tag:theconversation.com,2011:/au/topics/obesity-series-2018-47507/articlesObesity series 2018 – The Conversation2020-11-06T13:31:08Ztag:theconversation.com,2011:article/1478102020-11-06T13:31:08Z2020-11-06T13:31:08ZCOVID-19 reveals how obesity harms the body in real time, not just over a lifetime<figure><img src="https://images.theconversation.com/files/366242/original/file-20201028-15-16viybz.jpg?ixlib=rb-1.1.0&rect=28%2C0%2C6253%2C4190&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A COVID-19 patient is connected to life-sustaining devices at Mount Sinai South Nassau Hospital in Oceanside, New York on April 14, 2020. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patient-in-a-medically-induced-coma-is-connected-to-life-news-photo/1219995479?adppopup=true">Jeffrey Basinger/Newsday via Getty Images</a></span></figcaption></figure><p>The COVID-19 pandemic has thrust the obesity epidemic once again into the spotlight, revealing that obesity is no longer a disease that harms just in the long run but one that can have acutely devastating effects. New studies and information confirm doctors’ suspicion that this virus takes advantage of a disease that our current U.S. health care system is unable to get under control. </p>
<p>In most recent news, the Centers for Disease Control and Prevention reports that 73% of nurses who have been hospitalized from COVID-19 <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6943e3.htm?s_cid=mm6943e3_w">had obesity</a>. In addition, a recent study found that <a href="https://www.nature.com/articles/d41586-020-02946-6">obesity could interfere with the effectiveness of a COVID-19 vaccine</a>.</p>
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<p>I am an <a href="https://uvahealth.com/findadoctor/profile/catherine-w-varney">obesity specialist and clinical physician</a> working on the front lines of obesity in primary care at the University of Virginia Health System. In the past, I often found myself warning my patients that obesity could take years off their life. Now, more than ever, this warning has become verifiable. </p>
<h2>More damage than believed</h2>
<p>Initially physicians believed that having obesity increased only your risk of getting sicker from COVID-19, not your chance of being infected in the first place. Now, <a href="https://doi.org/10.1111/obr.13128">newer analysis</a> shows that not only does obesity increase your risk of being sicker and dying from COVID-19; obesity increases your risk of getting infected in the first place. </p>
<p>In March 2020, <a href="https://doi.org/10.1016/S0140-6736(20)30566-3">observational studies</a> noted hypertension, diabetes and coronary artery disease as the most common other conditions – or co-morbidities – in patients with more severe COVID-19 disease. But it was the <a href="https://doi.org/%2010.1002/oby.22808">editors of Obesity journal</a> who first raised the alarm on April 1, 2020 that obesity would likely prove to be <a href="https://doi.org/%2010.1016/S0140-6736(20)30566-3">an independent risk factor</a> for more severe effects of COVID-19 infection. </p>
<p>Additionally, <a href="https://www.jwatch.org/na52156/2020/09/01/obesitys-influence-mortality-patients-with-covid-19">two studies</a> including nearly 10,000 patients have shown that patients who <a href="https://doi.org/10.7326/M20-3214">have both COVID-19 and obesity</a> have a <a href="https://doi.org/10.7326/M20-3742">higher risk of death at days 21 and 45</a> compared to patients with a normal body mass index, or BMI.</p>
<p>And a study published in September, 2020 reported higher rates of obesity in COVID-19 patients who are critically ill and <a href="https://doi.org/10.1097/CCM.0000000000004455">require intubation</a>.</p>
<p>It is becoming overwhelmingly evident from these studies and others that those with obesity are facing a clear and present danger. </p>
<h2>Stigma and lack of understanding</h2>
<p>Obesity is an interesting disease. It is one that many physicians talk about, often in frustration that their patients cannot prevent or reverse it with the oversimplified treatment plan that we have been taught in our initial training; “Eat less and exercise more.”</p>
<p>It is also a disease that causes problems physically, such as sleep apnea and joint pain. It also affects one’s mind and spirit due to societal and <a href="https://doi.org/10.1186/1472-6963-9-106">medical professionals’ bias</a> against those with obesity. It can even <a href="https://doi.org/10.1016/j.ehb.2010.02.001">adversely affect the size of your paycheck</a>. Can you imagine the outcry if the headline read “Patients with high blood pressure earn less”? </p>
<p>We doctors and researchers have understood for quite some time the long-term consequences of excess weight and obesity. We currently recognize that <a href="https://obesitymedicine.org/what-is-obesity/">obesity is associated with at least 236 medical diagnoses,</a> including 13 types of cancer. Obesity can decrease one’s lifespan by up to eight years. </p>
<p>Despite knowing this, U.S. physicians are not prepared to prevent and reverse obesity. In a <a href="https://doi.org/%2010.1186/s12909-020-1925-z">recently published survey</a>, only 10% of medical school deans and curriculum experts feel that their students were “very prepared” in regards to obesity management. Half of the medical schools responded that expanding obesity education was a low priority or not a priority. An average of 10 hours total was reported as dedicated to obesity education during their entire training in medical school. </p>
<p>And doctors sometimes don’t know how or when to prescribe medications for patients with obesity. For example, <a href="https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity">eight FDA-approved weight loss medications</a> are on the market, but only <a href="https://doi.org/%2010.1002/oby.22696">2% of eligible patients</a> receive prescriptions for them from their physicians. </p>
<figure class="align-center ">
<img alt="A woman measures her A1C." src="https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/366252/original/file-20201028-19-12tfvmh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A woman measures her blood sugar level during lockdown in Paris in March 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-with-diabetes-monitors-her-glycemia-in-paris-on-march-news-photo/1208202019?adppopup=true">Photo by Franck Fife/AFP via Getty Images</a></span>
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</figure>
<h2>What goes on in the body</h2>
<p>So, here we are, with a collision of the obesity epidemic and the COVID-19 pandemic. And a question I find patients asking me more and more: How does obesity create more severe disease and complication from COVID-19 infection? </p>
<p>There are many answers; lets start with structure.</p>
<p>Excess <a href="https://www.sciencedaily.com/terms/adipose_tissue.htm">adipose tissue</a>, which stores fat, creates a mechanical compression in patients with obesity. This limits their ability to take in and completely release a full breath of air. </p>
<p>Breathing takes more work in a patient with obesity. It creates restrictive lung disease, and in the more serious cases, lead to <a href="https://www.nhlbi.nih.gov/health-topics/obesity-hypoventilation-syndrome">hypoventilation syndrome</a>, which can cause a person to have too little oxygen in their blood. </p>
<p>And then there is function. Obesity results in an excess of adipose tissue, or what we colloquially call “fat.” Over the years, scientists have learned that adipose tissue is harmful in and of itself. One may say that adipose tissue acts as an endocrine organ all its own. It releases <a href="https://doi.org/10.5114/aoms.2013.33181">multiple hormones and molecules</a> that lead to a chronic state of inflammation in patients with obesity.</p>
<p>When the body is in a constant state of low-grade inflammation, it releases <a href="https://doi.org/%2010.1097/AIA.0b013e318034194e">cytokines,</a> proteins that fight inflammation. They keep the body on guard, simmering and ready to fight disease. That’s all well and good when they are kept in check by other systems and cells. When they are chronically released, however, an imbalance can occur that causes injury to the body. Think of it like a small but contained wildfire. It’s dangerous, but it’s not burning the entire forest. </p>
<p>COVID-19 causes the body to create another <a href="https://theconversation.com/coronavirus-cytokine-storm-this-over-active-immune-response-could-be-behind-some-fatal-cases-of-covid-19-136878">cytokine wildfire</a>. When a person who is obese has COVID-19, two small cytokine wildfires come together, leading to the raging fire of inflammation that damages the lungs even more so than patients with normal BMI. </p>
<p>Additionally, this chronic state of inflammation can lead to something called <a href="https://doi.org/%2010.3390/biom10020291">endothelial dysfunction</a>. In this condition, instead of opening up, blood vessels close down and constrict, further decreasing oxygen to the tissues. </p>
<p>In addition, increased adipose tissue may have more ACE-2, the enzyme that allows the coronavirus to invade cells and begin to damage them. A <a href="https://doi.org/doi:%2010.1016/j.obmed.2020.100283">recent study</a> has shown an association of increased ACE-2 in adipose tissue rather than lung tissue. This finding further strengthens the hypothesis that obesity plays a major role in more serious COVID-19 infections. So in theory, if you have more adipose tissue, the virus can bind to and invade more cells, causing higher viral loads that stay around longer, which can make the infection more severe and prolong recovery.</p>
<p>ACE-2 can be helpful in <a href="https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928">counteracting inflammation,</a> but if it otherwise bound to COVID-19, it cannot assist with this. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>The novel SARS COVID-19 virus has forced the medical profession to face the reality that many U.S. physicians inherently know. When it comes to prevention of chronic diseases such as obesity, the U.S. health care system is not performing well. Many insurers reward physicians by <a href="https://www.cms.gov/files/document/mmpperformancedatatechnotes.pdf">meeting metrics</a> of treating the effects of obesity rather than preventing it or treating the disease itself. Physicians are reimbursed, for example, for helping patients with Type 2 diabetes to attain a certain A1C level, or a set blood pressure goal. </p>
