Hidden in plain sight


Yesterday I gave a presentation at the Nordic Ophtalmology meeting on the topic of weight loss in idiopathic intracranial hypertension (IIH). People with IIH have a large risk of going blind and they have frequent migraines, so treatment is obviously a priority. Patients are usually young women with obesity, and weight loss tends to result in drastic improvements of migraine frequency and strength for these patients, and they reduce their chances of sustaining permanent eye damage.

While the mechanisms for this debilitating disease are poorly understood, there is a clear link with obesity. But when the other speakers on the panel were speculating about why this disease develops no one hardly mentioned anything to do with environmental factors. Instead there was a very clear focus on biological risk factors, such as the increased mechanical pressure exerted by excess adipose tissue, anatomical factors, hormones and the like. While these factors can obviously be important they are likely to be a long way down the causal chain. 

When you consider than the vast majority of patients are young women with obesity, the things that come to my mind as potentially causal are a lot further up the potential causal chain, and include things like social pressures to be thin, body dissatisfaction, stigma, shame, childhood traumas, and stress. These, in turn, lead to drastic changes in inflammation, as well as substantial hormonal and metabolic changes, which could eventually trigger the intracranial hypertension. 

Personally, when it comes to obesity, I am very much leaning towards the environmental factors, specifically psychological and emotional factors/responses that we develop during the early years of our childhood as root causes of the disease. I would not be surprised if this applies to patients with idiopathic intracranial hypertension as well. That is why I think these patients can really benefit from a holistic treatment approach that includes things like weight loss, stress reduction, exercise, body acceptance, cognitive therapy, yoga, and mindfulness. 

Mindful of your feelings you must be


When obesity prevention experts get together it seems all they talk about is changing diet and exercise habits, i.e. things like removing vending machines from schools or building more parks. These are obviously good things to do, but they have not proven to be very effective. And pretty much the same goes for treatment, the main difference being that bariatric surgery is talked about a lot more. What many people fail to grasp, including the experts, is that there are very powerful forces that get in the way of behavioral control of diet and exercise.

At the very top of that list are negative emotions, such as sadness, anger, frustration, hopelessness, shame, guilt, fear and apathy. These are highly effective wrecking balls of diet and exercise initiatives.

Another factor very high up the destructive list is stress. Stress also triggers negative emotions in a highly effective way, making any conscious effort to eat more healthy food almost utopian. The same can also be said of thoughts. Negative or pessimistic thoughts will get you into a deeper and deeper hole, it’s that simple.

What experts need to focus on a lot more  – in terms of both treatment and prevention – is how to help people who have a lot of negative emotions, negative thoughts (especially about themselves), and stress. A good starting point could be to write a diary of all those situations when negative emotions, feelings and thoughts start racing, or situations when you often experience stress. Once you become more aware, you can start to devise a plan for feeling better, happier and more relaxed. That is when you can make real progress.

Socioeconomics, Mazlow and the obesity epidemic


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.


There has got to be a better way


I have seen many times how bariatric surgery can help people with severe obesity have a better and healthier life, at least in the short term. The benefits of surgery over other methods such as diet and exercise programs are also quite clear – in the short term. Does this mean I support surgery over other methods? No, it most certainly does not.

Here are some of my personal issues I have with bariatric surgery. It has become clear that there are serious risks to your health involved with the surgery. Examples include increased risk of alcoholism, depression and many forms of malnutrition. There is also likely to be an increased risk of suicide. I think you will agree that these adverse events are quite serious, and these are just examples. If any type of drug or other form of treatment was associated with such serious risks, it would probably never be approved.

The majority of people and colleagues I speak with also appear to have this notion that surgery is the only method that does not lead to long-term weight regain. This is wrong. I would argue that the long-term effectiveness of bariatric surgery to maintain a very large weight loss is very poorly understood. The landmark publications on the effectiveness of surgery have mostly come from Sweden as it happens (the SOS study). Slightly less than 300 individuals underwent gastric bypass in this study but the follow-up of body weight development some 15 years later was only done in 13 individuals, i.e. less than 5% of all starters, meaning a dropout rate of 95%.

And when you do a study of this kind, who do you think drops out? Those who generally do worse of course. So, by now I hope you realize that there are some pretty dark clouds hanging over bariatric surgery, including a very large risk of weight regain. Indeed, many patients who have had the surgery are now coming back having regained all their weight loss. And yet bariatric surgery has increased exponentially in Sweden and elsewhere in the last 5 years: it went from about 2000 per year to 8000 within 2 years.

