So what’s the Solution??

So far we’ve talked a lot about the problems associated with obesity and what can be done to reduce obesity at an individual. Thanks to some comments we’ve had on our blog we’ve decided to look more in detail at reducing obesity on a national or global level. Here are some interventions that have been implemented around the globe and have shown to be effective:

Government Policy Changes:

• Income subsidies for healthy nutritional choices for both the consumer and producer
• Ensuring low prices for healthy foods and taxing foods high in fat and sugars
• Regulation of food processing and nutritional labelling
• Ensuring stores stocking healthy food options are conveniently placed
• Increasing ability to exercise in urbanised areas
• Subsidise marketing of healthy alternatives
• Target groups of lower socioeconomic status, and others who are of higher obesity risks

Media Changes:

• Encourage promotion of simple health messages
• Engage in responsible advertising
• Publicise obesity success stories

School Interventions:

• Involve healthy eating and physical activity in curriculum
• Provide a supportive environment for reducing obesity and provide healthy food options
• Involve families in targeting obesity

Workplace Interventions:

• Provide healthy food options
• Provide space and opportunities for exercise
• Involve individuals and family members in creating policies

Community Interventions:

• Get involved in health education
• Enable group based physical activity opportunities for people at the same physical exercise ability level

Public Health Changes:

• Having positive ‘health at every size’ campaigns
• Ensuring health options are culturally appropriate
• Evaluate programmes for their effectiveness and adapt if necessary
• Increase health literacy through education campaigns
• Enable access (particularly for those in obesity risk groups) to weight loss programmes with regular follow up

 

Source: http://www.hsph.harvard.edu

 

Finland has become known for its successful reduction in obesity rates due to its health promotion. Read more about it here:

http://news.bbc.co.uk/2/hi/health/3451491.stm

http://www.eatingwell.com/nutrition_health/nutrition_news_information/miracle_up_north

 

Please comment if you have heard of anything that has successfully targeted obesity, or if you can think of some new alternative intervention opportunities!

Obesity: who is to blame?

We have been posting about importance of food, exercise, and how these factors affect in developing obesity.

What about economical factor?

To many people’s surprise, including myself, economics take a major role in determining obesity in different groups of a population.

In countries with high gross national income per capita, low-income group of the population has higher tendency to be obese. To understand how this came to be, we need to break down and work ourselves from the bottom.

Purely economically, price of nutritious food such as fruits, vegetables, lean meat, and fish are quite expensive. On the other hand, improvement in agricultural technology and food technology provided us with unhealthy food, such as added sugar and fat, at an inexpensive cost. This also means that fast foods can be purchased at a relatively cheap price.

What this means to the people of low-income is that they are left with a dilemma. They know that it is healthier to purchase fruits and vegetables, but that means paying for their son’s school fee will be a struggle. So they take the second option and go for the cheaper food, leaving nutritious food as the opportunity cost.

What economics has taught us is that when there is an increase in demand, either supply has to move up or price needs to move up in order to balance out that increase in demand. Since it was the agricultural technology that brought down the price of these products, the price will stay the same. So the only thing left is to increase the supply of these foods to compensate for increased demand. At this point, it becomes something like “Inception”, where everything starts to loop around in a vicious cycle of increased demand and supply.

High income earners are more likely to be health-conscious, and since they can afford healthy food and exercise facilities, becoming obese is less likely.

In contrast, obesity rate is completely reversed in countries with low gross national income per capita. One explanation that I could think of that would cause this phenomena is that in developing countries, the poor usually engages in high level manual work and suffer from food scarcity, whereas the rich generally don’t engage in manual work and has better access to food. It’s all about energy input and energy output here.

Now, I am not suggesting that being obese is inevitable for the low-income group in developed countries. There is a solution. Of course, like many other great solutions, there are pros and cons. Dietary changes can improve nutritious value at an affordable price. Foods such as dry legumes, peanuts, and canned fish are nutritious and inexpensive. These foods, however, score low on taste, variety, and convenience.

