Why There is No Single Solution to the Obesity Epidemic–Dr. Jim Marks of the Robert Wood Johnson Foundation on Building a Culture of Health in America

By Melissa An, Emily Regier, Manu Venkat, and Kelly Close

Twitter summary: diaTribe sits down w/ the very highly regarded Robert Wood Johnson’s Dr. Jim Marks @ ObesityWeek, discuss the need for “culture of health” and social/policy changes

Short summary: The diaTribe team recently sat down with Dr. Jim Marks, the Senior Vice President of the Robert Wood Johnson Foundation. We discussed his views on the current state of diabetes and obesity and what he feels must be done to make real, impactful change. He explained the need to create a “culture of health” in America, and that both policy and societal changes are critical to improving this country’s health.

At the Obesity Week Conference in Boston, we had the opportunity to sit down with Keynote speaker Dr. Jim Marks (Senior Vice President, Robert Wood Johnson Foundation). In our discussion, we got to hear his perspective on the Robert Wood Johnson Foundation’s (RWJF) work in fighting childhood obesity and what he believes are the greatest challenges and opportunities in the field. As he did in his keynote address, he spoke eloquently about the importance of building a “culture of health”, which he stressed goes far beyond simply ensuring the absence of disease. Dr. Marks also cautioned against putting too much stock in technology as an agent of change, as he believes that the social and policy components of the healthcare system are far more powerful. He concluded on an optimistic note, saying that while American health and healthcare certainly has its flaws, “the underlying slope is improvement.”

Manu Venkat: Thank you so much for meeting with us, Dr. Marks! As the efforts to work against childhood obesity stand now, what’s the area that you think currently needs the most focus?

Dr. Jim Marks: When we think about the areas needing help, we’ve been encouraged by the signs of progress from places around the country that are reporting reductions in childhood obesity. But they’re early and they’re fragile. The early concern there is that the reductions tend to be more in white high-income populations. So the problems with disparities, especially in African Americans and Hispanics, are in essence, growing. This is clearly an area where we want to do more work in the future. The only place that we’ve seen slightly greater improvements in African Americans and Hispanics is in Philadelphia. Philadelphia also gives us hope that targeting efforts to those families whose children are at great risk can be successful in improving their health.

Kelly Close: We’ve been really lucky to see what Partnership for a Healthier America (PHA) has been doing and have been impressed with their work. We wonder if you could say a word about how the Robert Wood Johnson Foundation views this?

Dr. Jim Marks: The real point is that we need to move toward a culture that supports health. Really, every sector needs to be involved, whether it’s transportation, agriculture, or the private sector. All of these have a role to play. If we had to say one statement, it is that health begins, is nurtured, protected, and preserved, in our communities and our families. It’s not so much the doctor’s office. And we need to recognize that imbalance in our society.

To put this in more context, what we found in our obesity work is that it’s a proof of concept of what it takes to create a change in culture. Think about Earth Day and recycling – these are normal now but forty years ago, they were not. When I grew up, seatbelts and airbags – you couldn’t get them in cars and then they were extras you could purchase. Now they’re routine and everyone uses them. There are ways culture changes can occur. We can think of obesity and its causes as one of the most difficult areas to change. It’s related to an environment of food and physical activity.  We’ve supported a lot of work on the issue and we’ve seen progress and that gives us hope that we can see a broad culture of health embraced and developed. It also gives us recognition that obesity work won’t be sustained unless it is embedded in a bigger vision of health and well-being.

Emily Regier: If you had to pick one problem in obesity that you think is most solvable, what would it be and what would you do to solve it?

Dr. Jim Marks: I can’t pick one and I won’t. The central thing about the obesity epidemic is that it’s an aggregate of lots of little changes that have occurred in our nation. The net effect is a gradual accumulation of inactivity and increased calorie consumption. I’ve spoken to medical students and have asked them if they have ever in their lives had to get up to change the TV station. No one raises his or her hand. That is a bit of a silly example, but it illustrates the larger point that activity has been engineered out of our lives. When you go into most buildings now, stairwells are hidden behind a fire door and elevators are front and center. When you go into old buildings, stairways are prominent and sweeping and grand. And the elevator’s around the corner – a single elevator that is really only there to help move equipment or to help those with disabilities. All of those things are examples of the changes.

Manu Venkat: Given your perspective on so many different diseases, can you provide any big takeaways from other disease areas’ efforts that have worked very well?

