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Behavior and Public Health – To Nudge or Legislate

As health care costs rise and great attention is being paid to the health care system in many countries (perhaps especially the US), the debate is heating up over how to improve public health. Many health problems are greatly increased by the lifestyle choices individuals make – smoking, weight control, and exercise to name a few. The problem is that it is notoriously difficult to change behavior.
There are different ways to approach the challenge of improving lifestyle choices to reduce chronic illness. We can take actions aimed at the individual or aimed at society. These actions can be gentle or passive (the so-called “nudge theory”), or they can be more draconian, such as banning certain activity. We can, of course, do all of these things simultaneously, and may need to in order to have a significant impact.

Affecting Individual Behavior

A common criticism of mainstream physicians is that they do not have much impact on the lifestyle of their patients. This is largely true – although there is no convincing evidence that any practitioners have a significant impact on lifestyle. This is mainly the result of the fact that it is extremely difficult to get people to change their behavior.

The default tactic has been to give people information on the assumption that they will then be able to make a rational choice about their health. Psychologists have long known that we are much more likely to simply rationalize our behavior than take the more difficult path of changing it. This is true even of the “scared straight” approach – trying to frighten people with scary images or stories about lung cancer or diabetes.

It is true that physicians can affect patient behavior. For example, even brief physician counseling to quit smoking (less than 5 minutes) increases smoking cessation by 1.6 times. This sounds impressive, but this only increases the rate to 2-10%. Even if we use the higher number in that range, a 10% decrease in unhealthy behavior is very modest (worthwhile, but still modest). It seems that in general you can get about 5% of people to change their behavior with counseling alone.  Meanwhile, using medications to aid smoking cessation (nicotine patches and bupropion) can result in up to a 35% decrease in smoking.

The technology of changing individual behavior is advancing, however. The strategy of giving information and assuming rational behavior, while still useful, is highly limited and not sufficient. Psychologists recognize that the way to alter behavior is through psychosocial interventions – exploiting human psychology and peer pressure. One such technique is called motivational interviewing. Essentially, the patient is asked leading questions that get them to state their own health goals and concerns. Apparently we are better at persuading ourselves than being persuaded by others.

Sounds good, and generally the research shows that this approach is an improvement – but the effect size is still depressingly small. A systematic review of motivational interviewing for smoking cessation, for example, revealed only a 1.27 relative increase in cessation. So spending 5 minutes with a patient once improves smoking cessation by 1.6 times, and spending multiple 20 minutes sessions of motivational interviewing increases success a further 1.27 times. This is worthwhile in terms of public health outcomes, but it does look like such methods yield diminishing returns.

Motivational interviewing may be more effective for behaviors not related to addiction, such as weight loss and exercise. But still there is huge room for improvement.

Public Health Measures

It is increasingly looking like the way to have a huge impact on public health is at the societal, not individual, level. The goal is to make healthful lifestyle choices easier. Using heavy-handed legislation, however, is not popular (at least not in the US). Such strategies evoke images of a Big Brother nanny state trying to take away our freedoms. There are legitimate concerns about draconian state measures, especially if they are not rigorously science-based, but the looming health care crisis is making public health measures seem more attractive.

One approach is simply to ban unhealthy behavior. Outright bans of products, such as alcohol, have a disastrous history. Another alternative is to restrict the use of such products in certain locations and situations. The best example of this strategy is banning smoking in public locations. A systematic review of 10 studies indicates that such bans reduce the incidence of myocardial infarction in the population by an average of 17%. Banning smoking in public seems to be a clear public health win.

But banning unhealthy behavior gets more tricky when not dealing with addictive substances. Bans of fatty or high-calorie food, for example, are likely to meet much more resistance than restrictions on public smoking. New York City’s ban on trans fat, for example, has been highly controversial. Other states are considering laws to ban toys in kid’s meals, limit advertising, and limiting marketing behavior such as inviting fast food patrons to “go large.”

Resistance to heavy handed strategies has led to the proposal of the nudge theory – using more subtle legislation to influence behavior. Nudge strategies include printing the calories next to menu items. This is a situation in which information is likely to have a significant impact on behavior – because it addresses what may be a significant contributor to the increase in obesity. It is easy to consume far more calories than we think, especially when restaurants prepare menu items that are calorie dense in order to make them tasty and appealing. Having calorie information right in front of you when making menu choices does reduce caloric intake (in this study by 250 calories), although again, not as much as we might hope.

Another nudge approach is to make healthful choices the default choice. This still leaves consumers the freedom to choose what they want, but many more people will go with the healthier choice if it is the default.

Yet another approach is to regulate manufacturers. At present voluntary guidelines are being suggested, and the debate is ongoing about using legislation to require food manufacturers, for example, to produce healthier and lower calorie products. The public has been passively eating more calories simply because the products they buy contain more calories. They have also been lulled by false security – low fat products tend to make up their calories in carbohydrates, while low-carb products make up their calories with increased fat. Either way people eat more because they feel they are eating healthier products.

Conclusion

It is clear that we need to take a long science-based look at public health and ways to improve lifestyle choices. We need to reverse the obesity epidemic and further reduce smoking. Doing so is not easy – there is no silver bullet to changing human behavior. It is likely that we will need to use a combination of strategies while researching new and better ways to influence behavior.

Posted in: Public Health

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71 thoughts on “Behavior and Public Health – To Nudge or Legislate

  1. windriven says:

    Smoking among adults in the US has fallen from 42% in 1965 to 20% or so today. I have no data on which to base my surmise but suspect that changing societal mores played a substantial role. It the 50s and 60s smoking was cool. Today it is totally declasse – at least among the educated (49% of GED holders smoke, but only 5.6% of those holding a graduate degree*).

    The advertising industry has understood for years how to manipulate our insecurities to sell stuff. People will find ways to seek out prohibited items that they desire – see chapters on The War on Drugs and Prohibition. Isn’t it smarter to make these things less desirable?

  2. Harriet Hall says:

    What about financial persuasions? What if insurance companies charged higher rates for smokers or did not pay for smoking-related illnesses? Or for people 100 pounds over ideal weight? What if they refused to pay for injuries in car accidents if the policyholder was not wearing a seatbelt? Has that concept been tried or studied?

    The military has been successful in impacting life style (you are required to pass physical fitness tests and you are discharged if you are overweight and fail to lose). They could easily prohibit smoking in their ranks. Wish they would.

    CAM/integrative providers have claimed special expertise in prevention, in getting people to adopt lifestyle changes. Are there any studies showing that they are any more successful than mainstream providers?

  3. AlexisT says:

    Insurers already do charge smokers extra–I know it would cost us 20% more if one of us smoked. I don’t know if research has been done into the impact of such policies.

    Charging the obese more is much more fraught. In many cases, you’d be penalizing someone for a health condition. Success rates for dieting are low, so even a significant financial incentive runs a high risk of failure.

  4. Beowulff says:

    Indeed, bans won’t work, but incentives might. For instance, you could think about taxing unhealthy food, and using it to subsidize healthy food.

    Another thing that might help is to make healthy food more easily accessible. Do something about the food deserts.

