Monday, May 16, 2011

The "how" of obesity - laziness vs. complexity?

Photo by Michael Goodin

Last week I enjoyed debating Dr. Bob Ross on the relative merits of food vs. fitness, as they pertain to obesity treatment and prevention.

Ultimately we concluded, that of course both are important, though we disagreed on whether or not it has been primarily a decline in levels of physical activity, or an increase in caloric intake that has led us to this point.

Some might think that doesn't matter. That "how" we got here isn't important.

I disagree.

"How" is crucial because it's the "how" we got here that helps us to understand why effective treatment and prevention is so elusive, and also will hopefully help to inform future innovation and policy. While Bob and I disagree on the fundamental caloric basis of the "how", we certainly agree that the "how" isn't by means of personal choice.

What do I mean by personal choice?

Well, one camp of "how" is the camp that posits that we got here through the individualized personal choices of gluttony, sloth and laziness. That camp was actually well represented during the concomitant debate that was taking place on Twitter, while Bob and I were duking it out on stage.

Readers of my blog's comments will certainly know Paul Boisvert, but for those of you who don't, Paul is the coordinator of the Obesity Research Chair at Quebec's Laval University.

Paul's tweet reveals that his explanation for the "how" is that people with obesity are, ""Born to be lasy [sic]",

Which he then clarified with this statement,

Seemingly, according to Paul, the "how", is that obesity is the personal choice of people too lazy to exercise.

Bob and I would disagree.

While we were standing on opposite sides of forks vs. feet, we did share a common ground in that we feel it's changes to society as a whole that explain "how", not individually laid blame.

Bob explained how the world has changed in that life nowadays requires less "feet". We do far less physical activity, not because we're lazy, but because the world is now doing it for us. Labour saving jobs and devices have supplanted the need for physical labour, and our kids, when faced with a myriad of heretofore unknown, incredibly entertaining, sedentary alternatives to playing outside, often and not surprisingly, choose from their menu of heretofore unknown, incredibly entertaining, sedentary alternatives.

I explained how the world has changed, in that life nowadays goes out of its way to push energy intake. Virtually each and every one of us inadvertently consumes more calories than we used to, thanks to such things as our faster pace of life, federal farm subsidies that drive the increased availability of low-cost calories, an exponential rise in food advertising (especially the advertising targeting children), increased reliance on meals purchased outside of the home, scientifically engineered hyper-palatability, the health-halos of front-of-package health claims, mindless eating cues, growing portion sizes and the incredible failing of public health officials to provide useful, evidence-based guidance on nutrition and energy balance.

Couple those issues with what we're learning about things like genetics, epigenetics, obesogens, fMRI food addiction studies, weight contributing medical co-morbidities, drug-induced weight gain, and the failing of our medical education system to educate physicians about how to deal with obesity, and the "how" reveals itself to be a highly complex, multi-factorial, amalgam of cause.

It is this complexity that precludes simplified to the point of useless, "eat less, move more" messaging, and certainly it also reveals the error and bias in an individualized, blame based attribution to obesity's causes and solutions.

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  1. How about?
    Lazy eating :-)

  2. Thank you for stating: that the message "eat less, move more" is useless.

    Unfortunately, that ubiquitous phrase has become so ingrained in our culture that people believe it must be true.

    While I am a big fan of Michael Pollan (eat food, not too much, mostly plants) and Marion Nestle (eat less, move more ...), their "eat less" mantra that they repeat over and over perpetuates the "Eat Less, Exercise More" myth.

    So, thank you for trying to bust the myth.

    Ken Leebow

  3. Growing up in the 50's and 60's to see an overweight child was unusual. We had one TV with a couple of stations, no computers, no fast food establishments,very little processed foods, etc. We had 3 meals with few "junk" snacks and sent out to play. So I believe it is a societal shift - to move less and eat more calories. Combination!!

  4. It would help if we empowered the healthcare professional to train, treat and educate...not to name staying connected to their patient.

  5. Researchers recently studied populations in Europe and North America, examining trends in physical activity energy expenditure over time, since the 1980s. Energy expenditure was evaluated with a highly accurate method called “doubly labelled water.” They found that physical activity energy expenditure actually increased over time, although not by much. They conclude that the ballooning waistlines in the study populations are likely to reflect excessive intake of calories.


    Reference: Westerterp, K.R., and Speakman, J.R. Physical activity energy expenditure has not declined since the 1980s and matches energy expenditures of wild mammals. International Journal of Obesity, 32 (2008): 1256-1263. Published online May 27, 2008. doi: 10.1038/ijo2008.74

  6. Well said!

  7. "Far easier" is a pretty subjective standard to achieve in the first place. Lots of things are "far easier" when the supports necessary to make them easier are in place.