It all comes down to opportunity cost again. Would you give up on taste for the healthy life or would you stay on energy dense diet to satisfy your taste buds?

The choice is yours.

 

For further information, click on the links below to read articles about this issue:

The economics of obesity: dietary energy density and energy cost

Obesity and socioeconomic status in developing countries: a systematic review

Modern Weight Loss Diets: Fad or Fact?

You’re looking at your diary and you realise that your school reunion is coming up. Or that wedding where you’ve got to find a dress that looks good on a person with wobbly bits and not only a supermodel. Or it’s nearly bathing suit season. Or maybe it’s July and you’ve still done nothing about that New Year’s Resolution of losing weight. Whatever the reason, suddenly those diets featured on TV and in the glossy magazines start to look rather appealing. But which, if any, actually work at targeting obesity? We looked at calorie counting in a previous post but now it’s time to focus on some of the other diets as weight loss solutions.

 

Low Fat Diets

Shown to be effective in promoting weight loss without reducing calorie intake by restricting total fat intake. However, the amount of weight loss is no better than a simple low calorie diet so you can pick either and see benefits. It has been shown that weight loss can be maintained and it reduces saturated fat and cholesterol intake so there is a decreased risk of cardiovascular disease. However one word of caution: highly processed foods labelled as “fat free” are commonly high in calories. Many people unknowingly increase their calorie intake when on a low fat diet and can actually put on weight.

 

Low Carbohydrate Diets

This includes diets such as the Atkin’s diet and various ketogenic diets. These diets are successful because they are calorie restricting and leave you feeling full at the end of the meal. They initially have a very good weight loss, better than that of a low fat diet within six months. However after a year the weight loss in low fat and low carbohydrate diets is about the same. A low carbohydrate diet is typically high in “bad” cholesterol (low-density lipoproteins), which places you at increased risk of heart disease. Other adverse effects commonly experienced include constipation, headaches, halitosis, diarrhoea, muscle cramps and general weakness. Low carbohydrate diets also restrict intake of healthy carbohydrates such as vegetables, fruits and whole grains, all of which decrease risk of chronic diseases such as cancer.

 

Low Glycemic Index Diet

This diet restricts the intake of food that releases glucose into the blood quickly. Whilst it has shown to be beneficial in diabetic cases, there appears to be no weight loss benefit, with weight loss being less than that of the other diets discussed here. Similar to the low carbohydrate diet, it eliminates fruits and some vegetable (such as carrots) because they have a high glycemic index.

 

Mediterranean Diet

This diet shows promising weight loss results, and can also increase longevity and decrease risk of cardiovascular disease and cancer. But no, that doesn’t mean you can have spaghetti bolognaise and pizza every day. The mediterranean diet works because it includes vegetables, fruits, nuts, legumes, whole grains and olive oil as a fat source. One issue with this diet is that too much fat, even the good kind, can increase calorie intake and stop weight loss so it is easy to lose the benefits.

 

Paleolithic Diet

This diet works because it encourages healthy eating by avoiding processed foods and increasing intake of vegetables, fruits, nuts, seeds and lean meats. However it cuts out dairy and whole grains, which are important for a nutritionally balanced diet. Also, a true Paleolithic diet is difficult in this day. I don’t know about you but my local Woolworths doesn’t stock mammoth steaks. Meat today has higher levels of saturated fats than that our Stone Age ancestors would have been eating, making this premise of this diet somewhat redundant.

 

Commercial Programmes

The key to success in intervention programmes such as Weight Watcher’s and Jenny Craig is that unlike primary health care, you are held accountable to your promises. This, along with the ease of pre-packaged foods, increases the compliance with the diet. However, they can be quite expensive in the long term. Seeking advice from health professionals such as dieticians and getting a support network through group therapy or family and friends can be equally as beneficial.

