Should 8 Year Olds be on Cholesterol Lowering Medication?

In case you hadn't heard, last week the American Academy of Pediatrics recommended that kids between the ages of 2 and 10 be screened for cholesterol problems if they have risk factors for problems therein.

Risk factors would include strong family histories, obesity, high blood pressure or diabetes.

The Academy goes on to recommend that for kids over 8 with high cholesterol, medications be considered.

On the one hand, perhaps that makes sense. We know high cholesterol to be a risk factor for heart disease and these kids therefore have at least two risk factors. Presumably lowering cholesterol will therefore reduce long term cardiac risk in these children.

The problem is, given that generally we haven't been treating 8 year olds with cholesterol lowering medications, we actually don't know that there will be a long term benefit, we just assume there will be one and that there won't be any surprising long term complications from starting these drugs during years that their bodies and brains are developing.

On the other hand, by giving these kids drugs, at least in kids whose secondary risk factor is not a strong family history (in which case they may well have genetically high cholesterol levels), we're not addressing the root cause of their effectively middle-aged bodies - lifestyle.

Given that 8 year old kids don't cook for themselves, don't shop for food for themselves, don't pack their own lunches for themselves and all in all live the way their parents have taught and allowed them to live, I think it's a crying shame that there's no pill that we can prescribe to their parents to help them learn, set, live and lead better examples.

How to Use a Scale

A while ago I posted about scale addiction and how often you should weigh yourself. It was my opinion that while losing once a week, stark naked, before breakfast, after pee on Wednesdays was my preference, and that while maintaining, daily was a good idea.

Today I'm going to take it further and explain how to deal with the number you see staring back at you.

Firstly if you're trying to lose weight it's important before you step onto the scale, to ask yourself how you're doing. After all, what does the scale know? How you're doing depends on how you're living, and the scale frankly knows nothing about that. If you're happy with how you've been living and feel that you're making the healthiest choices you can enjoy, even if the scale goes up, it shouldn't take away your pride in your accomplishments.

So once you've decided how you're doing, next you step onto the scale.

Looking at the number, you've got to remember a bunch of stuff. You've got to remember that scales measure a lot of extra stuff. Clothing (if you're wearing any), constipation (can weigh up to two pounds), water retention (time of the month, after a salty meal, from sore muscles) and it doesn't know if there have been great reasons to have Calories - celebratory and comfort reasons that definitely call for indulgences.

Ok, now you're looking at the number. If you're happy with it step down and you're done.

If you're unhappy with it, you've got to ask yourself two questions:

1. Am I doing something about it?
2. Do I know what I'm doing?

If the answers to those questions are "Yes", then there's nothing to worry about, even if the number's not doing what you want. Remember there is the law of averages at play too meaning that some weeks you'll lose far more than you'd expect and some weeks far less and that at the end of the day, doing the best you enjoy, not the best you can tolerate, is truly the best you can do sustainably.

Going back to that question number 2. What does knowing what you're doing mean? Well to me it means knowing how many Calories you're eating, otherwise it'd be like getting upset at your Visa bill despite having gone shopping without looking at price tags.

Bottom line, you may not love the number you see staring back at you, it may be distressing to you, but at the end of the day, if you're doing something about it, and you know what you're doing, you're doing great.

The "You Look Soooo Great" Speech

4 years of exclusively working in obesity medicine later, I've learned a few things that certainly aren't taught by society, medical school or weight loss books.

One of those things was the, "You should stop losing weight phenomenon" which I blogged about in the past.

Today I'm going to share another.

It's the "You look soooo great" great speech and why you shouldn't deliver it.

Now I realize that on the surface going on about someone looking great doesn't sound insulting, but let me give you a different way to hear it.

Let's say that over the course of the past year you've lost a significant amount of weight - enough weight let's say that it makes folks you haven't seen in a long time's heads' turn and eyes bug out.

Let's say that they're then so inclined to come over to you and deliver an oration on how great you look now, how much better you must feel now, how wonderful it is you've finally done this, how much happier you must be now, and so on and so forth.

You might thing, "So what's wrong with that? Those are all compliments, no?"

Sure they are. But of course their effusive enthusiasm about how great you look now translates into you hearing how terrible you looked before.

My advice?

If someone's lost a great deal of weight and you're so inclined to say something, three simple words, "You look great" is much better received than a full-on speech.

Think I'm nuts?

Let's ask my readers. Can you relate to what I'm reporting here or are the folks who have mentioned this phenomenon to me overly sensitive?

More Proof We're Failing

We in this case being a global we.

What are we failing at?

We're failing at ensuring the translation of evidence-based nutrition into easy to understand public education.

So what has been done?

