Do we have to change everything?
From the Rudd Sound Bites blog, an interesting entry on the numerous diet books that have been bestsellers throughout the years. People continually hold out hope that this book, this plan, this guru will have all the answers and so they keep buying diet book after diet book. What prompted this entry though was a link to this editorial by Dr. Martijn Katan. The editorial is ostensibly a response to this study published in the NEJM that found little difference in the efficacy of diets with differing macronutrient compositions (of course, as Dr. Katan points out, in actuality people didn’t manage to stick with their assigned ratios that well.) The editorial doesn’t just address some of the problems with adherence in this particular study though, but the problem of adherence and efficacy in basically all studies of dietary treatment for obesity.
It is obvious by now that weight losses among participants in diet trials will at best average 3 to 4 kg after 2 to 4 years and that they will be less among people who are poor or uneducated, groups that are hit hardest by obesity. We do not need another diet trial; we need a change of paradigm.
Or as the Rudd Blog put it
I’d like to see a book on the NYT best seller list called Throw Away Every Diet Book You Own Because IT’S NOT YOU; It’s Your Environment. There would be chapters on how your workplace, school, neighborhood, and home all contribute to your weight struggles, with challenges such as hidden stairways, omnipresent vending machines, industry-sponsored school events and supplies, televisions everywhere, and more.
This idea in particular is sticking in my brain a bit now due to the fact that I’ve been working on a post about the research into the genetics of obesity. I don’t know if I’ll ever post it*, but one of the interesting outcomes of a lot of research is that genes seem to affect our food choices more than our metabolisms. Or as one paper put it:
While there is widespread acceptance that hereditary factors might predispose to human obesity, it is frequently assumed that such factors would influence metabolic rate or the selective partitioning of excess calories into fat. However, it is notable that, thus far, all monogenic defects causing human obesity actually disrupt hypothalamic pathways and have a profound effect on satiety and food intake. To conclude, the evidence we have to date suggests that the major impact of genes on human obesity is just as likely (or perhaps more likely) to directly impact on hunger, satiety and food intake rather than metabolic rate or nutrient partitioning. At the risk of oversimplification, it seems that from an aetiological/genetic standpoint, human obesity appears less a metabolic than a neuro-behavioural disease.
So the concern is whether or not any dietary intervention can work for more than a small percentage of individuals in an obesogenic environment. Now, to be fair, and without basically copying the entirety of my post on fat and genetics, so far every gene they’ve found to be associated with being fat only has a very small affect – a few kg difference in weight at the very most. For a polygenic trait though it may be that there are many of these small-effect genes or it could be that environment is the ‘trigger’ so to speak, I don’t know.
Both the Rudd Center blog and Dr. Kaplan’s editorial think the solution lies in changing our environment.
From the Rudd Center blog;
..there would also be steps you could take to alter your environment, like making healthy foods most accessible in your home, joining your school’s wellness council to advocate for changes, limiting the number of televisions in your house, lobbying for improved sidewalks in your neighborhood…. Of course some aspects of the environment are a lot easier to change than others, but the point is that diets often fail because of the environmental obstacles that exist. We need environments that support our healthy aspirations, not hinder them. Perhaps if we all redirected our energy from following fad diets to changing our environments, we’d actually get somewhere.
Dr Kaplan points to an effort to curb the increase in overweight children pioneered by a community in France:
Everyone from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government joined in an effort to encourage children to eat better and move around more. The towns built sporting facilities and playgrounds,
mapped out walking itineraries, and hired sports instructors. Families were offered cooking workshops, and families at risk were offered individual counseling.Though this was not a formal randomized trial, the results were remarkable. By 2005 the prevalence
of overweight in children had fallen to 8.8%, whereas it had risen to 17.8% in the neighboring comparison towns, in line with the national trend.
I don’t know what I think about any of this. I think improving sidewalks (and neighborhood safety), making fruits and vegetables cheaper, and giving kids ample PE and recess time are good things no matter what their effect on weight happens to be. I hate to think any of these kinds of improvements might be tied to programs whose ‘success’ is measured by decrease in BMI. I also don’t know if this country could ever get away from its fetish for personal responsibility enough to get behind big changes in how we eat and move.
From a personal standpoint though, I do feel like in order to lose weight in a fairly sane and healthy way, I’ve had to change the way I live. Not just add a bit of exercise or eat a little different, but an almost entire paradigm shift in how I move and eat. It’s hard to explain, but the idea that the food and movement environment has to change in order for a lot of people to lose weight really resonated with me.
* I hesitate with any big science posts. I’m not an expert after all** and I’m almost pathologically afraid of not getting something right and giving out wrong information.
**Not that this stops anyone else on the internet from vomiting out all sorts of bullshit when it comes to diet, health and exercise, of course.