 

The problem with most of these diets is that they are difficult to sustain for any period of time, making long term weight loss unlikely. In order to actually decrease obesity we need to take what works from these diets: reduce intake of high calorie, highly processed, fatty foods and replace this with the nutritionally balanced low calorie diet we discussed in out previous post. This is the real ‘miracle’, quick(est)-fix solution to obesity.

23 and 1/2 hours

So after my previous post I received a few emails and comments from readers regarding calorie counting, metabolism and the like but one burning topic (no pun intended) of conversation was exercise and the health benefits surrounding it. It seems for a lot of people exercise is purely a measure to lose or manage weight and little thought is given to the other health benefits associated with it.

 

I recently watched a YouTube video by Dr Mike Evans that was creating a bit of buzz titled ‘23 and ½ hours’. The video is a fascinating ten minute snapshot of the benefits of exercise to a whole range of chronic conditions that really holds your attention and I urge everyone to check it out.

 

One particular part of the video got me thinking and that was the discussion surrounding a study that found fewer cases of chronic disease in overweight people who exercise versus those who are overweight and sedentary. Being ‘fit’ seemed to have a protective effect over being ‘fat’.

 

So we know obesity is a combined result of over-eating and under-exercising but it seems a massive portion of the blame of chronic disease is attributed to the extra weight. Could it be that because sedentary people burn less energy they’re far more likely to be obese and it’s actually their lack of exercise that’s inflicting most of the damage? Not moving is clearly not the only factor in ill health but it seems like it could at be playing a major part.

 

At the very least the video, and more accurately the evidence behind it, suggests that exercise is extremely good for our health, not just our waistline and this has the ability to play a huge part in how we motivate patients.

 

One of the biggest obstacles in treating patients with obesity is motivation. Fad dieting and short-lived gym programs are common. Take an obese person unhappy about their weight. They want to be healthy so they resolve to eat less and exercise more. One week later they have been working out at the gym plenty and have cut down on their junk food intake. However, take a look in the mirror and they’re still obese, their arteries are still clogged with cholesterol, they’re still a sitting duck for a heart attack…what’s the point? All that effort for nothing. Chuck on a movie and whip out the ice-cream… I’m depressed.

 

Contrast an obese person who just wants to be healthy. They watch this video or take your advice as a doctor and start to exercise more. With every walk and gym session they feel like they’re now part of the ‘intervention’ group receiving the ‘treatment’ of exercise. With every ‘dose’ they can be confident they are one step closer (seriously no pun intended this time) toward being healthy. One week later they look in the mirror. They’re still obese, their arteries are still clogged with cholesterol, they’re still a sitting duck for a heart attack… BUT they’re healthier. They know they’ve done some good things to their body that week and they know next week they will do more. On top of that because they haven’t been starving themselves and fixating on food they have no desire to reach for the ice-cream. In fact because they’ve made this positive step they decide to see what else they can do for their health. You tell them that making small adjustments to their diet such as limiting saturated fats and reducing calorie dense foods whilst increasing vegetable intake will help get them even closer to being healthy but a fad diet certainly won’t. You remind them that it’s health that’s the goal, not rapid weight loss.

3 months down the track and the patient is still ‘taking their medicine’ in the form of exercise because they know its making them healthier, even if they can’t see changes in the mirror. By this stage though they probably will have made some inroads on their weight motivating them even more to continue. Soo now yu’ve taken them much closer towards the healthy goal you started out with.

 

All in all I think this method points toward a far greater rate of patient compliance, (I can feel an RCT brewing in my loins) not to mention that this motivation can be used on normal weight people therefore helping to prevent them gaining weight in the first place.

 

Check out the video and let me know your thoughts.

 

I guarantee you’ll feel like taking a walk afterwards.

Calorie counting

We’ve discussed guidelines for a healthy weight, but what about guidelines for healthy eating? We used to have the good old ‘food pyramid’ but nowadays we’ve adopted this slightly more convoluted set of guidelines, which doesn’t even afford beer the dignity of being a ‘sometimes food,’ as the modern PC cookie monster would say. Nope, that along with all your other favourites such as tim tams and hot chips have now been designated as the patronisingly euphemistic ‘discretionary food choices’.

