The Unspoken Reality of the Obesity Epidemic: What the Experts Won't Say

From the fame of Michael Pollan to the outcry about agribusiness to the first lady's signature Move Your Body! program, it's impossible to ignore the American struggle with weight. The interest in the issue may be apparent, but the proposed fixes remain rudimentary. Anyone curious how and why the rate of obesity has skyrocketed in recent decades can find a growing library of well-researched, thought-provoking books. Looking for an expert speaker to summarize the country's dilemma? They abound.

However, if you're searching for an effective approach to the problem, you're in trouble. Some experts focus on regulation of agribusiness and the food industry, similar to the fight against tobacco, but that's a long-term project complicated by the fact that people can live without tobacco, but not without food. Others emphasize the truisms of the diet industry, eat less and move more, without divulging the fact that 99% of diets fail. So why would anyone believe the collective national diet will have any more success? And the physicians obsessed with "evidence-based" treatment are holding out for the miracle weight-loss drug while chastising their mostly overweight patients. That's no more than a pipe dream at this point.

Food and weight are not particularly complicated. The real issue is that no one wants to reveal the truths this country faces, much better to pretend that a magic solution is just around the corner.

The clear facts about food and weight are as follows. There is much more food available than ever before, and most of the increase is highly processed and inexpensive. The combination of successful marketing and the development of irresistible foods decreases any one person's ability to manage daily intake effectively. The regular person's life is much more sedentary than in years past. Chronic dieting leads to rebound weight gain  and a gradual weight increase over time. Due to these factors, rates of overweight and obesity have skyrocketed. 

Similarly, the facts about ways to fix the obesity problem are clear. None of the current suggestions work. If any one idea had merit, the word would spread like wildfire. As it is, every new crash diet or exercise program has its fifteen minutes of fame, while the well-meaning "healthy eating" programs are the neglected stepchild compared to the advertising and delectable offerings of the omnipotent food industry. Everyone is desperate for a new solution to cling onto, but no one wants to be clear about what really can be done.

The problem needs to be split up into two parts. First, what are the practical approaches for the currently overweight and obese? And the second part of that question no expert wants to address: what are reasonable goals for long-term weight loss? Second, what can the country do to ensure the obesity problem is limited to a few generations and does not become the new norm? Although the two pieces overlap, separating them clears up the difference between realistic expectations and activism.

Only one weight loss approach works. And it's completely obvious and intuitive. In order to change ingrained behavior, one needs a long-term, sustainable, consistent meal plan developed with a professional or a program since an individual who struggles with food inevitably reverts to old patterns without external intervention. That means working with a doctor, nutritionist or a reasonable program such as Weight Watcher's to implement and follow a clear daily approach to food. The plan needs to provide adequate calorie intake to sustain health and to stay within the person's energy needs. After years of excess food, it will take years for a body to adjust hunger cues and adapt its weight range to a lower food intake. All of the evidence makes it clear this is the only effective option.

There's a reason no expert will make this point. The diet industry preys on the collective desperation to lose weight now. Even the smartest, most experienced dieters know that no magic diet will ever work. Yet the masses suffer under the delusion that permanent, speedy weight loss is in their immediate future. No one will hear otherwise and no one is brave enough to face the wrath of saying it like it is.

What is the benefit of blowing the secret? And at this point would anyone really listen? No one wants to believe that the current overweight generation will remain overweight. Yet, with a little perspective, that fact is evident. As I have written before, chronic overeating drives up an individual's set point weight range. Since the body protects itself against weight loss much more than weight gain, as the set range increases, the low point of the range increases as well. The body will move easily within the range but will resist weight loss at the bottom of the range, even if the bottom of the range is still significantly overweight. Moving within the weight range is easy. Shifting the entire set range down is a much harder long-term proposition that involves sustainable, consistent decrease in food intake over years. It's not a big leap to realize how improbable that result is for an entire country.

It's important to recognize that even if this generation as a whole remain overweight, many individuals will find the right meal plan, rely on considerable support and gradually bring down the set weight range. As more clinicians and programs provide effective solutions, more people will find an approach to weight loss and maintenance that works. But the likelihood a country will do so is very slim.