We've allowed Big Food to come into our schools, consultations, dietetic organizations, influence national dietary recommendations and in general use their considerable clout to keep consumers confused to the point of paralysis regarding what's healthy and what's not.

So why am I ranting today?

According to a survey conducted by the international market research firm Mintel, British consumers felt that a food package's "recycling credentials" were more important to them than salt content, sugar content or Calorie content.

Why?

Probably because the average consumer doesn't have a clue how much salt, sugar or Calories they should be consuming and therefore those values on packages are effectively meaningless, whereas recycling information is consumable.

Unfortunately to date, governments, dietetic organizations, and of course Big Food, have been loathe to provide folks with consumption maximums. Instead they've been content to rely on fluffy, wishy-washy statements like, "there are no bad foods", or downright stupid statements like our Food Guide's, "Eat the recommended amount and type of food each day."

How about statements like, "Try not to eat more Calories than you burn" along with a calculator to help you figure out how many that might be, or, "aim for less than 2,000mg of sodium daily", or "aim for less than 50g of sugar daily"

Until we actually educate folks how to interpret a food label with actual recommended maximums, we're really not going to get anywhere.

I suppose one good thing will come of it all and that is apparently our food packages, and hopefully our effectively useless Food Guide, will at the very least end up in their appropriate recycling bins.

A BSc. in Obesity?

Yup.

According to a newspaper report in yesterday's National Post, the Univesity of Guelph and Humber College are teaming up to create a 4 year degree program in obesity.

To start next fall, the program will aim to train students to work with the obese through courses on nutrition, exercise science, anatomy and "the science behind obesity related diseases".

Graduates will receive two degrees: A BSc. in kinesiology from Guelph and a diploma in fitness and health promotion from Humber College. According to the University of Guelph's press release they will then be,

"qualified to work as personal trainers, kinesiologists, wellness consultants and fitness practitioners in both clinical and rehabilitation settings."

For me, this hammers home two messages:

Firstly, that clearly there's a crying need for more health professionals trained in obesity management.

Secondly, that medical schools and residency programs are failing our obese patients.

Frankly in an ideal world, I don't think obesity management should be a University course. The reason you don't see 4 year degrees in blood pressure or diabetes is because doctors are taught how to adequately manage those conditions in medical school and residency. Unfortunately the same cannot be said for obesity.

In my ideal world obesity medicine would be a sub specialty program within the department of Family Medicine and/or a real 5 year physician specialist program.

If you're interested in the course, you'd better have good grades - they've already received 430 applications for the 60 available spots.

The genetics contest called The Biggest Loser

It has become one of NBC's flagship shows.

Dozens of Americans meet at a ranch vying for half a million dollars during a weight loss contest.

The first 4 months they spend working out on the ranch all day long under the supervision of trainers and eating prepared low calorie meals.

Contestants compete in the requisite competitions, many of which involve the ridiculous "food temptations", but most of which involve feats of physical strength or endurance.

After 4 months on the ranch the remaining folks (people get voted off each week) go home and spend I believe an additional 6 months trying to lose weight on their own until finally they all return and get weighed and the person who lost the most weight (as a percentage of their initial weight) wins.

Perhaps the most dramatic part of the show are the weekly weigh ins on the incredibly over-sized scale that builds suspense by displaying the contestants' weights bouncing around for some time before finally displaying how much they've lost that week.

Weigh-in wise, week after week the numbers are dramatically fluctuant with some weeks folks losing more than 5% of the previous week's weight and others, virtually nothing. Those variations are simply a reflection of different degrees of hydration and they don't really interest me - what interests me is the fact that consistently, season after season, some people simply lose faster than others with a cadre of contestants usually losing weight twice as fast as another cadre of slower losers.

So the fast losers - do you think they're eating half as much and working out twice as hard? Do they have double the "willpower" of the people who simply don't lose quicker? Are they twice as motivated?

Of course not - as is clearly evidenced by the television show, everyone on that ranch is busting their butts exercising and eating low calorie meals as they all have the added motivational benefits of unlimited time and resources, millions of national viewers and let's not forget the $250,000 carrot dangling in front of them.

So what's the difference?

Genetics.

Weight loss is not simply a one to one relationship between how many calories you eat and how many calories you burn. The body's a big black box with food going in the top and coming out the bottom but in between there are dramatic between person differences in how calories are handled. The result of course- some people lose weight far easier than others.

My conclusion therefore?

The show's all about genes.

Oh, and there are two winners on the show by the way. There's the "Biggest Loser" from the folks who don't get voted off earlier on and then there's the person from the folks who were voted off who loses the most.

The two winners from last year?

Identical twins.

