Wednesday, May 16, 2012

Fatter and Fatter

I have some questions about America's obesity epidemic.


The New York Times has an article about a mathematician who has been looking for the causes of obesity-- In a A Mathematical Challenge to Obesity, an interview with Carson Chow, Claudia Dreifus  notes that the average person weighs 20 pounds more now than in the 1970's.  I was alive then and it was the hey-day of processed food back when skinny people fed their skinny kids white bread with butter and sugar.   Mayonnaise (or rather Miracle Whip, what ever substance that might have been) was on everything, and oh for  twinkies, ring dings, chef Boy-r-Dee, and scooter pies....those were the days.

The mathematician proclaimed that the answer is that there is more food.  More is grown, more is available, it's cheaper and cheap food allows for the existence of fast food, something you can't have if the food costs a lot.  What I've noticed is that food is everywhere.  All the push to make school food healthier, get rid of soda machines, and encourage children to be more active (ah, the kids I know, even the heavy ones, are doing 3 hours a day of sports after school, it's no guarantee you'll be slender), but it seems that every day is a "special" day....a fund raising bake sale, someone's birthday, end of year party, weekly advisory where the kids rotate bringing baked goods, language class meal, trip to restaurant, snack parent at every sports game, followed by dinner, and when you go out, the servings are huge, and I, for one, find it hard to stop eating really good tasting food if I'm hungry and it's on my plate.  So I'll believe that food availability is the reason why people are fatter.  

So here's my question.  Obesity researchers study obese people and how they differ from normal weight people.  Why isn't everyone obese?  Why are only 1/3 of Americans  obese and only 1/3 are overweight?  Why aren't they studying the people who remain thin despite the fact that they are surrounded by food? Okay, so some people have very fast metabolisms, but others are don't seem to have any desire to overeat.  There may be lots of available food, but they don't want it, or they want it when they're hungry, but they have some and that's enough, a 'stop eating' mechanism kicks in at a point that keeps their weight low.  Why don't they have the desire to eat more when food is available?  And finally, there are those people who want more food, but for the sake of their health or their appearance, they limit their eating.  I've heard it said, "Well, if she really wanted to be thin, she'd eat less."  I don't buy it, I think there are differences between people besides a simple desire, or a weakness of character that makes self-control harder for some then for others.  I want to know why some people have faster metabolisms, less desire to eat, or more will power.  Okay, Dr. Carson, how does your mathematical model work for that one?

I'm not an alcoholic.  It's not because alcohol isn't available-- at any given time my house is stocked with an assortment of beers (I keep dark on hand because Roy likes it) and wines.  It's available, but most days, it's just not on my radar.  It's not because I have great willpower.  I like a drink or two, but after that I get very tired, and it's not fun to be out with people just wishing I could lie down.  I'm not an alcoholic because I'm not wired to want  to drink very often or very much.  I tend to think it's the same with obesity: some people crave food, or the wrong food, or way too much food, and others don't.  Availability may make it easier, but there are still thin people, and isn't it interesting that in more affluent socioeconomic circles, where food has always been readily available, obesity rates are lower.


As a society, we've made the statement that if you're fat, it's your fault.  The obese are the last group of people that it's okay to pass judgement on.  "Exercise more, Eat less."  It's a simple recipe.  Dr. Chow tells us there's no magic bullet.  It's stigmatizing to take weight loss pills or have bariatric surgery.  I've heard morbidly obese people say it's their own fault, as though they don't deserve to be thin, and they loathe themselves for eating too much.  I sometimes wonder if our prejudices about obesity hinder pharmaceutical research because-- if anyone wants my vote-- there should be a magic bullet. 

30 comments:

SteveBMD said...

Interesting questions. What it boils down to is: what makes a person "average" or "typical"? (I would say "normal," but that would imply that non-obese = "normal," which is arguable.)

We're so obsessed with finding out what's WRONG with people-- especially in psychiatry-- that we fail to recognize health/wellness when it's staring us in the face. If we spent more time asking what makes the non-obese person NOT obese, or what makes the non-alcoholic person NOT alcoholic, or what makes the highly traumatized individual NOT develop depression or PTSD, etc, I think we would learn much more about what it means to be human, and have much more acceptance of the wide range of variability among our fellow men and women.

George Dawson, MD, DFAPA said...

There is a lot of overlap with the neurobiology of motivation and addiction. In fact there are the beginnings of the answer to the question about why the non-obese person is not obese. Pathological states are often arbitrarily defined but they are really variations in the conscious state. People often fail to see the connection between an idea and a physical condition and how it is medicated in the CNS.