 

As scathingly critical as I was of BMI, and as disappointed as I am to see my old favourite Bacon being demoted from real food to ‘discretionary,’ I would have to say the current eating guidelines are pretty useful. Unlike BMI, where every body is differently geared, nutritionally our cells have all the same enzymes and structural components. Therefore we all require (more or less) the same cocktail of nutrients, it’s just a question of how much.

This is another wildly variable parameter so naturally there can be no concrete guidelines. A simple way to look at it is [Energy in] – [Energy out] = Net weight loss/weight gain. This seems like a pretty simple and accurate assertion, but is it an appropriate model of weight loss? A lot of people seem to have taken it on board, with ‘high-calorie’ and ‘low-calorie’ being huge marketing buzzwords, and one only needs to type “calo” into google before the first suggestion is ‘calorie counter’.

 

I love to keep things simple so this model appeals to me. But I tend to think it is too simplistic for the delicate beast that is the human metabolism. For a start, that equation has different units on either side of the ‘equals’ sign. Matter (which has weight/mass) stores energy (which I’m pretty sure doesn’t have mass). So reducing energy in by X amount doesn’t necessarily directly translate to an X amount decrease in matter/mass/weight does it? 1g of fat has a lot more energy than 1g of glycogen, so this equation would have to also account for the energy-density of the mass which is being lost. Half my audience probably stopped reading after those last two sentences so I’ll go back to talking about something I actually know something about: My point is that simple equation can’t be simply manipulated by changing one of the two independent parameters. With a lot of careful calculations one may determine their exact caloric intake, but caloric output? Impossible. Unless you want to sit in a bomb calorimeter (not as exciting/scary as it sounds. Just a sealed room) all day every day. So without the second input to this equation, why are people even bothering to count their calories? I suppose if you monitor your intake and weight for a while you’ll get a pretty good feel for how many calories you burn daily, but you’ll never get anything like an exact number.

 

The government health guidelines seem to have taken this model onboard, offering their own estimator of your required caloric intake; down to the kilojoule (kilojoules and calories are two co-redundant metric units of energy). This is generated by asking you on a scale of 1-5 how active you are and what your age is. Needless to say it disregards basal metabolic rate and is a wild estimate. I guess my issue with this approach is just that there is too much measurement variation and uncertainty to make realistic, applicable calculations possible. Therefore, I refute the energy in versus energy out paradigm of weight gain/loss/maintenance!

I propose we think of the body as an engine that needs to be tuned. It responds appropriately to food intake and exercise. I believe the best way to limit fat deposition is training the body to metabolise/burn it. How to do this? You guessed it, exercise! Exercise, particularly high intensity exercise increases the expression of oxidative genes, increasing the body’s ability to burn fat, even at rest. Government health campaigns have in the past compared for example 1 packet of chips is equivalent to running on the treadmill for 13 minutes or whatever, and this fuels the fallacious concept that metabolism is a simple see-saw balancing hamburgers vs treadmill minutes. It doesn’t take into account all the extra calories you’ll burn for the next week as your muscles are repaired, and get hungry for energy. I would like to propose a more holistic paradigm which treats exercise not as a simple calorie-burning exercise, but as a way of training the metabolism, increasing fat burning capacity, improving body composition (more muscle, less fat) and increasing resting metabolism. Naturally you need to keep your calorie balance in check, but this should realistically be done by having ballpark figures (no calculations necessary), and monitoring for severe fluctuations in one’s own weight and body composition.

 

TL;DR Stop trying to count calories, exercise to improve your metabolism not to burn more calories.

 

Those are my thoughts, feel free to comment beneath.

 

Sources: http://www.eatforhealth.gov.au/, http://japphysiology.womanhealthtips.com/content/102/4/1439.short\

BMI

How do us well-educated medical types inform the lay public on what is a healthy weight? So far the model of choice for the Australian Government is BMI (body mass index) for weight, or perhaps preferably waist circumference.