    You could also think of measures to improve people’s standards of living in general to give them more time to cook and eat a proper meal together. I’m thinking of things like raising the minimum wage, so people no longer need to work two or more jobs just to make ends meet. Or improving infrastructure (including good public transport) to reduce commuting time. Or better worker protection to reduce overtime work. Etc. Obviously, these measures would have many other benefits.

    Apparently, a lot of people no longer know how to cook. Maybe offering cooking lessons in schools might help with that.

  5. Angora Rabbit says:

    Thanks, Steve, for a thoughtful and well-researched post. As you indicate, here in the nutrition field we think (and research) this topic a lot. As I tell the students, we already know how to eat and minimize disease risk; the problem is getting people to do it. This is why our dietitians take several classes in psychology and educational psychology as part of their training.

    The challenge is that we are trying to reverse incremental change that has crept up over the decades. In consequence people don’t notice how the environment has changed to promote, for example, poor eating habits. There is a lot of innovative thinking and research being conducted to address this. Steve’s post highlights some of these. In our own faculty, we have studies looking at inner-city gardening, because studies show that when people / children take ownership of growing good food, they are more likely to consume it. We have a study looking at urban design and ways to change the urban environment to encourage walking, thus calorie burning.

    Regarding Harriet’s and Alexis’s questions about financial penalties, I know the studies are out there in PubMed as economics and behavioral change is an active research area.

  6. Jojo says:

    Dr Hall – Just an antidote, but increased health insurance costs played a role in my decision to quit smoking. However, the main factor that allowed me to finally succeed was that I had never kissed my new boyfriend as a smoker and I didn’t want to gross him out by starting again. 15 years later and my boyfriend is now my husband and I haven’t smoked at all.

    As far as charging higher health costs for the obese, I suspect that would not be helpful in fighting obesity. Very few people are actually able to maintain a significant weight loss, and until we have better treatment options, it may not be possible for most people to achieve long term weight maintenance within a healthy BMI. Also, as Alexis T points out, obesity can be a medical condition. Charging people more for health insurance will create another obstacle for people who are battling problems such as hypothyroidism, PCOS, depression that may be playing a role in their weight management.

  7. Geoff says:

    In my opinion, this post is largely missing the point. It is my opinion that the reason that behavioral changes are so difficult is because the behaviors; which are presumed to be driven by conscious, rational choices; are actually largely driven by lower brain processes, and the conscious decision process is merely a backwards rationalization coming from the left brain interpreter.

    We live in a world of hyperstimulation. Television and video games are so addictive because they are hyper-rewarding activities (i.e. more psychologically rewarding than anything that would have been adapted for in our natural environment) that require very little energy expenditure. Modern processed food has similarly hyper-rewarding properties, and by design. It is my opinion that hyper-rewarding food has the effect of increasing the body fatmass setpoint in the hypothalamus. If the hypothalamus is driving fat accumulation, which I believe to be the case, then caloric deficits of 250 calories should be made up for pretty easily by temporarily downregulating metabolism or being only slightly more sedentary over the course of the day.

    While I do not think that it is the government’s role to tell food manufacturers that they cannot make “hyper-rewarding” food, I do think that the primary issue is agricultural subsidies leading to artificially cheap ingredients with which this hyper-rewarding food is produced. To take it one step further, the subsidized foods, particularly grains and soy, are the most toxic foods we can eat that don’t kill us immediately. In my opinion, nearly all modern diseases are caused by grain/legume lectins, excess linoleic acid, and excess fructose.

    To reiterate, I blame the government first for the obesity epidemic. Sure, pseudoscientists like Ancel Keys had a significant role, but at least they believed that what they were doing was right (the road to hell is paved with good intentions). The US government, on the other hand, overstepped in the subsidizing of food in general, and the most toxic foods specifically. I fear any more regulation in the area of food because these regulations are likely to cause more harm than good, particularly given the “consensus” understanding of things like saturated fat, whole grains and sunlight, all of which are ass backwards.

  8. cervantes says:

    there is no convincing evidence that any practitioners have a significant impact on lifestyle. This is mainly the result of the fact that it is extremely difficult to get people to change their behavior.

    You keep saying this but it is false. There is a vast body of evidence that Motivational Interviewing and Cognitive Behavioral Therapy do indeed have a significant impact on lifestyle.

    You should not pretend to be an expert on a subject of which you are clearly ignorant.

  9. cervantes says:

    (You cherry picked the example of smoking cessation — but even there the impact is indeed significant, even if you would like it to be greater. Alcohol abuse treatment is even more effective. Weight control is indeed very difficult.)

  10. Robin says:

    @ Harriet Hall, there is evidence that smoking is cost saving for insurers when payout is considered over lifespan – because smokers are more likely to die younger and thus eliminate the cost of age related care.

    http://www.usatoday.com/news/health/2009-04-08-fda-tobacco-costs_N.htm

    It may be similar with obesity:

    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050029

  11. cervantes – I have reviewed the literature and reported examples. I did not “cherry pick” smoking – I was using that example throughout so wanted to compare methods to the same problem. I then went out of my way to indicate it is more effective for non-addictive issues.

    I gave the numbers from the most recent systematic reviews. The reader can decide what they think of as “significant”. I said the results are worthwhile, but we are still dealing with low percentages of people changing their behavior, and so huge room for improvement.

    If you are such an expert, please point me to the research that indicates the effect size is more impressive than what I indicated.

  12. You brought up alcohol as an example of MI being effective. Here is a recent systematic review: http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008063/frame.html

    Basic conclusion – data is weak, more research is needed.

    There was a significant immediate effect, with decreasing effects at short and medium terms, and NO EFFECT at long term follow up.

    And this was when compared to the no intervention group. When compared to other standard interventions, where was mostly no difference.

    If this is the best you can do, then I remain unimpressed.

  13. Rick says:

    Like many issues there probably several causes (i.e. longer commute times to work, double income homes with little homemade meals, single family homes with little homemade meals, larger portions, decreased physical activity, PE being cut in school, Health classes being cut in school, etc.)

    Due to many causes, they must be many solutions or layers of solutions, which we (Americans) don’t like. Have High BP, take a pill. Lipids too high, here’s a pill for that. Over weight, fad diets abound. Public health funding is a joke, yet is must be part of the solution. For me it all starts with education. Perhaps instead of calories total restaurant and packaged meals should have the percent of daily calories on it based on the typical daily recommended. That way a quick glance would tell you what you are getting.

    Dr. Hall and others, if you mark smoking on a health questionnaire, then you are charged higher by the insurers that have members fill these out. Last year the group practice I worked for was in a dilemma, because one insurer want us to do a urine screening on all those members who marked that they didn’t smoke, because they thought many people (not surprisingly) were not truthful. As someone who also used to work at a staff model HMO we used to track BMI’s, but this wasn’t used to set rates since HMO’s by law in my state have to insure everyone when done through an employers. Individuals can be rated using health information. However, HMO rates can be determined by gender and age. For example females cost more age 21-40 due to child birth, then men cost more since all the problems they have put off start to come back to haunt them.

  14. Rick says:

    I don’t see smoking banned (although it should be) because the tax revenue lost couldn’t be made up (or the lobbyists won’t allow it). I would a like to see a tax on cigarette butts (actually a deposit) given the litter they cause.

