In some ways, it wouldn't even matter if the over-interpretations of the recent and already notorious meta-analysis about obesity and mortality were true, and we could get as fat as we might like with impunity. Alas, for all who favor that idea, it is not true—the adverse health effects of obesity are decisively established.
Overall rates of overweight and obesity in this country appear to have leveled off in recent years. This is no great surprise—they had to level off somewhere, even if it were at 100 percent. It's not 100 percent, of course, but it's not all that far from it either. So we were bound to push up against a ceiling eventually. More encouraging are indications that rates of childhood obesity may be declining, albeit by very small increments, in those places where the most is being done to achieve just such outcomes. The hopeful message in such data is: When we do enough of the right things, we get results.
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But even as overall rates of excess weight have stabilized, the rate of severe obesity has taken to the skies. Unlike the murkier elements in the recent meta-analysis, this is an observation no one is refuting. As I have noted before, it may no longer serve our public health objectives to ask how many of us are fat; we need to start focusing on how fat the many of us are.
And, indeed, we seem to be doing just that—judging by the frequency of bariatric (weight-loss) surgeries.
As we welcome our children into an ever more obesigenic world, we are inviting them to take their place among such statistics. Obesity and attendant chronic diseases, type 2 diabetes notable among them, are occurring routinely at an ever younger age. Severe obesity is occurring at an ever younger age. And with increasing regularity, bariatric surgery is being offered at an ever younger age.
As my friends and colleagues and patients have abundant cause to know, I am a strong supporter of bariatric surgery for those who need it. There are, at times, barriers to it—financial barriers in particular—and I work to overcome those. There are times when bariatric surgery can both avert a premature death, and renew hope for a good life.
But it is surgery—and the most effective forms are rather major surgery at that, involving a rerouting of the gastrointestinal tract. So my friends and colleagues and patients also know that I consider bariatric surgery a last resort. A last resort is far better than no resort—but not nearly as good as earlier options. We can all agree it's a shame at best, tragic at worst, to send a teenager through the operating room doors to have his or her GI tract surgically redirected, to fix what better use of feet and forks could have prevented outright.
The trouble is, simple as "better use of feet and forks" might sound, it is very far from easy in the context of modern living. Our culture does almost everything conceivable to make rare use of our feet, and bad use of our forks the norm. It takes both willpower and skill power to buck these trends, and however much of the former we may have, few of us have anywhere near enough of the latter. We don't have the skills, and neither do our kids.
And so, up until now, when we've addressed severe adolescent obesity effectively at all, we have done so with our last resort: scalpels.
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But we have a new option—and in my opinion, no offense to my colleagues in bariatric surgery—a far better one: school.
But not just any school.
Teens with severe obesity have to deal with far more than the injurious effects of that obesity—to their joints, their hearts, their livers. They also have to deal, on a daily basis, with the addition of insult to that injury. Insult hurled at them by peers in the form of ridicule.
That's a pretty toxic impasse. Kids who develop severe obesity often have pretty serious stresses and challenges in the home to begin with, which is part of why obesity develops. Then, the obesity invites abuse at school to compound whatever difficulties prevail at home. As desperation sets in and self-esteem disappears, comfort foods may be the last friends left on the scene. But of course, they make the obesity worse, and the cycle continues.
There's just no way for even a well-above-average school to deal with this scenario. In fact, it may be that these kids need to get away from the daily dose of derision they encounter at school more than anything. They may need, as we all do, a place where they fit in, are accepted, are supported, and understood.
It may be that Mindstream Academy, a unique boarding school for just such kids, is so stunningly effective because it provides such a place. Or perhaps it's because of the on-campus dietitian, or chef, or personal trainers, or psychotherapists, or equine therapy. Or the tranquil beauty of its 43-acre campus on a former horse farm. Or the blended rigors of its fully accredited academic curriculum, with a comparable devotion to the "sound mind, sound body" principle. Frankly, I think it's all of the above.
Whatever one attributes the effects to, they are stunning and unparalleled. This past semester, Mindstream hosted 13 students from the Independence, Missouri public school district. Collectively, they lost over 750 pounds. That's over 50 pounds on average and nearly 100 pounds in one case. And certainly, it puts the results in the rarefied territory dominated by bariatric surgery and "reality" TV.
But more importantly than what the kids lost is what they found. As the media coverage—which went global—attests, they found smiles. And confidence. And self-esteem. And the capacity to hug. In short, the kids got their lives back.
Whereas surgery makes us passive—we are, in fact, unconscious as it happens—school does just the opposite. School teaches us, then leaves us to use what we've learned. Even as these kids improved their overall academic standing, and lost an amazing amount of weight, they acquired skills with the potential to last a lifetime. They learned how to exercise daily in ways they enjoy. They learned how to identify nutritious food. They learned how to cook.
The true beauty of skills is that we can pay them forward. When one of us undergoes bariatric surgery, no one else directly benefits. But when one of us learns how to cook nutritious, delicious, convenient meals, we can help feed our families better. We can help teach our friends. We can share what we learned.
The Mindstream Academy, where I am privileged to make a very modest contribution as senior medical advisor, has already proved the principle: A school can do what only scalpels could do before. With that proof of principle in hand, what lies ahead?
My vision for that starts modestly. Boarding school is expensive compared to public school. But boarding school that can do in a semester what up until now only surgery could do—and more—is a bargain. But for it to be a bargain, the right people need to pay. The right people are not parents who can't afford it. The right people are those who are already paying: government and private insurers, who pay for bariatric surgery and visits to an endocrinologist.
For starters, insurers, self-insured employers, and the government might support pilot programs—sending select kids to Mindstream, and verifying both the immediate and lasting results. If the results are as expected, this should lead quickly to routine coverage as an often better alternative to surgery.
After that, the vision could grow. For now, Mindstream is in only one location, but it's a concept as much as a place, and concepts can travel. There could be Mindstream campuses around the country, providing a pressure-relief valve to public school systems trying desperately to help children with needs beyond their means, and failing. The schools could be spared the exhaustion of resources that failed to meet the need of these kids anyway, and redirect them to the kids they can help. The students sent to Mindstream could lose weight, find health, and get a new claim on the kind of life they deserve.
And, into the bargain—as was seen last semester—the families of the kids could benefit, too. And then, when the kids return to their original public school system with new knowledge, new confidence, and new skills—they could share those, as the recent cohort is now doing, and help others avoid quite so acute a need in the first place. Everybody wins.
What we have in hand is an extraordinary proof of principle: The right kind of school can do what only scalpels could do before. The true measure of the promise in this for our kids depends on what we choose to do with what we now know.
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David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.