<p>I believe is time to educate physicians and provide them with resources to combat obesity. Physicians can no longer deny that obesity, one of the strongest predictors for COVID-19 and at least 236 other medical conditions, must become public enemy number one.</p><img src="https://counter.theconversation.com/content/147810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cate Varney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The long-term effects of obesity have been well documented, but immediate effects have not been as evident. The coronavirus is changing all that, as those with obesity seem particularly vulnerable.Cate Varney, Clinician Physician, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1450172020-09-08T12:17:22Z2020-09-08T12:17:22ZA doctor’s open apology to those fighting overweight and obesity<figure><img src="https://images.theconversation.com/files/356603/original/file-20200904-24-3gd05a.jpg?ixlib=rb-1.1.0&rect=3%2C3%2C791%2C480&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have told people who are overweight to exercise more and eat less, when in fact their overweight may be due to genetic or other factors that exercise won't change. </span> <span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/image-library?#">UConn Rudd Center for Food Policy & Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Obesity has emerged as a significant risk factor <a href="https://news.yahoo.com/obesity-increases-risk-covid-19-230500610.html">for poor outcomes</a> in patients infected with COVID-19. Based on how doctors and others in health care have previously treated patients with obesity or overweight conditions, my guess is that many will respond by declaring: “Well, it’s their own fault for being overweight!” </p>
<p>In the spirit of recognizing that people who struggle with weight loss include our family and friends, let me propose a different sentiment. </p>
<p>To those who we have shamed for having excess body weight and/or failing diets: “You were right, and we are sorry. After giving you undoable tasks, we ridiculed you. When you tried to tell us, we labeled you as weak and crazy. Because we didn’t understand what you were experiencing, we looked down on you. We had never felt it ourselves. We did not know. And for that, we apologize.” </p>
<figure class="align-center ">
<img alt="A woman and a nutritionist." src="https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356607/original/file-20200904-14-87q46a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A nutritionist talks with a patient at an obesity clinic in Mulhouse, France.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/reportage-in-the-obesity-clinic-in-mulhouse-france-news-photo/481681619?adppopup=true">BSIP/Universal Images Group via Getty Images</a></span>
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<h2>‘Fat shaming’ doesn’t work</h2>
<p>This is just one version of the apology we owe our fellow human beings whom we told to lose weight using diet and exercise. Then, when it didn’t work, we blamed them for our treatment plan failures and smothered their feedback with prejudice and persecution. </p>
<p>As a <a href="https://www.linkedin.com/in/j-david-prologo-md-fsir-abom-d-40071861/">physician and researcher</a>, I have worked in this space for many years. I have witnessed firsthand the life-altering power of preexisting ideas, judgments and stereotypes. I have seen how unfounded, negative ideas are woven through virtually every interaction that those struggling with weight loss endure when seeking help. </p>
<p>And there are tens of millions of them. The Centers for Disease Control and Prevention classifies more than 70% of U.S. adults <a href="https://www.cdc.gov/obesity/data/adult.html">as overweight</a>, and more than 40% as obese. Those numbers continue to climb, and even when some manage to lose weight, <a href="https://www.apa.org/science/about/psa/2018/05/calorie-deprivation">they almost always gain it back</a> over time. </p>
<h2>Rash judgments</h2>
<p>To illustrate, imagine that I am your doctor. You have a body rash (which represents the condition of being overweight or obese), and you make an appointment with me to discuss a treatment plan. </p>
<p>During your visit, my office staff uses stigmatizing language and nonverbal signals that make it clear we are annoyed at the idea of dealing with another rash person. We invoke a set of assumptions that dictate the tone of our relationship, including the notions that you are lazy or ignorant or both. You will sense my disgust, which will make you uncomfortable. </p>
<p>Unfortunately, health care providers commonly treat patients who struggle with weight loss by assigning stereotypes, snap judgments and ingrained negative attributes – including <a href="https://4617c1smqldcqsat27z78x17-wpengine.netdna-ssl.com/wp-content/uploads/Weight-Bias-in-Healthcare.pdf">laziness, noncompliance, weakness and dishonesty.</a> </p>
<p>After this uncomfortable exchange, I will prescribe a treatment program for your rash and explain that it’s quite straightforward and easy to use. I will point you to several resources with pictures of smiling people with beautiful skin who never had a rash to emphasize how wonderful your outcome will be. “It’s just a matter of sticking to it,” I will say.</p>
<p>Back at home, you are excited to start treatment. However, you quickly realize that putting on the cream is unbearable. It burns; your arms and legs feel like they’re on fire shortly after you apply the treatment. You shower and wash off the cream. </p>
<h2>A dismal conversation</h2>
<p>After a few days, you try again. Same result. Your body will not accept the cream without intolerable burning and itching. You return to my office, and we have the following conversation:</p>
<p><strong>You</strong>: Doctor, I cannot stick to this plan. My body cannot tolerate the cream. </p>
<p><strong>Me</strong>: This is exactly why doctors do not want to deal with rash people. I’m giving you the treatment and you won’t stick to it. I put the cream on myself every morning without an issue.</p>
<p><strong>You</strong>: But you don’t have a rash! Putting this cream on when you have a rash is different than putting it on clear skin. I do want to get rid of my rash, but I cannot tolerate this cream. </p>
<p><strong>Me</strong>: If you don’t want to follow the treatment, that’s up to you. But it’s not the cream that needs changing. It is your attitude toward sticking with it.</p>
<p>This exchange illustrates prejudical behavior, bias and a disconnect between a provider’s perceptions and a patient’s experience. </p>
<figure class="align-center ">
<img alt="For people trying to lose weight, new approaches are needed." src="https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=550&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=550&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356452/original/file-20200903-24-1p8ih1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=550&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">New approaches are needed for those trying to lose weight.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cape-verdean-woman-weighing-herself-royalty-free-image/155771035?adppopup=true">Jamie Grill/JGI via Getty Images</a></span>
</figcaption>
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<h2>Prejudice and bias</h2>
<p>For someone who wants to lose weight, the experience of a diet and exercise prescription is not the same as for a lean person on the same program. Perceiving another person’s experience as the same as one’s own when circumstances are different <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1559-1816.2000.tb02464.x">fuels prejudice and bias</a>.</p>
<p>That night, though, you can’t help but wonder: “Is something wrong with me? Maybe my genes or thyroid or something? The cream seems so fun and easy for everyone else.” </p>
<p>At this point, the blame unconscionably lands on the patient. Despite an undeniable explosion of this rash, and abysmal treatment adherence rates while <a href="https://www.cdc.gov/nchs/products/databriefs/db313.htm">we have been touting the cream</a>, we stubbornly maintain it works. If the rash is expanding, and hundreds of millions of people are failing treatment or relapsing every day, well – it’s their own fault! </p>
<p>As time goes on, you feel increasingly discouraged and depressed because of this untenable situation. Frustration wears on your sense of optimism and chips away at your happy moments. You have this rash and you can’t tolerate the treatment plan, but no one believes you. They judge you, and say you choose not to use the cream because you lack willpower and resolve. You overhear their conversations: “It’s her own fault,” they say. “If that were me, I would just use the d#$% cream.” </p>
<p>This is the very definition of prejudice: an opinion, often negative, directed toward someone and related to something that the individual does not control. Although it has been extensively demonstrated that the causes for overweight and obesity are multifactorial, the myth that it’s the patient’s fault <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1559-1816.2000.tb02477.x">is still widely accepted</a>. This perception of controllability leads to the <a href="https://www.nature.com/articles/nrn3800.pdf?origin=ppub">assignment of derogatory stigma</a>.</p>
<h2>A setup for failure</h2>
<p>That evening you sit alone. You think there’s not a single person on the planet who believes your body won’t tolerate this treatment. Society believes you brought this on yourself to begin with; there doesn’t seem to be a way out. </p>
<p>We have driven those with overweight and obesity conditions to this place far too many times. We have set them up to take the fall for our failed treatment approaches. When they came to us with the truth about tolerability, we loudly discredited them and said they were mentally weak, noncompliant or lazy. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>So where do we go from here? If we agree to stop stigmatizing, stereotyping and blaming patients for our treatment failures, and we accept that our current nonsurgical paradigm is ineffective – what takes its place? </p>
