Friday, October 2, 2009
The inability of the volunteers to maintain their diets must give us pause. The study was led by
seasoned investigators who were experienced in the performance of diet and drug trials. The participants were highly educated, enthusiastic, and carefully selected. They were offered 59 group and 13 individual training sessions over the course of 2 years. Nonetheless, their body-mass index (the weight in kilograms divided by the square of the height in meters) after 2 years averaged 31 to 32 and was moving up again. Thus, even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic. The results would probably have been worse among poor, uneducated subjects. Evidently, individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices.
It is obvious by now that weight losses among participants in diet trials will at best average 3 to
4 kg after 2 to 4 years and that they will be less among people who are poor or uneducated, groups that are hit hardest by obesity. We do not need another diet trial; we need a change of paradigm.
A little-noticed study in France may point the way. A community-based effort to prevent overweight in schoolchildren began in two small towns in France in 2000. Everyone from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government joined in an effort to encourage children to eat better and move around more. The towns built sporting facilities and playgrounds, mapped out walking itineraries, and hired sports instructors. Families were offered cooking workshops, and families at risk were offered individual counseling.
Though this was not a formal randomized trial, the results were remarkable. By 2005 the prevalence of overweight in children had fallen to 8.8%, whereas it had risen to 17.8% in the neighboring comparison towns, in line with the national trend. This total-community approach is now being extended to 200 towns in Europe, under the name EPODE (Ensemble, prévenons
l’obésité des enfants [Together, let’s prevent obesity in children]).
Like cholera, obesity may be a problem that cannot be solved by individual persons but that
requires community action. Evidence for the efficacy of the EPODE approach is only tentative, and what works for small towns in France may not work for Mexico City or rural Louisiana. However, the apparent success of such community interventions suggests that we may need a new approach to preventing and to treating obesity and that it must be a total-environment approach that involves and activates entire neighborhoods and communities. It is an approach that deserves serious investigation, because the only effective alternative that we have at present for halting the obesity epidemic is large-scale gastric surgery.