  15. Rick says:

    One last thought. I can foresee in the not to distant future that insurers will either incentivize BMI’s as reported through V codes or registries. For example a physician gets an extra $50 for every child who get all their required immunizations by age two (yes, this is common). Insurers could offer an extra 50 cents per member who’s BMI is under say 22.5, or $1 for every diabetic who’s BMI is <25. Our PCP’s already get I think 25 cents for each BMI annually. This seems be the next logical step for insurers.

  16. libby says:

    @Novella

    Do you believe there is any correlation between the existence of the Monsanto vet drugs rBGH* and rBST* that are presently found in US dairy products (outside of alternative sources such as organic items) and the problem with obesity in America?

    *Note: Artificial growth hormones have been banned in Canada (although US imports are allowed), Australia, New Zealand, Japan and all 27 European Union countries (EU has banned US imports).
    Artificial growth hormones have been deemed safe by The Food and Drug Administration, World Health Organization, American Medical Association, American Dietetics Association, and the National Institute of Health

  17. libby says:

    Correction:

    I meant to say dairy and beef products, not only dairy products.

  18. CW says:

    I’ll throw this out there, but do general physicians ever ask their patients “what prevents you from [insert lifestyle change here]?” I’m guessing that most don’t because they don’t want to be confrontational or they assume their patients will give them a list of excuses.

    I recently dropped 25 pounds, been going to the gym regularly, and am keeping track of my caloric intake. It’s actually become pretty routine for me, surprisingly. But I’m always nervous that life will throw me a curveball and I’ll get knocked off track.

    Anyways, back to my point. My previous visit to my doctor, she asked me what prevented me from dropping the weight. I described to her my lifestyle, and she was able to give me some solutions that I’d not really considered – which have proved to be pretty successful.

    For example, I don’t cook. I eat out most nights. She noticed that I had an iPod, and encouraged me to get an app that helps me to count calories of food in stores and restaurants. She took the fact that I listen to podcasts, and told me to get a membership at a gym $15 a month – and listen to podcasts while on the treadmill. She talked me into drinking low-calorie beer or juice. And there are a few other things that were slight changes to my lifestyle, but have made an improvement. My follow-up visit was yesterday. My blood pressure’s never been better. And I should hopefully get good news about my cholesterol in a few weeks.

    So, maybe a possible option would be for general physicians to try and get their patients to talk about their lifestyle, and then provide some realistic, but helpful suggestions on making positive changes?

  19. DonSelgin says:

    My company currently bans smoking altogether, and includes that in the random drug testing we get yearly – a fireable offense.

    They also instituted, in steps, a “discount” program. First year blood pressure had to be 130/90 or better, glucose 125mg/dl or less. Second year, add cholesterol qualifications. Third year, add BMI.

    We are required to get a screening that includes obtaining this information each year, either through the company or our own doctor. Because of HIPAA regs, though, they have to trust us to put in the obtained values in the questionnaire. This does not lead to honest folks …

    I’m not sure what the solution is, but better education and better information sound like good first steps. I am leery of more regulation on industry or the public, including taxing, etc. Too much potential for abuse of government power, IMHO.

  20. Great article SN. I’ve been working on losing weight lately. One of the most helpful things for me is calories on labels and menus. Wish they’d put calories on alcoholic beverages too.

    The school lunch programs seem like an underused opportunity to improve the eating habits of the next generation.

    Lately I’ve been longing for a running track around the local playground. Walking paths, sidewalks, safe parks are all good ways to encourage fitness locally.

  21. chaos4zap says:

    Better segregation for smoking/non-smoking sections? Sure. Strict ventilation requirements for smoking areas? Very reasonable. How is it anything other than crossing the line to flat-out make it illegal for the business owners themselves to decide rather or not they would like to offer a smoking section? Also, on the subject of myocardial infarction being reduced by 17%…I have questions. When they measure the success of other interventions it is measured in the % of people that quit. Why in this case, are they looking at reduction of heart issues? There are so many factors that can influence heart disease. IT seems awfully suspicious to me and sounds a whole lot like they may have cherry picked a measure to make it seem more effective. How do they in draw the causation between the smoking bans and the reduction? In my experience, for what that’s worth, I have never met a single person that has quit or was even seriously considering quitting because of the bans. They just complain more about having to go outside in the dead of winter. I can’t even imagine that the pictures on the label are going to have anything other than a negligible effect either. One approach is simply to ban unhealthy behavior. Outright bans of products, such as alcohol, have a disastrous history. Another alternative is to restrict the use of such products in certain locations and situations. The best example of this strategy is banning smoking in public locations. A systematic review of 10 studies indicates that such bans reduce the incidence of myocardial infarction in the population by an average of 17%. Banning smoking in public seems to be a clear public health win.

  22. chaos4zap says:

    Sorry for the confusion on my post, I cut a portion of the article and pasted it in the comment box so I didn’t have to keep scrolling up and down. Clearly…..I forgot to delete said portion of the article before posting.

  23. mosered says:

    Great topic and article. I’ve been impressed with the research of James Prochaska et. al. regarding their “trans-theoretical stage of change” model (which expands the “change” process beyond the typical “action” stage i.e. it illuminates how ambivalence and/or lack of confidence/skills can thwart sustained lifestyle changes at any point). Prochaska identified many of factors discussed in the article and thread here: “social liberation (smoking bans)… consciousness raising (calorie listings) …emotional arousal (not wanting your boyfriend to kiss an ashtray).” No actual research studies to link, though I’m sure some readers might be able to, to better determine efffectiveness.

  24. I’m with all the folks upthread who mentioned time and access to healthy food as barriers to healthy eating. I prepare most of our meals at home. We eat mostly plants, and walk, swim, hike, or bike almost every day. This takes a great deal of time.

    It takes a ton of time to buy and prepare healthy foods that kids like to eat, and it takes lots of time to figure out which stores have menu ingredients on sale this week. I pull it off (most of the time) only because I have a flexible schedule. If I had a demanding full-time job, we would eat unhealthy food much more often. Still, I would love to lose about ten pounds and can’t seem to find an extra hour per day to exercise more. (I’m working on eating a little less, so maybe that will help….)

    Anecdotally, we recently started getting a box of local produce delivered every week. It’s a bit more expensive than conventional grocery store produce, but not significantly more. Still, the few extra dollars I spend and the extra produce I need to use before it spoils spurs me to incorporate whatever veggies we have lots of. For example, last week it was tomatoes. If I had gotten cheaper tomatoes at the grocery, I wouldn’t have flinched if one or two spoiled. Because I paid a little more and because I feel more personally connected to the local grower than the anonymous truck at the mega-grocery, we ate a few more tomatoes than usual last week.

    Food has a lot of ritualistic significance for me. (Food insecurity in childhood no doubt contributes to this.) I love the whole process of the truck bringing produce to my house, the washing and processing when the box arrives, clumps of rich soil falling into my sink, looking at recipes for kale or whatever, figuring out which foods are more perishable and which will keep longer, making sure we’re getting enough variety and protein, chatting with my children or listening to them read to each other while I chop and cook, and sitting together to enjoy the food and each other’s company.

