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But the cases of weight management patients like Kathryne Haywood suggest the limitations of expecting personal responsibility to cure the nation’s obesity problem.

Haywood has many motivations for losing weight. She was diagnosed with diabetes six years ago, and would reduce her risk of complications from the disease if she lost weight. Her mother, too, has diabetes, and had both legs amputated as a result. “I don’t want to go through that,” Haywood vows.

She is also receiving the best weight-loss care that science has to offer. A dietitian at Hopkins’ Weight Management Center helped her develop a balanced, low-calorie diet. An exercise physiologist assessed her metabolic rate and body fat composition, and gave her an exercise plan. Other specialists help her work through behavioral and psychological hurdles to losing weight.

But Haywood also faces strong traditions and habits that permit, if not encourage, her to remain obese. She comes from an African-American family that continues the Southern cooking traditions where the biscuits are rich and the greens are stewed in pork fat. “In my family it’s normal to be overweight,” says Haywood. “All the women are a little overweight. We use food as a celebration, as a reward.”

Over the years, says Haywood, food became her compensation for stress, and she’s had her share as she’s helped care for an ailing father and mother. After her mother had her legs amputated, Haywood put on 70 pounds in eight months.

Compounding matters, many of her co-workers are overweight or obese, yet show no interest in losing weight to improve their health. While Haywood does not feel stigmatized for being obese, she is isolated at work in her efforts to shed pounds.

Losing weight and keeping it off are an enormous struggle, Haywood says. “Just do it” does not cut it.

Cheskin says his philosophy of weight management emphasizes developing lifelong habits that enable patients to maintain a healthy weight after they leave the Center’s care.

He has some thoughts on what an overweight society could do to improve the odds. Just as a dieter should remove the junk food from his pantry shelves, a society should reduce the availability of junky food. “Promote, advance what’s helpful. Diminish, tax, restrict what’s bad for weight control. Advertise and promote healthy foods as much as we have unhealthy foods,” says Cheskin.

“Some people need constraints,” says Caballero. “Some people would never take the stairs unless we blocked the elevators. It will be very difficult to change the will of the people. So we need to create an environment where being more active is easier.”

For example: Developers should be required to include sidewalks when they build communities. Companies should be prohibited from filling school vending machines with soft drinks and fat-filled snacks. Schools should be mandated to offer physical education. Unions should demand exercise breaks in the workplace (much the way they lobbied for ergonomically designed work areas). The Nutrition Labeling and Education Act, adds Caballero, which requires that nutrition information appear on packaged food sold in supermarkets, should be expanded to include restaurants. “So people can read, ‘This hamburger contains two portions.’ ”

Basically, the healthy eating and exercise message needs to be repeated over and over. While these messages may seem like old news, says Cheskin, “they’re not getting through. Compare it to the hundreds of thousands of times you’ve been told to eat a Big Mac or, in effect, to be a couch potato.”

To override the blare of TV food commercials, the seduction of the super size, and the perfume of Cinnabon, messages about eating right and exercising need to blast through the airwaves, smile out from billboards, and saturate the culture. Marketers need to pitch healthy eating and exercise as something that is as “cool” as the competition.

Some answers may come from a project developed by Joel Gittelsohn, an associate professor with the School’s Center for Human Nutrition. The Healthy Stores Project involves promoting healthy foods and recipes in communities that have been plagued by high rates of obesity and obesity-related diseases. After completing a pilot study in the Marshall Islands, Gittelsohn’s team is beginning to introduce the interventions in grocery stores on the San Carlos and White Mountain Apache Reservations in Arizona, through funding from the U.S. Department of Agriculture.

When a customer enters an Apache “healthy store,” she might see a poster on the front window promoting the “healthy foods” label. As she strolls down the aisles, she finds such labels on shelves holding nutritious, low-fat foods, such as pretzels and baked chips in the snack food aisle. In the dairy section, the shopper might receive a free sample of low-fat milk, and information on the health advantages of low-fat rather than whole milk. In the deli section, she might find red skin potato salad and rotisserie chicken alongside the usual selections of fried chicken and chimichangas. Or she might watch a cooking demonstration of a healthier way to prepare a common recipe.

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