Dr. Sharma's Obesity Notes

Not quite, although this does make for a good headline.

The actual story, which accompanies the global media reports of the underground smuggling operation that illegally routes KFC contraband to Gaza, however does illustrate the lengths to which people will go to obtain their crunchy fat, salt and sugar fix.

The report in the International Herald Tribune describes the distance KFC has to travel as,

“…a journey that involved two taxis, an international border, a smuggling tunnel and a young entrepreneur coordinating it all from a small shop here called Yamama — Arabic for pigeon.”

According to this report, the entrepreneur, a Mr. Efrangi (aka “the Kentucky guy”),

“..has coordinated four deliveries totaling about 100 meals, making about $6 per meal in profit. He promotes the service on Yamama’s Facebook page, and whenever there is a critical mass of orders — usually 30 — he starts a complicated process of telephone calls, wire transfers and coordination with the Hamas government to get the chicken from there to here.”

While the report focuses on the “resilience” of the Gaza inhabitants, who are merely seeking to live a “normal life”, the story does speak to the lengths that people will go still their “cravings”.

While Mr. Efrangi, for logistical reasons, limits his orders to chicken pieces, fries, coleslaw and apple pie, he may not be in business for long.

As the Tribune reports,

“A Gaza businessman who asked to be identified only by his nickname, Abu Ali, to avoid tipping off his competitors, said he applied for a franchise from KFC’s Middle East dealer, Americana Group, two months ago. Adeeb al-Bakri, who owns four KFC and Pizza Hut franchises in the West Bank, said he had been authorized to open a restaurant in Gaza and was working out the details.”

Throughout human history, people have desired what is most difficult to get – bans and prohibitions have always made stuff more worth having than before (whilst upping the “cool-factor”) – apparently, junk food is no exception.

As an interesting side note, which perhaps speaks to the “addictiveness” of the KFC formula, some readers may recall that KFC (now belonging to PepsiCo) was at one time owned by R.J. Reynolds (now RJR Nabisco) – the makers of Camel, Pall Mall, Winston and other “choice tobacco products”.

AMS
Edmonton, AB

Professor Shiriki Kumanyika, University of Pennsylvania, Philadelphia

Based on the simplistic notion that excessive weight gain is merely a matter of calories-in and calories-out, conventional individual-level approaches to obesity have long focussed on restoring energy balance in individuals by attempting to influence energy intake and output (with rather modest success).

What affects weight gain in individuals, may well also influence weight gain in populations, at least that is the underpinning idea of the ecological approach to addressing obesity. But, as in individuals, interventions based on this notion are far from straightforward to implement or sustain.

This may well be, because, as at the individual level, complex sociocultural and psychological (not to mention biological) factors tend to occur that serve to push the energy balance towards the positive side of the equation – this is particularly true for minority and marginalised populations.

Thus, as presented by Shiriki Kumanyika from the University of Pennsylvania  at the 20th European Congress on Obesity in Liverpool, social inequalities can make certain population seqments particularly vulnerable for obesogenic factors.

In this context, she emphasised that the term “vulnerability” itself can be discriminating and should be clearly defined in the context of social inequalities that face certain population groups (e.g. ethnic minorities) rather than in terms of “deficits”.

In her talk, she presented an overview of her work demonstrating the markedly increased obesity rates in black women, American Indians and Mexican Americans in the US. As she noted, even in the context of clinical trials, not only do participants from these groups show less weight loss with interventions but also gain weight more rapidly when randomised to the control group.

While the nature of foods and activity options available to whose with limited resources accounts for some of the increased risk, it turns out that higher income does not appear to be protective early in the nutrition-economic transition. Rather, during this transition phase, upward mobility may actually further increase the risk of obesity as behavioural risks (increased caloric intake, sedentariness) become more “affordable”.

In order to better understand these patterns of differences in ethnic minorities, a network consisting largely of black American researchers, has developed a “Community Energy Balance” framework.

At the community level energy balance is mediated through the many factors that directly or indirectly affect food intake and physical activity.

This framework leads to the identification of a wide range of potential intervention targets at the levels of the community, family and individuals.

Other elements of this framework also consider cultural-contextual influences that influence obesity including historical experiences and adaptations, type of minority status, structural influences, and sociocultural influences.

The hope is that although both socio-economic status and ethnic differentials are important, this framework will facilitate a systematic analysis and identification of possible solutions to the inequalities that affect these minority populations.