UPDATE: A reader pointed out that in fact the contestants cook for themselves on the ranch - certainly this would allow for more variability, but still not enough to account for such wide divergences in weight loss.

So you say you want a resolution?

It's that time of year again.

The gyms are full, the fast food joints are slightly less busy and folks everywhere are trying to live healthier.

For many folks the resolutions are quite general,

"I'm going to lose weight",
"I'm going to exercise more",
"I'm going to eat better"

While there's nothing really wrong with any of those resolutions, I'd argue they're great intentions crafted far too broadly for long term success.

The answer?

Be specific.

The more specific you can make your resolution the better and make sure that the resolution has the "how" in it as well. You might think ok, I'll make my weight loss resolution more specific and say,

"I'm going to lose 15lbs"

and while that indeed is more specific in amount (though you know I don't like numerical weight loss goals), it still doesn't address how exactly you're going to do it.

Here's an example of a specific fitness resolution,

"Everyday when I get home from work I'm going to take a 10 minute walk"

Here are a couple of eat healthier ones,

"Before I buy anything I'm going to look at the food label and I'm not going to the supermarket without a shopping list"

Here are a few weight loss ones,

"I'm going to keep a food diary for at least a month to start looking for calories I can lose without missing them"

"I'm going to eat every 2-3 hours and will set alarms and reminders to help me do it"

"I'm going to include protein with every meal so as to minimize hunger"

"I'm going to eat within half an hour of waking and have at least 350 calories for breakfast"

So you say you want a resolution?

Don't forget the specifics and the hows. Oh, and keep it simple. Small steps might get you somewhere - flying leaps tend to land you on your face.

Happy New Year

Holiday Eating Strategy

Many of my newer patients are worried about Christmas.

They're worried about the family gatherings, the meals out, the eggnog, the celebrations etc.

They worry because every time they've tried to "be careful" or "be good" during the holidays they've either eaten foods they feel they "shouldn't" or they've succeeded at being "good" at the expense of feeling bitter.

Well I've got news for you - life includes Christmas (and the myriad of other religious holidays and life events that involve celebrating with food).

If your eating plan or weight management strategy is such that you can't celebrate with food or one that makes you feel guilty if you do, it's probably time for you to do some thinking and ask yourself the question I often tell folks to ask themselves, "Could you live like this forever?".

The fact is who in their right mind would forever deny themselves the ability to comfort and celebrate with food - a function of food that is integral to our human existence.

What would I recommend?

Simple.

Eat because it's Christmas, but not because you're hungry.

One of the most common mis-strategies employed by folks trying to watch their weight over a celebratory season is the, "I'll eat less all day long because I know I'll be eating more at night" approach. I think that's an awful strategy because inevitably what happens is they then arrive at their evening affair hungry.

Do we behave differently when we're hungry? Of course, and anyone who's ever gone to the Supermarket hungry can attest to the influence hunger has on their food buying decisions.

Do you think that sitting down to a meal hungry is any different? Nope, it's just that now instead of shopping from the aisles you're shopping from the menu, the table, your plate, the cupboards, the fridge or the freezer and rest assured you'll shop differently.

While you may well still eat more calories than a regular old day even if your hunger was prevented, without a doubt if you're hungry and faced with celebratory high calorie options the number of calories your hunger will lead you to over consume at dinner will greatly out weigh the number of calories you would have had if you had eaten regularly all day long and then sat down to a celebratory meal not hungry.

So this long winded post boils down to this. If you're not hungry at a celebratory meal or a restaurant meal you'll be able to pick foods thoughtfully and certainly having more indulgent foods for celebration is a very appropriate and human thing to do. On the other hand if you're hungry when you sit, well now you've got a great reason to eat (celebration) and you're combining it with a preventable reason to eat (hunger) and the synergy between those two eating motivations is going to have you eating far more than if you simply stuck with celebratory food.

Willpower is the absence of hunger.

Set your Treadmill Free

For those of us living in the Northern parts of the world, life is starting to get colder and for many of us, that means that the inspiration to exercise is starting to become more difficult as getting yourself out the door for a walk or run in the cold is definitely more challenging.

You see the thing is that people when it comes right down to it, are consumers of time. If we're lucky we might each find, interspersed throughout our days, a few precious blocks of time where we're not working, where we're not at our children's beck and call, where we're not eating, not on the telephone and not sleeping.

Those of us trying to include exercise in our lives then hope that somehow, during those fleeting free moments we can inspire our selves to use them to do intentional exercise.

Recognizing that these free moments vary in time and duration many of us have decided you know what, we might not have the time (or desire) to pack it up during those moments and head out to a gym, so instead we went and brought the gym home by going out and buying treadmills and exercise equipment.