<p>For starters, we need a new approach, founded on respect and dignity for patients. A fresh lens of acceptance and suspended judgment will allow us to shift our focus toward treatments for the body, rather than “mind over matter,” which is a concept we use for no other medical condition. A perspective based in objectivity and equality will allow caregivers to escape the antiquated blaming approach and perceive those with overweight or obese conditions in the same light as those with other diseases. Only then will we finally shift the paradigm.</p><img src="https://counter.theconversation.com/content/145017/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J. David Prologo does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>All too often the medical community ‘fat-shames’ patients trying to lose weight, when in fact obesity and overweight are complicated medical issues.J. David Prologo, Associate Professor, Emory University School of Medicine, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1294042020-01-22T13:37:40Z2020-01-22T13:37:40ZSnacks after youth sports add more calories than kids burn while playing, study says<figure><img src="https://images.theconversation.com/files/311237/original/file-20200121-117933-vut1pi.jpg?ixlib=rb-1.1.0&rect=0%2C198%2C3007%2C2069&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clark Moss, 12, of Gilbert, Ariz., shows the chips and drink he received after his soccer match, Jan. 18, 2020.</span> <span class="attribution"><span class="source">Kristi Moss</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Youth sports leagues are a great way for children to get physical activity, develop teamwork and create friendships. Research has shown that youth who participate in sports leagues are <a href="https://doi.org/10.1177/0044118X03261619">eight times as likely to be active</a> in their early 20s than those who don’t participate. </p>
<p>This is good news for the more than half of American youth ages 6 to 12 who <a href="https://assets.aspeninstitute.org/content/uploads/2018/10/StateofPlay2018_v4WEB_2-FINAL.pdf">participated in a team sport</a> in 2017, with baseball, basketball and soccer being the most popular. But our recent research showed that snacks after youth sports games contained more calories than the amount kids burned.</p>
<p>Both of us are faculty members in public health who study childhood obesity. Most of <a href="https://scholar.google.com/citations?user=87v4Nk4AAAAJ&hl=en">Jay’s work</a> is in physical activity and looks at the effect of the environment on health, including parks and city design. <a href="https://scholar.google.com/citations?user=wBHmJEkAAAAJ&hl=en">Lori</a> specializes in the food environment and has examined the effects of school breakfast and salad bar programs on student nutrition. </p>
<h2>Snacks and youth sports</h2>
<p>Our interest in this issue started years ago. When I (Jay) was growing up in the 1980s, I loved playing in youth basketball and baseball leagues. Twenty-five years later, I was excited to enroll my sons in youth sports, including basketball, soccer and flag football. </p>
<p>However, from the first team meeting, something was different. The coach passed around a sign-up sheet to bring a grab-and-go snack for the team. I was surprised by this. When I was growing up, the only sport that had a snack was soccer, and that was oranges and water at half time. Why did these kids need a snack at 2 in the afternoon? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/311192/original/file-20200121-117943-4xwn8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A hot dog and chips do not make a healthy snack for kids, but such a snack led to the authors’ interest in studying how many calories are typically in after-sport snacks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hot-dog-potato-chips-on-white-8721154">LM Photos/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>I signed up later in the season to see what the other parents were bringing as snacks. I was even more surprised when the snack turned out to be a hot dog in a bun, a bag of chips, a cookie and a sports drink! My son had just eaten lunch a couple of hours before and had only played for 20 minutes. </p>
<p>I thought to myself: They have got to be consuming more calories than they expended. A few years later, Lori Spruance and I decided to test this and find out if it was true.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/311190/original/file-20200121-117917-7k2nze.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Kids running up and down a soccer field can burn a lot of calories, but that expenditure can be negated by sugary or other unhealthy snacks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/four-multicultural-kids-playing-football-on-1505467880">LightField Shudios/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Testing our ideas</h2>
<p>Lori and her team went out between April and October of 2018 and observed 189 youth sports games for children in the third and fourth grade. The games included soccer, baseball, softball and flag football, and both mixed-gender and single-gender leagues. </p>
<p>To measure calorie expenditure, we used a highly valid and reliable <a href="https://activelivingresearch.org/sofit-system-observing-fitness-instruction-time">systematic observation tool</a> to assess the duration and intensity of children’s physical activity during the game. The researchers also assessed the calorie content of the food provided, either through the packaging or by measuring the amount of food served. </p>
<p>We found that on average children got 27 minutes of physical activity per game and burned about 170 calories. We were not surprised to find that children playing soccer were the most active, and softball players were the least active. At four out of five games, or 78%, parents served a post-game snack. </p>
<p>When a snack was served, it averaged 213 calories – on average, 43 more calories than the children had expended playing the sport. The most common snacks were baked goods, such as brownies, cookies and cake, followed by fruit snacks, crackers and chips. We were even more disturbed that the average amount of sugar provided was 26.4 grams, exceeding the American Heart Association’s <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sugar/how-much-sugar-is-too-much">recommendation of 25 grams</a> of sugar per day.</p>
<h2>Easy ways to make some changes</h2>
<p>We looked at the findings to try to develop a low-cost intervention to help change these effects. Beverages stood out as a major contributor of sugar. In the 145 games where a beverage was served, soda, fruit drinks and sports drinks were served over 85% of the time. Water (3%), milk (1%) and 100% fruit juice (8%) were almost never served. Sugar from drinks (18.3 grams) per serving exceeded sugar from snacks (12.3 grams). </p>
<p>Before the next sport’s season, we developed a <a href="https://byu.app.box.com/s/va2rale5oayfp7y1gi0xdu02jeozar9n">one-page fact sheet</a> on smart snacks for your athlete for teams that choose to provide a snack. It recommended water as the drink of choice and small healthy snacks, including mixed nuts, fresh fruit, string cheese, dried fruit and granola bars. These fact sheets were emailed to parents and posted on the local parks and recreation website prior to the season, and researchers came back during the season to see if any changes were made.</p>
<p>Our preliminary results show that the information provided made a difference. We found that 16% of the snacks in the second season included water instead of a sugary beverage; sugary beverage offerings dropped from almost 90% to 80%; and fruits and vegetables increased from 3% to 15%, with an overall drop of 20 calories per game. </p>
<p>These changes appeared to be an easy way for parents to make the smart choice and provide a healthier alternative for their children. </p>
<p>Although 43 calories may not seem like a lot, if a child plays two games a week across 50 weeks this can add up to 4,000 calories or more than a pound of weight per year. </p>
<p>Little changes can make a big difference in promoting healthy body weights in our children. So when your children are playing sports, we recommend making the healthy choice and choosing water, fruits and vegetables and a healthy protein source too, like nuts.</p>
<p>[ <em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129404/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Youth sports are a great way for kids to be active, but a recent study showed that after-sports snacks, on average, had 43 more calories than the amount burned during the activity.Jay Maddock, Professor of Public Health, Texas A&M UniversityLori Andersen Spruance, Assistant Professor of Public Health, Brigham Young UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1076502019-01-18T11:41:27Z2019-01-18T11:41:27ZFood is medicine: How US policy is shifting toward nutrition for better health<figure><img src="https://images.theconversation.com/files/253287/original/file-20190110-43538-fvltd2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Policymakers are responding to a growing recognition of food as medicine.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthy-food-heart-cholesterol-diet-concept-335916854?src=PNpCFrYdWeT2cRtJM0ZiFw-1-11">udra11/Shutterstock.com</a></span></figcaption></figure><p>In this new year, millions of Americans will make resolutions about healthier eating. In 2019, could U.S. government leaders further resolve to improve healthier eating as well, joining public health experts in seeing that food is medicine?</p>
<p>In 2018, Congress initiated a series of actions that represent a shift away from placing the full responsibility – and blame – on individual people to make their own healthier choices. These actions also show a growing recognition that many stakeholders – including the government – are accountable for a healthier, more equitable food system. This shift in thinking reflects an understanding that government can and should play a role in improving the diet of Americans. </p>
<p>As faculty members at Tufts University, our expertise spans clinical medicine, nutrition science, public health, policy analyses, Congress, federal agencies and government programs. It’s clear to us that the time is right for meaningful policy action to leverage food as medicine. </p>
<h2>Why healthier eating is a national priority</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/253291/original/file-20190110-43541-1cfi5jk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Poor diet has caused major health problems and claimed an outsized share of federal and state budgets.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unhealthy-products-food-bad-figure-skin-1042217737?src=wHaaZ6ZM7_EAzNQ4HSWBkw-1-56">beats1/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Poor diet is among the greatest health and societal challenges of our time, causing death and disability, soaring health care spending, budget challenges for governments and private business, diminished military readiness and population disparities. </p>