However, whether or not such interventions will prove more effective in communities than current individual-based interventions clearly remains to be seen. Knowing the intrinsic property of complex systems (including communities) to often respond and adapt in unpredictable ways, often with unintended consequences, it is by no means clear as to which community based approaches to addressing inequalities or other drivers of obesity will ultimately tip populations towards the negative side of the energy balance equation.

AMS
London, UK

Theresa Marteau, Director Behaviour and Health Research Unit, University of Cambridge

The second morning of the 20th European Congress on Obesity here in Liverpool was kicked off by a presentation by Theresa Marteau, Cambridge Institute of Public Health, on the use of “choice architecture” to “nudge” individuals towards adopting healthier behaviours.

Given the limited effectiveness (some may say “failure”) of attempts to change population behaviours based on conscious, goal directed, reflective interventions, “nudging” attempts to change behaviours through non-conscious, habitual or automatic interventions.

The idea of nudging, defined by Thaler and Sunstein as

“..any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives”,

is not a new idea to social psychologists and is based on the observation that our conscious processes are finite and that most of our responses to the environment occur below our conscious awareness.

Thus, while previous approaches to changing health behaviours have primarily focussed on conscious cognitive approaches, newer models attempt to change behaviours by targeting the sub-conscious non-reflective processes that underly these behaviours.

In her talk, Marteau described the results of a large-scale scoping review on use of nudging interventions for tobacco-, alcohol-, diet- and physical activity-related behaviours. Her analysis included ~350 articles describing two types of interventions that altered either the properties (ambience, functional design, labelling, presentation, sizing) or placement (availability, proximity) of objects or stimuli within the micro-environent where the behaviour is happening. In addition the analysis looked at priming and prompting interventions.

All of these approaches have in common that they typically require minimal cognitive engagement and can potentially influence many people at the same time. In addition, health nudging, by avoiding the use of literacy and numeracy, may be able to reduce social patterning thus reducing health inequalities.

To date, most of the work on nudging has been done in the context of dietary behaviours, mainly on food labelling and sizing.

As one may expect, studies in experimental settings have shown effects of ambience (e.g. effects of the tempo of music on speed of eating), functional design (e.g. change in packaging), labelling (e.g. use of exciting names or cartoon characters on healthier foods), proximity (e.g. product placement on the shelf), or prompts (e.g signs or announcements) on behaviours.

Thus, for example, ongoing research suggests that simply putting healthier foods at the ends of aisles changes shopper behaviours largely independent of pricing, suggesting that simply changing the placement of foods may be far more effective than changing pricing (e.g. taxation).

The big question, however, is whether these effects are indeed sustained and have large enough effect sizes. So far, the data on this is not clear, which is why Marteau and colleagues are currently working on a synthesis of evidence to see whether such nudging interventions do indeed influence health behaviours outside the laboratory.

In the real world, healthy nudges have to compete with unhealthy nudges – e.g. images or labels warning against overconsumption of fast food have to compete with the strong nudges created by the common association of fast food advertising and images with sporting events – this may well be an insurmountable obstacle given the almost limitless tool box and financial resources of the food industry.

Marteau also addressed the acceptability of nudging interventions. As one may expect, less intrusive interventions such as placing or health prompts were found to be far most acceptable than taxing, pricing, or limiting portion size, which are generally seen as overtly limiting choice.

Ultimately, the issue of acceptability will be the rate-limiting-step for legislators, who need to align public and political wills. This is something that is unlikely to happen without stronger evidence to support broad acceptability of such measures. Countermeasures by industry and the voices of those who oppose coercive paternalism will clearly further limit political enthusiasm for legislative interventions.

On a happier note, Marteau notes that there may be somewhat greater acceptance for choice architecture interventions in children and young people.

Whether or not her optimism is warranted, remains to be seen.

AMS
Liverpool, UK

Follow live tweets from this conference with #ECO2013

Last week, just as the CON-Students and New Professionals were hosting a passionate debate on the dangers and merits of corporate engagement (moderated by Diane Finegood and featuring Yoni Freedhoff and Kim Raine in the con-corner vs. Michael Lyon and Richard Ellis in the pro-corner) at the 3rd Canadian Obesity Summit in Vancouver, The Obesity Society (TOS) released its guidelines for accepting funding which turn out to be remarkably similar to those of the Canadian Obesity Network.

