Arya M. Sharma, MD

Last week, the media erupted in reports and commentaries prompted by an article by Robert Lustig and colleagues front the University of California, published in the journal NATURE, calling on governments to regulate sugar in a fashion akin to alcohol.

Although the media referred to this piece as a ‘new study’, the article did not actually provide any new data - it was merely an ‘opinion piece’ suggesting legislative approaches to the ill-effects of eating too much sugar.

Presented as a possible solution to the obesity epidemic, the jist of the arguments more or less were as follows: worldwide sugar consumption has increased, sugar is toxic and addictive and, therefore, regulating sugar like alcohol or tobacco (including taxation and limiting access to individuals below the age of 17), would reduce obesity and prevent metabolic syndrome.

In a number of media interviews, I took issue both with the proposal to tax and ban sugar as well as the rather simplistic causal linking of sugar to the obesity epidemic.

Here is why:

1) While there is no doubt that overconsumption of sugar (like consuming too much salt (not sodium!), trans-fats, alcohol, or perhaps processed foods in general) may well promote ill health, these links may be far less robust or scientifically proven than the article suggests. More importantly, there is very little evidence from high-quality intervention studies (outside of the rather artificial setting of a clinical trial) that the proposed population measures (namely attempting to restrict sugar consumption by banning or taxing it) would have the desired effect on obesity or anything else - if there are such examples, the article certainly fails to mention them.

2) As any reader of these pages will also realize, obesity is a multifactorial complex condition driven by a myriad of socioeconomic, psychological, and biological factors - some of which do indeed make many of us prone to ‘overconsume’ salt, sugar, fats, and perhaps alcohol or illicit drugs. In the case of sugar, the article unfortunately fails to seriously delve into what exactly these socioeconomic, psychological, or biological drivers to consume more sugar may be (beyond simply suggesting that sugar is cheap, omnipresent and ‘addictive’). Unfortunately, by reducing the solution to the obesity epidemic to simply a matter of banning and taxing sugar, the article not only reinforces the widely held stereotype that obese people are obese simply because they eat too much (in this case sugar) but also that obese people, because of the damage they do to themselves and society, need to be punished and policed for the benefit of all.

3) But, even if sugar was indeed a major driver of obesity (a few years ago we would have thought it was fat, others have recently suggested it is wheat or indeed all carbs, some think it is not enough protein, others point to our industrialized meat production, or is it simply having too much variety on the shelf?), calling for interventions primarily on the demand side (making sugar less accessible and more expensive) rather than the supply side (making sugar less attractive for farmers to produce) is problematic. Paradoxically, changing demand without changing supply, at least in the short term, may well have exactly the opposite effect - sugar becomes even cheaper, thus making it an even more attractive ingredient for food producers. Reductions in the price of raw materials will likely quickly neutralize any increased cost of taxation with the net effect on consumption being zero. If, in the long run, such interventions did actually reduce sugar consumption in countries where it is regulated, we would simply be diverting streams to countries where it is not (worldwide tobacco consumption is the perfect case study for this).

4) The article is also rather cavalier about how exactly such measures would be implemented and enforced. As we well know from the hopelessly lost ‘war on drugs’, if people really want something (like sugar, assuming it is indeed as addictive as the authors suggest), they’ll find ways to get it. So making something ‘illegal’ is meaningless unless government is also prepared to enforce any such legislation. For a substance as omnipresent as sugar, this would require a rather expensive bureaucracy (I can already see food and drug inspectors raiding schools, recreation facilities, and grocery stores to ensure that no candy is sold to anyone below the legal age). I would imagine that the money required to effectively police and enforce any such new legislation would more than outweigh any potential revenues from the ’sugar tax’ thereby snuffing any hope that such revenues could perhaps be used for other efforts to reduce obesity (like building bicycle lanes).

5) Finally, it is not clear to me why the authors would chose to simply focus their attention on sugar - it would have made as much sense to include all refined carbs, as it takes very little for our digestive systems to turn a slice of Wonder Bread or pizza into glucose. Will all refined carbs (and what exactly is the definition of ‘refined’ in this context? Do we include polished rice?) be next on the list of toxic substances that require a permit? And what about other natural sources of sugar - are we going to tax cane sugar, beets, honey, or perhaps even Maple syrup? Let us also not forget that biologically there is little difference (if any) between the ample sugar in fruit juice and the sugar I add to my cup of tea.

