Dr. Sharma's Obesity Notes

Having (predictably) annoyed the exercise and fitness community with yesterday’s post on the New England Journal of Medicine article on obesity myths, presumptions and facts, I am preparing myself for more flack with regard to Myth #6, which the authors state as,

“Breast-feeding is protective against obesity.”

In support of the notion that this widely held notion represents a myth, it may be important to recall what exactly the authors of this paper consider a myth:

“…beliefs held true despite substantial evidence refuting them.”

On that note, the authors note that a recent WHO report that suggests a positive impact of breast-feeding on obesity rates may have significant publication bias in the papers it analysed for this report.

They also state that,

“…studies with better control for confounding (e.g., studies including within-family sibling analyses) and a randomized, controlled trial involving more than 13,000 children who were followed for more than 6 years provided no compelling evidence of an effect of breast-feeding on obesity.”

But the authors are quick to point out that,

“Although existing data indicate that breast-feeding does not have important antiobesity effects in children, it has other important potential benefits for the infant and mother and should therefore be encouraged.”

Thus, as is the case with school phys-ed programs, breast-feeding has numerous important benefits for kids irrespective of whether or not it helps address obesity.

(Note that the authors do not address the question of whether or not breast-feeding is protective against obesity in the mothers!).

While I realise that this “myth” will not be welcomed by those who promote breast feeding (including myself), it should not deter us from encouraging breast feeding given its many better-established benefits.

The same, of course applies to yesterday’s “myth” on phys-ed programs. Just because there is little evidence to support their role in reducing obesity rates does not mean that I do not support such programs or consider them important for our kids’ health and well-being (as long as such programs are based on inclusiveness rather than competition-based exclusiveness).

AMS
Edmonton, AB

Government has an important role to play in protecting and improving the health of its citizens. This role also extends to promoting a healthy and wholesome food supply.

Anyone, who disagrees, is perhaps best directed to an article by Dana Olstad, Kim Raine and Linda McCargar (University of Alberta), published in Public Health Nutrition, which makes a strong case for government regulations in improving the quality of foods available to children in public facilities.

This paper follows on the heels a previous paper, in which these authors documented the appalling state of foods and beverages sold in publicly funded recreational facilities across Alberta.

The current paper is of particular interest, because it delves into the ‘whys’ that prevent some facility operators from offering healthier fare to their clients.

The researchers conducted in-depth structured interviewers with operators of all six privately operated, for-profit food service companies that provide foods in recreational facilities across Alberta. These included both companies that have and those that haven’t adapted voluntary, government-issued nutrition guidelines (Alberta Nutrition Guidelines for Children and Youth, ANGCY), which

“categorize food and beverages according to their nutrient content as ‘choose most often’ (consume daily), ‘choose sometimes’ (≤3 servings/week) and ‘choose least often’ (≤1 serving/week), and recommend that healthier options be available at all times and fresh, convenient, visible and attractively packaged and priced.”

The rather unexpected finding of this study was that,

“Most managers agreed that government-mandated adherence to the ANGCY was the only feasible means of achieving widespread adoption in recreational facilities, as voluntary adoption was not in their financial interests…. Ideally, managers felt adherence should be mandatory for the entire food service sector, or at minimum for those businesses located within close proximity to recreational facilities.”

In addition,

“The lack of a single, national nutrition standard was an important barrier to implementation of the ANGCY for franchised operations, which had to simultaneously comply with several different provincial standards.”

Overall, this ‘call for mandated regulation (even for Canada-wide standards), is perhaps not all that surprising, given that:

“Managers felt very susceptible to competitive pressures and were concerned that the ANGCY targeted a small number of sectors. If they could not sell the items their customers demanded, then patrons would simply purchase unhealthy items elsewhere….The problem was particularly salient for one vending machine company that had implemented the ANGCY in a facility where the concessions had not.”

Thus,

“Requiring all food service companies, or at minimum all of those within close proximity to recreational facilities to adhere to the ANGCY was seen as a means to level the playing field upon which all companies compete.”