  25. Simmerja says:

    Does anyone know of any reputable studies that have looked at how much of our current obesity problem can be plausibly linked to medical conditions?

    I’m just a simple minded medical student, and while I am learning about all kinds of pathology that can increase weight and/or make it difficult to lose, I can’t seem to shake off my undergrad physics and chemistry: Except in relatively rare cases, doesn’t it all come down to energy in vs. energy out?

    I guess why this bothers me is that I’m picking up a strong sense that it is becoming very un-cool to hold patients responsible for their mass (maybe just my institution?); the issue is even starting to be couched in terms of civil rights and anti-discrimination from the “plus size” crowd, who are a growing minority (pun intended) in our society. I can definitely empathize with the difficulty of maintaining a healthy weight, but I hear what seems to be a disproportionate number of excuses for peoples size that involve a “medical condition”. Has there really been an increase in thyroid problems and PCOS perfectly paralleling the obesity statistics for the last few decades?

  26. Simmerja “I guess why this bothers me is that I’m picking up a strong sense that it is becoming very un-cool to hold patients responsible for their mass (maybe just my institution”

    Hold patients responsible in what way? Like I hold my son responsible when he throws a pillow in the house and breaks a lamp? Except a doctor isn’t the parent and the patient hasn’t broken the doctor’s lamp (or anything else).

    Many folks don’t respond well to being judged by their doctor…particularly their young doctor. Perhaps your school is trying to prepare you for that. :)

  27. Mark P says:

    Hold patients responsible in what way?

    How about hold them responsible for eating too much!

    I’m with Simmerja. There’s far too many people who allege that obesity is not caused by eating too much. Yet amazingly people that have their stomach’s stapled lose weight, by a mechanism that is effective only by limiting input of food.

    I’ve seen people who claim it is genetic – yet have parents and grandparents with no weight issues.

    The obesity problem will not be overcome until it is accepted that eating too much is the primary cause. And that people have to accept that they are responsible for what they eat.

  28. Mark P’s comment reminded me that there may be evolutionary underpinnings for craving fatty/high calorie foods. Maybe some folks really are hard-wired to overeat.

  29. Mark P – I am fine with the fact that excess calories equals weight gain. It’s the term “Hold patients responsible” that bothers me.

    Who is the patient responsible to?

  30. Angora Rabbit says:

    @Simmerjaon

    You are absolutely spot-on. Obesity still obeys the laws of physics, and there are no special caveats for their thermodynamics. At day’s end, calories in must equal calories out. There are very good data showing that much of obesity is due to caloric imbalance and very little is due to “thrifty genes” and medical “conditions”. As one line of work, take a look at Dale Schoeller’s papers in PubMed; he developed double-labeled water to look at fuel choice and really documented well that much obesity is due to caloric intake and not due to little Scotty’s beaming calories into one’s midsection.

    I’m blanking on his name, there’s a researcher recently moved from UICU to Cornell and does nice work on behavioral issues that modify food intake. (Folder is at work and I’m writing from home.) He’s shown, for example, that people snack more from a big bowl of Chex mix rather than a little bowl, and that restaurant plates are much bigger (and hold more food) than those 20 years ago.

    Food prices have been rising in recent years and the cynic in me sometimes thinks that this is probably the only real way we will start to curb the obesity epidemic. The percentage of income spent on food is the smallest it’s ever been; is there any wonder that we are overeating?

  31. Angora Rabbit says:

    @Michele
    “Who is the patient responsible to?”

    Herself. Her family. Society. I would hope that a person would want to take good care of themselves to improve quality of life and spend as much time as possible with family and friends. We could have a looong discussion about why that doesn’t seem to be the case!

    Is it morally acceptable to inflict behaviors on one’s self that have adverse consequences?

  32. Turnkey says:

    On the obesity, is there a clear determinant of long term maintenance. Or a point where if a person keeps their weight healthy for x years they are statistically likely to be successful in the long term?

    From my experience, a lot of people I know in the last ~2.5 years have gone from over to ideal weight (self included). Nobody in my sample has seen any regain… so is weight maintenance really as hard as it is made out to be – or is their some giant physiological reason that leads to failure at 3 yr / 5 yr / etc?

    Surely the people that are overweight know why they are, so I’m not sure how much government intervention helps. Simple price comparisons could probably keep a lot of people in the cheap food bracket against rising prices, and it is not as if Kraft/Coke/etc cannot give up some margin.

  33. Angora Rabitt

    “Is it morally acceptable to inflict behaviors on one’s self that have adverse consequences?”

    A great question, for my religious advisor. It’s bad enough going to the doctor, with all it’s physical invasions of privacy, Do I have to feel I am being inspected morally as well? I’d prefer that my doctor focus her mind in figuring out problems and trying to find solutions, rather than “holding me responsible” for my problems.

    But maybe I’m confused. Within the doctor’s office context, what does holding the patient responsible look and sound like? How is it helpful to the patient?

  34. I think the real issue with “responsible” is to make patients feel empowered to change their own behavior and their own health, rather than helpless victims of genetics or circumstance.

    It’s should not be a moral judgment.

  35. Scott says:

    I’d rather have patients ACTUALLY empowered (a frankly meaningless term these days) to change their behavior than simply FEEL empowered.

  36. Kultakutri says:

    If it were so easy.

    My GP told me repeatedly that I should lose weight. We discussed it and I pointed out that yeah, sure, but there are a few things that should be noted, and that I don’t know what to do about them. First, I’m not exactly recovered anorexic. Any attempt of strict control of food intake triggers either a starve and binge episode, or I stop eating at all for days. I mean, 250g is scary, half a bowl is fine, it’s not about control as such but about certain definitions and a bit of slack, too.

    Also, the GP would ignore my constant whines about digestive issues and claimed that all that bloating, diarrhoea and pain is just nerves and all in my head. A year of playing with eliminaton diets later, I found out that nerves or not, gluten is the culprit, I went gluten free and not only that I don’t spend hours reading in the bathroom but I don’t have cravings for all things fat and sugary. I even started losing weight without trying much, just because I added some carbs in place of all those sandwiches and cakes I can’t eat.

    At the end, I’m doing okay, losing weight, eating reasonably well but I feel it’s rather despite my doc’s advice. I don’t really blame my GP, I believe that she has experience with way too many people who explain away why this or that lifestyle intervention is not possible, nor will I run to the nearest quack because my doc wouldn’t listen to me but it’s sort of sad. At least if my suspicion of bread making me sick was taken seriously, I could have saved me a year or two of feeling crappy

    @Simmerjoa,
    thinking of it, I don’t want to shift blame for my excess weight to anyone else. I know that I worked hard on gaining those 20 kilos… but asking for a professional help and finding only prepackaged truths that didn’t work for my situation was a bit disappointing.

  37. daedalus2u says:

    Libby, it is very likely that there is no effect of consumption of animal products from animals treated with rBST compared to consumption of animal products from animals not treated with rBST.