But in the end, my main criticism would be that, as so often, the authors have chosen to focus on the ‘what’ (eating to much sugar) rather than on the far more complex issue of the ‘why’ (why is this happening?). That of course would have been a very different paper requiring some very uncomfortable and complex analyses of the very core of how industrialized societies operate.

While the article is no doubt well intended, I sincerely fear that these rather simplistic and superficial ‘one-size-fits-all’ solutions to the obesity epidemic based on principles of shame, blame, tax, and ban, merely distract us from having a value-driven and non-judgemental discussion about the true drivers of the societal (e.g. industrialization and centralization of food production), psychological (e.g. stress, lack of sleep, emotional deprivation) and biological (e.g. fetal imprinting, endocrine disrupters) changes that have led to this epidemic, we will fail to even remotely begin to reverse this problem.

AMS
Ottawa, Ontario

Lustig RH, Schmidt LA, & Brindis CD (2012). Public health: The toxic truth about sugar. Nature, 482 (7383), 27-9 PMID: 22297952

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Before, I get into the promised review of the obesity papers in the January issue of the Canadian Journal of Psychiatry, I would like to set the stage by clarifying that I certainly do not consider obesity to be a mental illness.

Thus, I very much opposed the notion (proposed by some) to include obesity as a diagnosis in the the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and was very much relieved to see this proposal being rejected.

Although the brain is the ultimate regulator of energy balance and there is a significant and relevant relationship between mental health and the propensity for weight gain (as will be discussed in forthcoming posts), obesity itself is hardly a mental illness. In fact, the vast majority of overweight and obese individuals do not have any mental health problems that would be in any form or fashion differentiate them from the non-obese population.

This situation, however, is markedly different in the ‘weight-loss-seeking’ obese population, where an increased prevalence of mental health problems has been well documented. This is why clinicians dealing with obese patients, particularly those seeking obesity treatment need to be well versed in the diagnosis and basic principles of managing mental health problems.

What is also indisputable is the fact that for patients with mental health problems, weight management can prove particularly challenging.

When we consider how difficult implementing and maintaining the often complex regimens for weight management can be for most people, it should be no surprise that adding the additional burden of mental illness can make such efforts almost impossible.

Add to this the fact that many of the psychiatric medications can further promote weight gain, and we can easily see why obesity has become such an important challenge in light of the increasing use of such medications (whether indicated or not).

Remember, that in this discussion we are talking about significant and major mental health problems like depression, bipolar disorder, psychosis, anxiety, PTSD, or addictions. We are not talking about simple ‘overeating’ associated with stress, boredom, social pressures, or other factors that have little to do with severe mental health problems and should rather be considered completely normal and natural human behaviours.

Thus, it is important that in any discussion of the clinically important relationship between obesity and mental illness, we make sure that we do not add the stigmal of the latter to the already widespread stigma of the former.

In other words, while mental health problems can undeniably contribute to or complicate obesity, let us by no means assume that everyone with excess weight must somehow have a mental health problem - the vast majority of overweight and obese individuals do not.

Nonetheless, clinicians need to be well aware of this relationship, be able to identify it where it exists, and provide or refer individual obese patients, for whom this may well be a problem, to the appropriate services.

I would certainly love to hear from any readers who have experienced that addressing their mental health issues did indeed help them better manage their weight or from readers where their mental health problems are making contributing to their weight gain.

AMS
Saskatoon, Saskatchewan

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

Kukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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CBC Commentator, Rex Murphy

Regular readers will recall a host of previous posts on the issue of weight bias and discrimination.

Canadian Obesity Network members will hopefully also be aware that for the past four years, addressing weight bias and speaking out against weight-based discrimination has been the #1 strategic goal of the network.

Rather than listing all of the activities that the Network has undertaken to address this issues (the latest one being the launch of the image gallery “Picture Perfect at Every Size“), in today’s post I would like to share a story and explain why I continue to believe that this is the central problem at the the very heart of finding solutions to the obesity issue.

I remember this as though it was yesterday. I had just arrived with my family in Canada, having accepted a Tier 1 Canada Research Chair in Obesity at McMaster University. I was just discovering Canadian television and was quite impressed the first time I saw Peter Mansbridge on the CBC’s “The National”.

Interestingly, that evening one of the news items that caught my attention was an announcement by then Health Minister Anne McLellan, that the Government would spend $15 million to support obesity research - certainly good news for an obesity researcher just arriving in Canada.