This, as the researchers (and managers) point out, may only be achievable through legislation, as voluntary codes (even if adopted by the majority of players) would leave the compliers at a competitive disadvantage to those companies, who chose to not play by these “voluntary” rules.

As a strategy to move such an agenda forward:

“public–private partnerships can embrace public health goals in the short term, provided that industry perceives a potential for long-term financial gain.”

However, not all companies may realize or consider what may be in their own best (long-term) interest:

“Non-adopters maintained a strong focus on short-term profitability…. focused on immediate, visible outcomes, had a low tolerance for risk and preferred to conform to industry norms……Adopters, on the other hand, were innovators… took a long-term view of profitability and were willing to take small risks, sacrificing short-term profitability to remain on the leading edge of market trends.”

Obviously, forward-thinking innovators could perhaps themselves play a role in moving those “market trends” towards increasing demand for healthier fare by reallocating marketing dollars away from unhealthy foods to promoting healthier choices.

In the mean time, Olstad and colleagues may well be correct in that the best solution could be for regulators to step in and create a (Canada-wide?) level playing field that will nudge both vendors and consumers towards healthier foods.

AMS
Edmonton, AB

Olstad DL, Raine KD, & McCargar LJ (2012). Adopting and implementing nutrition guidelines in recreational facilities: tensions between public health and corporate profitability. Public health nutrition, 1-9 PMID: 23149122

.

…except perhaps that there is no universal causal theory of obesity.

In a world where everyone is looking for quick-fixes and approaches to dealing with almost any societal problem, quickly degenerate into opinionated activism, I often find it important to remind myself that obesity is not a simple problem where identifying (and eliminating) one cause will “solve” the issue.

I was reminded of this by some of the comments to yesterday’s post on emotional eating, which pointed out that too much emphasis on the emotional aspects of overeating simply adds another narrative to “pathologizing” people with excess weight.

In other words, not only are obese people gluttonous sloths without will power, they are now also emotionally-wounded wrecks (you can chose, which of these is worse).

The fact, however, is that the vast majority of people with excess weight are none of these.

There are countless people with excess weight, who eat as much or as little as skinny folks; the problem of inactivity and sedentariness in Canada affects 95% of the population (and not just the 60% who are overweight or obese); throughout history, overweight and obese individuals have expressed incredible feats of determination and will power; and psychiatric wards are full of skinny people with mental illness.

Thus, as I have often discussed in previous posts, the ‘root causes’ of obesity are as diverse as not having enough money or time to eat to taking medications for your allergies. Throw in an ounce of genetics (any of the the 1000s of genes involved in appetite, hunger, metabolism), and you have the perfect scenario for continuous and fruitless debates on what is really driving the obesity epidemic.

For those of us, who embrace activism, we can chose the target we happen to feel most strongly about and go for it with all our energy and passion.

The list of seemingly worthwhile and deserving targets is long: junk food, caloric beverages, TVs, computer screens, lost cooking skills, built environments, cars, automation, over-scheduled kids, poor parenting, sleep deprivation, environmental toxins, allergies, gut bugs, viruses, stress, dieting, fashion ideals, bullies, and probably a few more.

Which of these factors individually or in combination are most responsible for making us fat is anyone’s guess – what may have some evidence or support at a population level is often irrelevant when it comes to individuals (your reasons for being overweight are different from mine).

So, yes, my readers are right – most of the obesity epidemic is simply the natural response to living in an unnatural environment – or perhaps even just living.

For most people with excess weight, there is probably no real underlying “pathological” driver apart from being human.

This does not mean that obesity, once established, cannot become a pathological state in that it can adversely affect all dimensions of physical, emotional and functional health (or not).

After all, what do most thin people do to stay thin? The correct answer is probably, “not much”.

AMS
Edmonton, AB

Image source

Many years ago, I had a patient (let’s call him Tony).