<p>Medicare and Medicaid, the government programs that pay for medical care for people over age 65, low-income families, and the disabled, now consume US$1 in $4 in the federal budget. In addition, nearly <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf">$1 in $5</a> in the entire U.S. economy is spent on health care, creating massive threats to the health of the national economy.</p>
<p>Diet-related diseases are major contributors to these expenses. For example, the annual medical and economic costs of heart disease and stroke are estimated at <a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000350">$316 billion</a>; of diabetes, <a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000350">$327 billion</a>; and of all obesity-related conditions, <a href="http://assets1b.milkeninstitute.org/assets/Publication/ResearchReport/PDF/Weighing-Down-America-WEB.pdf">$1.42 trillion</a>. These costs create enormous economic challenges for federal and state governments as well as for private American businesses, families, and individuals through rising health care premiums, out-pocket-costs, missed work and lower productivity. </p>
<p>Diet-related health burdens and costs also influence military readiness. Two-thirds of active duty military forces are overweight or obese, while 71 percent of young Americans are <a href="https://www.strongnation.org/articles/737-unhealthy-and-unprepared">unable to join the military</a> for one or more reasons, with obesity as the leading medical disqualifier. </p>
<p>The overall U.S. food system – including farming and imports, supermarkets and retail, restaurants and cafeterias, and food manufacturers – also reflects and contributes to profound disparities, especially among children. Minorities and the poor often have the <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2684625">worst diets</a>, causing a vicious cycle of <a href="https://now.tufts.edu/news-releases/americans-supplemental-nutrition-assistance-program-snap-have-higher-mortality">poor health</a>, lower school performance, lost productivity, increased health costs and poverty. </p>
<h2>Hungry for good food</h2>
<p>As policymakers increasingly recognize the depth and breadth of these effects, they are beginning to act. In January 2018, House lawmakers created a bipartisan <a href="https://www.foodnavigator-usa.com/Article/2018/05/09/Food-is-Medicine-Working-Group-could-open-doors-for-personalized-nutrition-medically-tailored-meals#">“Food is Medicine” working group</a>, dedicated to innovations in nutrition policy to improve health and reduce diet-related health costs. Simply the existence of a group in Congress focused on “Food is Medicine,” which hosted multiple briefings for congressional staff on key legislation to integrate nutrition into federal policy, is an advance.</p>
<p>On June 7, 2018, Congress instructed the U.S. Government Accountability Office to perform a <a href="https://timryan.house.gov/media/press-releases/reps-tim-ryan-and-rosa-delauro-request-gao-report-food-policy-and-public-health">comprehensive assessment and accounting</a> of all federal policies related to food, chronic diseases and health care costs. The GAO is the government “watchdog,” providing independent audits of agencies and policies. The GAO has been asked to investigate <a href="https://timryan.house.gov/media/press-releases/reps-tim-ryan-and-rosa-delauro-request-gao-report-food-policy-and-public-health">six specific questions</a> across diverse federal agencies and programs, including the evidence linking diet to chronic diseases, the corresponding national and federal health care costs, and the current strategies and missed opportunities to reduce these risks and costs. A series of GAO reports on food policy will likely come out in 2019 and 2020. The launch of this investigation represents a federal milestone for its scope and recognition of the opportunities in food policy. </p>
<p>The <a href="https://docs.house.gov/billsthisweek/20181210/CRPT-115hrpt1072.pdf">2018 Farm Bill</a>, signed into law on Dec. 20, 2018, included several important provisions for healthier eating, especially in the Supplemental Nutrition Assistance Program (SNAP), which supports about one in seven Americans. This included expansion of the fruit and vegetable subsidy program to $250 million, a new $25 million Produce Prescription Program and strengthening of SNAP-Education, a $400 million/year nutrition education program. Several of these advances were recommended by the <a href="https://bipartisanpolicy.org/library/leading-with-nutrition-leveraging-federal-programs-for-better-health/">2018 Bipartisan Policy Center report on healthier SNAP</a>, chaired by former Senate Majority Leader Bill Frist, M.D., and USDA Secretaries Ann Veneman and Dan Glickman.</p>
<p>While there were advances in the Farm Bill, a proposed amendment to include pilot testing for <a href="http://www.fimcoalition.org/">medically tailored meals</a> was rejected. Medically tailored meals are ready-to-eat, personalized meals provided at home to low-income patients with complex medical illnesses like cancer, HIV, diabetes or heart failure. <a href="http://www.fimcoalition.org/new-page/">Several recent studies</a> show that providing medically tailored meals to patients is associated with reduced hospitalizations, emergency room visits and overall health care spending. While this is a missed opportunity in the Farm Bill, the state of California is currently testing the effects of medically tailored meals on health outcomes and costs in a <a href="https://calfimc.org/medical-pilot/">$6 million Medicaid intervention</a> across six counties, which will provide new evidence for possible future national expansion.</p>
<h2>Your produce is ready</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=277&fit=crop&dpr=1 600w, https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=277&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=277&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=348&fit=crop&dpr=1 754w, https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=348&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/253294/original/file-20190110-43544-ny625k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=348&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fresh produce such as this could soon be prescribed by doctors for good health.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unrecognizable-female-farmer-holding-crate-full-1104855071?src=yGHSEnmDBhP3c17-Zfc5Qg-1-4">ABO PHOTOGRAPHY/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Among the Farm Bill changes, we believe that the new Produce Prescription Program holds special promise. Already offered by some <a href="https://www.wholesomewave.org/">nonprofit and private insurance programs</a>, this new federal program will allow doctors to prescribe not just medications but also subsidized purchases of fruits and vegetables. While the $25 million represents a small relative investment, this direct federal commitment to evaluate produce prescriptions in health care has the potential to provide evidence to support future expansion throughout Medicaid and Medicare. </p>
<p>Together, these congressional activities in 2018 represent an evolution toward incorporating and addressing nutrition, diet-related diseases and their health care costs in federal policy. These actions build upon mounting public awareness of the central role of food in well-being; the accelerating consumer demand for, and corresponding industry shifts toward, healthier foods; and the growing recognition that individual consumers cannot be solely responsible for the current challenges in the food system. </p>
<h2>Recommended policy actions</h2>
<p>The recent congressional actions toward viewing food as medicine coincide with new scientific evidence on how <a href="https://link.springer.com/article/10.1007%2Fs11883-018-0726-x">specific government policies</a> can improve nutrition and well-being, reduce health care costs and reduce disparities. </p>
<p>We believe that meaningful progress on these national challenges will require far more substantive policy changes that can make healthier eating the easy, accessible, less expensive option. Based on <a href="https://www.bmj.com/content/361/bmj.k2426">recent reviews</a> of the science as well as <a href="https://food-price.org/">our new research</a>, particularly promising federal government strategies for consideration include: </p>
<ul>
<li><p>Strengthening of <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194555">nutrition standards</a> in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200378">schools</a>, after school, early childhood education programs and child feeding programs, as well as in cafeterias at federal worksites and other federal facilities, such as prisons and Veterans Affairs hospitals. </p></li>
<li><p>Federal incentives to incorporate nutrition into corporate worksite wellness programs, such as <a href="https://jhrewardslife.johnhancockinsurance.com/about-vitality.html">personalized, interactive technology platforms, gameification and economic incentives</a> already available in private insurance and corporate programs.</p></li>
<li><p>A <a href="https://now.tufts.edu/news-releases/junk-food-tax-legally-and-administratively-viable-finds-new-analysis">federal excise tax</a> on <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002311">sugar-sweetened beverages</a> and junk food, especially if tax revenues are used to <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0971-9">subsidize healthier foods</a>, making the latter’s prices both more affordable and closer to their true societal value.</p></li>
<li><p><a href="https://www.bmj.com/content/361/bmj.k2426">Integrating nutrition into health care</a>, including in the electronic health record, medical education and licensing standards, fruit and vegetable prescriptions, medically tailored meals, provider quality and reimbursement guidelines, and risk-sharing arrangements that incentivize providers to improve the health of their communities. </p></li>
<li><p>Leveraging the $70 billion per year SNAP program for <a href="http://www.bipartisanpolicy.org/SNAP">better nutrition for low-income families</a>, for example through further strengthening of <a href="https://snaped.fns.usda.gov/about">SNAP-Education</a>, increased <a href="https://jech.bmj.com/content/72/9/817.long">subsidies for fruits and vegetables</a> and a <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002661">combined food incentive/disincentive program</a> to nudge people toward healthier choices. </p></li>