Exceptionally Fat 
This is a tough subject. In some ways I completely agree. It’s outrageous that the majority, in some cases, all of the choices available are high-fat high-sugar low-nutrition. OTOH, I love bake sales, and girl scout cookies (except I’m not buying anymore until they stop using hydrogynated oil), but think these things should be occasional treats, not all the time food. Maybe it’s more education that is needed. I think it sucks that much of this country is built without sidewalks, that fruits and veggies are not subsidized like corn and soy, and that there is a culture that loves meat and disdains vegetables. Maybe more parents need to make their kids eat their veggies, develop a taste for them. Complicated, don’t know the answer. I just know that I have to exercise more, eat less/better than most anybody else I see, and I resent it slightly.
Where I am is something like “is there a way to improve eating habits on a society-wide scale that doesn’t do away totally with easy-ish access to tasty treat foods?”
I think portion sizes might be a big key. But so many people would rather try to hold to a standard from the (mostly imagined) perfect food past that I don’t think a lot of other practical solutions are out there.
Portion sizes, education, shift in thinking, I don’t know. I think a part of the problem is that although everybody says it’s about health, it seems more about looks/morality. Maybe we do need a paradigm change, I sure would appreciate one. I feel like I’m constantly swimming against the current.
The question that rears its head in my mind when the topic of genetics and obesity comes up ( . . . your mother is fat, your father is fat, your grandparents are fat, your brothers, sisters, aunts, and uncles are fat, so you’ll be fat too . . . ) is that these people aren’t just DNA contributors.
They are the very people who taught me about food as a child, who demanded I clean my plate, rewarded good behavior with tasty treats, and helped me build a goodly number of my underlying self esteem issues in the process of *raising* me.
Family contributes to environment as much (if not more) as it does to genetics.
Worse, it contributes to habits.
One of the big problems is that genes and environment work together so separating one from the other becomes very difficult. We know that identical twins who have been raised apart tend to have very similar BMI’s and body fat percentages regardless of the body types of their adopted parents.
BUT! Even for families’ with differing food traditions in our own country the availability of a lot of calories is fairly common. So even if someone’s genes predispose them to eating more, it takes the availability of lots of those extra calories in order for them to gain weight in the first place.
It’s hopelessly complex and, to be honest, the fact that I’m continuing to lose weight in a healthy way is what I’m holding on to.
I know what you mean re: paradigm shift. It’s hard to interact “as usual” in a society where so much high-fat food is threaded into all daily activities, even ones that don’t involve food (like work, strolling around, etc.), from morning till night. Even in food-loving societies like France and Italy, people don’t eat continuously like they do here.
In my family, where obesity is the norm, it’s really hard because choosing not to eat much makes you a visible weirdo, even when you don’t make a big deal about it and really want to be invisible.
It’s so funny, when I visit various health and fitness sites, it seems clear that compared to most folks I’m a complete slacker.
Yet in the “real world”, everyone thinks I’m some sort of obsessive health and fitness freak. The “healthy living” people and the “regular” people are living in two totally different worlds.
The problem is, I think many people are very attached to their self-indulgent lifestyles and don’t care very much if their environment or their food choices lead to poor health. You give many of them healthier options and they don’t take them. And so I don’t think that’s its gonna get better out until healthy living is a higher priority for more people.
And I think it’s admirable that you want to be careful not to disseminate incorrect information–I’m one of those unqualified vomit people who sometimes puts stuff out there even though I don’t really understand what it means!
Yet in the “real world”, everyone thinks I’m some sort of obsessive health and fitness freak. The “healthy living” people and the “regular” people are living in two totally different worlds.
I feel this way all the time. I don’t feel like I give that much of my time to healthy pursuits. I still watch tv. I definitely fart around on the internet all the damn time. And yet people absolutely believe that what I’m doing must be chalked up to my awesome willpower (or obsessiveness.) Which sitting here in my pj’s @ 6pm sipping iced tea and munching on cinnamon toast sounds ridiculous.
I don’t think I’ve seen any bad science on cranky fitness. I really like the kind of ‘look at this neat study!’ posts. My problem lies more in interpretations which, especially with the whole nature v nuture problem of obesity and genetics is kind of ripe for abuse.
I’m sorry attrice, but this is not one of your finest hours. I can’t say any more here because I’m just too disgusted.
An antidote to one of your studies: http://www.nature.com/ijo/journal/v30/n7/abs/0803331a.html Gist: the total activity level children of schoolchildren is insensitive to large changes in the environment eg. PE classes, walking to school and time spent in front of the telly.
I am curious about the “fetish for personal responsibility”. From your posts, the changes you have made to your lifestyle are far beyond the reach of a few government incentives – sidewalks, cheap veggies etc. Is this not personal responsibility, which you take very seriously?
Two things bother me when people talk about the need for societal and regulatory changes to combat obesity:
1. Let us assume that removing subsidies is the answer – Michael Pollan has written very effectively about king corn. Then it must be explicitly acknowledged that we are trying to change people’s habits by making their present diet more expensive/more difficult to obtain. This will disproportionately affect the poor and that is the intention. We shouldn’t dance around the unabashed elitism inherent in treating poor people like children.