 

As I’ve alluded to earlier, obesity is a complex issue and the morphological variation in the human population is quite astounding. Given this information, it doesn’t take a 1^st-year medical student to figure out that BMI is severely limited in usefulness. As the government health website says, “There are no perfect measures of overweight and obesity. (BMI) is used most often – particularly in assessing overweight and obesity at the population level. At the individual level however, BMI does have some limitations in that it can be influenced by age, gender and ethnicity. Also, BMI does not distinguish fat mass from lean mass, nor does it necessarily reflect body-fat distribution.”

BMI is rather useful for looking at population-level data, but for an individual it is pretty close to useless. I knew a hulking young recreational bodybuilder who was upset when he learned he was ‘overweight’ according to the BMI (it was pretty funny). I would hazard a pretty confident guess that every single current holder of an NRL contract is also ‘overweight’ according to the BMI formula. Likewise, I’m sure there are plenty of people around with a ‘spare tyre’ and not much muscle mass who think they are completely in the clear based on getting their BMI down to 24.8 through crash dieting. Accordingly, a preferred measurement of overweight and obesity is waist circumference, with 88cm for women and 92cm for men set as the cutoffs. Again, simply having a raw number as a national health guideline has obvious severe limitations.

 

At the moment you’re probably sitting there thinking “Yeah righto mate if you’re so smart why don’t you make yourself useful and come up with some better healthy weight guidelines that are actual indications of health?” Good question reader, and the answer is this: I won’t make any better guidelines because I can’t think of anything better. Neither can anyone else, and for communicating health information to the masses, this is about as good as it’s gonna get unfortunately. Probably the best advice I can give anyone about a healthy weight is to have a good long hard look in the mirror, and decide whether you are in healthy shape. Every individual knows their inherent body type and the quirks of their own metabolism, so they should be in pole position to make a judgement about whether they need to gain or lose weight. But here’s the rub; unfortunately psychology and self-esteem play a large part in this aspect of health so it is difficult if not impossible for individuals to make objective judgements about whether their body morphology is within a healthy range. Also, body weight and ‘health’ lie on a continuum without discrete ‘healthy’ and ‘unhealthy’ points, so Average Joan is on a hiding to nothing to decide whether she really needs to lose weight. So it’s back to the drawing board and we are left with broad, essentially meaningless guidelines like BMI.

Complexity of obesity

Throughout medical history there have been many wonderful discoveries and inventions that have eased the burden of morbidity and mortality and heightened mankind’s collective understanding of biology and disease. The invention of penicillin, anaesthesia, the germ theory, isolation of insulin, covered sewerage, fluoride in drinking water. These discoveries all ameliorated severe scourges on the health of general populations. Obesity is one such scourge which in modern times continues to spread around the globe riding swiftly on the coattails of its sociological gateway; economic development. The question springs to mind, ‘will medical historians look back at one brilliant individual or discovery which brought an end to the morbidity and mortality caused by obesity?’ Based on current knowledge, I personally consider this unlikely, and like the other NCDs which are currently endemic it would appear Medicine is in for a war of attrition with obesity.

 

Why is this? Will there not eventually be a brilliant ‘fat pill’ discovered and distributed, and the 1.5 Billion obese people worldwide systematically returned to good health?

 

The fact of the matter is that obesity is a completely different beast to historical health problems. It is a psychological disorder, a metabolic disorder, an endocrine disorder and a socioeconomic problem all in one. Add to that the fact that it very rarely causes mortality in and of itself. It merely predisposes individuals to a myriad of other health problems. Oh and one other thing – the cure has already been discovered and is widely available, in developed countries like Australia at least. That’s right; restricting the kilojoules available in one’s diet, eating fresh fruit and vegetables, and exercising regularly will cure all but extreme or extraordinary cases.

