Exercise | Bonnie Modugno, MS, RD

Do “Americans Eat Too Damn Much”?

May 17, 2012 by Bonnie

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.

Dear David,

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.

Filed Under: Blog Tagged With: appetite, calories, exercise, farm bill, food costs, gluttony, gut peptides, metabolism, obesity, weight

Losing Weight Is Not a Math Problem

May 7, 2012 by Bonnie

How many times have you read “a calorie is a calorie?” Countless weight loss studies test different diets and everyone loses weight. Calories are drastically limited in most of the diets. At a deficit of 500-1000 fewer calories a day, the diets typically allow people 50-75% of recommended intake.

Of course everyone loses weight. The researchers conclude that it doesn’t matter what diet you use, all of them will work equally well. So the mantra lives on, “Eat Less, Exercise More.” But losing weight is not merely a math problem.

In more sophisticated studies, some diets works better for specific individuals. In 2007 research by Chris Gardner (a nutrition researcher at Stanford University) found that a higher carbohydrate diet helped insulin sensitive people to lose fat weight more effectively. The higher protein diet worked better for people who were insulin resistant.

Researchers with David Ludwig at Harvard University studied a group of overweight adolescents. The teens eating lower glycemic carbohydrates (more whole grains, fruits and vegetables, beans and legumes) lost more fat weight than those eating a calorie restricted low fat diet with all the usual fare.

The test subjects ate whole grains, not refined. They ate oatmeal, not sugared refined cereals. They ate more fruits and vegetables. Not chips, pretzels and other refined snacks foods. They drank water, not sodas.

The teens eating more whole foods also sustained a lower BMI even six months after the research ended. The calorie restricted subjects regained the weight lost—and more. That’s a familiar scenario for too many people.

DIETING AND DISORDERED EATING

The endless struggle to lose weight has cultivated a population of yo-yo dieters, chronic dieters, and many people with disordered eating and diagnosable eating disorders. What’s missing is an approach to food that works with the body, mind and soul of the person who is trying to lose weight. Each person needs an approach to food that works for them.

Ironically weight is not a good measure of success. Many in the medical and public health community want to believe weight is a useful way to measure health. It isn’t. Thin people develop heart disease, hypertension, diabetes, digestive disorders, and cancer. The idea that body fat drives the disease state is one of the great distortions of modern medicine.

WHAT’S DRIVING WEIGHT GAIN? WHAT’S DRIVING DISEASE?

What we eat influences our body in ways not anticipated by people who think obesity is a math problem. For most of my clients, poor metabolic health precedes the diagnosis of disease regardless of their weight.

When people eat poorly, the body adapts—and not in a good way. A diet rich in refined starches and sugar can increase insulin resistance—an underlying condition linked to diabetes, heart disease, cancer, and more.

In addition, eating refined sugar and starch promotes a different bacteria flora to reside in our digestive tract. Eating excessive refined sugar and starch promotes the secretion of gut peptides that influence appetite. Certain gut peptides, like ghrelin, signal the brain and compel us to eat more. It is even thought that the gut microbes linked with refined sugars and starches can promote fat gain.

THERE IS NO ONE RIGHT WAY TO EAT

Ideally your food plan allows your body to metabolize both fat and glucose effectively for fuel. It allows you to feel satisfied after eating. It provides you with energy needed to complete the tasks of your day—both work and play.

A successful approach includes foods you enjoy, foods that are readily available, and foods that you can afford. The actual mix of food that works for you may be very different than the mix of food that works for someone else.

WHICH DIET?

Too many people ask me what kind of diet I support. Is it Paleo? Raw Foods? Vegan? Do I promote Weight Watchers? The Zone? Pritikin?

This question reveals a distorted understanding of the process. Decades of dieting has cultivated a belief that there is one right way to eat. You just have to find it. People spend too much of their lives trying one diet after another Sometimes they get stuck trying the same one over and over and hoping for a different result.

Ironically the medical world also needs to abandon the idea that there is a single dietary approach to treat any one disease. It is critical that we start treating the patient, not the diagnosis.

There should be is no such thing as a diabetic diet, as if every diabetic will benefit by the same exact food plan. The same goes for diets promoted for any single disease, as well as weight loss itself.

AN APPROACH TO FOOD THAT WORKS

Magical thinking distracts people from the real task at hand: cultivating an approach to food that works. Too many people try and eat like a thin friend, a thin sister or the biggest loser. That food intake may actually make everything worse. It may be so unsustainable that you soon abandon the effort.

We can do better. Anyone who struggles with their weight or their health deserves to figure out an approach to food that works for them.

Filed Under: Blog Tagged With: appetite, bacteria, cancer, diabetes, diet, exercise, fat, ghrelin, glycemic index, gut peptides, heart disease, obesity, Paleo, Pritikin, resistant starch, sugar, Vegan, weight loss

Weight Is Not a Good Measure of Obesity

October 18, 2011 by

Researchers and scientists are saying it out loud. Weight is not a good marker of obesity or health. When we will stop using weight as a surrogate for our health status?

I attended the American Society for Nutrition conference two weeks ago in San Francisco. After the last presentation of the conference I stood at the microphone available to the attendees and asked just this question. One of the presenters started clapping his hands. I heard applause behind me.

Yesterday I was looking for information about endocrine function and persistent organic pollutants. These are the studies linking chemical elements in our water, soil, air and food with hormonal dysfunction. I caught one slide in one of the presentations. “Weight is not a good measure of obesity,”

UNDUE FOCUS ON WEIGHT

Weight is measured in research, in clinical practice and community health centers. Weight is a key indicator in public health records and statistics. Weight is monitored at schools, at gyms and other fitness facilities, and in too many homes. It as if there is collective will for weight to be the concrete determinant of health if only because it is so easy and cheap to measure.