<li><p>U.S. Food and Drug Administration <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002551">labeling standards and limits</a> for additives such as salt, trans fat and added sugar; marketing standards to protect children; and evidence-based health claims for products that can help achieve better health.</p></li>
<li><p>Increased federal research funding, including a new National Institute of Nutrition at the National Institutes of Health; as well as economic incentives for transparent public-private partnerships for health-focused food innovation and entrepreneurship. </p></li>
</ul>
<p>Policy change is often not linear. Based on the significant impacts of nutrition on disease, health care, the economy, military readiness, disparities and the environment, federal actions in 2018 laid the foundation for nonpartisan federal leadership to create meaningful and lasting solutions.</p><img src="https://counter.theconversation.com/content/107650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Mozaffarian reports research funding from the National Institutes of Health and the Gates Foundation; and personal fees from GOED, Nutrition Impact, Pollock Communications, Bunge, Indigo Agriculture, Amarin, Acasti Pharma, Cleveland Clinic Foundation, America’s Test Kitchen, and Danone; scientific advisory board, Elysium Health (with stock options), Omada Health, and DayTwo; and chapter royalties from UpToDate; all outside the submitted work. </span></em></p><p class="fine-print"><em><span>Renata Micha receives funding from the National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Jerold Mande does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diet-related illnesses cost more than US$1 trillion and immeasurable human suffering and pain. Policymakers are beginning to understand that it makes sense to support food-as-medicine initiatives.Dariush Mozaffarian, Dean, cardiologist, professor, Tufts UniversityJerold Mande, Professor of Nutrition, Tufts UniversityRenata Micha, Associate research professor, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1064092019-01-08T11:40:10Z2019-01-08T11:40:10ZLet them eat more fat? Researcher argues that a balance of types of fat is the key<figure><img src="https://images.theconversation.com/files/252690/original/file-20190107-32124-vlzf8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"> A mix of fats, such as those found in nuts, avocados, salmon and olives, could be healthy and more satisfying.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selection-healthy-fat-sources-on-wooden-396446890?src=ekSdGUl72cn3WGKgPd-dZQ-1-2">Craevschii Family/Shutterstock.com</a></span></figcaption></figure><p>Public health guidelines, such as the <a href="https://health.gov/dietaryguidelines/2010/">Dietary Guidelines for Americans</a>, have long emphasized reducing dietary fat intake, but nutritionists and other health scientists now have more recent evidence that not all fats have adverse effects. Dietary fats differ with regard to their effects on health and risk for chronic diseases, particularly in regard to effects on risk for heart disease. </p>
<p>Indeed, <a href="https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/dietary-fat-and-disease/">some nutrition experts</a> now believe that certain types of dietary fat may even reduce cardiovascular risk. Some dietary fats may lower fats in the blood called <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/triglycerides/art-20048186">triglycerides</a>. They may also increase levels of HDL, or what is known as the “good” cholesterol, and <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/the-facts-on-fats">reduce LDL-cholesterol</a>, or the less healthy type of cholesterol, thus improving the HDL to <a href="https://www.sciencedirect.com/science/article/pii/S0735109707032597?via%3Dihub">total cholesterol ratio</a>. </p>
<p>Also, many diet plans that do not strictly limit the total amount of dietary fat a person consumes have been associated with <a href="https://onlinelibrary.wiley.com/doi/full/10.1177/0884533611405791">better diet satisfaction</a>, weight loss, and preservation of muscle mass. </p>
<p>As a research professor in the field of nutrition and dietetics, I am convinced that findings <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306330/">from our work</a>, along with other published current evidence, show that the concept that dietary fat is “toxic” is very much outdated and misguided. </p>
<p>Although there is conclusive evidence that one type of fat, trans fat, has no place in a healthy diet, it’s important to learn how to balance the other types of fats in the diet.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ro4UObvPpdo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Prof. Heidi Silver discusses the role of dietary fat.</span></figcaption>
</figure>
<h2>A balancing act</h2>
<p>While not all fats are alike, they do share some things in common. They provide energy with approximately <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/monounsaturated-fats">nine calories per each gram of fat</a>, they are all broken down during digestion by enzymes in the gastrointestinal tract, and they are well absorbed as fatty acids, or <a href="https://www.britannica.com/science/hydrocarbon">chains of hydrogen and carbon</a>. </p>
<p>But these carbon chains vary in length and their degree of saturation. As a result, dietary fats vary in their effects on the body.</p>
<p>In some instances, the carbon molecules bind to other carbon molecules. In others, they bind to hydrogen molecules. You likely have heard names for these two types of fats – unsaturated and saturated. Unsaturated fats are those in which carbon molecules bind to other carbon molecules. <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/saturated-fats">Saturated fats</a> are those in which carbon molecules bind to hydrogen molecules. Within the two broad types of fat, there are differences still.</p>
<p>Among the unsaturated fats, there are those that are <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/monounsaturated-fats">mono-unsaturated</a>, or those that have one unsaturated carbon bond, which are found in olive oil and certain kinds of nuts, and there are those that are <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/polyunsaturated-fats">poly-unsaturated</a> and are found in such foods as walnuts, plant oils, salmon and sardines. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=260&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=260&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=260&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=327&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=327&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252693/original/file-20190107-32127-7th6aw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=327&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This illustration of stearic acid shows the 18 carbon molecules binding to 36 hydrogen molecules and to two oxygen molecules.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/stearic-acid-molecular-formula-c18h36o2-saturated-1085497997?src=14tXPwxJ0chL73lBWd85aw-1-15">Orange Deer Studios/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>We also have learned that different kinds of saturated fats affect the body in different ways. For example, the 12-carbon lauric acid, 14-carbon myristic acid, 16-carbon palmitic acid and 18-carbon stearic acid are all saturated fats. But, <a href="https://www.nejm.org/doi/full/10.1056/NEJM198805123181905?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">stearic acid</a> does not increase LDL-cholesterol levels like the other saturated fats. </p>
<p>While these differences are not new, the understanding of their effects is new, mostly due to findings from more recent studies like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306330/">my own</a>. </p>
<p>Thus, the amount of total fat in the diet no longer is the sole measure of the health effects of dietary fat. It’s also about the type of fatty acid, how long the carbon chain is, and whether the fat is saturated, mono-unsaturated or poly-unsaturated. </p>
<h2>The link to heart health</h2>
<p>The scientific discourse about the potentially toxic role of dietary fat and cholesterol on human health started in the late 1950s and early 1960s, when scientists discovered how to analyze fats in the lab. They also discovered the link between <a href="https://www.ncbi.nlm.nih.gov/pubmed/13376806">dietary fat intake</a>, serum levels of total and LDL-cholesterol, and risk for cardiovascular diseases in animals. </p>
<p>Because heart disease has been the leading cause of death in the U.S. since the 1930s, the Nutrition Committee of the American Heart Association in 1968 recommended <a href="https://www.heart.org/-/media/files/healthy-living/company-collaboration/inap/dietary-fat-recommendations-timeline-pdf-ucm_474998.pdf">reducing total and saturated fat intake</a>. The emphasis on <a href="https://health.gov/dietaryguidelines/dga95/12DIETAP.HTM">lowering dietary fat</a> intake was advanced further in 1977 with the publication of the first Dietary Guidelines for Americans by the Senate Select Committee on Nutrition and Human Needs. </p>
<p>Health care professionals in turn shifted their nutrition counseling efforts toward encouraging a low-fat diet. And, the food industry began to develop and produce of a wide-ranging assortment of “low-fat,” “reduced-fat,” “light” and “fat-free” items. </p>
<p>In the mid-1980s, advice to consume a low-fat diet also became a strategy for weight control. Evidence from the landmark <a href="https://www.framinghamheartstudy.org">Framingham Heart Study</a> uncovered that obesity increased risk for heart disease, and national data showed that the entire population was getting heavier. </p>
<p>Americans responded with a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598942/">substantial reduction</a> in the percentage of calories consumed as fat. But humans have a <a href="https://www.ncbi.nlm.nih.gov/books/NBK53528/">biological preference</a> for the taste of fat. And with fat off the table, millions increased their consumption of dietary carbohydrates to compensate for the loss in flavor and appeal of foods. As a result, there has been a substantial increase in the waistlines of Americans. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252709/original/file-20190107-32145-gp9s07.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Studies have shown that humans have a preference for foods that contain fat, such as this slab of steak.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/against-sliced-raw-steak-344404673?src=ph6BufMyu5FU49Nb8xZ90A-1-20">Paolo Santos/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>An alternative approach</h2>
