War is Hell

The basic problems facing the world today are not susceptible to a military solution. –John F. Kennedy

Despite what JFK once said, it seems that the way our American culture faces into crises is by declaring war against the perceived perpetrator.  Even when no guns are fired or troops deployed, we have adopted the language of war as the way to demonstrate we are serious about domestic problems, particularly those that have a highly damaging effect on our right to life, liberty and pursuit of happiness.  As such, we have fought wars on communism wars on drugs, wars on terrorism, wars on taxes and now it appears we are in the process of declaring an all-out war on obesity.  Cue the Battle Hymn of the Republic:

Glory, glory Hallelujah,

Trade your tater tots for tuna,

Better quit the foods that screwed ya,

Or you’ll be passing on!

 

During the past week I have been inundated with examples of the coming preparations for battle.  It started with an opportunity I had to introduce a panel at a conference hosted by Health Evolution Partners.  The panel featured Microsoft Health Solutions Group’s GM Nate Mclemore interviewing David Kirchhoff, CEO of Weight Watchers, and Dr. Michael Roizen, Chief Wellness Officer of the Cleveland Clinic.  The panel focused on the Cleveland Clinic’s very aggressive program to reduce its employees’ weight through a program put together with Weight Watchers.

You really could not find a better business model than that of Weight Watchers.  Heading into their 50^th anniversary as a company, they have an endless user base that sadly keeps replenishing itself. Similarly, the Cleveland Clinic has an endless supply of people who need its help, often directly as a result of a lifetime of overeating.  I once heard a comedian say that the best business model in the world was that of Arm & Hammer Baking Soda.  Their product has a label on it that directs you to take it home and pour it down the sink, thus guaranteeing a subsequent purchase.  Given how hard it is to lose weight, much less keep it off once lost, Weight Watchers may be giving Arm & Hammer a run for its money.

However, by working with Weight Watchers, the Cleveland Clinic has been waging a war on obesity on multiple fronts.  The Clinic’s 41,000 employees have lost nearly 300,000 total pounds, which is roughly equal to the collective weight of the Cleveland Browns and just slightly less than the weight of Rush Limbaugh.

According to Dr. Roizen, this program was a success because everyone committed 100%, starting with the CEO.  Key to ensuring the program’s effect were four critical actions:

1. Giving people an “aha moment” by installing leaders who themselves had lost a lot of weight; this enabled people to say, “if they can do it, I can do it”
2. Creating cultural and environmental change, such as removing all high sugar, high fat foods from the cafeteria, making the fitness facilities free and banning smoking on the entire 15×6 block Cleveland Clinic campus (at least two employees who refused to honor the smoking ban were ultimately fired).
3. Ensuring each employee had a buddy who supported them through the process; and,
4. Providing financial incentives to both employees and the doctors who oversaw their process of achieving the “5 normals.”  Patients who could achieve normal levels of smoking (none), blood pressure, lipids, glucose, and body mass index were awarded $2000; providers whose patients were successful received financial rewards for their department; the ultimate plan is to pay the providers $2000 for each successful patient as well, according to Roizen.

By implementing the program 60% of all employees with chronic disease achieved the 5 normals and 80% of all employees who had no chronic diseases achieved them.  This was a marked increase from the 8% of employees who had “5 normals” before the program.  That’s pretty impressive.  There was a lengthy discussion about whether a program such as this could scale to be utilized elsewhere.  Everytime they said the word “scale” I had to stifle a little bit of a laugh…I mean seriously, what is a weight loss program without a scale?

My favorite part of the Cleveland Clinic program, however, was the requirement that the campus police force get “fitness certified,” presumably so they could chase after people who were dashing off campus to get a cheeseburger and fries.  I’m a little concerned about the wisdom of taking donuts away from the cops while leaving them with their firearms, but so far so good out there in Cleveland.  Dr. Roizen did say that he got 71 death threats when he directed the cafeteria to eliminate sugary beverages; he got only 3 death threats when he banned smoking.

I really appreciated Weight Watchers CEO David Kirchhoff’s comments on the importance of sustained efforts to build new health habits, rather than rely on willpower, to create weight loss success.  Kirchhoff said willpower was akin to “waterboarding.”  It eventually wears you down and results in “decision fatigue.”  It is only when truly persistent new habits of eating, exercising and other healthy behaviors are formed that success can be achieved.

Based on the success of the Cleveland Clinic program, U.S. Senators Ron Wyden and Rob Portman have introduced an actual Senate bill to institutionalize a $400 reward for Medicare members who achieve the 5 normals.