 

With that in mind, how does one approach this problem? Previous post on the topic addressed the socioeconomic side of the issue. In poorer but developing countries, the masses who struggle to get by in relatively low incomes are enticed by cheap, nutritionally unbalanced, calorie-rich foodstuffs. The relationship between socioeconomic status and obesity varies from country to country, with it being an inverse relationship in Australia. So does the solution lie in economic improvement and social equalisation? I haven’t even begun to discuss smaller-scale social influences, such as peer pressure, body image, advertising and lifestyle pressures. How about pharmacological intervention? Surely some clever pharmacist can develop a magical fat-burning pill with negligible side-effects? There are many on the market describing themselves as such, but the proof of the pudding is in the eating, and the fact is obesity rates continue to rise. And besides, if we consider obesity a metabolic or endocrine disorder then pills, like liposurgery, are merely a band-aid solution.

 

How about the psychological factors? In a country like Australia, almost everyone can afford fresh food and exercise opportunities abound, and millions of taxpayer dollars are spent educating the public about healthy lifestyles. Granted there are time pressures which influence peoples’ lifestyle choices but the fact remains that many people become and remain obese due to laziness and/or apathy. In this regard it could be considered a psychological disorder – perhaps sufferers are addicted to a certain lifestyle just as a smoker is addicted to nicotine. How should health authorities approach this situation? Government health campaigns have led the public to water, but it may not be possible to make people drink.

 

Many cancer experts say there is no silver bullet for curing cancer because what we call cancer is actually hundreds or thousands of different cellular diseases which manifest a macroscopically similar pattern of symptoms. Likewise obesity is a complex multifaceted health issue facing an increasing proportion of the world’s population. The causes of obesity are not entirely within the realms of Medicine, but the consequences almost exclusively are and it will take many years of multidisciplinary research to gradually break down and reduce the prevalence of this disease.

 

From Hungry to Heavy

Poor people all around the world are starving. Or are they?

 

For sure there’s still many nations gripped by hunger and poverty but more recently some of the world’s developing nations are facing a new problem – poorer people are getting fat. ABC’s Foreign Correspondent aired a great documentary looking into this very issue (1).

Cheap calorie dense foods are flooding into nations such as Mexico, China and Brazil and the locals, understandably, are embracing them with great enthusiasm. Western manufacturing techniques have enabled food companies to pack fat and sugar into foods or drinks without the nutrients that naturally accompany them in whole foods. They are able to do this on a massive scale and often in a way that makes the food non-perishable allowing them to export this stuff by the container load. The poor farmer trying to sell some fresh vegetables at the local market really does not stand a chance. The nutritional value in some of these foods is so bad, and they’re being consumed so exclusively, that doctors are seeing patients presenting both obese and malnourished at the same time.

 

So how do you combat this issue? Let’s look at a few options:

 

1. Educate.

This obviously makes good sense but judging by trends in our reasonably health literate society that may be an uphill battle.

2. Limit importation of these foods.

This sounds logical but these countries aren’t third world anymore and companies with local ownership would have no problem filling the void. The same argument could be used when suggesting that big companies such as Coca Cola and Nestle have a moral obligation to limit trade in these environments.

3. ‘Junk food’ tax.

There’s been talk about this in already developed countries and a ‘fat tax’ was trialled in Denmark but seems to be failing. Could taxation have a greater effect on people with lower income though? It’s certainly going to be complicated. Are you only going to tax Coca Cola or are you going whack a tax on white bread, potatoes and rice? Good luck trying to convince the Chinese on the last one.

 

Whatever way you look at it this is an issue that isn’t going to go away on it’s own and I’d urge anyone with an interest to take a look at the doco. Look forward to hearing your thoughts.

 

You can check the doco out at;

http://www.abc.net.au/foreign/content/2012/s3547707.htm

 

1. Globesity – Fat’s New Frontier. Foreign Correspondent: Australian Broadcasting Corporation 2012. p. 60 minutes.