Anonymous said...

The magic bullet that you wish pharma would develop will come with side effects: loss of libido, akathisia, insomnia ,and oh yeah, weight gain. Dang.

Sunny CA said...

I totally agree with your commentary. For a long time, I have had what I think is the "answer" to why some people are obese and others are thin. I wish somebody would do a study and confirm (or disprove) my idea.

I was born in 1951. Our family had friends who were dairy farmers in upstate New York. Sometime in the 50's we visited the dairy farmer and Kurt, the farmer, was thrilled because he had started using growth hormones in his immense dairy business. He was astounded at the huge size of his dairy cows and bulls and at the fabulous increase in size of their udders and increased production. I imagine back then they did not know how much to give the cows. If a little works, why not double the dose and see what happens? There must have been a lot of tinkering going on. Anyway, our dairy farmer friend who had hundreds of cows had begun what now is common throughout the dairy and meat industry: administering growth hormones.

My husband is "naturally" thin. He did not like milk and never drank it. I was naturally skinny as a child, but my parents made me drink a really tall glass of milk with every meal and another one before bed and I continually struggle with my weight. The meat they gave me probably had growth hormones also.

Bovine growth hormones are very similar to human growth hormones. If growth hormones make dairy cows tall and fat with big udders, why wouldn't the growth hormone we drink in the milk make us tall and fat? I think it would and does. Our "fatness" is caused by growth hormones. It probably is more important when children are developing.

Dinah said...

Sunny CA: I think you can find thin people who drink milk.
However, after I read about growth hormone in cow's milk, I started buying organic milk for my family (? close to 10 years ago) and have ever since. I should probably buy organic beer for Roy...

I imagine the answer is multifactorial.

My magic pill would not cause weight gain. Baldness, maybe...

Anonymous said...

Dinah,

My doctor told me that my magic pill would not cause weight gain. This is going back several years. The doctor had never prescribed the magic pill before. The doctor did not believe that a person could gain 40 pounds in a few months as a result of the magic pill. I stopped taking the magic and lost all the weight without any dieting or change in exercise. Every time I land in hospital I get more magic pills and emerge magically fatter. I go in a thin person and come out a few sizes larger.
As for milk, one household member does not consume any dairy or meat products and while not fat, this person is the "beefiest" of us all.

Sarebear said...

Having recently been prescribed phentermine, and having so much guilt about failing to control myself and needing a diet pill, I am in a muddle with all that myself.

There were several symptoms including spreading numbness in a particular area that made me suspect diabetes; thankfully it's not so but my GP chalked the numbness up to being weight-related and he prescribed the phentermine. And exercise and diet changes, of course. Exercise is painful for me, because of the pain and other negative consequences of my total knee replacements, but that doesn't mean I'm not capable. I did exercise about 3-4 times a week (sometimes 2, but mostly the other) for about 5 minths last year. Motivating one's self to do something painful, is often difficult. But, things could always be worse. I just hate it when people say or think, just exercise, dammit . . . making it sound easy and painless. It is difficult and painful, thank you very much. I had intended on resuming it anyway, for mental health reasons as well as physical. I guess I'll see how I do.

Anonymous said...

I'm not sure if I agree with your theory. I work in hospitality and in this field there is never a shortage of food. I am a student and so every single day, we generate a lot of food and beverage. We go through 10 liters of milk in a lesson, just to practice coffee making. There are 8 commercial kitchens on campus and the kitchens generate a lot of food, some of this goes to homeless shelters but a lot of it is thrown out because of food hygiene regulations (when the food is transported, there is a risk with certain types of food). A lot of the time, the food is passed around other classes, and we find ourselves having seconds and thirds because we don't want the food to go to waste. Quite a few of the teaching staff are overweight, the ones who stay thin are the ones who have strong willpower.

I also want to ask this in return: should there be a magic bullet for a hangover?

rob lindeman said...

At the risk of bringing in old arguments that people are tired of hearing (no, not THOSE arguments, I mean different tired arguments), here goes:

Humans have evolved (or were created with, if you prefer) the ability to survive privation. That is we are relatively good at getting along in an environment poor in calories. We're STILL that way, even though calories are plentiful and cheap. We are victims, in a sense, of prosperity.

Now, do you want to go back to the days when calories were scarce, expensive, and life was "solitary, poor, nasty, brutish and short"? I sure don't. We don't need to.

We need to moderate portion size, get plenty of exercise, and plenty of sleep. Very easy to say, extremely difficult to do. After all, if it were easy, we wouldn't be having this discussion.

The language of addiction does not belong in this discussion.

Anonymous said...