This brief sense of having arrived in the right place at the right time, however, was shaken by what followed - a scathing, derisive, and contemptuous commentary by Rex Murphy, Canada’s premier TV commentator - not known to mince words.

In brief, as far as I can recall, the gist of his commentary was that this funding for obesity research was another perfect example of wasteful spending of tax-payer dollars.

To paraphrase his words, “so now the Government of Canada is spending millions of dollars to show that Canadians get fat by eating fast food and lounging in front of their TVs“.

I don’t remember the exact wording or the many ‘humorous’ angles that Rex Murphy took in this typical meandering monologue but I do recall the immediate effect it had on me. In my mind I could see Canadians across the country nodding and agreeing with Murphy, that spending any money on obesity research was indeed a complete waste - we already know the reasons: ‘gluttony and sloth’ - what’s there to research?

It became blindingly obvious that Rex Murphy was simply stating aloud what most people think - no wonder governments would be hesitant to support obesity research, or worse still, actually consider providing obesity treatments to Canadians.

I admit that prior to hearing this commentary, I had not given much thought to the issue of how weight bias ultimately stands in the way of finding solutions to the obesity epidemic.

Unfortunately, while Rex Murphy could perhaps be forgiven for failing to recognize the true psychosocial and biological complexity of this problem, I continue to be baffled that so many of my professional colleagues continue to trumpet simplistic notions of “eat-less-move-more” as a solution to the problem.

Frankly, I do not believe that they fully appreciate how, by reducing the entire problem of obesity to simply a matter of diet and exercise, they do little more than reinforce what most people already believe - obesity is simply a matter of ‘gluttony and sloth’.

No talk of food insecurity, abuse, depression, stress, time-pressures, addiction, genes, incretins, adipokines, hypothalamic pathways, adipostats, mitochondrial inflexibility, medications, or any of the other countless ’scientific’ intricacies that may indeed result in the ’symptoms’ of overeating or undermoving.

By reducing obesity simply to a matter of ‘lifestyle’, they provide the perfect excuse for funding agencies to rather fund research on ‘real’ health problems, for regulators to tighten the criteria for obesity medications, for payers to deny or limit the access to obesity treatments, and for health professionals to not see obesity management as part of their job.

This is why there will be no solution to obesity without first solving the issue of weight bias and discrimination.

This is why, addressing this issue remains the #1 strategic priority of the obesity network.

To anyone unhappy about how much funding is going towards supporting obesity research, unhappy about availability or access to obesity treatments, unhappy about lack of obesity training for health professionals, unhappy about reimbursements to health professionals for obesity counselling, unhappy about integrations and accommodation of people struggling with severe obesity, or even just unhappy about the surprising fact that Canada’s only national obesity organisation receives virtually no government funding to sustain its efforts - I have one simple suggestion: begin by showing zero-tolerance for ‘fat jokes’ or ‘fat talk’, do not use language, images, or messages in your presentations and writings that further promote stereotypes or reduce this complex problem to simply a matter of ‘lifestyle’, and please do stand up and speak out on the issue of weight bias and discrimination.

If the Canadian Obesity Network does nothing else but bring awareness to this aspect of the obesity problem  - it will have well been worth the ride.

AMS
Edmonton, Alberta

The mantra about the benefits of weight loss seem to be gospel in most discussions about solutions to the obesity epidemic.

It was therefore quite refreshing to follow the presentations and discussions at yesterday’s session on weight bias and discrimination at the Journées annuelles de santé publique (Québec).

One of the most innovative presentations was in fact a review of the many programs and initiatives by ÉquiLibre, a Québec non-profit organization with the mission:

“to prevent and reduce problems related to weight and body image in the population, through actions encouraging and facilitating the adoption of healthy lifestyle and developing a positive body image.”

For the past 20 years, this organization has been providing “Choose to Lose Weight?“, a program for women concerned about their weight, that focusses on size acceptance and ending the cycle of ‘yo-yo’ dieting.

For people fluent in French, the site provides ample advise on myths regarding weight loss, the potential risks of dieting and weight obsession, and tips on how to recognize ‘ethical’ weight management programs.

The ÉquiLibre site also links to an most interesting interactive site called ‘Behind the Mirror” aimed at youth, that most engagingly challenges weight and appearance stereotypes.

For non-French speaking readers, I recommend exploring the site in the Google translation mode, which does a remarkably efficient job of translating the content of these pages.

French speakers should of course browse the original site for information on ÉquiLibre.

I’d love to hear from anyone, who has participated in their courses.

AMS
Montreal, QC