And what did we do with our great intentions and our new equipment? We banished them to our basements - out of sight, in a part of our homes that often is less welcoming, beside the kitty litter and the boxes, atop the cold unfinished concrete floor.

We might have used them for a few weeks after that. You see the money spent on them was fresh in our minds and consequently it raised the value of time spent with the equipment - by using it we didn't feel like we had wasted our money. But as our memory of money spent dwindles, too often so too does our use of the equipment.

If you want to actually use your home exercise equipment, you need to find new ways to increase the value of the time you spend with it and one of the easiest ways is to put it back in your line of sight. Seeing it may remind you you've got it and potentially even of the money and good intentions that brought it into your home. Put it somewhere where you can see it, and ideally somewhere you think might be enjoyable to use it - staring out a window, at a television, whatever.

If you choose to put it in front of a television, consider "conscripting" your favourite shows whereby you create a rule that only allows you to watch them while on the treadmill (never mind the speed, just get on it). Alternatively you could set up a reward system whereby if you log enough time, you get a specific reward.

Bottom line, unless you create an environment that includes some measure of enjoyment in your exercise, an environment that increases rather than decreases the value of the time you spend doing it, well guess what, you're probably not going to be doing much of it for long.

Set your treadmills free!

Weight Loss is Personal

Even if you're blogging about it.

So currently I'm working with one of the local newspapers as one of their panel of experts for a lengthy series on nutrition.

The launch was last weekend and included in the launch was an article written by a very young man who's just barely overweight. The article was about his month long experiment of following Canada's Food Guide and he's also keeping a blog about his experiences aiming at reaching a numerical goal weight (the weight needed to give him a body mass index of 25).

Now readers of my blog will certainly know that I'm not a fan of using BMI or "pound" goals because frankly they overlook the bigger picture - reality. Fact is, the best goal is whatever weight you reach when you're living the healthiest life you can enjoy. But put that aside for now. The important question to ask regardless is, "So is he enjoying his life?"

Not according to his newspaper articles and blog entries he isn't.

According to them he's been saving up his calories for supper and in so doing often finding himself starving and battling hunger demons (like the ones that live in Pizza shops). He reports being "desperate" for steak because his Food Guide approach doesn't allow him to eat large ones. He reports being tired and finding it difficult to find 60 minutes a day of exercise. He reports that he fell off his new wagon within one month of embarking on it. He notes that on at least one occasion when he ate more than he planned in the daytime he compensated and went to bed following a dinner consisting solely of a plate of green beans with two slices of toast. He reports that the "red numbers" on the scale motivate him and help him with what he feels his efforts require - "focus, attention and willpower".

In short, he's on a diet.

Given my chosen career and my experience with quite literally thousands of folks trying to lose weight, reading his article and his blog, I decided that there's no way that he's adopted a long term approach here. He's dieting and both anectdotally and in the medical literature, diets fail in the long term over 95% of the time.

So what type of diet behaviours does he admit to? By using the scale as a source of support, he's chosen the proverbial dark side of weight loss, letting the seduction of the numbers inspire him to greater acts of willpower - a problem when the scale stops whispering sweet nothings into his ear. By saving calories until the end of the day and cultivating blindly restrictive food limits, he's cultivating hunger which will lead him to battle hunger - a battle that if fought frequently, eventually just gets too irritating and bitter to fight. By trying to cram 60 minutes of exercise a day into likely a very busy and youthfully all over the place lifestyle, he's liable to get frustrated with the exercise and simply let the whole thing go. He appears to be trying to live the healthiest life he can tolerate - and for me, that's the definition of a diet.

So here's where it gets interesting.

I decided to write to him and in the email I told him that it seemed painfully obvious that he didn't particularly relish his new healthiest-he-could-tolerate lifestyle and that in the long run, if he didn't enjoy his life, he wouldn't continue living that way.

I also offered him our help with no strings attached. I recommended that he see our dietitian and told him that should he come and see her, he need not feel that he would have to mention the visit or our help in his blog or in his articles.

I logged onto his blog the other day and read what sounded to me like a fairly irritated entry from him stating that I had written to him, told him that he was going to fail and that I tried to convince him to join my office's weight loss program.

Now the later part's simply not true, I had offered him a free visit with out dietitian with no strings attached, but I'll chalk that one up to misinterpreted email, but the former part I suppose is true, and frankly, I'm sorry that I emailed him and more sorry that I clearly have upset him.

You'd think of all people, I'd know that weight loss is personal. It's my exclusive area of practice and thinking about weight and weight management probably takes up at least 2/3rd of my total waking hours.

