The obesity and poverty paradox

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.

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.

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.

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

Is this what the solution for obesity looks like?

Obesity has been a major medical, psychosocial and economical problem for decades. It really took off in the US in the 1950-60 and went from there all over the world, and now the problems are stacking up all over the world. I just read a report saying that Kuwait now the world leader in obesity prevalence:

World's most obese nation? Kuwait (and the next four are Middle Eastern) http://t.co/Ml8UEzgZKy via @NutraEurope

— Erik Hemmingsson PhD (@ErikHemmingsson) November 26, 2014

But the rest of the world is obviously not very far behind the Arab countries, and I have yet to see any major breakthroughs in either prevention or treatment of obesity worldwide. That’s not to say that everything is gloomy: there are some encouraging signs that obesity prevalance rates are starting to level off in places. But it does appear as if the levels of obesity are quite high (around 30-40% but this probably depends on how obesogenic the environment is) before the curve starts to flatten. In short, we have not coped very well with obesity, and I haven’t really seen much that could start to reverse this trend.

We obviously need some major reforms to the way we live if we want to get rid of obesity, so what do we need to do? What does the solution for obesity look like?

Firstly, we need to drastically reduce stress levels. This means a major reform of the economy, so that we eradicate poverty and make sure that everyone enjoys a much greater measure of abundance and freedom. Contrary to what most of the media is telling us, I actually don’t think that there is a shortage of money, it’s just that the distribution of money is mind-bogglingly skew, leading to stress and other problems.

Explosion in wealth inequality needs urgent plan of action, says @Oxfam http://t.co/ZST0crlMPa pic.twitter.com/5mGq10hLv4

— sebastian kraemer (@sebkraemer) November 1, 2014

Getting rid of fiat currency, and reintroducing a gold standard will help to stabilize the economy and reduce rampant corruption. It would also help if our politicians realized that war never solves anything, and spent our taxes on rebuilding our societies instead. This would undoubtedly create a more stable, prosperous and harmonious living environment, as opposed to a society burdened by increasing debt levels, conflict and corruption, where many (if not most) are more or less in survival mode on a regular basis.

Personally I would also reform the school system, which seems eerily set up like a factory to create obedient worker bees. All children needs to be given much greater freedom and opportunity to cultivate their own unique talents and interests. Teachers’ principle assignment should be to inspire their students, as opposed to constantly pressuring them with never ending exams and grades from increasingly younger ages.

Improved nutrition for everyone is a no-brainer in this context, including a ban on many (if not all) of the current pesticides, steroids, preservatives and other toxins that we regularly consume. Processed junk food likewise needs to be seriously reduced, and hopefully people will not be drawn to this type of food once stress levels are lower. Nutritious food should be cheap and affordable for everyone, whereas junk food should be expensive, not the other way around.

Increased physical activity is likewise a no-brainer, and includes measures like more parks and play areas, and more bike lanes and less cars in our cities. We would also reform our school and workplaces so that we are more physically active during the day.

The list of possible solutions could go on, but I stop there for now. If you think that this list is completely unrealistic, I would encourage you to think about what the prize of obesity now (and the prize for other obesity comorbidities like diabetes, arthritis and depression) and is likely to be in the future.

The obesity epidemic costs the world $2 trillion a year, the McKinsey Global Institute says http://t.co/PgmMCUVRmu pic.twitter.com/ZGXi75gaTQ

— Real Time Economics (@WSJecon) November 20, 2014

Let me know what else you would like to see introduced as a solution to obesity. We can’t afford not to act.

Erik Hemmingsson

How can we possibly prevent obesity when there is so much inequality?

Make no mistake about it: wealth inequality is one of the main drivers of health and disease generally. Inequality is strongly associated with outcomes such as obesity, depression, diabetes, cancer, heart disease, arthritis, etc. The list is very long.

Given that inequality is reaching new heights every day it seems, we have to ask ourselves how we can possibly hope to prevent obesity, and other major diseases, in the face of this massive inequality? Please watch this short and very informative video of how skew the distribution of wealth really is.

http://consciouslifenews.com/viral-video-us-wealth-inequality/#

If you have the time, you can also listen to self-confessed plutocrat Nick Hanauer talk about how the pitchforks will come out soon if this situation is not remedied.

Indeed, the situation in the US, the UK and elsewhere is not unlike the pre-revolution situation in France some 225-230 years ago. The good thing is that a financial crisis like we have today can act as a very powerful catalyst for replacing the current dysfunctional economy, that only works for the wealthy few, with something that allows everyone to thrive.

Because obesity mostly affects the poor, it is not surprising that the epidemic is doing so well, since more and more people are crossing the poverty line and the middle class is being squeezed. How would you react if you were below that poverty line, and you were being told to buy more vegetables and exercise more, when you are working 2-3 jobs just to stay alive and put food on the table, and not knowing if you are going to have any job next month or even next week?

If governments were really serious about preventing disease, they should first do their utmost to reduce wealth inequality. Only then will it be realistic to expect our prevention programs to have any kind of positive effect on the obesity epidemic.