This new TOS policy,

“..expressly eliminates all forms of evaluation or judgment of the funding source (other than the stipulation that funding is reasonably assumed not to be derived from activities deemed ‘illegal’).”

Rather than deeming any source of funding as “off-limits”,

“TOS chooses instead to focus its ethical mission on transparency in disclosing the sources of funding, clear stipulations outlining our commitment to the ethical use of funds, and a commitment to non-influence of the funding sources over the scientific aspects of funded projects and TOS as a whole.”

Not unlike the Canadian Obesity Network, TOS adopts adopted the following 5-point criteria for accepting external funding:

- The donor desires to provide financial support to TOS to further our mission to fight obesity and improve public health.

- The donor agrees that the projects that they support will bear the donor name (e.g. corporate entity, foundation etc) only and not specific products or services.

- The donor agrees that they will have no authority to direct or influence the scientific aspects of research or other projects.

- The donor agrees that the relationship with TOS can in no way be used to imply that TOS endorses the donor or any of its products, services, or mission(s).

- Donors are encouraged to make unrestricted contributions; however, they are permitted to make contributions restricted to a specific purpose, so long as that purpose is consistent with the mission of TOS and does not violate any aspect of the TOS funding policy.

It is further stipulated that:

Funds will only be accepted to do those activities for which TOS is constituted (see Laws and Bylaws).

Funds will not be accepted if they:

i. Set condition(s) above the inferences to be drawn from research or other activities by members of TOS.
ii. Set any conditions about the views to be presented in any TOS forum (including the views of non TOS members).
iii. Restrict the dissemination of any information about or from any TOS activity.
iv. Restrict acceptance of funding from other sources.
v. Entail any obligation to support in any way the goals of the donor, except for those goals that are mutual with TOS for the specific activity funded.
vi. Could, through other kinds of coercion, result in conditions i – v above.

Interestingly enough, the “debate” at the Canadian Obesity Summit last week, based on anonymous polling of the audience, revealed that only a small minority (7%) of attendees would categorically deny industry any place at the table. The majority (88%) stated that they would welcome industry engagement with the majority of these (57%) supporting the acceptance of financial contributions without (39%) or even with (18%) co-branding.

This is not to say that the participants did not acknowledge the potential negative perceptions of accepting such funding – however, as with TOS, this perception can best be managed by complete transparency and ensuring that the activities and programs of the Canadian Obesity Network meet the highest scientific standards.

I agree that “perceived” conflicts are best dealt with through full disclosure, which was why all symposia and workshops hosted by commercial and non-commercial “third parties” were clearly identified as such.

Indeed, I would be quite surprised should the evaluations of the Summit reveal anything but the complete absence of commercial bias in the main “scientific program”.

AMS
Edmonton, AB

Moving beyond its expected focus on food and physical activity, I certainly find it refreshing that the Ontario Healthy Kids Panel’s report No Time to Wait: The Healthy Kids Strategy released yesterday, also touches on the issue of childhood mental health.

Thus, the authors do make the point that,

“Children and youth who enjoy good mental health respond better to life’s challenges and make healthier choices. We can foster children’s resilience by focusing on positive relationships, experiences and inner strengths such as values, skills and commitments. We can create a strong sense of belonging at home, in school and in communities; build on children’s strengths and competency; and encourage their autonomy and ability to make decisions that will enhance their health and well-being.”

They also include the following in their recommendations,

“Because of the strong links between mental health problems and unhealthy weights, the Healthy Kids Strategy should work closely with the province’s Mental Health and Addictions Strategy, focusing particularly on helping children develop the confidence, self-esteem, resilience and coping skills that will improve their mental health and empower them to make healthy choices throughout their lives. Youth should be actively involved in planning and implementing these strategies.”

Regular readers will certainly appreciate that I have always championed the notion that obesity and mental health are two sides of the same co-epidemic and that strategies to address the root cause of either of these problems will hopefully help address the other.

Readers may well recall that last year, the Canadian Obesity Network together with a number of partners released the Toronto Charter on Obesity and Mental Health – hopefully elements form this charter will find their way to decision makers as they decide which of the panel recommendations to focus on.

I, for one, have no doubt that attention to mental health and resilience (in both the parents and their kids) will be a key determinant of the success of this strategy.

AMS
Edmonton, AB