I should have known better than to offer my opinions or even offer to help because the mistake that I made, was assuming he wanted my opinions or my help.

Weight loss is a personal journey. No one should feel comfortable muscling in on someone else's weight loss effort.

My mistake was an honest one. For heaven's sake, having a blog and writing articles about weight management pretty much opens the door to having folks comment on your efforts, but frankly I still should have known better.

Best of luck to him, and should he decide that in fact my opinion and help would be useful to him, he's still welcome to give me a call.

For all of the friends and spouses of folks trying to lose weight out there, here's the only question you should ever ask your weight-conscious friends, "Is there any way that you feel I can help you". If the answer's "No", then just leave it at that, if they want your opinion or help, they'll ask.

Do you have scale addiction?

It's certainly not a condition written about in medical textbooks.

I'm talking about scale addiction. An affliction that causes the sufferer, usually someone in the midst of a weight loss effort, to step on the scale multiple times a day whereupon if the scale does not go down or goes up, they suffer mild to severe mental anguish.

I've met many folks who are scale addicts.

They tell me that rationally they understand that getting on the scale multiple times a day won't make a difference, but that they just can't help themselves.

For those folks I usually offer to babysit their scales in my office or I recommend that they turn them over, take out the batteries or put tape on the solar strip.

The thing is scales are truly frustrating devices because they don't simply measure caloric intake vs. caloric expenditure. They measure clothing, water retention, constipation and time of day differences.

Folks who do weigh frequently will know that weight fluctuates both day by day and within a day.

So for scale addicts out there, here are two things you need to know.

Firstly, there's 3,500 calories in a pound, and while bodies are not mathematical instruments whereby if you do or don't eat 3,500 calories you'll see a pound change on the scale, bodies do obey the laws of thermodynamics and if you step on a scale on a Wednesday and it's 3 pounds heavier than Tuesday, unless you consumed at least 10,500 calories more than you burned, the scale is weighing something other than true weight.

Secondly, your weight doesn't matter. What do I mean by that? To put it simply, what moves the number on the scale is not the act of standing on the scale, it's what you're doing and choosing during the times you're not standing on the scale. It's your lifestyle and your choices that change your weight. You need to determine how you're doing by how you're doing. What have your dietary choices been like? How's your fitness? Are you being thoughtful? Are you organized and consistent?

Scales can be helpful to illustrate trends, but weight fluctuation, both inter and intra day fluctuations are normal.

At the end of the day, it's your life that can change the scale, not the other way around.

My recommendations? During a weight loss effort weigh yourself once a week, stark naked Wednesday morning before breakfast. During a weight maintenance effort weigh yourself daily and get to learn your body's weight fluctuations and more importantly, use the scale to nip any weight regain in the bud.

Break the habit, stop the weighing.

(P.S. Those aren't my feet, just a scary picture from the internet)

"You should stop losing weight"

In my practice I get to see a great many people lose a great deal of weight and I've noticed two trends.

Firstly it's usually somewhere between a 15 and 20 pound weight loss when folks start noticing, but it's the second trend I want to talk about, the, "You should stop losing weight" trend whereby if you lose enough weight, folks will start telling you to stop.

In my experience it happens at somewhere around the 15-20% mark (i.e. a 30-40lb weight loss if your starting weight is 200lbs). Now there is a difference in terms of how starting weight affects this phenomenon and the higher the starting weight, the less likely this phenomenon will occur but as an anecdotal rule, if your starting weight is less than 250lbs and you lose more than 20% of your starting weight, somebody will tell you to stop. They'll often even do so despite the fact that you may still want to lose more weight and may still have a significant amount of medical risk associated with your weight.

Sometimes they'll even come right out and say you look bad.

I've got two theories about this. There's the less likely theory - jealousy, but honestly I don't believe that plays a big role for most folks. I think the more likely theory is the fact that consciously or perhaps unconsciously as a function of evolutionary biology, we interpret weight loss as reflective of illness.

The fact is that many major and sometime fatal illnesses have a wasting away component to them and I wonder if we as a species have it hardwired in us to recognize weight loss as a sign of illness. Many of us too have personally watched friends and relatives waste away and seeing a friend or a relative lose weight may trigger memories and emotions that less than pleasant.

For all those obesity researchers who may be reading my blog, I think this phenomenon would be a fascinating study and it's certainly not one I've read about. There'd be two ways to study it. One with a prospective study whereby the folks losing weight keep track of when they first run into someone whose concerned about their weight loss or perhaps an easier study using photographs of folks as they lose weight with captive audiences and well designed questions.

Anybody out there experience this phenomenon?

Obesity - maybe your stomach is depressed?