  8. I would like to bring some precisions that tweeter does not give. First of all, in prevention of weight gain, physical activity plays an important role in helping to counteract all the complex daily temptations we are challenged (that Yoni described very well today) to overeat an average of about 100 kcal a day, and which lead a typical weight gain of 1 pound a month. Consequently, I am agree with Yoni about the strong influence of the food and physical sedentary environment into our mindless eating behaviour drived by our physiology. So yes it is not related to the conscious individual choice.

    When I say "Far easier to not eat 500 cal a day than to burn it off... when comes the choice between exercise and diet restriction", it seems obvious to me, and I am sure to most readers, that I am refering to weight loss and treatment, not to prevention. Right?

    So, when Yoni refers to the How we get there, he refers to weight gain and the prevention side of the dabate. Right? So why does Yoni try to prove his point of prevention by quoting me while I am talking about treatment? It is like comparing fruits and meat! Of course meat is different that fruits. So weight loss treatment approaches are different than from prevention of how we got to the population to gain weight.

    This is exactly the argument I have been struggling to denonciate on the cyber space since the article published in the NY Times in August 2009, which said that physical activity was useless for weight loss, "forgetting" to acknowledge the contribution of physical activity into weight gain prevention, and the improvement of most health markers in the absence of weigth loss into overweight people.

    So, sorry Yoni, but your argument here is not only wrong, but distorded.

  9. Paul,

    Your distinction is inconsequential to this discussion.

    Both here in these tweets, and in many of the discussions and comments we've shared, you've made it exceedingly clear that your belief is that obesity can be effectively treated through exercise.

    In your tweets you've asserted that the reason people don't exercise is because they're too lazy to choose to do so.

    Consequently your argument would seem to be very clear. You believe that people who are obese are so because they are too lazy to exercise.

    That argument is consistent with our prior discussions on this subject, and unfortunately I feel, inconsistent with reality for many of the reasons I've highlighted.

  10. This is the golden paragraph:

    "Couple those issues with what we're learning about things like genetics, epigenetics, obesogens, fMRI food addiction studies, weight contributing medical co-morbidities, drug-induced weight gain, and the failing of our medical education system to educate physicians about how to deal with obesity, and the "how" reveals itself to be a highly complex, multi-factorial, amalgam of cause."

    Our (eating and moving) behavior alone didn't move the center of the bell curve that expresses our average weight. We are a broken people, and we fight nobly even still. Generally, we are NOT lazy. We are NOT uninformed. Sadly, most professionals insist on perpetuating the behavior myth, which gives authority to discrimination, and causes great hurt.

  11. With friends like Paul Boisvert, who needs enemies? I would just love to be in one of his studies, knowing all along that he already has me pegged as a lazy oaf.

    His research is already done. Why is he wasting his time when he has the answer?

    Merci infiniment, M. Boisvert.

  12. Considering our food and physical facilitating environment, it is true that it is much easier to eat 500 kcal than to burn 500 cal by exercise. This is for that reason that we gain weight.

    So what can we do to lose weight? That seems easy for Yoni who pretends that (as stated and summarized by Michele Simon @Appetite4Profit) Bottom line: "Far easier to NOT eat 500 calories a day than to burn it off" - @yonifreedhoff.

    Unfortunately, this is an oversimplistic view of energy balance thermodynamic law in line with eat less because it is far easier than to exercise! This argument put out of context numerous etiologies of obesity (the why's).
    So my comment was that if we were not that lazy, we would consider exercise as part of the solution, not as something to reject totally in the "bottom line" conclusion from Michele Simon.

    You also pretend that I "believe that obesity can be effectively treated through exercise". Well, although this was in fact very well demonstrated by Bob Ross, I have never said that. I was just rejecting your attitude to dismiss completely exercise from weight loss treatment, and said that exercise is a (little) part of the solution, as small it can be along with diet.

    My opinion was more about the important contribution of exercise into weight gain prevention.

    You also pretend that I "believe that people who are obese are so because they are too lazy to exercise". NOt at all. As I said clearly in the previous comment, I was refering to losing weight, not to gaining weight.

    You also pretend that I belong to "one camp of "how" that posits that we got here through the individualized personal choices of gluttony, sloth and laziness." This is false, I belong to the environmental influence of our food and sedentary behavviour, but that exercise can help us to fight against the overconsumption, but that is not easy, as much it is not easy to not eat 500 calories by cutting dessert and other treats. Then each individual should be a little bit conscious of his behaviour and adopt the right strategies to try achieve weight control whenever possible.