I can only speak for myself on this issue. I used to be overweight by about 35 pounds on my 5'4" frame. Although I knew I was overweight, and I wanted to not be overweight, in the abstract, I just didn't care enough about it to change the habits that were keeping me overweight. I wanted my unhealthful habits more than I wanted to not be overweight.

Then,for a variety of reasons, I wanted to not be overweight. My motivation changed. I wanted to not be overweight more than I wanted to keep my unhealthful habits. I wanted it enough to suffer some short term discomfort. It took me nearly a year but I took the weight off and I kept it off.

So for me, positive motivation specifically to lose weight was what it took. When the motivational scale tipped to the point that I wanted the weight loss more than the unhealthful habits, I was able to do it.

Blue

jessa said...

I'm inclined to think this isn't any one thing, that we're not going to find some big overarching cause for all of this. We've posited so many things already, they all seem vaguely plausible, but none of them seem able to explain all of the obesity or obesity for everyone. I suspect it is just a convergence of these things. Some people affected or reacting to one factor, others to more. Some exposed to more factors than others.

Of course, I could be 100% wrong, which would probably be a good thing because it would probably make this easier to "solve" insofar as that makes sense.

Haven said...

When does personal responsibility come into play?

I'm diagnosed with many mental health issues including a personality disorder and people are not sympathetic to the fact that I can act in ways that are not socially acceptable. My brain is programmed this way, but I still have the choice to try and work in ways that are counter to what my mentality desires. Hence, therapy.

Just because someone has a predisposition for something doesn't mean there isn't still some personal responsibility there.

Anonymous said...

After years of being obese and in denial,a few yo yo diets here and there, it took a medical scare to wake up to the reality that I was going to have to change my entire lifestyle. Granted, some people have medical reasons that they cannot exercise. Losing weight and keeping it off means strict adherence to an exercise in addition to saying goodbye forever to all the yummy fattening foods we love to eat. It means watching what you eat as closely as a person with diabetes would have to. It means keeping it up once the weight has come off, which it will unless you have a metabolic disorder than an endo workup can rule out. It does mean going out with friends and being surrounded by things you used to eat but deciding not to indulge. It means eating smaller portions of healthy food. Eventually you learn that you are not starving and do you do not feel those old cravings. It is hard but doable. Docs expect psych patients to be compliant with meds. Psych patients would love a magic bullet that did not involve those meds. Docs have trouble understanding why bipolar patients go off meds. "But I like my manic highs" is kind of the same (in some respects) as "but I like my chocolate covered peanuts". This does not answer why we are fatter now as a population but truly, we don't need to be.

Noni Mausa said...

The problem is spread right across the population and has progressed steadily since the 50s, (check out this scary timeline map from the Centre For Disease Control http://www.cdc.gov/obesity/data/adult.html) I think we can dismiss an epidemic of weakness of will as a cause.

Of course, some individuals living in the same environment will not become obese or overeat, just as some people smoke cigars all their lives and live to 100. It's good to study the outliers, but the current problem is from a shared set of pressures on the whole population.

-- Automobiles
-- plastics and other novel chemicals in the environment
-- very poor public transportation options
-- a move to sedentary employment and entertainments*
-- swimming in food designed and advertised to be as tempting as possible
-- no longer deemed unusual or even uncouth to eat in almost any location and at almost any time of day
-- cheap, rather addictive foods (salt, sugar, fat, starch and caffeine)
-- worse, fats and starches have a sedative effect
-- increased anxiety levels in the population at large, leading to more comfort eating
-- huge servings at restaurants

A perfect storm of causes have come together to plump up westerners like Strasbourg geese. Which single change would have the best outcome? Probably a change in the cost and manner of transportation of people and goods.

Noni

rob lindeman said...

Excellent analysis, Noni! Your list of contributing causes is not very different from my (admittedly elliptical) list.

I offer another single change that would have a substantial outcome: Increased tax on food. I don't want to see this happen, which is not the same as not believing it would work.

Noni Mausa said...

Thanks!

Increased taxation on food might make the problem worse, especially for people who have to make every penny count.

I once thought it would be a good thing to put food carts on the streets, near busses and in poorer neighborhoods, selling very good, spicy vegetarian dishes in a wrap or ice-cream cone format, very cheaply, just to get people used to these foods and to spread their recipes around. Like many of my ideas this one is too complex to be accomplished unless I win a lottery or something.

Jane said...