Tony was 48 years old, had a BMI of 43, elevated blood pressure (uncontrolled), reflux disease (Tums PRN), and occasional gout attacks (Tylenol 3s PRN).

Tony fitted every imaginable obesity stereotype – his diet consisted essentially of donuts and pizza (with a few chicken wings and fries thrown in for good measure). He was a self-proclaimed “meat and potato” guy (and proud of it). His daily consumption of beer was essentially unchanged since college.

Tony’s activity levels consisted largely of moving from his bed to his car to his desk to his car to his couch to his bed. HIs idea of exercise was watching Hockey Night in Canada.

When I first saw him, it was immediately apparent that he had no interest in seeing me (or anyone else in the clinic). He was here because his wife threatened divorce unless he lost some weight, his daughter threatened to no longer let him see his grandkids till he changed his attitude and lifestyle, his boss had passed him up for promotion twice because of his size.

Despite this Tony was in complete denial. He was not “obese” (just husky!), hypertension was something invented by the pharmaceutical industry so they can sell drugs, his heartburn was because he had a hernia, his painful toe was because of having stubbed it years ago (the doctors never fixed it!). He felt he was in the best of health for a man in his age and thought this was all a waste of time.

As you may imagine, Tony was not very open to any form of lifestyle counselling. Nevertheless, the rest of the team and I saw him several times over the next six months despite him regularly missing appointments and showing virtually no “progress”.

Finally, after six months of little progress, the team had come to the rather strong opinion that it was time to discharge him from the clinic.

Thus, I was tasked with ‘firing’ him at his next visit.

When Tony came in, he was in a bad mood. His toe had flared up. The pills I had prescribed for his blood pressure were affecting his sexual function. His boss had finally threatened to fire him.

I quietly listened to his complaints and then told him that the team had decided that we felt that we were not helping him and that we saw little point in his coming to see unless he was ready to actually start doing something about his health.

Tony was shocked!

What did I mean by insinuating that he wasn’t doing anything?

He pointed out that he had actually cut down on his drinking (down to four cans from six). He no longer polished off a dozen wings – just half dozens at a time. He had stopped ordering “extra cheese” on his pizza. He had begun wearing a pedometer and some days actually clocked 2000 steps! And, best of all, a week ago he had actually (apparently for the first time in his life), eaten an actual vegetable (a deep fried zucchini), which he had bought for his grand daughter at the rodeo!

And, he pointed out, all of these changes had happened simply because his wife and daughter continued to insist that he come to the clinic.

But, I argued, these may well be changes, but they are simply not enough!

“You are still eating pizza and donuts, you are still drinking, you are still not exercising, you are still not taking your pills, your are still the same weight as before – how can you call this progress? You are just wasting our time. We could be helping other people who really want our help.”

“Please doctor, give me some more time – I am trying – I am trying hard – I just cannot change everything at once. I know I have only made a few ‘baby steps’ but give me time and I promise, things will change for the better. But, if you really think you are wasting your time on me, tell me and I promise you’ll never see me again.”

At that visit, I could have followed the demands of my team – I could have simply discharged Tony for non-compliance.

I chose not to.

Six years later, Tony still occasionally eats pizza, he still drinks a can or two of beer everyday, he still loves donuts and still misses breakfast on most days of the week. The extent of his exercise is essentially taking out the garbage and occasionally mowing the lawn. At least his blood pressure is now controlled and he seems to be in a better mood. Surprisingly, he has managed to lose about 10 lbs.

Has he done enough? Certainly not!

Is there further room for movement? Sure there is!

Would any of these changes have happened, had I simply fired him from the program six years ago? Probably not.

What helped Tony in the end was the fact that we noticed and appreciated his baby steps.

Rather than pointing out all the things that he would still need to do to get healthy, we applauded every little move in the right direction. We cheered him on.

We accepted his reality but kept up our gentle nudging.

But most importantly, we keep the dialogue going.

In the end, what was more important in helping Tony change his lifestyle and improve his health?