    All animals have their own endogenous growth hormones which they use to regulate size, growth rate, milk production and maturity timing. Animals that have been bred to be larger, produce more milk, grow faster and mature sooner, do so by invoking the same growth hormone pathways and producing larger quantities of what ever growth hormones are necessary to produce the traits selected for.

    rBST is a peptide and is digested in the gut. It needs to be injected to have effects. All cattle already have BST in them, changing the quantity is very unlikely to have an impact on those who consume animal products from animals treated with rBST.

    As I understand the legislation, it was adopted not because of any health concerns for consumers, but rather as protectionist legislation to protect those not using rBST from economic competition with those who do use rBST. It was for economic protection not health protection.

    Kultakutri, as a recovering anorexic, your situation is completely different. You should probably consider getting a GP with experience in treating recovering anorexics. A case like yours, of a recovering anorexic is a situation that absolutely cannot be treated the same as people who are not recovering anorexics and is a situation where one-size-fits-all legislation could be extremely damaging and even fatal.

    For readers who are not aware, eating disorders have a very high mortality rate, the highest mortality rate of all neuropsychiatric disorders.

  38. Steven Novella “I think the real issue with “responsible” is to make patients feel empowered to change their own behavior and their own health, rather than helpless victims of genetics or circumstance.
    It’s should not be a moral judgment.”

    Yes, I think that is the approach that my doctor takes and it has been helpful.

  39. Geoff says:

    @Simmerja

    At this point, this idea of “calories in, calories out” as a causitive factor rather than being a downstream effect is pretty debunked. Overweight people eat less on average than normal weight individuals. No overfeeding or underfeeding study anywhere demonstrates the amount of weight gain or weight loss respectively that would be expected by a strict calories in/calories out analysis. Further, the makeup of the calories plays a significant role in how the body responds to the deficit. For example, if you feed people the types of foods that Ancel Keys fed his subjects in the Great Starvation experiment, the body will have a starvation response, whereas if you feed someone a tasteless liquid goo like described here: http://wholehealthsource.blogspot.com/2011/05/food-reward-dominant-factor-in-obesity.html; something very different happens.

    Obviously all of this is quite oversimplified for the purposes of this comment, and may not be up to the level of scrutiny of SBM, even for a comment section on a blog post, but there is a VERY compelling argument to be made that food quality, rather than quantity, is the driving factor behind the obesity epidemic. To be perfectly frank, I do not think that ANY of the things that we would expect to be true in a “gluttony-sloth” model of obesity actually hold up experimentally.

    @Kultakutri

    All of your symptoms, including your bloating and GI problems, as well as your psychological issues with food, and of course the weight issue, are in my opinion, all symptoms of the same food quality problem. The GI symptoms and weight issues are mostly if not totally reversible through proper diet, and the psych problems are probably less so, but I would still expect significant improvement as your brain biochemistry corrects itself.

    It should be noted that the gut and the brain are highly related, and this is probably due to a number of things, including intestinal hyperpermeability, but I think that the biggest factor is the way that the top portion of the small intestine interprets food reward, and how that impacts dopamine and other neurotransmitters that I don’t know enough about to go into further details. This, of course, would also explain why bypass surgery is so much more effective than any other type of bariatric surgury, and why gastric bypass patients do not experience the starvation that Keys’ subjects did (which would be predicted by proposed mechanism of nutrient absorption).

  40. Harriet Hall says:

    @Geoff,

    It seems to me that all the heated arguments about the calories in/out principle depend on a miscommunication of what proponents mean by “cause.” An excess of calories for the individual’s metabolic balance causes weight gain. That is undeniable. The real questions are what causes one to take in more calories in the first place (genetics, exercise, psychosocial factors) and what practical measures will decrease calorie intake. “Calories in/out” does not mean “gluttony/sloth.”

  41. WilliamLawrenceUtridge says:

    @Angora Rabbit

    Food prices have been rising in recent years and the cynic in me sometimes thinks that this is probably the only real way we will start to curb the obesity epidemic. The percentage of income spent on food is the smallest it’s ever been; is there any wonder that we are overeating?

    Doubtful since the problem is that low-nutrition, high-calorie, quickly digested snack foods and preprepared meals are still extremely cheap (and convenient) compared to fresh, whole foods you have to prepare yourself. If we made high-calorie, low-nutrition foods more expensive and used the balance to subsidize low-calorie, high-nutrition foods (i.e. fresh stuff) that might help. Another option would be food production companies putting time, energy and money into making healthy food taste better, last longer and cost less. A third option would be subsidizing healthy convenience food like pre-cut vegetables and whole fruits. In my travels to countries outside of North America, where we would have a fry wagon, news stand that sells only chocolate bars and chips, or a sausage cart, they have fruit stalls.

  42. vicki says:

    Does it even need to be subsidized? As far as I know, the fruit sellers I pass on my way from the subway station to my office aren’t getting any sort of subsidies. Mostly fruit, bananas and apples and whatever is seasonal, so right now blueberries and cherries and things. Some of them also have tomatoes and those pre-cut “baby” carrots and such. The only problem from my viewpoint as a buyer is that it’s a seasonal business: when it gets cold enough, they’re not standing out there all day in the cold. (The carts that sell hot dogs and coffee and donuts and gyros and such are year-round.)

    The fruit sellers are yet another thing that I take for granted on my small island off the coast of the United States, and then get odd looks when I mention to friends in other cities. (They don’t have the coffee-and-bagel carts either.)

    The key variable seems to be density: these stands are a lot more common in the business districts than in more residential areas (where we’re more likely to have outdoor fruit stands as part of grocery stores, though again, not enough of them).

  43. AlexisT says:

    The issue with “calories in/calories out” is that it is oversimplified. When someone obese says they don’t eat “too much”, what they mean is, “I don’t eat what people would consider to be an unreasonable amount of food” (as opposed to popular perceptions that the obese are simply eating fries at every meal and snacking on doughnuts in between). This often does turn out to be the case. The issue here is that the obese person may have lower than normal caloric requirements. The entire “calories in/calories out” equation turns out to be complicated and difficult to control. Bariatric surgery works because it forces you to consume a low calorie diet and makes you feel full on a much smaller volume of food. You can’t accomplish the same thing via willpower. If your brain thinks you need to eat when you don’t need the calories, you’re going to eat. Trying to tell yourself that your hunger signals are faulty is a futile exercise. You’d actually need to cut off someone’s access to food and provide them with only pre-portioned meals. I went through a period where I knew I could not possibly need to eat as much as I was eating, but I was constantly hungry. (I suspect psych meds; I was on one that is known for weight gain.)

    There’s also a difference between gaining the weight in the first place, and losing it once it’s there. Eating more will make you gain weight, no question; but eating less to lose weight proves to be much more difficult.

  44. Scott says:

    One issue I have with fresh fruit is that presently, my household is only two people. Which means we have a good bit of trouble eating, say, the bags of grapes available at the supermarket before they spoil. Things like apples and oranges you can get a few at a time, but packaging sizes for a lot of fruits are a definite problem. It can effectively double the price per unit actually eaten.

  45. Geoff says:

    @Harriet

    I’m actually really interested in your theory/opinion on the subject of weight gain. I know it’s beyond the scope of SBM to put forth hypotheses, but maybe if you have a personal blog somewhere or something like, I would love to see you post a primer on your thoughts. After all, you have to have beliefs, otherwise you would not be able to decide what to eat every day.

