David Lazarus recently wrote a diatribe scolding gluttonous Americans in the Los Angeles Times. The notion that Americans just “eat too damn much” is a popular screed. Experts weight in and determine that it is advertising and marketing to kids that is the problem. Others claim there is not enough exercise. Well yes, and no. The issue is far more complex than these solutions suggest. Here are a few thoughts I shared with Mr. Lazarus.
I am glad I read your column on a regular basis. You have written insightful pieces, made poignant arguments, and exposed many wrong doings. I trust you are an intelligent and thoughtful man, but your screed regarding obesity is absolutely off the rails. You faltered the minute you embraced weight as the problem and assumed that the calorie balance equation is all there is to understand about energy metabolism. You assume that if people are obese it is merely because they are too gluttonous for their own good. You couldn’t be more mistaken.
Ironically, those of us in the trenches as well as many researchers are beginning to recognize the many ways and reasons people gain fat weight preferentially. Calories are only one of many factors. There are fewer and fewer people invested in the simplistic belief that “eat less, exercise more” is the answer to the growing obesity epidemic. In fact, the people who are still believers tend to be those people who have little personal or hands on experience with weight management (and please take that literally—researchers who mostly crunch numbers and publish the articles don’t count. Talk to those of us who work with patients and clients on a one-to-one basis)
Most of my clients struggle mightily. Of course calories count, they just are not the only thing that counts. Far more impressive people than I have argued that the issue is multifaceted and very complex . These authors identify 10 putative factors that have at least the same potential to impact the obesity epidemic as the currently popular and repeated arguments re: marketing to kids and not enough exercise. Studies show that thinner children can eat more calories, sugar, refined starch, and fat than their heavier counterparts. Clearly, obesity is not merely a math problem.
In my own work, I notice significant lifestyle factors that influence energy metabolism and create an environment that makes it more difficult to utilize fat and glucose effectively for fuel.
- Poor food composition and distribution
- Poor food quality (often an economic issue—see Adam Drewnowski’s work for more details) that is subsidized by government farm policy. Highly refined starch, sugar and fat is far cheaper to purchase per 100 calories than fresh fruit, vegetables, and lean protein sources
- A preoccupation with “safe” that destroys all bacteria, including healthy bacteria that can improve gut microbiota and immune function
- A gut microbiome that is linked to greater fat synthesis secondary to poor food quality
- Gut peptide secretion secondary to food intake and gut bacteria that seems to alter appetite regulation
- Sleep deprivation and poor sleep hygiene that increases sugar cravings and alters appetite
- Chronic pain and may other sources of stress that exacerbate insulin resistance secondary to excessive cortisol secretion (consider a society that keeps raising the bar, increasing expectations, evaporating a safety net, etc)
- Long hours at work and extensive commute time that erode time and energy for physical activity; anxiety on the part of workers that if they don’t sacrifice their personal life, they will soon be out of a job
- Preoccupation with (financial) success, both in school and work, that pushes aside quality of life factors
- Little or no appreciation or time to adequately shop, prepare and eat whole foods. We pretend we can do it even with 10-12 hour days away from home
- Poor nutrition status for women of childbearing age. We know that pre-pregnancy nutrition status and the intrauterine environment influences the offspring’s metabolic health. Babies born to mothers with gestational diabetes and other states of insulin resistance (including obesity) are much more likely to become diabetic and/or struggle with metabolism and suffer high rates of birth defects. About 50% of births are unplanned for both married women and unwed teens. This does not bode well.
- Exposure to endocrine disruptors and other obesogens that influence glucose tolerance, thyroid function, and insulin sensitivity via the environment—especially secondary to plastics, pesticides, and other contaminants (95% of which reach us via our food supply)
In addition, there are fundamental societal and system issues that complicate people’s access to adequate nutrition care and support.
- Little money, time or willingness to teach life skills (including cooking, shopping, menu planning, budgeting, etc) to students. Somehow the overworked parents are supposed to do it all.
- Negligible resources for adequate nutrition education in K-12. It is not easier to eat well today. It was easier when all we had to worry about was getting enough. Most schools don’t teach nutrition, and if they do it is taught by someone who isn’t really educated about nutrition. The information ends up being dogmatic and rigid—not very effective. Maybe the instructor’s degree is in PE or health, biology or the like….not good enough.
- Pretending primary care doctors and nurses can deliver effective nutrition counseling. Doctors don’t get much nutrition training and often demonstrate even less skill in counseling. Nurse’s get about one semester’s worth. Have you ever asked how many patients get referred to dietitians or qualified nutrition counselors even with legitimate diagnoses?
- Medical nutrition therapy (MNT) is rarely covered except for diabetics and folks with renal disease. Even then, time and access to an RD is laughable. Diabetics are supposed to be effectively “managed” at one local institution with four 15 minute appointments a year. And we wonder why people are “non compliant” and “lost to follow-up”
- Everyone with dyslipidemia (cholesterol problems), hypertension, inflammatory states like gout, asthma, and allergies, and even cancer is likely to have to pay for MNT out of pocket unless dietitians accept a fraction of usual billing costs (but this is nothing new—it’s just that I can’t see 8-10 people in an hour and do any good—that’s not counseling, it’s pretending that knowledge is the same as behavior and there is only one right way to eat)
- Individuals struggling with obesity, disordered eating and outright eating disorders are likewise not typically covered unless they are seen within a medical setting with an MD on board. The medical model doesn’t work so well when it comes to nutrition counseling. Our process is much like the therapeutic model used by mental health practitioners.
- The government’s latest position with new funding for covering obesity basically establishes the primary care MD as the gatekeeper and employer for all nutrition services. How ironic that as someone with 25 years of experience working with clients in my own practice I am now expected to have an MD set the protocol and standards for my practice. Currently I teach MD’s, nurse practitioners, physician assistants and other health providers how to effectively help patients regain metabolic health.
Despite all of this, obesity isn’t the real issue. Weight has never been an effective bio-marker for disease or surrogate for health. It is sloppy and lazy science/journalism/public policy that continues to perpetuate the myth. The real issue is metabolic health.