If Diets Don't Work, What's the Solution to Obesity in America?

Trying to teach adults how to lose weight is about as effective as teaching house cats to swim. For most people, diets simply don't work. The latest evidence: a recent study published in the New England Journal of Medicine examining diets with different proportions of carbohydrates, protein, and fat. Not surprisingly, it made no difference what kind of diet people followed; if they reduced calories, they initially lost weight. But after two years, average participants had regained weight, leaving them with a net loss of just 9 pounds . . . and on a path toward further regain. A similar study published in 2007 also found that dieters regained weight regardless of their regime.

Certainly, a small portion of dieters do manage to keep weight off; about 15 percent of participants in the latest NEJM study dropped at least 10 percent of their body weight. There may be things to be learned from looking at how they differ from their less successful study participants-perhaps they simply have better willpower or more time to come to counseling sessions. But in looking for a broad-based, cost-effective solution to the problem of obesity, some wonder whether the field needs a major attitude change.

"[It's a] basic instinct, even stronger than the sexual instinct, to store calories to survive the next period of starvation, says Martijn Katan, of the Institute of Health Sciences at VU University in Amsterdam, who wrote an editorial that appeared in NEJM along with the most recent diet study. "And we live in an environment where there's food every half mile. It's tasty, cheap, convenient, and you can eat it with one hand," he says. Against that background, he argues, individual treatment, whether focusing on dietary components or behavior, is most often futile.

He and others, including obesity researcher Barry Popkin, urge that more research dollars be directed toward studying community-based efforts that tackle the problem from multiple angles: Towns might build more bike paths and playgrounds, students might get more physical education in schools, nutritionally vacant foods might be taxed to discourage consumption, families might have access to free counseling. The point isn't that any one of these measures has been so proved to work that it should be rolled out nationwide but that these components need to be studied. "What really works, if you look at it in a cold, scientific way?" wonders Katan.

There's been some preliminary research suggesting that broad, community-based efforts may help. One program, in two small towns in France, was described this way by Katan in his editorial: "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." Inspired by some evidence that it works to curb the prevalence of overweight and improve the health of adults as well, a larger program called EPODE is now being rolled out in France and elsewhere in Europe. While EPODE is promising, more research is needed to see whether such a community approach works and how it might be implemented outside Europe.

That's especially true in the United States, where the individualistic culture is supportive of the idea that obesity is more a matter of personal responsibility and less one that requires regulation of industry and other large policy changes. "It's great for people to be responsible, but we have to make it easy for them," says Marlene Schwartz, deputy director for the Rudd Center for Food Policy and Obesity at Yale University. "We have to create an environment that facilitates responsibility." She says that after training as a clinical psychologist and studying therapeutic techniques for treating eating disorders such as binge eating disorder, she came to believe that "a very small percent of the obesity problem is due to emotional distress and that the largest contributor is the environment. So I've shifted my research more towards policy change."

Some of her former colleagues in the treatment arena, while fully acknowledging that the environment encourages overeating, are still interested in developing therapies for individuals. Two smallish Swedish studies have suggested that cognitive therapy—which teaches people the mental and emotional skills they need to make and sustain change—can help people lose weight and keep it off for at least a year and a half, says Judith Beck, director of the Beck Institute for Cognitive Therapy and Research.

In addition to cognitive therapy, other approaches are being applied to binge eating and have potential to help general overeating. (Studies suggest that up to 30 percent of people seeking help at weight-loss clinics are binge eaters, according to Eunice Chen, codirector of the Eating Disorders Program at the University of Chicago Medical Center.) Dialectical behavioral therapy, as applied to eating disorders, assumes that sufferers are attempting to "suppress, avoid, or numb out emotional experiences so that they're less painful," says Debra Safer, a psychiatrist at Stanford University. The goal is to teach people to regulate their emotions, through techniques including mindfulness—paying attention to how you are feeling in the present and self-acceptance. Mindfulness on its own is already being used as a method to treat overeating. But efforts to roll out any of these techniques on a large scale as treatments for obesity are still in their infancy. "We are just now trying to articulate with data where the treatment of binge eating disorder fits into the treatment of obesity," says B. Timothy Walsh, a psychiatrist at Columbia University who studies both psychological and pharmaceutical treatments for eating disorders.

In the meantime, lacking a proven method for weight control and trapped in a world that encourages overeating and underexercising, what is an obese or overweight person to do? First, remember that we are all an experiment of one. Some people do lose weight and keep it off by modifying their own actions; studies have shown that in addition to changing their eating behaviors, those folks tend to get a lot of exercise and monitor themselves carefully by frequent weigh-ins or food diaries. It can't hurt to try some of the mindfulness techniques that are part of dialectical behavioral therapy and espoused on their own and some of the cognitive techniques, too.

Also, while you can't control everything about your environment, you can focus on your microenvironment. Cornell University's Brian Wansink has some great ideas about structuring your immediate surroundings to reduce the risk of mindless eating. And don't forget your social environment—recent research suggests social networks are important in promoting or discouraging obesity. "The data are pretty clear that adults are pretty much going to need ongoing care and support . . . we need to try to help them build that into their lives," says Denise Wilfley, director of the Weight Management and Eating Disorder Program at Washington University. That means making sure family and friends support healthful behavior whenever possible—and even extending that into the workplace, by bringing in fruit as an office snack for example, says Wilfley.