For many overweight and obese people, getting in shape can feel like an act that is meant to be publicly announced and privately executed. Consider NBC’s The Biggest Loser, which has consistently drawn in millions of viewers over the last 10 years by showcasing the spectacle of rapid physical transformation. Sure, the contestants’ dedication to improving their health might be inspiring, but more alluring is the promise of watching a sweaty, shout-filled struggle, with a Big Reveal at the end of the season.
In non-reality show reality, being gawped and sneered at by their fit peers has actually led heavier gym-goers to become members of facilities like Downsize Fitness in Forth Worth that cater exclusively to bigger clientele. There’s a sense that no one will be singled out for the state of her health but, instead, welcomed as part of a community with a shared goal. Emphasizing the importance of community to curtail the prevalence of obesity is the goal of Drs. Walter Willett and Malissa Wood, the co-authors of Thinfluence: the powerful and surprising effect friends, family, work, and environment have on weight.
Dr. Willett is a professor of epidemiology and nutrition, and chairman of the department of nutrition at the Harvard School of Public Health, whose research helped to instate modifications to the USDA Food Pyramid. Dr. Wood, a clinical cardiologist and staff physician at Massachusetts General Hospital in Boston, is co-director of the Corrigan Women’s Health Program and an assistant professor of clinical medicine at Harvard Medical School. As lead investigator of the HAPPY Heart Program, she researched the impact that community-based programs might have on the health of low-income and minority women in a Boston suburb.
Jointly, the two hope to counter the notion that getting in shape is a solitary pursuit and the sole responsibility of the obese. I spoke with the pair about the influence of friends, family, and public policy on weight loss.
Thinfluence’s subtitle states that the book is about the “powerful and surprising effect” that friends, family, work, and the environment have on weight. Why is it important for people to understand the significance of these networks?
Willett: If you look around the world at wealthy countries like the United States, you see very different rates of obesity. In Japanese women, prevalence of obesity is under 5 percent; in Swedish women it’s about 6 or 7 percent. In the U.S., it’s between 35 and 40 percent—and we know that when people come from these countries to live in the United States, they fatten up. That’s a clue that there is something pretty important going on that’s related to where we live, and that there are very important factors operating [outside of us as individuals].
We’ve started to understand some of these; they’re often complex but it’s a clue that Americans aren’t simply completely irresponsible people. And looking at kids, too, their obesity rates have about tripled over the last four years, or quadrupled among some groups. It’s not that kids have become massively irresponsible in such a short time, but that there are obviously factors outside the kids’ inner-selves that are operating here.
So much of what people have been told is that weight is just about individual change. We’re not saying that there is no such thing as individual responsibility, but sometimes even very responsible people can have a hard time making the choice that’s in their best interest if there are a lot of barriers in their daily life and environment. Most diet books just focus on what we should or shouldn’t be putting in our mouths [without] looking really comprehensively at all of the factors around us.
One of the ways you try to categorize the impact of different areas of people’s lives is through a “circle of influence” graph. What are the most important areas to focus on, at least in the beginning of a weight-loss or healthy-eating initiative?
Willett: The closer-in factors will probably be the first things that people pay attention to, because that’s usually where you can make a difference the fastest. You have more control over things like yourself and your relationships, and as you go farther out you have less and less control—but not zero. A lot of people, for example, live in a place where healthy foods are relatively unavailable or very expensive, and often there are small convenience stores that don’t have many healthy choices. Those more distant factors are possible to change but it takes active individuals in groups to make it happen, and change often happens over a period of years, not weeks or months. So you may be working on these bigger factors more for your kids, perhaps, than for yourself.
In terms of the circles of influence, you parse through various internal and external factors that impact weight and unhealthy eating habits. What is the dividing line between those sides?
Wood: Internal factors are important because we don’t give enough credence to the fact that stress, anxiety, and depression are really driving a lot of overeating; those drivers are behind this unhealthy relationship with food that a lot of people have. Many people take an internal struggle and try to solve it by getting comfort from something that’s attainable. What we try to point out is that the links between those factors—stress, depression, anxiety, and obesity—are so strong that addressing the inherent cause of some of those things can have a benefit downstream.