In the fight against long-term obesity, the current generation will have a very specific role. The fate of the overweight generation is to attempt to reject chronic dieting in favor of a sustainable change in eating and live with the modest weight loss and health benefit. Adults can teach children how to survive the world of plentiful food and how to avoid the cycle of overeating and dieting and thus not become obese themselves. That's the topic of activism in the fight against obesity, and I'll address it in the next post.

What do the Experts Say about the Obesity Crisis: A Summary of the Current Information

The clamor for practical, effective information about obesity and weight loss is growing rapidly. Although the latest fad diet, magic cleanse or false nutrition claim still attract the most attention, word has spread through the major news outlets that 99% of diets fail. A quick review of the available resources reveals that the recent global transformation of lifestyle and food supply created and now perpetuate the obesity epidemic. More scientists, researchers and clinicians recognize that the issue needs thought, concern and action to counter the disastrous effect of unregulated food and diet industries. So what's the verdict of these newly minted experts thus far?

Even a quick summary of the available data about dieting is unequivocal. It doesn't work. Diets pretty much always fail. Any combination of severe calorie restriction, magic nutrient compositions and newfound supplement concoctions are sheer quackery meant to capitalize on the desperate willing to try anything for success. The underlying motivation of every diet guru is monetary gain. The diet industry is huge business and is sure to quash the obvious conclusion that diets fail at every turn.

Another consensus opinion is that nutritionism is man made myth, not true science or medicine. Nutritionism, as explained in previous posts, is the process of creating meal plans based on food components, protein, carbohydrates, fat, vitamins, minerals, etc., rather than actual food. The concept implies that current knowledge of nutrition is complete and that the best, healthiest meal plan is easy to create based food components and is completely effective for weight loss. Experienced academic nutrition professors and scientists dismiss nutritionism and instead expound on the dangers of spreading such misleading information. Omnivores one and all, humans need to eat a wide range of foods, not food components. We adapted to survive on an extremely wide range of diets, a trait sure to extend our longevity. The sage advice of the experts is that the best meal plan is simple and general: not too much food with ample variety. These are simple words to live by.

Yet the simple advice has been woefully inadequate to make a dent in the problem. At this point, the conversation inevitably turns to metabolism and weight management, basic facts needed to tackle the problem of obesity, which are incompletely understood and surprisingly complex. Metabolism encompasses how the body uses food, our energy source, to function. Weight is generally stable within a range but varies according to overall food intake and energy expenditure. The body stores energy during excess and uses that stored energy during lean times. And that balance has been very effective to maintain weight, until the last few decades. Put simply, the recent introduction of significant excess food with high fat and sugar content apparently overrides the mechanism that maintains weight and has triggered the obesity crisis. Human evolution protects against weight loss effectively but much less so against weight gain, something that has never before been a problem in human history. The experts then conclude with this statement: years of human function and evolution show that moderate food intake and moderate physical activity lead to a stable weight range, and we need to return to that basic concept. Beyond that, the experts, one and all, throw up their hands. As of now, they all seem to agree: that's all we have to counter the issue of obesity. Since everyone is still hooked on a quick fix for the crisis, the experts' message is largely ignored. Although the experts' opinion is undoubtedly accurate, it's the presentation that needs a little work.

The underlying premise of the obesity crisis is that we need a fix now. Our current knowledge about weight and metabolism relies on the largely unchangeable evolutionary adaptations of the human body. Maintaining stable weight and energy stores is essential for life. Human survival depends on a body that can adapt easily to change and is resilient in hard circumstances. In fact, we even have multiple backup systems for any possible failures to essential organs, much like a backup generator for a power failure, all to maintain the status quo, or in medical jargon, homeostasis. Homeostasis means that the body always will work to keep things stable. This can refer to blood levels of various electrolytes and blood cells, heart rate and blood pressure, hormonal balance and pretty much all body function. Of course, metabolism and weight are included. In recent decades, the average weight range has gone up but that hasn't done away with homeostasis. Instead, the body recognizes the new norm is a higher weight range, and the body uses the evolutionary system to protect this new range. So a quick fix tests an age-old system and repeatedly fails. But if we apply the experts' advice, any approach to the obesity problem has to respect that homeostasis is here to stay.