    Still, my comments were specifcally in response to Simmerja, who said, “Except in relatively rare cases, doesn’t it all come down to energy in vs. energy out?” The answer is no, because energy-in and energy-out are not independent variables that can be manipulated, at least in my model here.

    “Energy-in” is a variable that is dependent on blood leptin levels, hypothalamic leptin sensitivity, and the hypothalamus fat mass setpoint (and I suppose to a lesser extent caloric availability, but with the exception of medical ward starvation experiments, food availability in the modern world is infinite). “Energy-out” is a variable that is dependent on energy-in in relation to that setpoint. So when someone overeats, their body upregulates energy output by increasing NEAT, producing heat (while maintaining normal body temp by sweating, we’ve all heard of the “meat sweats), and motivating the individual to make choices that cause him to exercise more. But again, in the case of the latter, while the individual is making a conscious choice to play soccer for example, but the reason he is making that choice is because his hypothalamus is telling him to burn more energy, not because he’s telling his body that he wants to have abs for the beach. The choice to play soccer is a left brain interpreter backwards rationalization, not a top down decision.

  46. daedalus2u says:

    It is pretty clear to me that the “problem” of obesity is in the regulation of calorie intake. Over the long term, excess calories above metabolic use are converted into fat at ~3500 calories per pound. That is if you are overweight by 20 pounds, you have consumed 20 x 3500 calories in excess of your metabolic consumption. It takes relatively little to maintain a pound of fat as opposed to a pound of lean tissue. That is why metabolic rate is usually estimated in terms of calories per pound of lean tissue.

    The metabolic rate of obese individuals is higher than lean individuals, and when the obese lose weight their metabolic rate goes down. I know this seems counterintuitive, but it is what the data says.

    In the rural undeveloped world, obesity is very rare and the diseases associated with obesity are very rare. In cities in the undeveloped world obesity approaches western levels even though they eat essentially the same food as does the rural countryside. There isn’t some magic good or magic bad food that if you eat it you will become obese.

    In wild animals, obesity is extremely rare. When wild animals acquire very large food supplies, they don’t use it to become obese, they use it to increase reproductive rate. Obese humans have reduced fertility.

    I see the problem of obesity completely as a “setpoint” issue. If your “setpoint” compels you to eat, you will feel hungry until you have eaten. You will feel like you are starving unless you eat what your “setpoint” tells you to eat. If you feel like you are starving, it is extremely difficult to not eat when food is available. There are very powerful anti-starvation mechanisms that have evolved to prevent starvation.

    To me, the question of obesity is why is the “setpoint” out-of-whack? I think it relates to the basal nitric oxide level.

  47. Simmerja says:

    Michele: “Many folks don’t respond well to being judged by their doctor…particularly their young doctor”

    I don’t think it’s a question of being judgmental, at least not in any sort of moral sense, and I certainly have better things to do than judge. I just don’t think that I’ll be doing them any favors by not addressing the underlying issues (Dr. Hall’s “real questions”).

    Ultimately, patients are responsible for themselves (although given how likely the cost of their care is to be state funded in one way or another the question of how much individually determined self-destructive behavior should be tolerated by society without penalty is debatable), and I am not, as a young doctor or otherwise, trying to treat them the same way I do my children.

    What I am trying to figure out is how I can act to empower these patients as Dr. Novella says. Doubtless it is an artifact of youth and inexperience, but I am still genuinely humbled at the thought that another human being will be trusting and depending on me – frankly, it’s scary! My frustration regarding this topic stems from what I see as barriers to a productive doctor/patient relationship, specifically a widespread eagerness to assign a medical or genetic cause to what is more commonly a behavioral problem, and to a common lack of personal responsibility.

    Expecting your doctor to focus on how to treat your problems rather than assigning blame for them is a reasonable expectation, but can’t I be more effective if I can be both honest and non-judgmental? Why does pointing out that nobody else is putting food food in their mouth seen as blaming rather than a statement of fact? Doesn’t true empowerment require a frank assessment? Yes, in most cases it is pretty silly to “hold someone responsible” for their condition, but for something that is so intimately associated with personal, modifiable choices and behavior I refuse to ignore the obvious common denominator in the interests of being more PC.

  48. AlexisT says:

    It is perceived as judgmental because you are not stating something new. Every obese person has gotten the weight lecture before. Usually, we get it every time we see a new physician. By going into “personal responsibility”, you’re turning this into a moral issue and hence into judgment. Further, you will not have the time or the ability to do anything about the patient’s behavior beyond telling them what they already know. You are not going to be able to sit there with your patient, discussing the details of their diet and lifestyle.

    You do not know, when you encounter a new patient, how much of the issue is behavioral and how much is medical. You need to decide: How important is it to you to tell a patient the unvarnished truth, and how important is it to treat them? Patients who view their doctors as judgmental or fatphobic will simply not come, and their secondary conditions will worsen. As an obese patient, I would view you as judgmental. What you view as a barrier to the doctor/patient relationship is the opposite. The patient will lose weight when s/he is able and willing, if that ever happens. For some of us, it won’t.

    Weight and diet are not untouchable. It’s perfectly appropriate to tell a newly hypertensive patient that the DASH diet and weight loss have been shown to help. But you don’t need to tell your obese patients to take responsibility for themselves. It’s patronizing.

  49. simmerja, I guess the particular phrase you used put my back up…maybe I’m just hot and cranky, maybe creative direction past makes me very sensitive to wordsmithing.

    But my complaints are not about any political sensitivities. It is more about respecting boundaries and individual decisions.

    Regarding the impact of obesity on state funded care, I’m always confused by how people can discuss the negative economic impact over over-consumption without looking at the positive economic impact. Do we really think that people’s food consumption has risen enough to fuel an obesity epidemic without food distributors realizing greater profits? One would think that an increase in profits would result in a (gasp) increase of revenue to the government. But that is never included in the equation.

    If, as a nation, we decide to let food manufacturers increase their profits without requesting they share in the cost of the consequence of those increases, then I believe we all share the responsibility of giving an industry a free ride at the expense of state dollars.

  50. What are the rates of overweight and obesity among MDs? Is it less than the general population? If so, why?

  51. Harriet Hall says:

    I couldn’t find any data on the rates of overweight in MDs, but here’s a survey on smoking rates: http://www.biomedcentral.com/1471-2458/7/115

  52. AlexisT says:

    Would you only want to compare it to the general population? Wouldn’t you also want to control for social factors? An upper middle class person from the Northeast is already less likely to be obese than a poor person from the South, whether they have an MD or not.

  53. Simmerja says:

    AlexisT: I really don’t see it as a moral issue, but I can see how terms like personal responsibility have that connotation. When I use the phrase, it’s because I know that my role can only be supportive or facilitative – their life is ultimately their responsibility.

    Also, I think there is a large grain of truth when you say:

    “Further, you will not have the time or the ability to do anything about the patient’s behavior beyond telling them what they already know. You are not going to be able to sit there with your patient, discussing the details of their diet and lifestyle.”