I like Rob's idea of increasing tax on food, but I only would want to see that with unhealthy food. I actually think that LOWERING the price of fruits and vegetables and then making candy, ice cream, frozen cheeseburgers, etc more expensive at the supermarket would help. What if McDonalds was 10 dollars a meal for a cheeseburger fries and coke, but their dollar menu was made up of salads with low fat dressing, fruit and low fat yogurt, herbal tea with no sugar, etc?

rob lindeman said...

I'm just the "idea guy" here. I'll leave it to Noni and Jane to work out the details!

Dinah said...

Anon: You're talking about a completely different magic pill. My magic pill allows people to eat 3,000 -4,000 calories a day and not gain weight. It's my magic, I can wish for whatever I want.

Sarebear: Good luck! (let us know how it goes).

Anon: So I want to know why some of the people have stronger will power. It would be a useful question to have an answer to on my levels, not just regarding food. I have no problem with a magic pill for hangovers, I don't think it would impact alcoholism rates. I may be missing something here, but is the assumption that if you drink, you deserve a hangover and if you eat you deserve to be fat?

Rob: I disagree with you, I think the language of addiction might be useful here. With other "addictions," however, there is the option for all or none and not with food. And I don't think 'addiction' is behind every obese person's issue. But for those who crave food, who eat in out of control ways, thinking about it in this way may be helpful-- there are people who take methadone or bupronorphine who manage their lives so much better than when they were shooting heroin, and many former-alcoholics out there.

I do think that for many it's something other than weakness of will, and as long as we're fixed on the idea that the problem is 'personal responsibility' it's fine to blame 2/3 of the population for being overweight and it stifles looking for a cure. Obviously, I think we should also be looking for the cause.

Noni: Please add sugar drinks to the top of your list. Somewhere in there people started thinking it was healthy to give children Gatorade, high sugar sports drinks,
(they may be fine for preventing dehydration in someone with diarrhea, but 300 calories in Gatorade kind of undoes the 45 minute sports practice. And for the second baseman, the calorie balance may well be negative. And Soda? What role does that have in our diets????

Sunny CA said...

Read this article in the New York Times:

http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=all

This is especially for those above who suggest self-discipline as the way to be thin. For those of you who "succeeded" at weight loss, have you kept the weight off for 10 years, 20 years, 30 years? I have been fighting overweight for 43 years now. It is really easy to lose weight the first time. Now read the article above and see why it is not so easy once you have lost 75 pounds.

operator said...

The language of addiction is absolutely relevant to food. It's a foreign substance you consume daily (if not constantly) and it has well-established psychotropic effects.

Everyone is addicted to food, but food is a disgusting addiction for those who understand the nature of modern agricultural, processing, and marketing practices.

The least you can do is visit a dairy farm, a poultry farm, and a meat packing plant before you pick your poison.

Anonymous said...

Sunny: the article makes it clear that the people who did keep the weight off remained "hypervigilant" about food intake and exercised often and intensely. If they let that go then of course it would all come creeping or piling back on. Yes, i have kept it off but I eat eat far less than other people can and I do not touch foods that are meant to be eaten in moderation, such as desserts, not ever. Other people can have the piece of birthday cake. I got used to the fact that for my body it is toxic.

Anonymous said...

Dinah it's not that I think that obese persons or alcoholics deserve it. I just think magic pills kind of defy the natural laws of the universe. What comes up must come down. Magic pills is kind of 'playing god' as some put it. I am not anti medicine pro nature mind you, just a bit suspicious on grand solutions. Having said that I know that this is an ideal and hypothetical. I know that I do live a very enchanted life in terms of health so my answer is probably a bit biased- I feel tired when I don't sleep, my medications don't give me side effects and they work very effectively, etc. I have never been in a situation where I have exhausted all possibilities

K said...

Obesity seems to be a very complex interplay of genetic, environment and psychological factors. If it were well-understood, it wouldn't be the worldwide problem that it is now. Countries like India and China have experienced rapid increases in levels of obesity (and the comorbidities like Type II diabetes) with the rapid development of their economies in the last couple of decades.

I've found the following medical blogger to be very informative as a source for a fresh perspective on obesity that offers more than the simple "Eat less, move more" model.

http://www.drsharma.ca/

As someone who has struggled with overweight/obesity since age 6-7, it is good to read information that doesn't come with a not-so-subtle stigmatising message of "it's your fault, you're weak, lazy and you get what you deserve".

Sophia said...

I agree with everyone that this is complex and I agree with a lot of points Noni made.

My husband's grandfather told us about the job he had in the '50's and '60's. It was an office job, but he worked six hours a day (9-4 plus a paid one hour lunch) and was paid more than a living wage. He spent his remaining time working on his yard and playing with his kids. Being of German descent, they were all about the meat, potatoes, and desserts. He lived well into his 80's, eating bits of candy every day, having a nice drink every night, and was an avid fan of soda.