    The major point is that I don't understand why after extensive discussion on that subject you still continue to put prevention and treatment approaches in the same basket.

  13. Paul ... simpletons like me appreciate simple statements that say it all. So ...

    Diet drives the weight loss and exercise maintains it.

    Ken Leebow

  14. As a sociologist I heartily endorse Freedhoff's acknowlegement that societal changes have impacted individual health and weight. The purely psychological approach to understanding obesity is incomplete and there misleading. There is a reason that entire societies have seen increasing weight levels and rising rates of diabetes and these macro-level patterns of change cannot be understood simply by viewing individuals as lazy or greedy. Our food supply consists of chemicals that encourage overeating. Enhanced flavoring and coloring methods encourage us to eat for pleasure and not for nutritional health. (I read once that Cheetos are gray and larva-like in appearance without the neon orange coloring. Who would eat them without the added chemicals?)

    It is my belief that many of the solutions being developed as part of the green/sustainability movement to save our plnet and other living species will also help us to improve human health. The fight against highly concentrated sugars in our foods, the creation of walkable neighborhoods, the development of wind turbines, and the growing interest in micro-farming are examples, but much more is needed.

    There are so many societal-level issues associated with the health crisis we are experiencing in this country that a sociological approach is needed not only to understand it, but to produce feasible solutions.

  15. Paul, hopefully your longstanding confusion regarding my stance on the value and role of exercise was cleared up by the debate itself.

    In regard to your confusion as to prevention and treatment, truly, I have no idea what you're talking about.

    Of course, it doesn't really matter either way, because regardless of whether we're talking about prevention or treatment, I disagree with you that laziness is an issue.

    Laziness is no more a barrier for treatment than it is a hurdle for prevention.

    Put another way, people aren't choosing to be obese, any more than they're choosing not to lose weight.

    Obesity isn't about laziness.


  16. Hi Yoni,

    I notice that in this post you list, inter alia, "scientifically engineered hyper-palatability" (HP)of foods as one of the drivers of modern obesity.

    I remember that you reviewed Kessler's "The End of Overeating" (in which he enunciates the theory of HP) a while back and were quite critical of his approach (insofar as you didn't think that avoiding exposure to HP foods was consistent with your precept regarding 'choosing a diet that you can enjoy').

    Have you altered your views on this in the interim?


  17. Hi Harry,

    As I recall, the section on food engineering was my favourite part of the the book.

    Where I struggled with Kessler was the fact that it seemed to me he was suggesting that the way to deal with struggle was to set up a series of rules. To rely in a sense on mental fortitude, on a capacity to resist temptation, albeit in part by means of a preemptive strike.

    The problem I have with that is that if "willpower" (for lack of a better term) was a successful weight loss modality, we'd all be skinny. People don't lack willpower, they lack skillpower, and the skill I think's required isn't mental gymnastics, but rather organization. Organization in terms of timing and frequency of meals and snacks, along with organization of macronutrients and sports nutrition.

    Studies on our capacity to resist anything, suggest we have something of a finite daily amount. Organization makes out thinking temptation easier.

    My experiences in my clinic suggest that just setting rules, and not focusing on organization, sets a person up to fail. One of the most clearly defined triggers for binge eating is blind restriction, and ultimately, it seemed to me that blind restriction was what Kessler was advocating, and while setting up mental rules in advance may help increase capacity to resist some, I don't think it does enough.


  18. Hi Yoni,

    Thanks for that...this clarifies things quite well.

    I agree that Kessler's solutions are a tad proscriptive and programmatic, and that a more process-driven approach is better for most. Having said that, I think you're probably emphasising the salient differences between you more than the many points of agreement.

    I'm only banging on about this because I feel that your approach and Kessler's are such a 'natural fit' and that the main point (i.e. that the frequent consumption of HP foods fundamentally alters appetite regulation and ultimately eating behaviours) is an extraordinarily powerful explanatory tool in obesity etiology and in suggesting a solution (especially childhood obesity).

    Perhaps you can generate a synthesis that captures Kessler's work on HP foods as well as your clinical learnings on efficacious interventions?

    With so much toing and froing on the ideas (and so little actionable consensus), we really need coalitions of like-minded thinkers to work together in advancing the things that they agree on...we can deal with the minor adjustments on the run.


  19. Thanks Harry.

    Am working on it!

  20. Hi Yoni,
    You said:
    "The problem I have with that is that if "willpower" (for lack of a better term) was a successful weight loss modality, we'd all be skinny. People don't lack willpower, they lack skillpower, and the skill I think's required isn't mental gymnastics, but rather organization. Organization in terms of timing and frequency of meals and snacks, along with organization of macronutrients and sports nutrition.