Erik Hemmingsson

Bullying and obesity go hand in hand in so many ways

If you have any working experience in an obesity treatment facility you would be very familiar with the many gut-wrenching stories of bullying that the patients have experienced. A routine question to ask the patients is if they have any clue as to why they gained the extra weight to begin with. It’s not unusual to hear that it all started with the bullying, usually from a young age.

You may think that this is mainly peer-to-peer, but it can definitely be from parents as well. Usually this would be related to something they perceive to be not quite right with the child, perhaps carrying a tiny, tiny amount of extra weight. The child will then be told that there is something wrong with them. Obviously this is not the case, it’s the parent who is wrong for instilling the child with an erroneous negative self-belief (there is something wrong with me).

And how many stories have we not heard about  the completely insensitive bullying athletics coach/PE teacher who thinks that the child is overweight and needs to lose weight ASAP, and who always picks these children last for the teams, et cetera, et cetera.

The message for these bullied children is unbelievably negative: you are not good enough, there is something wrong with you, nobody wants to be with you. It’s not exactly strange that the obese in general have lower self-esteem and confidence than normal weight individuals, both as children and as adults.

Then there is the more classic case of bullying among children, sometimes from pre-school, because of a lack of tolerance and respect for what looks slightly out of the norm, particularly give our completely unrealistic body shape ideals. More and more studies are now confirming all those anecdotes about the toxic effects of bullying:

http://www.ncbi.nlm.nih.gov/pubmed/25157018

Indeed, obese children are much more likely to suffer bullying than normal weight children, which is confirmed by both the children themselves and also the teachers. But this does not mean that the bullying only happens during the childhood years. Studies on obesity bias and discrimination are becoming much more common, for example by Rebecca Puhl and colleagues at Yale. Please take the time to watch some if not all of this excellent talk, for example on how stigmatization has a profoundly negative effect on our physical, social, psychological and emotional health and well-being:

If we are serious about preventing obesity, we cannot emphasize enough the importance of zero tolerance towards bullying, in whatever form it comes in, and regardless of where it comes from. We also need to address all those negative self-beliefs and fears that arise as a result of bullying. This include things like body dissatisfaction because we perceived our body as the reason the bullying started in the first place.

I also firmly believe that anyone who wants to lose weight long-term needs to overcome their more or less inevitable body dissatisfaction, and connect in a more positive way with their bodies, as opposed to rejecting them and seeing them as the source of shame and discomfort. The more you have of negative thoughts and emotions in relation to your body, the more weight you are likely to trap. It’s not exactly a surprise that more and more studies are now confirming that bullying leads to weight gain, which leads to more bulling, which leads to more weight gain, which leads to more bullying…

Erik Hemmingsson

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Obesity prevention: what on earth are we waiting for?

Please allow me to start with a little name dropping here (sorry): my PhD opponent was professor Steven Blair from the Cooper institute in Dallas, notably of fitness/fatness fame, and his really groundbreaking research on fitness and numerous health outcomes. I am sure Steve’s work has helped to save countless lives and will continue to do so. Anyway, one of the things I clearly remember Steve saying was how we (in medical science) have all been led to worship at the shrine of the randomized controlled trial. And if your research is not founded on a randomized controlled trial then work is so flawed, so biased, that you may as well quit and do something else entirely.

His point was very clear: it is far too easy to discredit sound studies that do not use a randomized design. Most people who critique or even completely discard science have never done any science themselves, let alone a randomized controlled trial, and are employed as full time bureaucrats, or work for big pharma, and so they lack the understanding that such evidence is often utopian and oftentimes makes very little sense. In other words, good science is many times discredited for very petty reasons.

But here is my point: we can easily become very stupid if we insist on scientifically proving everything that we want to do. Not only is it utopian for many reasons such as cost and time, it’s often completely unnecessary. We don’t need, for example, a randomized trial to prove beyond any meaningful doubt, that certain things are either good or bad for us such as exercise, junk food or stress.

So far there are very few examples of obesity prevention programs that have been scientifically proven to be effective. That does not mean that we should refrain from very commendable initiatives such as building more parks and bike lanes, taxing junk food much more severely, banning junk food marketing, reducing harmful chemicals from our food such as steroids, preservatives and antibiotics, etc. There is no need to validate all these preventative measures in a gargantuan randomized controlled trial that will take years, if not a decade, to design, fund, carry out, analyze and publish.

The burocrats can always find things to nitpick at if they so wish (they usually do) and use this as an excuse for their inertia. Everyone should know, however, that science is never perfect. We have to trust and use our common sense when it comes to tackling the epidemic, just as much as we have to let good science guide us when we design programs that reduce obesity.

So what are we waiting for? Why is there so little action to prevent obesity? The numbers are getting worse by the day it seems, partly because we are in fact allowing the epidemic to run around more or less unchecked. It’s time to get serious about prevention, and do all these things that can start to slow it down, and don’t sit around waiting for the perfect study to show us exactly what to do, because that could be decades. We can’t afford to sit around any longer hoping that someone else is going to solve this for us.

Erik Hemmingsson

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