    What is frustrating to me, and to many of my peers just getting started in medicine, is that we honestly WANT to make a difference, to be able to have those substantive conversations that can actually change behavior instead of giving them the same spiel that they’ve heard before. But until our primary care model changes that may be tricksy….Guess maybe I should’ve gone to a naturopathic school, eh? ;)

  54. Alexis T, I was just thinking that if MDs had a lower rate generally, regardless of where they live or other demographic factors, then maybe the culture of clinical practice differs when the patient is a fellow MD. Or maybe they are ahead of the cultural curve. Or maybe they have access to and technical understanding of the medical literature that informs their personal behavior. Maybe there’s more comradery and mutually encouraging practice than they have time or boundaries to share with patients. Maybe they are more judgmental with each other and that lowers their rates. I’m curious.

    I thought this bit was interesting from the discussion section of the smoking study Harriet Hall posted above:

    “Doctors incur a certain responsibility as exemplars for patients with regard to healthy behaviour [118], as well as the public image they inadvertently portray outside of the work environment [119]. Having any physicians who smoke may increase public scepticism, with people inclined to ask why should they stop smoking when their doctor continues to do so? [120]. Continued tobacco usage by health care workers undermines the message to smokers that quitting is important…”

  55. SD says:

    @Steven:

    “The problem is that it is notoriously difficult to change behavior.”
    “We can take actions aimed at the individual or aimed at society.”
    “We can, of course, do all of these things simultaneously, and may need to in order to have a significant impact.”
    “The technology of changing individual behavior is advancing, however.”
    “It is likely that we will need to use a combination of strategies while researching new and better ways to influence behavior.”

    … My God. Did you even bother to *read* what you wrote?

    “One approach is simply to ban unhealthy behavior.”

    Yes, because after a decades-long ban on ingesting illegal substances – heroin, cocaine, marijuana, methamphetamine – it is no longer possible to find such substances on the street, nor to find people who do this on a regular basis. Anywhere.

    In fact, it is as difficult to find people abusing those substances as it was to find people abusing ethanol while the Volstead Act was in force.

    “Such strategies evoke images of a Big Brother nanny state trying to take away our freedoms. There are legitimate concerns about draconian state measures, especially if they are not rigorously science-based, but the looming health care crisis is making public health measures seem more attractive.”

    Yes. And clearly, that is a completely *unreasonable* image for readers to have in their heads, given that you discuss alteration of other people’s behavior with the icy detachment of an NKVD Commissar drawing up schematics for the reduction of a village full of kulaks and other undesirable elements.

    Indulge my curiosity – who, precisely, do you think you are? That’s a serious question, by the way.

    Here’s another one: Is it considered ethical in medicine, these days, to use parlor tricks, mind games, and advertising gimmicks to brainwash your patients?

    @Harriet:

    “What about financial persuasions? What if insurance companies charged higher rates for smokers or did not pay for smoking-related illnesses? Or for people 100 pounds over ideal weight? What if they refused to pay for injuries in car accidents if the policyholder was not wearing a seatbelt? Has that concept been tried or studied?”

    Here’s a news-flash, Harriet, since you clearly have no idea what insurance coverage really costs for those of us living in the real world – the insurance companies *do* charge higher rates for smokers. The typical rate is about 25%.

    But let’s blue-sky some possibilities. Here’s a hard one for you: What if insurance companies charged higher rates for people who admitted homosexual activity during the worst years of the HIV epidemic? For that matter, what if they did so now? AIDS is a disease that, historically – and even now – costs a helluva lot of money to treat. They “cost” the rest of us, speaking from an actuarial standpoint.

    By all means, tell us to what extent you believe that individual *voluntary* activity should be deterred by financial pressures, Harriet.

    “are you serious?”
    -SD

  56. Harriet Hall says:

    @SD,

    Please note that I was asking questions, not making recommendations. I would like to know what measures will effectively improve health: that is the scientific question. Whether those measures should be implemented is a societal/political decision with many ramifications that fall outside the scope of this blog.

  57. SD says:

    @Harriet:

    “Please note that I was asking questions, not making recommendations. I would like to know what measures will effectively improve health: that is the scientific question. Whether those measures should be implemented is a societal/political decision with many ramifications that fall outside the scope of this blog.”

    As a physician, you do not exist in a moral vacuum, even though you pretend to the title of “scientist”.

    I further note that, since my questions are imputed with moral intent, fairness dictates that I be allowed the same courtesy.

    I will do you the courtesy of answering your questions: yes, financial incentives *do* matter. When it costs more to smoke, people tend to smoke less.

    Now, do me the courtesy of answering my questions: What are the implications of insurance companies charging higher premiums for known homosexual clients?

    Here’s an additional question: Would such charging improve health? Would it *have* improved health earlier in the AIDS epidemic?

    “appalled”
    -SD

  58. “But let’s blue-sky some possibilities. Here’s a hard one for you: What if insurance companies charged higher rates for people who admitted homosexual activity during the worst years of the HIV epidemic? For that matter, what if they did so now? AIDS is a disease that, historically – and even now – costs a helluva lot of money to treat. They “cost” the rest of us, speaking from an actuarial standpoint.”

    Actually if memory serves, they did, and in areas hit hard by the AIDS epidemic sometimes they refused coverage to gays altogether.

  59. Harriet Hall says:

    @SD, “Here’s an additional question: Would such charging improve health? Would it *have* improved health earlier in the AIDS epidemic?”

    That’s exactly the kind of question I was asking. You tried to answer my questions but you offered no data.

    “do me the courtesy of answering my questions: What are the implications of insurance companies charging higher premiums for known homosexual clients?”

    I don’t think I owe you much courtesy, since you have repeatedly tried to hijack comment threads to voice your political opinions and have used inflammatory descriptions of my colleagues as “commissar” and “comrade.” I won’t rise to the troll bait.

  60. Geoff says:

    @daedalus2u

    It sounds like we are basically in agreement with everything other than the cause of the alteration of the setpoint.

    I have never heard anything about the basal nitric oxide level, but if you could point me to a primer on why you think that this is the cause, I am interested. My gut reaction tells me that if there is a correlation, it is probably downstream of the actual cause, and is likely related to gut flora that gets selected for when toxic foods are ingested rather than actually being causitive in and of itself.

    In my opinion, the alteration of the setpoint is caused by hyper-rewarding food. I don’t know too much about the neurochemistry, but it is something relating to dopamine being released in response to food, and that causing an upregulation of the setpoint in the hypothalamus. Highly rewarding food is good, we evolved our food preferences in response to what is healthy, but many processed foods in the modern world are specifically designed to be more rewarding than anything that we have run into in our evolutionary experience. Also, some grains, wheat in particular, have proteins in them that bind to opiate receptors in the gut, making the food even more rewarding than the taste bud mix would predict. There’s quite a lot of evidence in favor of the food reward hypothesis, take a look at Stephen Guyenet’s series on the subject here: http://wholehealthsource.blogspot.com/search/label/Food%20reward

    There’s another element to this as well. The inflammatory response seems to interfere with leptin signaling, resulting in leptin resistance. So while the leptin levels in the blood are very high, the level interpreted in the hypothalamus is much lower, making the body think that it is still underfed. Excess linoleic acid, anti-predation proteins in wheat and other grains, these are toxic to the human body, and result in the systemic inflammation response that interferes with leptin signaling. In my opinion, of course.