    Studies on our capacity to resist anything, suggest we have something of a finite daily amount. Organization makes out thinking temptation easier."

    I'm a bit concerned that this makes it seem as if the culprit is then "disorganization" -- and again we are back to an individual-level solution for a complex, multi-system problem. I wouldn't define obesity as a problem, I think that obesity is a visible symptom of many problems that you talked about in this post.

    I would hate to see "disorganized" be subbed for "lazy" in the stereotype. And I don't know what level of organization is sustainable when it's such an uphill battle to have enough time/energy/resources as it is.

    You might not be saying it's as simple as "eat less, move more" but saying it's a matter of being sufficiently organized is just slightly less simplistic.

  21. Hi acceptancewoman,

    Assuming (a) the obesogenic environment (i.e. multi-system problem) is the driver in the rise in modern obesity, and (b) that it's unreasonable to expect that this environment will become less obesogenic anytime soon, there aren't many other options other than those that imply increases in individuals' responsibility.

    There doesn't need to be a symmetry between the etiology and the solutions to obesity. To wit, it's not necessarily the case that the reasons why we get fatter can simply be reversed to provide us with the modality by which to get slimmer.


  22. Yoni, You don't know what I am talking about? So gaining weight follow the same rules than losing weight? Just reverse the energy balance? Totally disagree.

    Any way, here is what I am really talking about: my bottom line is that to demonstrate your point, which is interesting in itself, you extracted one word from one of my tweets and making a whole fabulation around me. And by taking an image of my tweet, you tried to reinforce your point of view. This is oversimplifying the complexity of my thought and intellectually dishonnest. You have been using me, categorizing me, foolish me, and I do not appreciate it.

  23. Paul,

    You have never been shy on my blog to tell me what you've thought about what I've had to say, so I'm not sure why you feel I can't do the same.

    You clearly stated that you felt people don't choose to exercise because they're lazy.

    I called you on that.

    It's also quite consistent with discussions we've had before where you've tried to impress upon me your belief that it's entirely reasonable to expect society to exercise 60-90 minutes daily and that there really isn't, for you, a great explanation as to why people don't.

    So no, I don't think I'm mischaracterizing anything.

    Further, I don't censor my blog comments, and you can now, as always, feel free to disagree with me here, and present any information or arguments that you'd like.

  24. Wow, you guys are getting very serious here.

    I think you need a little levity. So, be sure to check out these incredibly funny videos about ... how we eat.

    Interestingly, while you are ROTFL, you will find a lot of truth in this humor ...


  25. You said about me: "you've tried to impress upon me your belief that it's entirely reasonable to expect society to exercise 60-90 minutes daily". It's not true and I have never said that. The weight loss registry demonstrated that 60-90 min of exercise is what is needed for people to maintain weight loss over time. It is very difficult and few people can achieve that. This is one major reason why 90% of diet fail over time.
    So, this is an other good example here of your sense of exageration and unfair extrapolation and fabulation.

  26. Paul,

    The fact that your recollection of our discussions doesn't match mine doesn't make your recollection accurate or complete.

    I remembered that one of our exchanges about the 60 minutes of exercise was via Twitter.

    Twitter remembers too.

    It was January 6th and 7th 2010.

    Here's how it went down,

    Me: Marion Nestle (and I) think it's about food and not exercise. Discusses new study I'd like to read:

    You: I Think It is easier to reach energy balance when exercising 60min/day every day. It is called intrinsic instinctive control

    You: Public has the choice between exercising 60min a day and don't care about calories or fight with food control and weight gain

    Me: Not much of a choice for many people. Long days at work, not setting own hours, limited family time = gym low priority.

    Me: Forgot to add - many people's 60 mins are the only free ones they have all day and would prefer to be with family than gym.

    You: It's still a CHOICE, 60 min with family, or at the gym or to blog, or business lunch; I prefer 60 at the pool with friends

    You: and this is why they do not cook, eat chips at night and skip breakfast because they have to rush to work.??

  27. Jennifer1:10 pm

    I watched the videos on Youtube this morning and I agree with you completely. Exercise alone will not make you lose weight if you continue to overeat. I think most people are clueless when it comes to calories in and calories out. It may take 1 minute to eat several high calorie cookies/cakes but it will take jogging a mile or so to burn the equivalent amout of calories. Most people are also clueless on how many calories it takes to maintain body weight. If you sit at a desk all day, you are burning few calories. Between sleeping and sedentary jobs, that is 2/3s of your day doing next to nothing. The calorie intake required to maintain that is less than what people are eating b/c they don't realize how many calories are in the food they are consuming. Of course, the quality of the food is also an issue. Fast food and convenience foods are cheap and do not have the nutrients people need, not to mention all the added chemicals. I think this is where the organization piece comes in. If people would sit down, plan their meals around their schedules, and prepare/cook their meals, they can avoid the drive thru and need for convenience foods.