That’s exactly what we did at HAPPY Heart. We recognized that those women had stress and anxiety that were off the charts, and we tried to address the major source of their angst, whether it was, “I don’t know how to balance my checkbook,” or “I’m worried about my home being foreclosed on.” Then, we gave them a forum to really discuss these things and get support from their friends to ameliorate some of the stress in their lives. In this book, we’re trying to do the same by helping people address some of these internal factors that they can manage—and obviously a chemical kind of depression would need to be managed by a professional—so that they can take steps to climb out of that dark space that overeating becomes a part of.
We feel very strongly that there has been so much guilt associated with being overweight or obese as a personal failure, that we want to open it up and say, number one, recognize that your choices reflect a web around you of many environmental factors, which are very important. Second, understand that some of those things you can change and some you can’t, and learn to recognize what you can. It’s harder to change that unless you really help them to see that this is something they have control over.
Thinfluence isn’t only geared toward people who want to become healthier, but to the family members and friends of people who want to lose weight. What is the best way to be supportive but still realistic about a friend or relative’s state of health without badgering them or shaming them? Is that even your job at all?
Wood: I think it is your job in the sense that if you have made some successful choices and you see someone who’s struggling, giving them a bit of advice or support and being there to encourage their choice improves the likelihood that they’ll be able to successfully make that choice consistently. The perfect example is someone who is a really big smoker, and you basically sit down with them and say, “Hey, I know you’re used to this, but I’m here to support you to make other changes. Not only that, but let’s think of things we can do together.” In this case, that could mean walking together or getting involved in some group exercise.
The more people you engage in your process and the more supporters you have in your circle, I think the more likely you are to succeed. Although it’s very extreme, you see something similar in the CrossFit world. If you go to one of their gyms and talk to the people that are there, a lot of them are formerly very, very heavy people. They got into the concept of that group dynamic and were able to stick with it because there was a group of people that were going through the same thing they were going through, and sweating it out, and doing the workouts, and afterward celebrating and enjoying each other’s company. I think that kind of thing is the magic sauce.
Wood: Well, I think there are friends that you have to get rid of. If you know someone is going to drag you down and they’re not interested in making a change, then I think it’s important to kind of separate yourself from them, at least when you’re in that behavior-changing mode. You really have to get into a space where it is automatic that you’re not going to drink six margaritas and eat four bowls of chips with your friends every time you go out. If they’re not interested in doing something else, you’ll have to break from them for a while. It doesn’t mean that you don’t like them or can’t spend time with them down the road, but when you’re adapting to a new change in your life, I think it’s really hard to continue spending time with people like that.
I think some people would find that incredibly off-putting, for the sheer fact that it might seem extreme. It’s hard telling a friend that you can’t—or don’t want to—spend time with them. Is this something that you’ve seen patients do successfully?
Wood: To be clear, I think the only reason to separate from someone is if you really can’t be around them without doing what they’re doing. We’re certainly not encouraging people to stop spending time with the people they love and care about, but if you’re actually making an effort to succeed at weight loss, and the person we’re talking about is someone for whom food is the center of their life, it’s really not in your best interest to spend a lot of time with them while you’re adjusting to your new lifestyle. If they’re not willing to adapt a little bit to accommodate your needs, that’s the only reason to cut them loose.
But I think many of us have friends that would say, “Yeah, I’m totally willing to do that. I think it’s great”—and then they’ll go and do what they want on their own time. So, in the book we try to put more of a positive spin on it: Choose to spend time with people that are willing to support you and join you in this move, versus getting rid of the ones that don’t. Just spend less time with them.
How does that work in the office? Some workplaces ban things like communal treats out of consideration for people who find constantly being bombarded with food difficult, whereas at other places, a smorgasbord contributes to the feeling of community.
Wood: If it’s a big group at work and you’re having a birthday celebration, you have to learn that in that situation, you can’t change a large group of people. People have to have a life and need to enjoy special occasions, so I’d focus much more on making those day-to-day positive changes rather than banning cake in the office. People will bring in snacks, or food, or have bowls of M&Ms in the office that everyone will chow down on, but I think the work culture change is about making healthier choices most of the time.
