include physical education and training, with an emphasis on strategies to fit fitness into every kind of daily routine. And by providing this and more in an environment where all the kids have run the same gauntlet, such a program could offer the therapeutic benefits of community, and compassion, and understanding.
And finally, if we could “fix” severe obesity in kids by empowering them with skills for healthy living, the kids could pay such benefits forward — to family members, and peers. Imagine re-integrating such kids into their public schools of origin, where their success at not just losing weight, but finding health — could inspire hope in others. Imagine such kids acting as peer mentors with a unique fund of knowledge and experience on which to draw.
And then stop imagining, because at least one such program exists. I have been privileged to serve as senior medical advisor to Mindstream Academy, which is the very model I’m describing. The results to date are stunning — with kids losing an average of nearly 50 pounds per semester, and some losing closer to 100. More important still is what the kids find: hope, self-esteem, and a renewed capacity to believe in themselves, and dream. And all of this is achieved by teaching a set of sustainable skills, not with any quick-fix gimmickry.
Why is the Mindstream model not more widely known, not mentioned in Circulation, and not accessible to the hundreds of thousands of kids who need it? In a word: money.
The families of severely-obese children tend to be the very families least able to afford treatment of any kind. Third-party payers can fix this, but they are accustomed to looking only at “medical” treatments. We tend to be rather blind to the possibility of lifestyle, or culture, as the medicine we need. But these are, in fact, the best medicines we’ve got – and with the potential to save us dollars along with lives.
Admittedly, we need to prove it. The Mindstream experience to date, for instance, needs to be published in the peer-reviewed literature; that’s in the works. We need to know more about the overall cost-effectiveness of such an approach, its sustainability, and how the program might be modified and still work. But we have routinely reimbursed for “medical” treatments before having such data. Even now, we know little about the long-term effects of bariatric surgery in tweens and teens. We might at the very least give school the same benefit of doubt we give scalpels.
There are many reasons why a problem that is hard but not truly complex, and amenable to remedies involving better use of feet and forks, has defied us for so long. We are inclined to medicalize obesity to legitimize it. But obesity as a “disease” implies a need for treatments of a clinical nature, drugs and surgery in particular. There are many good reasons why we do not have, and are unlikely to have, good drugs for obesity treatment. Surgery works, although just how long and how well for children, we really don’t know. But even if it worked well and sustainably, would we really want to sanction sending our sons and daughters through the operating room doors, to reorganize their gastrointestinal tracts, because we couldn’t manage to find ways to keep them from passing under the Golden Arches quite so often?
Even as we tear our proverbial beards, and gnash our teeth, we manage to turn a blind eye. Obesity is a cultural problem and requires a cultural solution we have the knowledge and means to administer. That we fail to apply those means — that we can watch television shows telling us of this threat to our kids, while our kids watching television are bombarded with intensive marketing of the very products that propagate the problem — bespeaks our ambivalence at best, our profit-driven hypocrisies at worst. Are we truly willing to mortgage the health of our children to fortify the corporate bottom line?
This is largely a problem of will, and money. Money, too, figures in the new report. The authors note that access to effective treatments for severe obesity is limited by lack of insurance coverage. In fact, the closing line of the article closes with a focus on dollars: “The task ahead will be arduous and complicated, but the high prevalence and serious consequences of severe obesity require us to commit time, intellectual capital, and financial resources to address it.”
Given the dire consequences of severe obesity left unaddressed, pecuniary neglect is at best penny-wise and pound-foolish. But given the prospects for losing far more than pennies as the pounds accumulate to rob our vulnerable daughters and sons of both years of life, and life in years, it is far worse than that. It is a colossal, collective cultural failure of the first order.
The new report speaks to the grave threat of severe obesity among our children and hints at the solutions we need. The solutions exist; the will to cultivate them seems to be in question. So, the words in this report are just a start. The question now is this: Will we put the needed money where these erudite mouths are?
David L. Katz is the founding director, Yale-Griffin Prevention Research Center.