Monday, March 22, 2010

A review of David Kessler's The End of Overeating

Last week I attended a health promotion conference in South Carolina. My flight book on the way there was David Kessler’s The End of Overeating.

Kessler, a paediatrician by trade, and the former commissioner of the FDA responsible for tackling the tobacco industry, takes on his own lifestyle demon – something he calls, “conditioned hypereating” in his book, The End of Overeating.

His premise is compelling. Big Food, over the course of years of trial, error, science and focus groups, have manufactured a food environment that for those susceptible, conditions like Pavlov conditioned his dogs - to overeat. Cues are everywhere. Packaging, smells, product placement on supermarket shelves, menu descriptions of meals, tenacious marketing – the world has become a Big Food marketer’s dream playground. Even the food itself has undergone hypereating evolution whereupon food has simply become fats, layered on fats, layered on sugars, layered on salts or some combination therein.

In one of the most fascinating segments on food’s evolution Kessler discusses chewing. He quotes Gail Civille, the president of food consulting's Sensory Spectrum corporation who reported that in the past it would take roughly 25 chews before a mouthful was ready to be swallowed but now as a consequence of the processing and “pre-chewing” the average person only needs 10 chews to down a mouthful allowing that person to eat faster and outpace their body’s satiety cues in place of bursts of neuronal reward. The primary means to accomplish this “pre-digestion”? The inclusion of fat which makes swallowing easier.

At one point Kessler talks with a food consultant who explains saliently that the hedonics of food involves five factors – anticipation; visual appeal; aroma; taste and flavour; and lastly mouthfeel and that mass manufacturing and processing allows the food industry to control these variables like never before with partial frying (to add a layer of fat), chemical inclusions to add aroma and flavour, and an exacting addition of the perfect amounts of fat, sugar and salt to “dial-in” irresistabilty.

Consuming these foods causes conditioning because they're highly neurochemically rewarding. We learn that when we eat these foods we feel better, even if only momentarily, and in turn that will motivate us again and again to seek out those foods that our brain has recognized as positively reinforcing. The more the cycle repeats itself, the more ingrained the behaviour and the more the pattern becomes reinforced while at the same time our memory stores the cues surrounding the behaviour. If you have become conditioned to eat highly rewarding food in response to a fight with a loved one or a stressful day at work that ties together the reward with the situation such that when you have a fight with a loved one or a stressful day at work your mind automatically steers you towards food. In Kessler’s words, “Action builds on response and response builds on action” until eventually it becomes automatic leaving us with a cue-urge-reward habit.

This leads to Kessler’s overarching theory,

Chronic exposure to highly palatable foods changes our brains, conditioning us to seek continued stimulation. Over time a powerful drive for sugar, fat and salt competes with our conscious capacity to say no
We’ve become conditioned to hypereat as the food we’re eating for comfort leaves its mark on our brains that leaves a void ready to be filled the next time we’re cued.

Kessler’s belief is that in order to break this cycle we have to enter something he’s trademarked as “Food Rehab” which involves a series of steps:

1. Figure out your cues. Food cues, situational cues, all of them.
2. Refuse everything you can’t control.
3. Create an alternate plan with a specific behaviour to adopt in place of what normally would be conditioned hypereating.
4. Limit your exposure.
5. Remember the stakes. When faced with a situation that may involve conditioned overeating ensure that your visualization takes you all the way through to the inevitable end of the eating episode where you acknowledge that following momentary pleasure may come the pain of guilt or depression or the simple fact of it being counterproductive to your health.
6. Reframe things in terms of you vs. them. Kessler calls this active resistance. Recognize that Big Food is out to get you and try to see food in those terms.
7. Thought stopping. Try to stop your food related thoughts dead in their tracks.
8. Add negative associations to your normal cues.
9. Talk down the urge. Approach it with rationale thoughts. “Eating this will only satisfy me momentarily”, “If I eat this I’ll demonstrate that I can’t break free”.

Ultimately Kessler’s premise is that Big Food created this mess, but that doesn’t abdicate our own responsibility to manage it. He likens it to alcohol in that alcoholics are often told that their disease is not their fault but it’s still their responsibility.