Weight is assumed to be a significant marker determining whether one is healthy or not. BMI is blindly used to determine who is overweight, who is obese and who gets bariatric surgery. Despite it’s flaws, weight and height along with it’s cousin, the BMI index, have been given far too much credibility. So if not weight, what else?

MORE ACCURATE BIOMARKERS OF DISEASE RISK

My wish is to focus on the actual bio-markers of health and disease. Clinicians already measure blood pressure regularly. Blood glucose is often included in standard laboratory blood tests, but we need to pay attention to slow gradual increases, not just whether someone is diabetic or not.

We need to pay more attention to better markers of cardiovascular disease risk. Total cholesterol and LDL cholesterol predict less than 50% of risk. Our undue attention to these markers are unduly influenced by drug companies that have products that lower the numbers. Small dense LDL, elevated triglycerides and depressed HDL-cholesterol are proving to be much more effective bio-markers for risk. Small, dense LDL is typically indicated with lower HDL levels (less than 40mg/dl for men, 50 mg/dl for women) and higher triglyceride levels (greater than 150 mg/dl).

It may be simpler still to focus on how the body gains weight. Central body fat distribution–the apple shape–is more problematic. For years clinicians have been encouraged to measure waist:hip ratio. A ratio of >0.9 is considered higher risk for men; a ratio of >0.8 considered a higher risk for women.

AN ALTERNATIVE TO WEIGHT/HEIGHT RATIOS AND THE BMI

Today, an alternative to BMI is being introduced, the BAI–Body Adiposity Index. BAI a measure that purports to assess body adiposity, not merely weight and height ratios. The BAI index is a complex ratio of weight to hip circumference. It’s a start.

There is still too much attention to weight, but at least BAI begins to focus on where the weight is stored. We have a long way to go before we drop our preoccupation with weight. The sooner we do, the sooner we can focus on the behaviors that truly make a difference in our health status.

BEYOND BIO-MARKERS: LOOKING AT BEHAVIOR

We need to start focusing on what lifestyle behaviors contribute to elevated glucose levels, dyslipidemia seen with low HDL-C and elevated triglycerides, and elevated blood pressure and what behavior changes those numbers. Weight isn’t necessarily cause the cause of these problems. Often these bio markers are off because of the metabolic process that increases weight. Too often weight is the result of the problem.

It is time for lifestyle factors to get more attention and more respect in the research and health care community. Diet, activity, stress management, medication management are all viable behaviors that deserve attention, monitoring, and support. Continuing to focus on weight distorts our perception of health and diverts our attention from the lifestyle factors that can make a real difference in health status and quality of life.

Filed Under: Blog Tagged With: BAI, behavior, blood pressure, BMI, cholesterol, diet, exercise, glucose, HDL, Hgb A1C, LDL, lifestyle, obesity, stress management, weight

I Was Told To Lose Weight

October 18, 2011 by

I recently completed a health questionnaire on the Kaiser website. Here is the 2nd of 5 blogs on the findings.

A range of 120-163 pounds is given for my height. The last time I weighed 120 pounds I was anorexic. So 120 is too low for my size and body build. What about 163?

I’m not so sure I am ready to feel like I am starving myself. I am already extremely careful with what I eat. The health screening tool didn’t have much to recommend on that front.

ALREADY EATING A NUTRIENT DENSE DIET

I got high marks for the fruit and vegetables in my diet. I eat mostly whole grains, albeit very few of them. I just don’t handle carbohydrates very well.

My diet is rich in grass fed meat and milk from grass fed cows. I enjoy fish several times a week and take omega three supplements regularly. I use pastured butter and olive oil preferentially for cooking. I cook at home using raw ingredients 5-6 nights a week. I shop at farmer’s markets for delicious farm fresh produce and farm fresh eggs, chickens, pork and beef.

I eat when I am hungry and mostly stop when I am satisfied. I rarely feel full or uncomfortable. I don’t eat many sweets, except for the occasional piece of dark chocolate two or three times a week.

ASSUMPTIONS WITHOUT ENOUGH QUESTIONS

Maybe this tool needs to ask me why I am unmotivated to change instead of assuming that there is change to be made. The assumption is made just because my weight is higher than the ideal range. I wonder how many muscular and athletic people are also given misguided direction to lose weight?

There is no place to address lean body mass even though I was asked about my usual activity level. I bike most days of the week both for transportation and recreation. I walk with friends 1-2 times a week and enjoy a yoga twice a week. I received a hearty “good job” for my level of exercise from the screening tool.

The evaluation summary did mention I could increase my weight bearing activity. Evidently the tool assumes that yoga is only good for stretching, not building muscle. These people don’t know the class I attend.

JUST A NUMBER, NO PERSPECTIVE

I wonder if the designers ever considered asking me what I already do to manage my weight before suggesting what I should do differently.

In the end, I suppose I am just not willing to be more restrictive. I understand that quality of life and longevity have far more to do with overall health and not some silly ideal number range.

How many of us are tired of mindless recommendations with little perspective? I’m only slightly less annoyed that this recommendation comes from a digital screening tool. I am appalled it is supported by my health care provider.

Filed Under: Blog Tagged With: anorexia, cycling, dark chocolate, exercise, fruits, grains, grass fed, health screening, hungry, Kaiser, lean body mass, lose weight, muscle, restriction, vegetables, walking, weight, yoga

Do “Americans Eat Too Damn Much”?

Losing Weight Is Not a Math Problem

Weight Is Not a Good Measure of Obesity

I Was Told To Lose Weight

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