This has to be one of the most ridiculous comments I've read in a long time to describe obesity and it comes from Dr. Nora Volkow the director of the U.S. National Institute on Drug Abuse.

Dr. Volkow, in an editorial published in May in the American Journal of Psychiatry says that,

"some forms of obesity are driven by an excessive motivational drive for food and should be included as a mental disorder in DSM-V"

She then goes on to compare obesity with drug addiction with food of course being the drug.

Yes, let's add one more stigma to obesity and label it a mental illness and compare the obese to drug addicts. Brilliant! Helpful! Oy!

You know what should be included in the Diagnostic and Statistical Manual V (the bible of psychiatric disorders) as a mental disorder? Quobesity.

Quobesity occurs when a person, just because they eat, believes that they are experts in all things obesity related. Side-effects include ridiculous editorials and quotations that often manifest as blog entries here.

The comparison of eating behaviours and drug addictions is certainly not a new one, but it does have a fatal flaw - how many folks do you know whose addictions only exist from 4pm onwards?

The vast majority of food addicts (chocoholics, carb-addicts etc) will report that their addictive behaviours and struggles with food only manifest from the mid to late afternoon onwards. It is an exceedingly small proportion of these folks who struggle all day long. The all day long folks, if they meet certain criteria, may indeed have a diagnosable psychiatric condition entitled binge eating disorder, however to reiterate, in my experience, the vast majority of bingers tend to only do so from the afternoon onward.

Those same folks, when taught to eat frequently, not skip meals or snacks and include foods helpful with hunger prevention tend to see their binging disappear, in many cases literally overnight.

If Dr. Volkow is keen to make changes for the up and coming new Diagnostic and Statistical Manual V (the bible of psychiatric disorders), might I suggest an exclusion criteria for binge eating disorder whereby the diagnosis cannot be given to an individual who skips any daytime meals or snacks.

For food addicts or binge eaters who might be reading this post - try this recipe to see if it helps minimize your addictive type behaviours. Worst case scenario you prove me wrong and you may indeed be a truly food addicted binge eater. Best case scenario, you regain control over what is most certainly a very frustrating and potentially demoralizing behaviour:

Breakfast within 30 minutes of waking, at least 350 calories with at least 15grams of protein

Eating every 2.5 hours with between meal snacks of 100-200 calories a piece with at least 8 grams of protein

Lunch of at least 300-400 calories with at least 15 grams of protein

Dinner of at least 400 calories with at least 15 grams of protein

For every hour of sustained exercise add an additional 100-150 calories that are primarily carbohydrate based.

The Primary Cause of Obesity

I'm constantly amazed by quotes detailing how complicated it is to pinpoint blame in the obesity epidemic. In my mind, it's the treatment that's complicated, while the problem, well I think it's pretty obvious.

As everyone on the planet knows, the world is getting heavier - fast. So what's changed?

Have our genetics changed in the past 100 years? Of course not.

Is there a terrible virus, bacteria, fungus or parasite that we can blame? Nope.

Is it genetically modified crops, or pesticides or us using the air conditioner more frequently? Good grief no.

So what's changed in the past 100 years? For lack of a better term - our foodscape.

Sure genetics, hormones, learned behaviours and maybe even the temperature you set your thermostat on have a bearing on weight, so do thousands of other variables, but without any question whatsoever the environment is to blame.

I read an article yesterday in a Big Food tradezine that had a fabulous quote by a food marketing big wig named Harry Balzer (I swear I didn't make up the name),

"Americans now use restaurants like their parents traditionally used grocery stores"

This particular article looked at how our use of restaurants has changed in the past 50 years. It stated:

Americans spend 48 percent of their food dollars on restaurant fare, up from 25% 50 years ago.

The average American ate 208 meals prepared outside the home last year.

Americans gobbled down an average 127 to-go meals per person in 2006, compared with 81 eaten inside a restaurant.

To live in 2007 and maintain a healthy body weight while eating out an average of 208 meals outside of the home would border on the impossible. The calories associated with restaurant portions and foods are ridiculously high and while certainly it is possible to make some healthy or lower calorie restaurant choices, eating out 4 times per week, you're almost certainly going to make quite a few that are less than ideal. Furthermore you're also going to train your eye to expect the restaurant sized portions that we have seen evolve over the past 4 decades.

Now I'm not blaming solely restaurants, I'm blaming food in general because that is what has changed - how we eat has changed, where we eat has changed, what we eat has changed, how often we eat has changed, and why we eat has changed.

Rich Rojko, a manager at the high end Ruth's Chris steakhouse chain that now offers takeout had this to say,

"Eating has become something that people do while they're doing something else."

Indeed.

Should we ditch nutrition in schools?