2. (strictly imo) If all of society has to change to reduce obesity rates, it is tantamount to saying that it won’t happen. In other words trying to rewind back to the golden era of smaller portions, more playgrounds and fewer coke machines all at once, is a fool’s errand.
Regarding your point #1, it would also follow that it wasn’t fair to make cigarettes more expensive, because it disproportionally hurts the poor, because they are more likely to be smokers, and they can’t afford the price increases. Yet, supposedly this works.
I can’t for the life of me understand why ANYBODY would think that taking away these subsidies would be a bad thing. The people who grow my celery, cherries, citrus, carrots, apples, (referred to as boutique crops-anything but corn, soy, wheat) etc., don’t get subsidies to keep their land idle. Furthermore, if the weather gets funky, nobody pays for their ruined crop. Maybe the government should subsidize THEM, then good food would be cheaper.
I didn’t actually say it was fair, just that it should be addressed honestly. Re smoking: Cigarettes were taxed as a luxury (throughout the world) independently of their effect on public health. And more importantly there is a distinct lack of empathy for smokers – office workers can be forced to take breaks outside the building even when it’s freezing, and taxes can be raised arbitrarily without more than a shrug from nonsmokers like me.
Food is another matter entirely. Do you think any politician is willing to tell people that their fried chicken and coke costs a dollar more but here is a good deal on broccoli in return? And that we will keep raising prices till you eat less of that bad stuff?
IMO, provided one has access to a supermarket, most veggies are quite cheap in America. The price of frozen greens is not an obstacle. Food habits, especially that of cooking at home, are.
I don’t reject the concept of personal responsibility. I just believe that if we’re talking about large-scale changes to how we eat and move that the concept is somewhat meaningless. What it means for me as an educated woman of the middle class to take responsibility – becoming a regular gym-goer and fitness geek, spending more time and money on making healthy food – isn’t going to be applicable to someone using food stamps or someone without a real grocery store in their area.
The way I see it is we need some changes that can at least provide most people with the means to improve their fitness and eating habits. What theses changes are, I don’t know. I would say changes in portion sizes as well as changes in the cost of a lot of healthy foods combined with community improvements that make regular movement more realistic for most people would be a start. We also need some serious education, imo. At that point, yeah, we can talk about personal responsibility and really have it mean something.
As to your first point, I agree. One of the parts of the movie “King Corn” that I really liked was near the end when they’re talking to the former sec. of agriculture responsible for the drop in corn prices who says something along f the lines of it being a good thing that people don’t have to spend such a huge chunk of their money on food. People like Pollan (who don’t ever have to worry about the price of their organic broccoli rabe) are way short-sighted in this regard I think.
However, no matter what this issue becomes about the poor. People in the poorest classes are much more likely to be obese and to suffer from the conditions associated with obesity. So if we talk about personal responsibility, we are, again, placing the greatest burden on the people with the least resources.
As to your second point, you may be right. I sometimes think that increased adiposity might just be something that comes along with having an abundance of food. Maybe the best we can do is get to a point where everyone has access to smaller portions (have fast food places offer 6 oz sodas, make the 100 calorie packs cheap and available) and subsidize healthier food as well as corn, soy and wheat so that everyone at least has a choice. And, like I said above, try to increase community walkability, add bike trails and all that. At that point people can really decide for themselves and we at least all have the option to live a different kind of lifestyle.
And even then, there’s issues about people who have to work multiple jobs to get by and whether or not offering a more realistic living wage is also part of making people healthier in the long run. And issues of environmental pollution….etc etc etc…
I also wanted to say that I do agree with a lot of what you’re saying. Part of my question is: Is there a way to make society less ‘obesogenic’ without basically making life harder by making food more expensive or life less easy? Because, like you said in your reply to Julie, people don’t want tasty food to cost a ton while broccoli is cheap. Nor would anyone want to revert back to wood stoves and wash tubs just because labor saving appliances are one of the reasons we burn less calories.
Yeah, so fat people have LOTS of different genes associated with fatness and each one makes them eat a little bit more, so they end up eating 5000 calories every day. RIGHT.
Where are you getting this from? Nothing I’ve quoted or said should lead anyone to the conclusion that fat people are eating “5,000 calories every day.”
Yes, there is a high heritability for bmi. Yes, so far, the genes they’ve found to be associated with fatness have relatively small effects and those effects don’t tend to be on metabolic rate or nutrient partitioning.
What is it that you have a problem with? The research? The methodology? The conclusions? Every time you post here you seem to be angry (which is fine) and extremely skeptical. Skepticism is great if you tell me what is it that makes you think this information is wrong. Otherwise, I just think you’re projecting all sorts of nefarious ideas onto what I think is uncontroversial information.