    As far as exercise goes, it is hard to expect someone to exercise 60-90 minutes a day. The biggest excuse I hear is how people do not have time. In my opinion, people have time, they just don't make time. It's an opportunity cost. Instead of watching one hour of tv, go take a walk or play ball with the kids. Wake up one hour early or 30 minutes early, whatever and workout. Exercise does not require a gym membership. Like you said, most people would prefer to be with family. It's about being active. Involve the family with fun activities.

    Though I know it is all easier said than done. Personally, I wake up and workout while my kids are sleeping. I also go into work early and go to the gym on my lunch break. I'm getting my exercise in without interfering with my family time. I also try to prepare all of my meals and have enough leftovers so I can take my lunch to work and even for dinner if I will not be home until late due to my kids ballgames, dance lessons, what have you. It took me a long time for these behaviors to become habit but it's finally sticking.

    Great debate!


  28. Anonymous9:52 am

    "Everyone knows" that we are fatter, less fit, eat more high cal foods, etc. Well, everyone, I have a picture of my grandfather's family from about 1900. Most of the men worked strenuous jobs in coal mines, and the women did hard physical labor at home without any modern conveniences. They were not rich, and there was no fast food. They were all short, round people. They would probably be considered obese by today's standards. Much of what "everyond knows" is opinion and prejudice, not fact.

    1. actually, that's probably not unreasonable...think about it

      the short stature is likely an artifact of low protein intake as children, coupled with chronic deficiency of Vitamin D and Calcium (think about Asian countries and the remarkable increase in average height over the post-WWII era)

      As adults, their diets would have been extremely high carb diets by our standards since bread and potatoes would have been the main source of calories, fresh fruit and vegetables only available in season and good quality meat, eggs and cheese likely too expensive to eat in quantity

      couple that with a hard, dreary and painful existence and you probably had to throw in a fair bit of alcohol into the mix, since that was the only thing that made this kind of life bearable for many people (men and women) so the chronic ingestion of sugar/alcohol and presence of chronic pain and depression would prevent people from looking fit and perky

  29. Wow...I think that this discussion demonstrates why obesity and the management thereof is so complicated

    Metabolic management is a balancing act (between calorie consumption and expenditure) and there are several actors who are forever putting their thumb on the scale (genetics, personality, culture, economics, etc), upsetting that balance, even when you think that you have all the main components dealt with

    Let me throw another bone to the dogs...

    I was a competitive wrestler for many years and like most activities that are concerned with strength vs. mass, I constantly used both components of the weight loss equation, calorie restriction vs. massive amounts of exercise for years on end

    Despite the incredible amount of training that I did, without strict calorie restriction, I could never keep my weight and body fat content where I wanted it to be (this is in the pre-anabolic steroid days btw)

    Now that I don't train that way, with a sedentary job in an area that is not pedestrian/bike friendly, I struggle to maintain a healthy weight, and my principal tool is still calorie management

    I've come to conclude that weight management for ME is not so much about laziness (most of the time) but rather ignorance

    My theory is that, by design, we will eat as many calories as we can, in the absence of any limiting factors, regardless of our level of activity.

    The only counter to that is a conscious decision to limit that intake to a reasonable belief is that that decision is most influenced by ignorance

    Before anybody strokes out though, I qualify that by saying that there are at least two kinds of ignorance that play a role:

    "Honest" ignorance is just that...I see patients all the time who have no clue what their food is made of and have only a vague idea of caloric content, composition and portion size...this is where education helps and dishonesty on the part of food companies hurts

    "Wilful" ignorance is harder to deal with because these are the little lies and excuses that we tell ourselves in place of rational thinking about food. We kid ourselves about portion sizes, food choices and whether the calories we consume in secret actually count

    Again, I deal with patients who insist that they are managing their diets but can't get their weight / bG / lipids down, but refuse to believe that eating donuts or drinking ice-capps at Timmies have any role in this

    It would be easy to say that they are just bad people, but it isn't that simple, eating is emotional as well as physical, so shaming people for making bad decisions isn't always helpful

    So, that's my book, just a wild-assed idea that encouraging more active lifetyles, educating the public on food quality issues, reigning in out of control food companies and encouraging people to make honest, healthy decisions about food consumption will improve public health

    ok, back to the cockfight