Food Rehab can be summarized by a single line of Kessler’s,
The enduring ability to eat differently depends on coming to view these foods as enemies, not friends
It is this view that leads me to disagree with Kessler and I also wonder if he even agrees with himself. Kessler himself notes,
the loss of control that characterizes conditioned hypereating is magnified by diets that leave us feeling deprived
Yet at the same time Kessler advocates for blind, overt, rule based restriction and deprivation as a means to treat conditioned hypereating.

David Kessler's The End of Overeating is certainly a fascinating and engaging read, especially the sections on Big Food's engineering, but as a treatment plan I find it lacking. Like it or not the world has become one enormous Willy Wonkian Chocolate Factory and foods which help to condition hypereating are here to stay. To succeed with food in this world requires navigating the Chocolate Factory, rather than as Kessler suggests trying to avoid it.

To paraphrase Nuval's Dr. David Katz, managing nutrition and weight today requires skillpower, not willpower. There's no amount of thought stopping or blind restriction that's going to change the fact that food is indeed pleasurable to consume and my belief is that the type of blind restriction that Kessler is suggesting will ultimately and eventually do exactly what he predicts - magnify conditioned hypereating. Zero tolerance as a dieting strategy has been around forever. If it worked, the world would already be skinny.

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  1. I'm so glad you reviewed this book, I have been eyeing this one since the summer, but was holding off purchasing it for the time being since I'm a student and need to budget my reading time and money for the moment.
    I know for me, his writings (that I briefly read while at the bookstore) were extremely helpful in my own battle with overeating/cues/behaviour, and I agree, it takes knowledge, education, and skills to make behavioural changes. His book helped me in that it was a piece to the puzzle, but I did have some moments of "yup, I kinda thought so..." while reading.

    Keep up the great work Yoni!

  2. Anonymous3:16 pm

    Yoni, my take on what you call Kessler's "blind, overt, rule based restriction and deprivation" approach. My take is that the prohibition is very focused to the conditioned hypereating circumstances while allowing for indulgences at other times. I suggest to my patients who are conditioned to "wanting" hyperpalatable foods between dinner and sleep to be extremely diligent with what I call a dinner and done rule. This allows for the deconditioning process to take effect. Yet the hyperpalatable foods are in no way prohinited at other times. In fact allowing for these foods at other non conditioned times blocks the rationalization one might otherwise have such as "well I can't never eat chocolate and so I should be able to have just one piece." The cognitive competition at that point should be "well I can eat chocoalte, I am not being deprived of it, it is just at night that this food has caused extra calories for me and made managing my weight so challenging, and so at night I am not going to eat it". The definitive rule allows for the patient to become as Dagher calls it, "non expectant" and this non expectant state allows them to minimize the "wanting" reflexive dopamine release. Clinically my experience is patients find this empowering rather than depriving. WOuld love to hear your thoughts.

  3. Not sure why but in this view Anonymous' comment isn't visible.

    Anyhow Anonymous, I'd agree with you only in one specific category of patient. That'd be the patient who struggles morning, noon and night with conditioned hypereating. In my experience, that's a small number of patients where the majority of folks tend to only struggle with what Kessler would label conditioned hypereating in the late afternoons, evenings and nightimes.

    For me the temporal distinction strongly suggests that the conditioned eating behaviours are dependent on something time best and my best guess is the temporal production of ghrelin. Consequently with these patients my focus is to ensure they're eating at least every 2-3 hours, having minimums of calories and minimums of protein and in many if not most cases, that seems to allow folks who've struggled with conditioned eating to instead enjoy control and allows them to ask themselves, "What's the smallest amount of X that I need to be happy" and actually follow through with controlled intake.

  4. Yoni,

    In my research for dieting and living a healthy lifestyle, Dr. Kessler was one of my influencers - as was Michael Pollan, Marion Nestle and many others.

    You mention Dr. Katz. In fact, Dr. Katz's presentation about the polar bear in the Sahara is outstanding. I recommend it to all.

    With that said, each and every one of these people (and others) have holes in their theories/ideas. However, the reader can edit out some of the information and retain what is important.

    By the way, there are some outstanding video presentations from all of the people mentioned above online...and for free.

    And, as a bonus, it can be put on your iPhone so you can watch and learn while...driving.

    Only kidding about the driving. How about while waiting forever at the airport?