That's what a recent non-scientific study conducted by the Associated Press would suggest.

In the study the AP examined 57 nutrition education programs conducted at schools and of them, only 4 showed anything even remotely resembling a positive result.

Some programs offered kids free fruits and vegetables, others gave prizes to students who ate fruits and vegetables, and most simply provided more in depth nutritional education. All programs were rather time and/or resource intensive.

Sounds discouraging, right? Kids will be kids and just won't change, right?

Maybe. However I can't help but wonder if the problem isn't with the kids, but rather with the programs. I've had the misfortune of being involved in the planning of some of these programs. I say "misfortune" because certainly in the cases where I've been involved the organizers involved in the programs' designs were often a hodge-podge of very well intentioned, but not necessarily expert folks who always want to promote the same old tired, overly simplistic and clearly useless messages of:

Eat more fruits and vegetables

Eat less fast food

Exercise more

Watch less TV

Play fewer video games

Eat less fat

If I was setting up school nutrition curricula, certainly the one thing I would ensure was front and centre was the concept of energy. Calories. People are afraid of talking about calories. I've often heard folks express concern that if we teach kids about calories, we'll promote eating disorders. Never mind that there's never been a study that suggests that teaching calories leads to any sort of disordered eating behaviour; never mind that by teaching calories you could argue you're providing kids with minimum calorie targets thereby perhaps reducing anorexic risks; and never mind of course that calories that are the currency of weight. It's only in calorie blind world where low-fat muffins, fruit juice and smoothies are healthy choices. Teach kids how many calories they need and how to find them and perhaps they'll make different choices.

Don't believe me?

It worked in Pennsylvania with zero additional guidance. Four schools there simply posted calories on their cafeteria menu board and then tracked cafeteria purchases and low and behold, immediately kids started choosing the lower calorie options - the study was published here in the Journal of Child Nutrition and Management. A followup study showed that when you combined school nutrition programs with point of sale nutrition information, students were happier with the school nutrition programs as a whole.

Schooling aside, regular readers of my blog will know that my belief is that the best way to combat childhood obesity is to walk the walk which is why when I counsel parents of overweight or obese children I always provide them with the same message,

"Live the way you want your children to live and then hope for the best"

As far as I'm concerned, the bigger problem here is the fact that adults aren't taught what's healthy or how to maintain a healthy body weight and consequently they're unable to walk the walk for their children. That's also why it's such a horrible shame that the Canadian government decided to put out a Food Guide that spent more time promoting industry in Canada than promoting an evidence-based approach to healthy eating with clear and useful guidance on weight management. I guess for now we should all just keep our fingers crossed that it doesn't take the government another 15 years to revise this one.

How to Choose a Weight Loss Program

So let's say you have decided you want to try to lose some weight and that you've also decided that you'd like some help - who should you call?

Unfortunately I know of no country that regulates the weight loss industry. I say unfortunately because literally for centuries, weight loss scams and snake oil salesmen have been commonplace.

Some programs have celebrity endorsements - of course that doesn't mean that the celebrity has used the program or products. Just last week Rachel Hunter, new spokesperson for Slimfast admitted to Newsweek that she'd never even tried any and in fact the closest she could come to saying that she might try their product (though certainly her weight does not carry with it much in the way of medical risk) was this statement,

"I'm kind of more than willing to try their product."

Currently I'm working on a short set of questions to ask when considering a weight loss program based on some simple truths and principles regarding weight loss. As soon as they're done, I'll post them up here, but until then, there's a very extensive checklist/fill in the blanks document published by the FTC which you can print out and bring with you to any weight loss program you consider.

Some for sures:

1. Don't join a program that makes you pay up front and doesn't offer refunds
2. Don't join a program that makes you sign a contract or guarantees your weight loss
3. Don't join a program that requires the purchase of products of supplements
4. Don't join a program that has you eating fewer than 1,200 calories daily
5. Don't join a program that can't explain their success rates through a maintenance period.

To print up the FTC's checklist, click here.

My Take on Body Fat Percentage Scales

Short version - don't buy one.

Here's the longer version.

You've all seen them, and I'm sure many of you have them - the scales where you take your shoes off and magically it tells you your body fat percentage.

The scales work via bioimpedance analysis which involves a small electrical current being passed through your body from foot to foot. The signal travels through the various components of our bodies (fat, muscle, bone) and the time it takes is measured by the scale. The more water there is in the tissue, the faster the transmission and because fat has less water content than muscle, the more fat you have, the slower the electrical current travels and the more fat is registered by the scale.

A good body fat percentage scale will have an error range of at least 4% and frankly you can affect more error by varying your hydration level.