Dr. Jim Marks: I think that there are always differences between disease areas. The most common one that people make comparisons to is probably tobacco. But I think there are really important differences. Tobacco is lethal when used as intended. Food is not that way. Food is part of every culture and part of celebration. So there is a nuance that is difficult for us to work with in the health community. How do we support and foster changes that are good for health but recognize the importance of food and family and celebration and culture? It’s the same for activity. I think it is useful to pay attention to those other areas but it’s also really important for us to recognize the differences. I actually think the most interesting solutions may come from outside health. What are other things out there that are going to change trajectories of other sectors? How might they be considered?

Manu Venkat: There has been a lot of research to redesign a large scalable program for diabetes and obesity prevention. For when those arrive, how do you think we are going to support them? Will this be from payers, government, or others?

Dr. Jim Marks: I believe that the greatest challenge to providing good quality medical care to everybody who needs it is that we have too much disease in our nation and it is occurring too early in life. So we need to make it fun to be active, not a chore. Healthy food is fun to eat and cool to eat – it’s not a deprivation. Those things will happen outside of healthcare. If I could think of a population measure to show what was happening and in more than just children, it would be age at diagnosis of diabetes. Because we know that it’s moving younger and younger, but as people are becoming more active and watching their weight more, we expect to see the age at diagnosis move up. That could become an early indicator that improvements in obesity are paying off with a decrease in disease.

Kelly Close: On a related note, Dr. Marks, we’re increasingly troubled by the poor incentives for young medical students going into areas where they’ll be addressing a lot of obesity and diabetes. What can we do?

Dr. Jim Marks: I think that’s a challenge because that’s caught up in the cost of the healthcare system. Most medical students graduate with a lot of debt, and that makes it hard to go into primary care or low paying specialties. They’re counseled on their debt too; they’re told if you’ve got $100,000 in debt, how much it will cost to pay it off, and what that means you can afford in terms of a house, a car, and other expenses. Diabetes prevention will not be something that’s ever reimbursed well. I suspect we’ll be moving much more toward mid-level providers: nurses, counselors at the YMCA/YWCA doing the diabetes prevention work. Depending on the individual, some may need close medical advice, or close medical oversight, and others do not. I think we need to think more holistically as a society. Suppose you went to Walmart and you had prediabetes and the nurse said, “Let me go and look at your shopping list and show you how to make changes.” That could be a kind of training that could be easily available at a Walmart. You don’t have to have a physician or even a serious dietitian.

Melissa An: What RWJF project is getting started now that you are particularly excited about?

Dr. Jim Marks: If I were to say which one, I think it’s the coming together of sectors of society, and the recognition that health is different from absence of disease. What people want is not health in the way we in healthcare think they want it; they want a good life. I’ve got two grandkids and a third on the way. I want to get to know my grandkids; I want to play with them. I like the work I do; I want to keep working. I may have to take care of the grandkids if their parents work. My best shot to be able to do those things, and to travel, is to maintain my health. Don’t smoke, watch what I eat, exercise, get my flu shots. I talked with L’Oreal in the past, and how do they market a product? They put in the lifestyle that potential customers want. We have to think of health that way. It’s the framing of health as the World Health Organization definition: physical, social, and mental wellbeing. When you have health like that, then you have the best chance for a fulfilling life, warm relationships, a job that’s meaningful, a close family, and a close community. That’s the American dream: equality of opportunity. We’ve got to put health in the middle of that dream instead of framing it as the absence of suffering only.

The other part, which I’ll say as my closing, is that people are very concerned about our health and healthcare. The only scientifically defensible position is optimism. A hundred years ago, one in four infants died before their fifth birthday; almost every family had that happen. People used to live 40 to 45 years; they live 30 years longer now. The leading causes of death were diarrhea, respiratory disease, and things like that, which are now uncommon causes of death in this country. It’s sort of like the stock market with ups and downs, but the underlying slope is improvement.

Kelly Close: Dr. Marks, we can’t begin to thank you enough for sharing your time with us today. Your Foundation is a beacon to all working on public health and we’re so lucky that Obesity Week persuaded you to speak to the many thousands of doctors, nurses, researchers, policymakers, and advocates here and we thank you enormously for spending time with the small group of us as well.

Dr. Jim Marks: Of course – and thank you so much for all you are doing on the public health front as well.