    Ken Leebow

  5. David Macklin MD CCFP4:09 pm

    Hey Yoni, it's me David Macklin, not sure why anonymous will try and fixit. I like your take on afternoon evening and nightime. I suggest those times are highrisk simply because they have been. When I discover a high risk set of circumstances in a patient invariably the history is of the event happening hundreds to thousands of times before paired with hyperpalatable foods (or smokes and alcohol). This can suggest that it is a conditioned, cue based reflexive wanting or craving for reward. Rather than grehlin , my suggestion is this is dopamine release based on previous reward in similar to identical circumstances.
    Incidentally my experience suggests at least 7 common conditioned hypereating "circumstances.
    The big lunch
    the afternooner
    the just as you come homer
    the big dinner
    the night eater
    the weekender
    the social eventer

    when a patient gives a history of any of the above, I find invariabely they have paired hyperpalatable foods with these circumstances hundreds to thousands of times.
    It's very rare that someone is conditioned to crave HP foods in all the above and more comonly 1-4 in my experience. I suggests kesslers early and definitive rules around the conditioned hypereating with leniancy under all other circumstances, obviously combined with a mild calorie defecit health promoting diet spaced every three or so hours.
    Would love to hear your thought!
    Note apology for syntax I am hammering this out on my iPhone.
    David Macklin MD CCFP

  6. Hi David,

    My philosophy has always been for folks to live the healthiest lives they can enjoy, not the healthiest they can tolerate.

    For many, the hard rules on hyperpalatable foods, while initially easy to follow also lead to the inevitable breaking of the rules which for many may sprial them down a pit of guilt and despair that they've blown everything.

    I have no doubt that Kessler's premise that foods today can condition hypereating through the brain's reward system, but I believe that system can be attenuated by timing, calories and protein with rare exceptions.

    Generally those exceptions are folks who I'll suggest consider pharmacotherapeutic aid and certainly I'd have no issue trying Kessler with them but as noted above, worry about what will happen when inevitably the rules get broken.


  7. Anonymous7:11 pm

    Delicious, fat and sugar laden food, and cues everywhere to eat ...

    My Mom beat Big Food to that -

    cakes, cookies, treats, fried everything, eat huge meals,
    and tasty snacks, and eat for celebrations and for solace, eat because "you're weary" and eat because "you'll feel better if you have a little something"

    I am obese, jeepers, wonder why.

    (As an adult, now that I recognize what was going on, it is, of course, my responsibility to eat properly now)

  8. I think the key thing for me was in order to begin to tackle my conditioned responses, I had to eliminate the processed, high fat/sugary foods from their "hold" on me, and in a practical sense, this then opened the door to embracing whole foods, and learning how to prepare them in ways that appealed to me. Sure, the pendulum just swung in the other way for awhile in that I went ALL out in only eating "real" food, but as I began to physically recover from the side effects of eating "crap" (headaches, lack of energy, constant hunger, etc) then I was able to gradually re-introduce small treats in a more reasonable, controlled manner, and work on the "why" because then/now I have a healthier base to work with. In that sense, I think that Kessler's work is but one piece to a larger puzzle.

  9. Hi Yoni

    I think your reading of Kessler is a little harsh...

    Your idea of "the best diet you can enjoy" is actually consistent with what Kessler advocates, namely that people should reduce (not eliminate) their exposure to HP foods, and that they should set up rules around the consumption of these foods, to avoid the cue-stimulus-reward spiral (e.g. eating HP foods as a free meal once/week, eating them a la the French in very small doses etc.).

    I really think you need to revisit the HP foods connection, as it is arguably THE driver in modern 'hedonic' obesity.


    P.S. I think you're fair on 99.9% of your views; just wanted to help out with this one to raise your stats to batting 1000 !

  10. I agree with Harry. Speaking from personal experience, I have struggled with this my entire life. During stressful times I would unconsciously reach for that donut - which I normally made practice never to eat - and it provided that calming that I needed and also led to a 20 lb weight gain in a matter of weeks. I think it opened the flood gates to chips and pop on the occasional evening and suddenly I was fat again.

    I agree with personal responsibility but when is BIG FOOD going to have to face some of their responsibility in the obesity epidemic? Why does ANYone need HP food to be so prevalent and in-your-face as it is today anyway?

    I feel that regulations are needed (like they were with cigarettes) to control HP food marketing. Like cigarettes, it can be there (if it must), but behind closed curtains and at the bottom of shelves and higher priced (obesity tax). That is, if we want to see the obesity numbers stop climbing and start falling for a change. Because somehow I don't see a 12-step program for reducing obesity working so well on its own.