The difference?

1. He wasn't so exhausted from work that he found physically challenging activities overly difficult. Having done the office work thing myself, sitting at a desk all day is mentally taxing. And there is a point where sitting in a desk so long that it takes an incredible amount of exercise (not enough time in the day) in order to keep health under wraps. I feel like I read somewhere that if you have an desk job, the one hour recommendation for activity just won't cut it. I'll have to hunt for that article.

2. It was easier for him to control his stress level with working fewer hours and having lots of leisure time. Stress = rise in cortisol, which may be implicated in extra pounds. Stress also = exhaustion, and eating quick energy foods when exhausted isn't terribly uncommon.

3. Sleep. Rather than go to work at 7 or 8 in the morning, he didn't work until 9. A lot of people are not built to wake up prior to dawn - its outright painful. Lack of sleep = rise in cortisol = see above.

4. The man walked all over. He lived in a small town that was pedestrian friendly. Later in life, walking to the grocery store or meeting friends for lunch was no big deal. Many parts of the US - my city included - aren't too kind to folks walking around. City won't shovel sidewalks and neighbors can't always get to it right away, some neighborhoods are very dangerous, and things are just too spread out.

5. On another note - we give young people a lot of crap for not having future-oriented thinking, but let's face it, adults don't have it either. We're simply not wired that way. Thinking in the immediate was likely necessary way back when people were getting chased by lions and walking through deserts. Nowadays, not so useful. I don't think people necessarily look for quick fixes (crash diets, pills, overkill exercise programs) out of laziness, but more because lack of immediate results feels like results will never happen. And that is incredibly emotionally painful.

6. Excess weight causes metabolic problems. Metabolic problems make it hard to lose weight. Vicious cycle.

7. As crappy as food was decades ago, even compared to the '90's when I was growing up, it has gotten increasingly unhealthy. Food companies employ researchers to devise ways to make food more tasty - and I have to agree with equating overeating to addiction. Food has more sugar and more chemicals to make things taste way better to a lot of folks than it did twenty plus years ago. Its not surprising that people overeat.

8. Time management. Even though '50's women were expected to cook as frequently as possible, they could be pretty efficient. Crockpots and casseroles made food a lot easier, so hitting the drive-in could be reserved as a treat versus necessity. Set aside a day per week to chop, assemble throughout the week. A set of decent knives and a mandolin will totally cut prep time - I can knock out slicing an onion in less than thirty seconds. Oh, and canning, freezing, and gardening are helpful as well. Of course, one has to muster up the energy to do these things, and that's pretty tough if you're working fifty hours a week, carting kids around, and trying to have a social life on top of it all.

Those are just a few of my sorta-educated guesses and observations. Messy, messy issue.

Anonymous said...

As smoking has declined in the US, weight has increased. Smoking keeps people thin and suppresses hunger. I wonder if that isn't part of the change.

elbee said...

Here, here. There should be a magic bullet! I agree. They say some foods are "comfort foods" but to say I eat for comfort would trivialize the feeling I get. I never feel fully relaxed. When I eat--especially fatty, sugary foods--I experience a "high" and feel not just emotional satisfaction but even physically better. Comforted in every sense. This probably would explain why I am on a diet right now. I must give a shout out to my psychiatric meds for making food taste so damned good. This may sound hard to believe for those not taking them, but I lose weight if they are removed. The antidepressant I take turns sugar from a not-ideal dietary component into...crack. No, exaggeration! Time to get off the pipe! The sugar not the psychiatric meds. :) It is SO not easy!

elbee said...

Also, former general surgeon David Kessler makes the point in his book The End of Overeating what many have pointed out in this discussion--food scientists have found ways to manipulate our tastes for fat and sugar by making foods specifically engineered to be irresistable. A case in point, they may have had twinkies in the 60s and 70s or perhaps even Doritos, but did they have 15 different kinds of Doritos? They had ice cream, but did they have ultra premium ice cream loaded with chunks of cookies and candy? Neither David Kessler or I believe that this robs anyone from personal responsibility, but there's an entire industry geared toward making us want to eat more and that has to be acknowledged as much as blaming the overweight.

Anonymous said...

well the psych meds killed me weight wise which is why i am so careful now about what i eat and why i don't take the meds. they are poison and the harm they do over the short term-weight- is nothing compared to how they kill you over the years.

jane walts said...

Dinah, I haven't heard about the growth hormone on cow's milk. Can you give me a link about that?

Thanks!

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