The next step is to combine expert opinion and change the time of the conversation. Moderate food intake with variety and moderate exercise will, slowly and steadily, chip away at the obesity problem. Weight loss can only come with a gradual decline in each person's normal weight range as the body slowly reacts to a more moderate daily calorie intake. The key to effective weight loss is sustainable, consistent and small calorie decrease over a long period of time. For this message to work, the focus needs to shift from a quick fix to a reasonable, sustainable solution, one that takes into account how our body functions, not the desire to just fix the problem.

The next post will address how to apply this information practically and how to spread the word.

How Doctors Harm People with Eating Disorders

The prejudice against people with eating disorders extends to clinicians, who are as misinformed as the public. The basic medical and psychiatric understanding of anorexia and bulimia are not part of medical training. Primary doctors have sporadic exposure to patients suffering with these illnesses but no guidance about how to manage them. Even psychiatrists in training can graduate with no more than a cursory knowledge of the diagnostic criteria for eating disorders. If anorexia is the most fatal of all psychiatric diseases, then medical education is missing the boat.

The life of a recovering patient remains isolated, lonely and gravely misunderstood. While family and friends struggle to comprehend how anyone could have trouble eating, something so basic to human existence, the sick are typically silent. But what happens when physicians approach anorexia and bulimia with similar ignorance? The risks are much more consequential.

Too many of my patients have had difficult experiences with doctors. For some, the scars are emotional and that makes seeking medical help in the future a scary proposition. Arrogant doctors typically think one of two things: that they will save the patient or that the patient needs to just buck up and eat. Either erodes a patient's trust in medicine and prompts the person to go it alone. Many others are physically harmed by doctors unaware of the precarious balance the human body reaches to survive an eating disorder. A person with bulimia can adapt to usually lethal blood potassium levels and frightened doctors may dangerously raise the level too fast. Doctors also don't know that overfeeding a very underweight person with anorexia is potentially lethal and will do so anyway. The bold medical interventions aren't just pointless, they can kill.

This leaves treatment in a difficult spot. On any typical day, a doctor relies on the nearest hospital emergency room. I suspect everyone has heard a doctor's voicemail message stating the obvious, "If this is an emergency, please hang up and call 911 or go to your local emergency room." In this message, a doctor is sure to impart a clear directive to a scared and confused patient. In addition, the doctor implies confidence that the ER will address the problem adequately and quickly.

I don't say that in my voicemail message for a reason. It's not because my patients don't often need an emergency room. They do. It's that emergency room doctors do not know how to treat people with severe eating disorders. The sight of a malnourished patient tends to elicit horror and hasty action. The shockingly abnormal lab values in a very sick patient with bulimia leads to the same reaction. An ER doc is supposed to have seen it all. They are supposed to be able to handle any form of crisis and use their knowledge to save a patient. The misinformed, judgmental response of many of these doctors makes an ER one of the least safe places for anybody with an eating disorder. When I do send my patient to a hospital, I am sure to be on standby to protect them as much as anything. These patients often need immediate medical care I can't provide, but when in an ER they practically need an escort to be sure they survive.

Sadly, much of the problem lies in the prejudice. Doctors absorb most of their information about eating disorders from the press and entertainment industry. Convinced of their suspect views about food and weight in general, doctors typically know even less about eating disorders but have no trouble expressing faulty opinions, even when on call. And that precipitates poor, dangerous treatment decisions. Most doctors consult textbooks and supervisors when faced with an unfamiliar situation, but who can help treat anorexia and bulimia? There is ever-growing public attention on food, weight and eating disorders; the problem is ubiquitous and garners significant attention. Just a little time engaging with the main stream media attests to the topic's popularity. It's about time the medical community pays attention and realizes our job isn't to form an opinion but to learn how to keep these patients stable and safe.