The obesity and poverty paradox

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The recent TOS obesity congress in Boston was an excellent opportunity to catch up with the latest research. While it is interesting to hear about what other people are working on, it is also interesting to note what isn’t trending so much.

Many areas of research have obviously come and gone from the limelight as we naturally go through cycles and phases in research, with some topics having considerably more longevity than others.

Short-lived topics with rapid cycles of boom and bust include things like new diets or exercise fads, something many (if not most) obesity experts got fed up with a long time ago. The basic rule here is that the more extreme the new diets are, the more volatile the cycle. Such strategies rarely make sense if you are genuinely concerned about obesity, even though they can stir remarkable amounts of curiosity in the short term. The science eventually catches up.

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Obesity research is inevitably a mix of trending topics with shorter cycles, and less trendy but enduring topics that have withstood considerable scientific scrutiny over decades. While these long-lasting areas of research might not always be the most exciting for lay people, they arguably have a more robust potential for providing effective solutions.

For me, there was one such long-lasting topic I had hoped to hear much more about in Boston, namely the negative influence of low socioeconomic status. Obesity and poverty may appear to be a paradox but it was a long time ago, at least in developed nations, that obesity was a condition among the wealthy.

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It is now well established that obesity is much more common in individuals at the bottom of the socioeconomic pyramid, and rare towards the top. This particular association is also noted for its strength and consistency across populations in developed nations. Since such associations are rare in obesity research, socioeconomic adversity could well be the strongest risk factor we have for obesity development, hence its long-lasting appeal to researchers.

When we investigate causes behind the obesity epidemic we can obviously point to the junk food invasion and increasingly sedentary lifestyles, for example, but we also need to be aware of the quite dramatic changes in wealth distribution, with financial inequality now at its highest level in seven decades.

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So, since socioeconomic adversity is so well established as an obesity risk factor, the topic I wanted to hear much more about in Boston was why this association is so strong. In other words, what is it about being at the bottom of the socioeconomic pyramid that increases the risk of obesity so drastically?

While there were very interesting studies in Boston that touched upon the potential mechanisms, such as food insecurity, stress, junk food, mental health issues, addiction, lack of sleep, and malnutrition, I would have liked to have seen much more.

This is clearly an area where we can find many interesting pieces of the obesity puzzle and really develop our understanding of weight gain and body weight regulation. This work clearly needs to be multifactorial in nature and not just include experts on socioeconomics, but also experts on social interaction/family dynamics, psychology, emotion regulation, behaviour and lifestyle, diet and nutrition, sleep, fitness, metabolism, endocrinology, immunology, inflammation, genetics, epigenetics, and so on.

Once we start to identify the drivers of weight gain among the socioeconomically disadvantaged, the road to some much needed progress in terms of both treatment and prevention of obesity should be considerably wider.

Erik Hemmingsson

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New exciting frontiers in obesity research

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Some of you may be aware of that I used to do research on the role of behavior therapy and low calorie diets in the treatment of obesity, but that I realized some time ago that such treatment options did not provide any long-term solution to the treatment (or prevention) conundrum. Instead I decided to dig a little deeper and look into traumatic childhood experiences, which was very interesting, but to say that obesity is a result of childhood trauma would be a gross exaggeration and oversimplification.

Through a combination of listening more and more to patients as well as copious reading, I have come to focus my efforts on the early life (childhood) social environment. This also includes the time spent in the womb, and such factors as maternal distress and malnutrition, which has a huge effect on the baby.

The path to weight gain and subsequent obesity generally starts before the age of 5, so this is clearly the time we need to investigate more. What is becoming more and more clear is that any type of family dysfunction can very easily transfer to the child in the form of negative belief systems, negative emotions, stress, insecurity, low self-esteem, low self-worth, and so on. The real catalyst of family dysfunction is socioeconomic adversity, but obviously there are other factors as well, such as relationship discord, job insecurity, segregation, a lack of support and cohesion, disease, and food insecurity.

Let me stress that family dysfunction does not imply gross disturbances or failings, it can probably be quite subtle to have a negative effect, depending on factors like resilience and external support, perhaps from a significant other such as a grandmother or grandfather. More or less all families have some kind of dysfunction within them, it’s all shades of grey, perhaps not all the time but at least during critical periods. The effects is likely a balancing act between the amount, duration and type of adverse social exposure, combined with the above-mentioned protective factors.

What is clear is that as we grow older, we carry the effects of those early years with us, consciously or not. If someone is exposed to a lot of early life adversity, it will only be a matter of time before physical manifestations occur in the shape of increased stress, inflammation, as well as metabolic and endocrine perturbations. There is also likely to be behavioral disturbances, such as eating to suppress negative emotions. Eventually, this will lead to a disruption of homeostasis and weight gain.