In terms of your own choices, in the book you say that it was important to you to teach your patients how to make and stick with better choices in the long-run, rather than “placing stents in the heart arteries and sending patients on their way.”
How are you able to successfully provide personalized information, and how feasible is that for other physicians given the many constraints, particularly time?
Wood: I think that for me it’s been doable because I’m pretty effective at communicating. I’m frequently able to meet somebody and quickly identify their situation by asking the right questions and developing a plan. I recently met with a 29-year-old woman who had very bad hypertension during her pregnancy, which was complicated by preeclampsia. That is a marker of early heart disease and stroke, and she came to see me because her cholesterol was high.
It has been a year and a half since her baby was born and she still weighs 180 pounds, but she’s not exercising for all the usual reasons: She has work; she’s busy, and she has a baby to take care of. I spent 15 minutes with her giving my encapsulated version of what a working mom can do at home, spending no extra money, for 20 to 30 minutes a day. I know not everybody has 15 minutes, but I think the key is being able to identify which people need that counseling and providing the right resources after that.
If you can seek out a physician specifically for counseling, that’s a luxury and that’s great, but I think that people who are caring for patients need to have more access to reasonably-priced or free opportunities. I try to tailor the resources I mention based on my patient’s financial picture. If they’re low-income, I know they’re not going to be able to get a personal trainer and probably don’t want to spend $80 to see a nutritionist. So I’ll tell them about other options and tools that are available online. Maybe they can invest in a Fitbit instead or use sites like MyFitnessPal to get basic nutritional counseling, support, and to connect with others—which is huge—at minimal cost.
At the more overarching level of policy, what are examples of effective policy work that you have seen, Dr. Willett, with regard to weight loss?
Willett: First, policies can operate at all levels. You can have policies in your home: “We don’t keep soda in the house.” That’s a health policy that can be really helpful, especially for kids. If it’s not there, they’re not going to drink it, and then that becomes the norm. There can also be policies at work, for example, that there are healthy options like whole grain if you have food service. Then there are policies that operate at the state, federal, or global level, like the World Trade Organization, which has policies that are sometimes not in the best interests of people, but are more about protecting corporate interests. And of course there are lots of agricultural policies at national level that sometimes are intertwined with global policies, as well.
One that we have worked on quite a bit is trans fat. We did a lot of work showing the adverse affects on health outcomes, and then we tried to make that information available to consumers. We worked with other groups and got the FDA to require trans-fat labeling; that was a big step forward. Food manufacturers conducted their own consumer knowledge surveys and found that a high percentage of people, especially women, didn’t know that trans fats weren’t good for them. Now if it was on a food label it had to be taken out of the product. That was a policy decision that actually helped a lot of people; even if it consumers weren’t concerned with or thinking about trans fat, it was out of the product in a very visible way.
Another example is a soda tax as a potential policy. A lot of subsidy goes into making the ingredients in soda extremely cheap so that it can be sold for a cheap amount and still make a huge profit. The problem is that the price of soda is not really paying for the consequences of drinking three sodas everyday. You’re really ramping up your risk of diabetes, and you’re not the only one paying for it because we do have healthcare insurance. So there is a good justification, I think, for a soda tax that really makes bare the true cost of soda. And we know that that will influence behavior and cause alternative beverages to be available at a lower cost so that people will have more choices.
Are there any starting points that individuals can begin at to have some sort of influence, even if it’s the first step of something that might take years?
Willett: Getting sodas out of schools has been a policy achievement that essentially happened because of concerned parents starting in a local school district; then it spread and became a national movement. A group of people realized that it was very hard for one kid not to drink soda when everybody else around them was drinking soda. A parent could have their hard work at home totally undermined by what was going on at school. There are lots of other issues in schools where things start with one school at a time, or two concerned parents who talk to others, or at parent-teacher organizations. I think that’s very interesting.
When you look at changes that have been important, they’ve almost always started that way—it wasn’t national. They started in single towns or cities with a few people, sometimes just one person. And it’s pretty clear that if everybody is just acting on their own, these changes would not have happened. It means that part of the solution comes from people working together to make changes, not just for themselves but for their community, which can wind up being the whole country.