The threats from his wife and daughter or the positive encouragement and support from the clinic team?

You decide.

AMS
Mississuaga, ON

Yesterday, the big news was that Coca Cola has decided to embrace their responsibility on the issue of obesity.

This is clearly a smart business move for a company that is being widely accused of being a big part of the problem.

While pundits may argue about exactly how big a problem Coca Cola actually is (e.g. vs. snack foods, sugary cereals, chocolate, ridiculous portion sizes, or alcohol – not to mention computers, omnipresent computing devices, automobiles, and countless other factors that contribute to our “Western” lifestyles), there is no doubt that sugar sweetened beverages (like juices) can contribute a significant proportion of calories to some people’s diets.

No one, not even Coca Cola, denies this!

It is therefore indeed “refreshing” to see Coca Cola step forward and acknowledge their responsibility – which, they have now done with considerable media fanfare (both positive and negative).

Of course, the “spin” in the video ensures that these efforts are presented in the best possible light. As they point out:

-About one third of their products are now available as low- or no-calorie options.

-Most products are available in smaller package sizes.

-The actual total caloric content is now clearly visible on the front of the package (instead of being hidden in unreadable nutrition labels).

But no one, for a moment believes, that any of this would have happened without “social pressure” from their critics. I am also certain that all of this is motivated in part to pre-empt any moves to further regulate and police this company or its products. Thus, this campaign is sure to make good business sense and is probably fully supported by its shareholders.

Indeed, there are many public health advocates, who suggest that companies like Coca Cola should be forced to pay a “health tax”, which, although not markedly reducing Coca Cola consumption (only a very heavy tax would do that), would at least provide governments with a revenue stream that they can (hopefully) put towards obesity prevention and treatment.

I do not see why such a “health tax” needs to go to the government (only to likely disappear into their bottomless coffers).

Why not have Coca Cola “voluntarily” pay such a “tax” directly to one or more organisations that are already working in that space and can likely put that money to immediate good use (without creating another cumbersome and unwieldy government bureaucracy)?

Not only would this make good business sense for Coca Cola (in terms of further “health-washing” their brand), but it would certainly ensure that such monies are indeed spent directly on the problem at hand.

It is perhaps time to kick off a “virtuous cycle” that may in the end benefit everyone:

Coca Cola pours a few million $$ into an organisation that educates Canadians on the importance of watching their calories, thereby getting Canadians to increase their demand for low- and no-calorie beverages, which Coca Cola can then happily sell more off, thereby making even more money, part of which they can plough back into the organisation that educates even more Canadians…..you get the picture.

Anyone, who thinks that this would be the same as a tobacco company supporting an organisation to promote cessation of tobacco use is WRONG. As there is no healthy alternative to tobacco – that relationship can only end with the tobacco company going out of business.

Fortunately, in the case of Coca Cola, it does make a healthy profit from its low- and no-caloric alternatives – in the end, I don’t think its shareholders would really care whether Coca Cola makes its money from Coke Classic or Coke Zero – as long it can continue to make money selling Coke.

This is why I can actually see a win-win for a Coca Cola-Obesity NGO partnership, that would simply not exist for a Tobacco-Anti-Tobacco NGO.

But why stop at Coca Cola?

A similar formula could well work for any beverage or food company – all of these companies also make “healthy” (or at least “less unhealthy”) choices – which they cannot sell as much of, simply because consumers don’t want to buy them.

Here again, an obesity NGO, by addressing the ‘root causes’ of obesity, can work towards helping create a greater demand and willingness to pay for healthier products – thereby allowing these companies to sell more of these products – in the end, hopefully, making even more money for their shareholders.

Fortunately, Canada has an obesity NGO that is happy to take on the task of educating and working with professionals and consumers to prevent and better manage obesity.

Perhaps it is time for us to help Coca Cola sell even more low and no-calorie beverages to those Canadians who simply will not drink tap water.

AMS
Edmonton, AB