Hot on the heels of the Health Evolution Partners’ conference, I received an email from a colleague alerting me to an upcoming television series put together jointly by the Institute of Medicine and HBO, among others, called “The Weight of the Nation.”  This four-part television event, which will be shown May 14-15 on HBO, examines the scope of the obesity problem, the science behind it, its consequences, how it has personally affected families and especially children and the forces behind it, including: agriculture, economics, evolutionary biology, food marketing, racial and socioeconomic issues, physical inactivity and the influence of the food and beverage industry.  I am guessing that the latter are the ones wearing the black hats and Snidely Whiplash mustaches in this particular television extravaganza.

Let’s forget for the moment that, being on HBO, only a small segment of the population who is willing to pay for premium channels can watch this.   This program (slogan: To Win, We Have to Lose), is publicized as being far more than just TV fare; there are companion community screening, employer/employee awareness, and even a pledge you can sign.  The idea is to make this a phenomenon, not just a TV show, which increases awareness and spurs broad action.  We shall see.  It is a great idea but again, it has to lead to habits, not willpower.  TV doesn’t really lend itself to long-term calls to action, but one never knows and it is certainly worth a try…provided that the people watching this are not sitting on their couch eating ice cream while doing it.  There is a certain irony to asking people to learn about physical inaction and its negative consequences while sitting on their butt in front of the TV screen, but I guess you gotta meet people where they live, right?

Numerous other signs of the simmering war against obesity floated by me this week, but the last I will point out is the incredible amount of scientific effort that is being channeled to find medication-based alternatives to good old-fashioned hard work.  UCSF announced a scientific breakthrough that turns “bad” fat into “good” fat, rendering it potentially possible to use our own good brown fat cells to vanquish their evil pasty twins, the bad white fat cells. Apparently we all have two kinds of fat cells in our bodies, white fat that stores calories and brown fat that actually burns calories.   Who knew?  For those people who tend to think white is superior, this is incontrovertible truth of the opposite once again.

According to an article on the breakthrough by a UCSF team lead by Shingo Kajimura, Ph.D.:

“Scientists say the brown fat cells help small mammals like mice keep their body temperatures up by producing heat as they burn calories. The same is true for human babies. But the ratio of brown cells in our bodies typically plummets as we grow.  But what if there was a way to change that equation to safely increase the number of brown fat cells in obese patients? Kajimura and his team believe they have made a breakthrough that could ultimately allow doctors do just that. While investigating a common diabetes drug using a mouse model, the UCSF researchers isolated a protein that converts ordinary white fat cells into the calorie burning kind. The protein exists in both mice and humans…If successful, Kajimura believes the result could be a new form of anti-obesity drugs.”

I am guessing that if there were a simple pill that caused our own fat cells to attack each other, many of us would be out buying mouse costumes so we could get in on the study right now.  Everyone loves the idea of a magic pill solution to the problem of obesity, but so far one has not emerged despite multiple attempts.  I, a non-scientist, am convinced that this is because overeating is not simply a physical problem, but a psychological problem as well.  People eat for comfort, reward, when depressed, when lonely, and for an abundance of other reasons that have nothing to do with physical cravings or the proximity of candy vending machines to their gym.

Cleveland Clinic’s Dr. Roizen said that the one thing he would have done differently in his program was to start with group counseling focused on stress reduction, rather than add that in at the end as they did, acknowledging the importance of the mind-body connection.  If we are going to win a war against obesity, we are going to have to remember that the enemy includes sadness, depression and stress, not just the Denny’s Mac & Cheese Big Daddy Patty Melt, the single most-fattening American fast food item at 1690 calories.  Oh, and by the way, Denny’s, purveyor of said Patty Melt, has a highly evolved employee wellness program targeted at good nutrition and weight loss.  Life is full of irony.  It’s going to be tough to win a war on obesity with Benedict Arnold in the kitchen.

In a country that prides itself on freedom, even freedom to destroy one’s own health through neglect and slothful behaviors, it will be interesting to see how we strike a balance in the efforts to foster personal accountability.  Paternalistic efforts such as those of the Cleveland Clinic are not easy to replicate and are not always welcomed either.  On the other hand, by leaving people to their own devices we have created a cellulite-riddled monster, and that monster is the Mac & Cheese Big Daddy Patty Melt and all it stands for.  Clearly the battle lines are now being drawn between and among government, employers, individuals and communities.  With nearly 36% of Americans now considered obese, we had better hope the cavalry shows up to save us from ourselves.

War is hell. –William Tecumseh Sherman