I understand that people are frustrated and need more effective methods than what we currently have in the non-surgical arena, but this does not mean that there is a license to go overboard with a very drastic method with serious safety issues. Moreover, we also know that there is minimal screening before surgery, for example of factors like drinking habits and mental health. But surely, you think, there must at least be a massive follow-up after surgery to make sure that the patients are all right, coping well and not malnourished? Unfortunately no, apart from a tiny minority of centers. Many patients are left more or less completely on their own.

So what do I mean by saying that there has got to be a better way? I mean it’s time we invested some time and effort into understanding more about what caused the weight gain to begin with – this is obviously unique to each individual – and then try to reverse the situation through much safer means. This is likely to include counseling, therapy, diet, exercise, stress management, mindfulness or whatever is needed to steady the ship.

Who knows what will happen to all those patients who suffer long-term damage after 10, 20 or 30 years down the line as a result of their surgery. And bear in mind that, if you do suffer adverse events, that this surgery is not easy to reverse.

Yes, I still think surgery is called for in extreme cases, but this calls for much enhanced screening and follow-up, not to mention many more long-term safety studies, including a proper intention-to-treat analysis of body weight. But the current thinking, at least here in Sweden, is to start operating younger and lighter individuals, even children.

Confused about food?

Bild 2014-08-05 kl. 15.53

Even though my work involves a lot of nutrition science, I admit to having been somewhat bewildered about food in the past. I certainly would not think less of someone who claimed to be confused about what to eat and what not to eat, given how the media continue to write contradicting messages to the point where I almost think they deliberately want to confuse us. I have a few points to get across here and if you can grasp them, I hope that you will find food less of a challenge in the future, and actually something to give you joy and not anxiety.

My first point is that the science of nutrition is not very robust. It is certainly a lot less robust compared to the science surrounding the health effects of exercise. Good science relies on good data, the building blocks of science. In terms of understanding how food affects our health, we as scientists need research participants to tell us about their eating habits in a very accurate way. This is the core problem: people are not very good at accurately reporting what they are eating, how much, and so on. Moreover, people often change their food habits, which further weakens the science and our ability to find notable associations. The building blocks of nutrition science are definitely lacking in quality, and this is the number one reason why this field of science is hard to understand. You therefore need to be a little careful in how you interpret food studies.

My second point is that there is so much food marketing and lobbying from the food and drink industry that consumers are in reality rarely told a straight story by the de facto producers. Moreover, journalists seldom have the time, competence or interest to accurately paint a balanced picture and they end up pushing angles that makes everything extreme, i.e. something is either very harmful or very beneficial one week and the next week it’s the other way around.

Academics can also be pretty confusing about what they go on record with, often using too much jargon or overly complicating the messages. The end result is often too complex for regular people to understand. Academics also tend to focus too much on the details, with more or less endless debates about the role of, say, sugars vs fat for weight gain (oh yeah, this debate is still on-going).

In short, I totally understand why people are confused about food. The good thing is that food really doesn’t have to be very complicated at all. Here are my two cents on what to eat and what we need to do differently:

Instead of breaking down food into molecules, which gets us close to nowhere, we need to focus more on the overall quality of the food we are eating. For example, is is loaded with pesticides and preservatives, or is it organic? Has it been deep-fried or just pulled out of the ground in your own back yard? Does it contain healthy nutrients or is it just empty calories? We don’t actually need a lot of calories, but we do need nutritious and natural food. Many people in affluent countries are now in a state of malnutrition these days as a result of eating junk food.

So, in theory it’s actually pretty simple and not complicated at all. Good food is something that has been growing in the ground without pesticides, preservatives and other harmful chemicals, and is free of industrial ultra processing. Basically think organic fruit and veg, nuts, beans and whole grains and drink plenty of water. It’s not that complicated, is it?

By now it should also be pretty clear what to avoid. That’s right, ignore the large-scale ultra-processed junk food that has gradually taken over our diets, especially in poorer areas. You will also do well to avoid meat where the animals lived in cramped spaces under appalling conditions and fed all kinds of junk and antibiotics – where do you think it’s going to end up?

If you want a bit of science behind this go ahead and read this new study by Wang et al. in the BMJ on the very powerful role of fruit and vegetables in giving us longer and healthier lives (http://www.bmj.com/content/349/bmj.g4490).