    Any dietary restrictions will reduce the reward quality of food, which explains why low carb and low fat both seem to work. However, in my opinion, the most effective weight loss diet is one that is grain, legume and vegetable oil free, and contains only whole food sources. Also, probably an 8 hour feeding window, leading to a 16 hour daily fast.

  61. margaretrc says:

    I think a big, public apology by the government for telling us, without any scientific basis for it, to eat less fat (thereby loading up on carbohydrates), substitute trans fats and easily oxidized, disease causing polyunsaturated vegetable oils for natural saturated fats, and eat plenty of government subsidized grains (and ending those subsidies) would go a long way toward changing our behavior in a positive way. At least 6 years of research into the subject–and my own experience–tell me that the scientifically unfounded USDA dietary guidelines that have shaped eating habits over the past few decades are largely responsible for the skyrocketing rates of heart disease, diabetes, and obesity. To turn around now and tell people we’re going to tax some of the very substances the government already subsidizes with our tax dollars or charge people more for health insurance if they are obese (thanks to those government subsidies and guidelines), would be unconscionable. Until those change–yes, by and large, people do follow those guidelines and federal subsidies of corn, soy and wheat, which industries use to make cheap processed food and beverages, make it cheap and easy to do so–and the subsidies and guidelines either disappear (preferable) or at least are determined by people who are not tied to industry so that the guidelines have a solid scientific basis, nothing is going to change.

  62. margaretrc says:

    To add one thing to my comment above, most doctors and health professionals do not help, either. They endorse the government guidelines, tell their patients to eat a low fat, grain based diet and then wonder why they aren’t losing weight, become diabetic, etc. etc. (and blame them for not following doctor’s orders, when most likely they are.)
    Disclaimer: I am not obese, do not have type 2 diabetes or heart disease and neither does anyone in my family (most likely because I ditched the government guidelines and my fear of fat/sat. fat long ago when I learned they were bogus and doing us more harm than good.)

  63. NYT has this article. What an interesting topic!

  64. margaretrc says:

    Please, please, I say it again, taxing and regulation is not the answer. Honest, real, science based education is–and perhaps returning to traditional cuisines that have worked for centuries. How is it that people in other cultures who follow a variety of traditional diets don’t have to tax or regulate food to keep from having obesity, heart disease, and diabetes epidemics? How is it that they don’t have to count calories or fat, don’t need to print calorie counts on menus and menu boards, don’t have to exercise like a maniac in the gym, or do any of the other things that we have recommended and/or done, yet don’t have the skyrocketing rates of obesity, heart disease, and type II diabetes that we do? How do they manage, for the most part, to instinctively control their food intake to match their energy out put? What we really need to do is go back to before our epidemics began and look at what changed in our diets at that time. I’ll give you a clue–a couple: We vilified saturated fat and recommended substituting trans fats and polyunsaturated vegetable oils for the sat fat in our diets. We told people to reduce their total fat intake, leading to increased consumption of refined carbohydrates, especially sugar, which industry was only too happy to supply in the form of easily accessible, cheap processed food. Yes, we also got busier and depended more on those same, industry supplied, mostly low fat, high in refined carbohydrates and sugar, processed foods–and eating out. But people in other cultures eat out, too, though they do eat a lot less processed food. I’d rather not have my food further taxed or regulated in any case, but I especially don’t want it regulated/taxed by people who have no clue as to what real, unbiased science says is or is not healthy.

  65. WilliamLawrenceUtridge says:

    I believe there were fat people before the introduction of the modern western diet. In traditional Oceania, obesity was a sign of prosperity, which suggests they used to get fat. Not to mention “non-western diets” are also accompanied by non-western lifestyles of physical labour and death from preventable diseases. Plus, there has been a massive investment into the food infrastructure in North American to ensure a secure food supply in general, resulting in a general excess of cheap, high-calorie foods. Claiming relationship between diet and heatlh is simple and experts-are-idiots claims smacks of sloganeering rather than science.

    Education isn’t a panacea. There’s a fair bit of education regarding the health effects of smoking, but people still smoke. Knowledge of AIDS is ubiquitous yet people still have sex without condoms and use dirty needles. Taxation and regulation is one tool among many. Education requires a substantial investment of time and effort, and people have to be willing to listen. On the other hand, expensive junk food is nearly its own argument.

    The whole “saturated fat isn’t evil” argument never convinced me and it sniffs of quackery in my mind. “Everyone but me is BIASED and STUPID because they can’t see the SCIENCE that supports VIRGIN COCONUT OIL (that I sell on my WEBSITE)”. Excess fats, sugars and proteins are all converted into stored fats, excess calorie intake leads to weight gain. Whether different types of fats offer unique risks or protection is a very complicated question, certainly more complicated than a quick-point-to-hunter-gatherers warrants.

    I blame Gary Taubes :)

  66. Sorry for the length, but I need to give the backstory. I’m attending a really great lecture series. The dean of the program, J. John Cohen, MDCM, PhD*, spoke about cell biology tonight. During the audience Q&A, someone asked if exercise is good for mitochondria and metabolic efficiency, why does exercise trigger hunger. Dr. Cohen said he actually finds exercise to be appetite-suppressing, and took a quick poll of the audience. The results were about 50-50.

    I was astonished to learn exercise does not trigger hunger in everyone. This seems to me like a potentially productive avenue of obesity research. I will be the first in line when someone figures out how to flip that switch.

    *Dr. Cohen is an amazingly charismatic lecturer. I think he might have originally founded the Mini Med School program, and they claim to have graduated 17,000 students. What a powerful way to promote science literacy in the general population. I’d like to suggest him as an interview guest on the SGU. I have his email if you’re interested.

  67. Anthropologist Underground – The way I dealt with the exercise hunger issue was this.

    I used to exercise in the afternoon(a tine I typically got hungry) When I got done I was really hungry and would sometime exceed my calorie limit in snacking.

    I shifted my exercise to morning (when I am typically not hungry) When I am done exercising, I have only average hunger and am satisfied with my typical breakfast, which is included in my calorie limit.

    So possibly if one is a hungry exerciser, shifting the exercise to before a major meal could result in less calorie consumption overall.
    just a guess…

  68. Micheleinmichigan: Good point, but that’s not what’s going on here. Dr. Cohen was saying that exercise actually made him less hungry than if he hadn’t exercised. He claims that it suppresses his appetite.

  69. @anthropologist underground – this is terribly anecdotal, but my experience is that doctors or other counselors who work in diet or weight loss fields generally underestimate the impact of appetite. At least when it comes to my individual experience. :)

    Have no idea why that would be.

  70. …which is why this is so interesting, IMO. People may have significant differences in how they subjectively experience hunger. If only, roughly, 50% of doctors experience the impact of appetite, then they may be experientially unaware of its impact.

    Dr. Cohen said that he was really surprised the first time he heard someone say that exercise made them feel hungrier than if they hadn’t exercised.

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