<p>Given the mixed scientific evidence on fat, and the diverse roles of dietary fatty acids in health and disease, about four years ago I designed a diet that is moderately high in fat but the types of fat are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306330/">proportionally balanced</a>, that is, one-third of total fat comes from saturated fats; one-third comes from monounsaturated fats; and one-third comes from polyunsaturated fats. </p>
<p>Based on this balanced moderately-high fat diet approach, my research team developed a 14-day cycle of menus comprised of three meals and two snacks per day that increases intake of foods high in the 18-carbon monounsaturated fat, oleic acid, and the 18-carbon and longer chain polyunsaturated fats (more commonly known as omega-3 and omega-6 fatty acids). To do this, we replaced high simple carbohydrate snacks with nuts, we replaced croutons in salads with avocado slices, and we used salad dressings high in safflower oil, canola oil and olive oil. </p>
<p>We have been studying the effects of this balanced moderately high fat diet in adults who are overweight or obese. In a study with 144 women over a period lasting 16 weeks, we found that study participants had <a href="https://www.ncbi.nlm.nih.gov/pubmed/24559846">significant reductions</a> in abdominal fat and waist circumference; a 6 percent improvement in blood pressure; reduced blood levels of markers of inflammation; and overall a 6 percent reduction in their five- and 10-year cardiovascular risk. </p>
<p>Study participants reported that they found our diet to be highly palatable, satisfying and economically feasible to adhere to. The firm adherence to our balanced moderately high fat diet in the four-month study was reflected by significant changes in participants’ plasma fatty acid profiles (the array of saturated and unsaturated fats in the blood) that reflected the fatty acid composition of the diet menus.</p>
<p>In a follow-up study using more in-depth analysis of the lipid response to the balanced moderately high fat diet, we found a difference in response between Caucasian females and African-American females. While the Caucasian females had improvements in serum triglyceride and LDL-cholesterol levels, African-American females had the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29382504">most significant improvement</a> in HDL-cholesterol levels. These data support the concept that not all people respond to a dietary approach in the same way and there is no one optimal diet for all people. </p>
<p>In another follow-up study of the response to a higher fat diet, we also found that people with a specific genotype had a stronger response, and that response differed by sex, particularly with regard to improvements in HDL-cholesterol being <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306330/">stronger in females versus males</a>. </p>
<p>Thus, I believe the choice of an effective dietary approach must be determined based on an individual’s goals and an individual’s clinical and metabolic response to the interaction between genes and environment. </p>
<p>There are limited studies on the strategy of balancing the type of dietary fat. While current scientific consensus is that extremes of dietary fat intake, too high or too low, are unhealthy, I believe that a paradigm shift focusing on the types of dietary fats consumed may offer the opportunity to modify our cardiometabolic risk factors without requiring major changes in the amount of fat or calories we consume.</p><img src="https://counter.theconversation.com/content/106409/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi J. Silver received funding to study dietary fat from the Atkins Foundation. </span></em></p>When did eating become so confusing? In the 1960s, studies began to show a link between heart disease and dietary fat, and fat was demonized. As it turns out, fat is nuanced and may not be so bad.Heidi Silver, Associate Professor of Medicine, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1064842018-12-07T11:40:46Z2018-12-07T11:40:46ZBeware of natural supplements for sex gain and weight loss<figure><img src="https://images.theconversation.com/files/249343/original/file-20181206-128190-hd2cwb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Natural supplements may be popular, but they can have dangerous side effects when they include prescription drugs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/muscular-man-protein-drink-shaker-over-548586616?src=dZrpQEpAprfLrAJaUdrkmQ-1-64">Oleksandr Zamuruiev/Shutterstock.com</a></span></figcaption></figure><p>Many consumers consider dietary supplements to be natural and, therefore, safe. In fact, the Council for Responsible Nutrition reported in 2017 that 87 percent of U.S. <a href="https://www.crnusa.org/newsroom/dietary-supplement-usage-increases-says-new-survey">consumers have confidence</a> that dietary supplements, such as vitamins, minerals, herbs, botanicals, oils, microbiome bacteria and amino acids, are safe and effective. Unfortunately, their confidence may be misplaced when it comes to supplements for male sexual dysfunction and weight loss.</p>
<p>According to the Food and Drug Administration, 776 dietary supplement products from 146 different manufacturers sold between 2007 and 2016 contained <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706496">synthetic/prescription drugs</a>. Most of these products are marketed for just <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706496">two conditions</a>, sexual enhancement (45.5 percent) or weight loss (40.9 percent). </p>
<p>Why does this matter?</p>
<p>As a pharmacist and dietary supplement researcher, I’m concerned about the <a href="https://www.ncbi.nlm.nih.gov/pubmed/14722148">hidden inclusion</a> of these prescription drugs in supplements. It increases the risk of patient harm, and it allows people to attribute the benefits and harms they experience to an herb rather than to the true culprit – the added drug. This makes it harder for doctors and pharmacists to decipher in what types of patients these natural therapies could be used and in whom they should be avoided.</p>
<h2>Risky sex enhancement pills</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249344/original/file-20181206-128217-5cg3bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Packaging for Viagra in a Madrid pharmacy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/madrid-spain-july-4-viagra-drug-1127047736?src=RPw803JCOEcrMa-Apr6VWw-1-6">Enriscapes/Shutterstock.com</a></span>
</figcaption>
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<p>It is considered malpractice for pharmacists to fill prescriptions for erectile dysfunction (ED) drugs like Viagra, Levitra or Cialis if patients are taking nitrate drugs, such as nitroglycerin pills or spray or isosorbide mono/dinitrate. These nitrate drugs are often used to treat chest pain or heart failure. Combining them with a drug to treat ED; as the FDA said the makers of Willy Go Wild did, can cause a patient’s blood pressure to drop precipitously. This in turn can lead to <a href="https://www.medscape.com/viewarticle/556235_7">hospitalization or death</a>. </p>
<p>Some patients taking nitrate drugs, who cannot safely take one of the ED drugs, have turned instead to so-called natural products. Had they bought one of the 353 tainted products, they would have gotten the <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706496">same active ingredients</a> nonetheless. </p>
<p>In addition, prescription erectile dysfunction drugs can cause <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236300/">priapism</a>, a medical emergency where the penis can be irreparably damaged. The higher the dose consumed, the greater the risk. So imagine you want to enhance your prescription erectile dysfunction drug with an herbal remedy only to find out you were getting a prescription drug’s active ingredient instead. There are <a href="https://www.ncbi.nlm.nih.gov/pubmed/23386071">cases of priapism</a> with herbal sexual dysfunction medications. </p>
<h2>ED drugs and antidepressants</h2>
<p>Some other dietary supplement products for male enhancement added a drug called <a href="https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/medicationhealthfraud/ucm479105.htm">daptoxetine</a>. The FDA has not approved it for any reason, including sexual dysfunction. People on other serotonin-enhancing drugs for depression or intestinal issues are more likely to end up with a condition called <a href="https://www.mayoclinic.org/diseases-conditions/serotonin-syndrome/symptoms-causes/syc-20354758">serotonin syndrome</a> when inadvertently exposed to this undisclosed drug. Serotonin syndrome is a life-threatening problem with high body temperatures, muscle stiffness, seizures and kidney damage.</p>
<p><a href="https://www.everydayhealth.com/drugs/sibutramine">Sibutramine</a>, an appetite suppressant, was removed from the U.S. market by the FDA in 2010 because its use increases the risk of heart attacks and strokes. However, 269 dietary supplement products touted for weight loss <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706496">contained sibutramine</a>, and others contained the stimulants ephedrine and fenfluramine. </p>
<p><a href="https://www.rxlist.com/ephedrine-side-effects-drug-center.htm">Ephedrine</a>, a stimulant, was banned in the U.S. because it also <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706496">increased cardiovascular risk</a>. <a href="https://pubchem.ncbi.nlm.nih.gov/compound/fenfluramine#section=Top">Fenfluramine</a>, an amphetamine derivative, was combined with phentermine in the popular “fen-phen” <a href="https://www.webmd.com/heart-disease/news/20081105/lasting-heart-damage-from-fen-phen#1">diet that was banned</a> after numerous cases of pulmonary hypertension, heart valve damage and heart failure occurred. </p>
<p>Still other dietary supplement products for weight loss contained the laxative phenolphthalein or prescription diuretics. <a href="https://pubchem.ncbi.nlm.nih.gov/compound/phenolphthalein#section=Health-Hazard">Phenolphthalein</a> is no longer used as a laxative in the U.S. because it may cause cancer and hurt fetuses. Laxatives and diuretics only cause weight loss through diarrhea or loss of water weight. They do not result in fat loss. They can cause <a href="https://ccforum.biomedcentral.com/articles/10.1186/s13054-015-1017-3">dangerously low blood pressure</a> and low blood potassium concentrations.</p>