So why don't I like them? Wouldn't it be a good thing to know your body fat percentage? Umm, why would that be a good thing? Would it change anything? Would you live any differently or choose any differently if you didn't see those numbers going down?

The answer to the above questions should be "no", because regardless of your body fat percentage what I'd be recommending you be doing is living the best lifestyle that you can enjoy.

What many folks don't know buying a body fat percentage scale is that body fat percentage changes slowly - very slowly and frankly aside from exercising and losing weight, there's really nothing for you to do to bring that number down. Add in the wide range of error that these scales tend to have and now you've got a tool in your bathroom with the potential of providing you with daily discouragement utilizing a number that you can't do anything specific about to change. Not so smart.

A good practice for a physician is not to order any test that you're not prepared to act on or where the results will not add to the person's health and well being. In my mind body fat percentage is just such a test.

I'll reiterate the goal that I tell everyone in my program is the only goal worth having,

"Live the best life you can enjoy, not the best life you can tolerate."

Sure there will be days with more calories and days with less exercise, but that's real life and in real life, if you're living a life you don't enjoy (a diet for example), eventually you'll decide to stop living that way. Knowing your body fat percentage will only confuse that goal.

Set Point Theory

Yesterday someone in the comments asked me what I thought about "Set Point Theory".

What set point theory suggests is that a person's body, metabolism and caloric drive strive to maintain a specific preset weight and therefore if your "preset" weight is high and you lose weight, your body will just try its darndest to gain it back.

I think it's an asinine theory.

Some obvious problems (one pointed out quite rightly by the comment yesterday):

1. Why have the world's setpoints gone up dramatically over the course of the past 50-100 years?
2. Why is the world getting bigger so much faster (are all of our setpoints 1,000lbs?)
3. Why do the setpoints of indiginous peoples (like the Pima Indians) seem to change the moment they step into North America?

Set point theory is something that allows folks and governments to take even less responsibility in treatment design and implementation.

Now it is indeed true that as the body loses weight it does compensate in multiple ways to try to preserve the weight it's losing. The body of course perceives weight loss as an environmental threat - an ice age or a flood or something, and so it jumps into action and changes the way the body handles certain processes, decreases something called the thermic effect of food and basically tries to hold on but it doesn't throw any magical switches to get folks to open their freezers and cupboard doors.

I don't completely discount the whole theory however. I do believe that there is a range of weight within which a person can comfortably live, but I also believe that range is very wide and it depends not only on the genetic makeup of the individual, but also his or her learned and fixed environment.

You might even stretch and say that I do believe in set point theory, but in my own version of it - I'll call it Life-Set Theory with weight being primarily lifestyle related.

People regain their weight as they regain their old lifestyles.

I say this to new patients daily,

"The more weight you'd like to permanently lose, the more of your lifestyle you'll need to permanently change"

The problem is, most weight loss efforts don't really do much to address lifestyle. Weight loss usually involves a food regime - either overt overall restriction and hunger or the magic food approach of this food's good and that food's bad. Those approaches are of course non-sustainable becase they invoke the suffering of hunger or of blind, thoughtless restriction. Any weight lost through suffering will be gained back when the suffering stops and the person reverts back to their prior life that might have led them to have weight to lose, but was easy to live.

The environment also of course matters. Look at the Pima Indians - heaviest people in the World in Arizona and healthy weights back home in Mexico. I'd imagine this would work in reverse too. For example, take someone who's lost weight with a restrictive approach while working a sedentary job in an urban environment and plop him or her down on a farm where they've got to work all day long and there's no access to food other than what they cook and grow themselves. Do you think their "set point" will have them magically gain? Of course not, because their environment no longer allows for their prior calorie rich lifestyle.

So to sum up this rant. For me lifestyle dictates set point. Change your lifestyle and eating patterns (combining hunger prevention strategies like frequent eating and increased protein with calorie awareness and an explicit lack of forbidden foods) and you've definitely got a shot, but do remember with lifestyle change it's not necessarily the changes that are difficult, it's change itself.

Why newspapers are bad sources of medical information

I'm not even going to bother doing the work here. The anaethetist blogger I mentioned before did a great job of deconstructing news reports that suggest that based on a recent study, getting a chest XRay to rule out cancer is a good idea.

Bottom line - quite often, mass media is an atrocious place to look to for medical information....unfortunately that probably also includes blogs (but not this one or bookofjoe :-) ).

Always ask yourself, who's the source and what's their motivation. In the case of the media, the motivation may simply be sales. An article entitled, "Chest XRay screening doesn't help to prevent lung cancer" will sell less articles than the one that says, "Get a chest XRay - it may save your life!"

That being said, there are some excellent medical journalists out there - you just need to learn who you can trust.