This why I am very excited to dig deeper into this new field of research that focuses on the child’s social/family environment, and how those early years continue to influence us as adults many years later. The ACE study, which I wrote about recently, conclusively shows that adverse childhood abuseis the #1 cause of early mortality, numerous morbidities, addiction and functional limitations, so there can be no doubt about the very powerful effects that adverse childhood experiences has on us.

It really is time we took those early childhood years more seriously in the obesity field. Personally, I think there is a gold mine of information there, just waiting to be explored. Hopefully this will get us closer to the root causes of obesity, which should be of great benefit for eventually banishing the whole epidemic.

 

Erik Hemmingsson

 

Where and why did the obesity epidemic start?

World-wide epidemic

Obesity has definitely gone global. Although it will be difficult to prove using scientific methods, which can be pretty blunt for this type of investigation, I have no doubt that the epidemic started in the US around 1950-1960. This is the era that saw the rise of the junk food industry, mechanized transport, more stress, increasing social disconnection, more aggressive marketing, and changed consumer habits. But the main change was undoubtedly the junk food invasion.

It did not happen overnight, and the epidemic did not get its breakthrough until around 1980. Like a snowball rolling down the hill, the epidemic was now fuelled even more by other changes to society. Both Reagan and Thatcher, for example, started to gradually dismantle the welfare system during this period, meaning that poor people got pushed over the edge financially and had no choice but to eat cheap junk food. The rise and rise of junk food marketing also reached new levels through TV, and use of colorful images and messages. We were told to consume and consume we did.

Trends in obesity, US

 

If you walk around major cities in Europe and the US today it is quite staggering how much food, transport, lifestyle, family, working hours, stress, etc has occurred during the decades when the epidemic really took off. There has also been a large disconnect from nature and a more balanced lifestyle through massive urbanization and who knows how much toxicity we are exposed to today in the cities compared to the days before the epidemic as a result of pollution, pesticides, steroids and antibiotics in our food. Children have also increasingly been growing up in environments where they see less and less of their parents, who both work full time to pay their mortgage. The increased stress levels is certainly a major factor that fuels the the epidemic more and more.

We are suckers for these types of very gradual changes, and the prize for this lack of vigilance is that one day we find ourselves in a hole that we struggle to get out of. And as always in epidemiology, it is the combination of causal factors that tip us over the edge. And those environmental changes I have mentioned as causal obviously also play a very prominent role in many other health epidemics, such as diabetes, cancer, heart disease, and depression. How much more of this will it take before we take action and get back to a more balanced lifestyle?

Obesity in Asia

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Although the obesity prevalence is still low in most of Asia, the incidence is quite high, especially in places that experience strong economic growth. This includes the urban areas of China and India, as well as large parts of the Arab world, such as Saudi Arabia and the wealthy gulf states.

There is, unfortunately, a very depressing pattern of economic growth and increasing obesity rates. Once the economy picks up in Asia and elsewhere where food used to be more scarce, these countries are very quick to establish the so called western lifestyle consisting of junk food, shopping malls, mechanized transportation, increased social isolation, and stress.

Another twist to the obesity epidemic in Asia is that Asians develop type 2 diabetes at a much lower BMI than caucasians, meaning that there is a very serious diabetes epidemic spreading across Asia as well. This is why Asian countries need to invest heavily into preventing new cases of obesity. 

If I were them, I would kick out the Western lifestyle junk and stick to their more balanced native foods, cultures and ideals. The longer these countries wait in introducing preventive measures, the harder it will be to succeed.   

Socioeconomics, Mazlow and the obesity epidemic

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The association between socioeconomics and obesity is strongly inverse in countries that have gone through the nutrition transition (from healthy food to junk), mainly the US and Europe. Basically poorer people have more obesity than rich people in these countries. And that goes for a lot of diseases and adverse outcomes, including depression, diabetes, anxiety, suicide, alcoholism, inprisonment, caries, and so on.

Poor people are at the bottom of the socioeconomic pyramid. This is when you are more or less in survival mode, fighting to make sure that your basic needs are cared for. This has a wide range of adverse physiological effects, such as increased stress, sleep disturbances, metabolic disturbances, reduced immune function, reduced cognitive function, and so on. This is when the path of least resistance becomes very appealing (think junk food and TV), and choices such as buying and cooking nutritious (expensive) food and exercise become harder.

Having spent considerable time in the US and UK, I have not seen such clear examples of the socioeconomic pyramid anywhere else in the Western world, and this is very much reflected in the more or less disastrous obesity statistics for those two countries. Indeed, studies now show that poverty is increasing in the US and elsewhere, the middle class is shrinking, and the rich have become even more rich. This very skewed distribution of wealth is certainly no way to fight the obesity epidemic.

Unless the US and Europe can help people towards the higher dimensions of Mazlow’s hierarchy of needs, for example through better living conditions and a redistribution of wealth, we should not expect any great progress in terms of obesity prevention and treatment.