<p>A study in the New England Journal of Medicine in 2015 estimated that dietary supplements led to 23,000 emergency department visits and over <a href="https://www.nejm.org/doi/full/10.1056/nejmsa1504267">2,000 hospitalizations</a> a year. Weight loss products or those related to increased energy also caused <a href="https://www.nejm.org/doi/full/10.1056/nejmsa1504267">72 percent of supplement-related adverse events</a>, including palpitations, chest pain or racing heart rate. I suspect the predominance of deliberate synthetic drug tainting of these dietary supplements might explain some of these findings.</p>
<h2>How can you protect yourself?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249346/original/file-20181206-128196-19mwbcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If a package claims to be magic or to provide a miracle cure, don’t buy it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/medicine-packet-named-magic-pills-medical-1092206453?src=fe-3-I4DB_EUukoawP7P2w-1-7">Peter Hermes Furian/Shutterstock.com</a></span>
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</figure>
<p>The FDA does not approve dietary supplements, and in many ways you are on your own. The Dietary Supplement Health and Education Act (DSHEA) of 1994 created a <a href="https://www.fda.gov/Food/DietarySupplements/">new category of health product</a>. As long as the product contains natural ingredients intended to promote or support health and not to diagnose, cure, treat, or prevent any disease, it qualifies as a dietary supplement. Under DSHEA, the FDA has to prove risk to human health before removing these products from the U.S. market.</p>
<p>The FDA, however, does have an <a href="https://www.accessdata.fda.gov/scripts/sda/sdNavigation.cfm?sd=tainted_supplements_cder">ongoing list</a> of products in which they have detected synthetic or prescription drugs, and you can check that out. If the product you have purchased is on that list, don’t use it. On Nov. 20, 2018, two dietary supplements for pain or drug addiction were found to be <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm626349.htm">tainted with tianeptine</a>, an antidepressant drug that is not FDA-approved for use in the U.S. market. If your product is not on that list, however, it doesn’t guarantee lack of tainting. The FDA simply does not have the resources to check the tens of thousands of dietary supplements on U.S. shelves. </p>
<p>Independent laboratory verification from the United States Pharmacopeia (USP) can help assure that the vitamin or herb specified on the label is in the bottle and that the product has a <a href="https://qualitymatters.usp.org/sites/default/files/user-uploaded-files/when-food-is-not-enough-download_0.pdf">low risk</a> of microbe, heavy metal or PCB contamination. Unfortunately, USP does not routinely test dietary supplements for synthetic or prescription drug tainting. </p>
<p><a href="https://www.consumerlab.com/methods_index.asp">ConsumerLab.com</a> does not usually test for prescription drug tainting during their product verification either. However, for <a href="https://www.consumerlab.com/reviews/review-of-sexual-enhancement-supplements-yohimbe-horny-goat-weed-arginine/sexenhancers/">sexual dysfunction drugs</a>, ConsumerLab.com did test for prescription drug tainting.</p>
<p>Beware of dietary supplements manufactured in Asia, because they are more likely to be contaminated and tainted according to the FDA. Also, ethnically diverse, non-English speaking and poor people are more likely to come across <a href="https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm466588.htm">tainted dietary supplements</a> because they shop for these products at ethnic stores, flea markets, swap meets or online. Buying from reputable brands in reputable stores or websites might reduce the risk. Finally, don’t believe miraculous claims of effectiveness, especially if the only data to back it up comes from testimonials.</p><img src="https://counter.theconversation.com/content/106484/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C. Michael White does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Men who can’t take drugs for erectile dysfunction and overweight people who can’t lose weight sometimes turn to natural supplements, thinking they are safe. Many times, they are not.C. Michael White, Professor and Head of the Department of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/978132018-06-27T10:43:05Z2018-06-27T10:43:05ZHow does your body ‘burn’ fat?<figure><img src="https://images.theconversation.com/files/224095/original/file-20180620-137714-1dcd549.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Increasing the amount of exercise is one way to use the energy stored in fat cells, or to 'burn' fat.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/three-friends-spinning-class-gym-133394168?src=II9xoptT9KKCDRMW0fq98A-1-3">HoonQ/Shutterstock.com</a></span></figcaption></figure><p>Many of us may be considering “burning some fat” so we feel better in our bathing suits out on the beach or at the pool. What does that actually mean, though? </p>
<p>The normal <a href="http://www.sportsci.org/encyc/adipose/adipose.html">fat cell</a> exists primarily to store energy. The body will expand the number of fat cells and the size of fat cells to accommodate excess energy from high-calorie foods. It will even go so far as to start depositing fat cells on our muscles, liver and other organs to create space to store all this extra energy from calorie-rich diets – especially when combined with a low activity lifestyle.</p>
<p>Historically, <a href="https://theconversation.com/stored-fat-is-a-feat-of-evolution-and-your-body-will-fight-to-keep-it-52468">fat storage</a> worked well for humans. The energy was stored as small packages of molecules called <a href="https://www.britannica.com/science/fatty-acid">fatty acids</a>, which are released into the bloodstream for use as fuel by muscles and other organs when there was no food available, or when a predator was chasing us. Fat storage actually conferred a survival advantage in these situations. Those with a tendency to store fat were able to survive longer periods without food and had extra energy for hostile environments.</p>
<p>But when was the last time you ran from a predator? In modern times, with an overabundance of food and safe living conditions, many people have accumulated an excess storage of fat. In fact, more than <a href="https://www.cdc.gov/obesity/data/adult.html">one-third</a> of the adult population in the United States is obese. </p>
<p>The major problem with this excess fat is that the <a href="https://academic.oup.com/ajcn/article/83/2/461S/4650268">fat cells</a>, called adipocytes, do not function normally. They store energy at an abnormally high rate and release energy at an abnormally slow rate. What’s more, these extra and enlarged fat cells <a href="https://www.acs.org/content/acs/en/pressroom/presspacs/2010/acs-presspac-october-13-2010/new-evidence-that-fat-cells-are-not-just-dormant-storage-depots-for-calories.html">produce abnormal amounts</a> of different hormones. These hormones increase inflammation, slow down metabolism, and contribute to disease. This complicated pathological process of excess fat and dysfunction is called <a href="https://link.springer.com/chapter/10.1007%2F978-3-319-39409-1_5">adiposopathy</a>, and it makes the treatment of obesity very difficult. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/224092/original/file-20180620-137734-dar3fv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A fat cell is loaded with triglycerides, or fatty deposits, and does not resemble other cells in our body.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/fat-cells-adipose-tissue-adipocytes-3d-400777933?src=sQKjdYuIWnE-T4fN1dwbfw-1-7">Pavel Chagochkin/Shutterstock.com</a></span>
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<p>When a person begins and maintains a new exercise regimen and limits calories, the body does two things to “burn fat.” First, it uses the energy stored in the fat cells to fuel new activity. Second, it stops putting away so much for storage. </p>
<p>The brain signals fat cells to release the energy packages, or fatty acid molecules, to the bloodstream. The muscles, lungs and heart pick up these fatty acids, break them apart, and use the energy stored in the bonds to execute their activities. The scraps that remain are discarded as part of respiration, in the outgoing <a href="https://www.merckmanuals.com/home/lung-and-airway-disorders/biology-of-the-lungs-and-airways/exchanging-oxygen-and-carbon-dioxide">carbon dioxide</a>, or in urine. This leaves the fat cell empty and renders it useless. The cells actually have a short lifespan so when they die the body absorbs the empty cast and doesn’t replace them. Over time, the body directly extracts the energy (i.e., calories) from food to the organs that need them instead of storing it first.</p>
<p>As a result, the body readjusts by decreasing the number and size of fat cells, which subsequently <a href="https://jamanetwork.com/journals/jama/fullarticle/196344">improves baseline metabolism</a>, decreases inflammation, treats disease, and prolongs lives. If we maintain this situation over time, the body reabsorbs the extra empty fat cells and discards them as waste, leaving us leaner and healthier on multiple levels.</p><img src="https://counter.theconversation.com/content/97813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Prologo is the founder of The Catching Point Transformation.</span></em></p>Trainers and fitness gurus often tell their charges how to ‘burn fat.’ But what does that actually involve? Here’s a Speed Read on something that actually takes a fairly long time.J. David Prologo, Associate Professor, Department of Radiology and Imaging Sciences, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/946152018-04-12T10:54:27Z2018-04-12T10:54:27ZOvereating? It may be a brain glitch<figure><img src="https://images.theconversation.com/files/214317/original/file-20180411-543-svfqvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The drive to overeat may be rooted in survival brain circuits.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-eating-marshmallow-jar-89764468?src=EG8vab09dAWu99tgZXeeqg-4-12">Phovoir/Shutterstock.com</a></span></figcaption></figure><p>With summer comes the desire to shed those few extra pounds, in preparation to don swimsuits and head to the pool. Obesity research is making it easier to find a pathway that is right for us.</p>
<p>There is no doubt that weight loss is a higher priority than ever before. Americans have never been fatter, with <a href="https://www.cdc.gov/nchs/fastats/obesity-overweight.htm">close to 40 percent obese</a> and <a href="https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity">70 percent overweight</a>. Clearly, wishful thinking that the problem is going to go away is not working. Meanwhile, the risk of those extra pounds is ever more apparent. Even one condition, pre-diabetes – with <a href="https://www.niddk.nih.gov/health-information/health-statistics/diabetes-statistics">84 million Americans currently affected</a> – can be daunting, as well as expensive. Moreover, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278808/">the annual cost of diabetes</a> in the United States is projected to climb to US$600 billion by 2030.</p>
<p>We want to lose weight and keep it off, but quick weight loss may not be the answer as it can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387402/">dramatically slow metabolic rates</a>, making weight rebound more likely. Nor is finding the “right diet” the solution as new research has shown that a variety of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29466592">healthy eating plans</a> all work similarly well, and with dieting rarely producing lasting weight loss, more people are <a href="https://jamanetwork.com/journals/jama/fullarticle/2608211">giving up on weight loss</a> altogether. </p>
<p>I am a health psychologist whose neuroscience research has led me to study the underlying causes of overeating and weight regain, specifically how physiologic stress or “brain stress” sets up a myriad of chemical changes that makes overeating and weight regain almost inevitable. I am convinced that much, if not most, of people’s struggles with food are based in the emotional part of the brain, specifically circuits that process stress, or circuits that we can rewire.</p>
<h2>Why do people overeat?</h2>
<p>One of the primary reasons people overeat and regain lost weight is that they have not changed the underlying behavior that leads them to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425607/">crave comfort from food</a>. These mechanisms play out mostly in the brain. Studies have shown that they are related to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4766925/">habitual ways of responding to stress</a> that leave us triggered to overeat and awash in the chronic stress that promotes weight regain. It is difficult to overcome physiology with behavior change, medications or surgery, but <a href="https://www.ncbi.nlm.nih.gov/pubmed/29616916">a new study</a> demonstrated that changing how we process stress changed food behavior without rigid dieting. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214325/original/file-20180411-584-1i242sq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When stressed, many people turn to comfort food, be it macaroni and cheese or chocolate cake.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/creamy-macaroni-cheese-stoneware-bowl-on-71591752?src=G5la6AhOjsfjWsseywsTvA-1-16">Marie C Fields/Shutterstock.com</a></span>
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<p>The patterns in the brain that control how we respond to stress are “wires.” Whether we reach for a cookie or bury ourselves in overwork, our daily responses to stress are the reactivation of instructions of how to respond that were encoded years or decades before. The hand that dips into the cookie jar is driven by the activation of a wire that was encoded during stress long before and unleashes chemical and electrical impulses that make us overeat in our currently daily life.</p>
<p>Traditional weight loss programs have not focused on changing these stress reactions that trigger overeating and I believe this is one reason their long-term effectiveness has been so dismal: Even if people lose weight, two-thirds of them <a href="https://www.ncbi.nlm.nih.gov/pubmed/17469900">regain more weight than they have lost</a>. </p>
<h2>Focus on the brain’s habits</h2>
<p>The good news is that there are promising ways to retrain the brain and to help people change the way they think about food. In developing a neuroscience-based approach to weight loss, which we call <a href="http://www.hypothesisjournal.com/?p=955">Emotional Brain Training</a>, my colleagues at the University of California, San Francisco and I decided to focus on changing the brain’s wiring that triggers stress eating. Our approach was to ask people to focus on something more positive than counting calories or measuring portion sizes: identify moments when they have cravings, indicating the offending circuit is activated and open to rewiring, and use <a href="https://www.ebtconnect.net">simple emotional tools</a> to process their stress and change the instructions encoded in that wire to reduce their desire to overeat. </p>
<p>This approach give practical application to the long-established <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4766925/">stress-weight link</a>. We know that in times of stress, <a href="https://www.annualreviews.org/doi/full/10.1146/annurev.med.59.103106.105628">three brain structures</a>: the amygdala (“fear center”), the hypothalamus (“appetite center”) and the nucleus accumbens (“reward enter”), activate a cascade of biochemical changes that increase hunger, slow metabolism and favor fat deposition. </p>
<p>The missing link has been to find practical ways to control “brain stress” and those overreactions that trigger mindless eating, sugar appetites and food binges. The neuroscience-based approach is to focus on changing our stress wiring, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3055445">self-regulatory circuits</a> that are triggered in a matter of nanoseconds that control our response to stress (and whether we eat that cookie or go for a walk instead). These stress wires are stored in parts of the emotional brain that activate automatic, unconscious responses. If we could change those wires, behavior change could be easier and, as activation of these wires contribute to chronic stress, lasting weight loss might be possible. </p>
<h2>Survival circuits drive overeating</h2>
<p>The specific wires that trigger stress eating and other stress-induced emotional and behavioral patters are called <a href="https://www.ncbi.nlm.nih.gov/pubmed/22365542">survival circuits</a>. They encode instructions about how to feel, what to think and what to do when stressed and, once encoded, reactivate that response automatically. We all have some of these wires as our hunter-gatherer ancestors survived because of these primal instructions: If they ran to a cave and escaped the jaws of a hungry lion in rapid pursuit, a survival circuit was encoded to ensure the automatic replay of their response in a similar stressful situation. </p>
<p>However, there’s a glitch in the way the brain responds to stress in that the survival instructions that enabled our ancestors to reflexively race to a cave to survive a physical threat were generalized to emotional stress. Any random experience of emotional stress, particularly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232061/">early in life</a> or in adulthood during those inevitable times of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159187/">stress overload, encodes this survival drive</a>. If we coped by eating sugary, processed treats, the brain strongly remembers that response based on the <a href="https://www.ncbi.nlm.nih.gov/books/NBK10878/">associative learning of long-term potentiation</a>, a process of encoding recent experience into circuits that control our strongly ingrained, lasting responses. The brain then reactivates that circuit in response to small daily stresses (to be sure that we “survive”) and we find ourselves with strong urges to overeat, as if our life depended upon getting that food.</p>
<p>I call these survival drives “food circuits” and once one has been encoded, dieting becomes very stressful as the circuit tells us that we need to overeat to meet our survival needs (safety, love, protection, security). We can eat healthy for a while, but when stress comes our way, our food circuit fully activates, and we cannot do what we “should” do and stay with our diet. Instead, we surrender to the instructions encoded in our food circuit to eat sugary, fatty foods that cause blood sugar highs followed by blood sugar lows that trigger hunger, stress, lethargy and weight grain. We are caught in a <a href="https://www.ncbi.nlm.nih.gov/pubmed/20368473">vicious cycle</a> of dieting, weight loss, overeating and weight regain.</p>
<h2>Zapping these circuits</h2>
<p>What can we do about these wires? Researchers at New York University have opened the doors to <a href="http://grantome.com/grant/NIH/R01-MH097085-03">using neuroplasticity to erase stress circuits</a>. They found that these circuits could be rewired, but only if we intentionally activate a momentary level of stress that matched the stress level we were in when the circuit was encoded. We cannot relax our way to rewiring these circuits or think our way around them. We needed to learn how to stress activate them in order to change them.</p>
<p>The Emotional Brain Training approach draws upon this research, but involves two steps. Initially, participants <a href="https://www.ebtconnect.net/science">target and weaken the circuits</a>. Instead of counting calories, grams or points, they profile the circuits that trigger their overeating. They then use a technique that stress activates the offending drive and reprocesses the emotions stored in the circuit. This changes the wire’s faulty instructions that promote overeating into instructions to eat healthy. Second, after their drives for comfort food fade, they turn their attention to eating healthy and losing weight. </p>
<p>The field needs more research, but the approach is promising. A recent study showed <a href="https://www.ncbi.nlm.nih.gov/pubmed/27138110">sustained improvements in physiologic stress</a> in a seven-week controlled clinical trial that EBT but not the behavioral comparison group maintained improvements in the stress that underlies weight regain at 20 weeks. In an observational study conducted at UCSF, researchers followed participants after 18 weekly trainings on the method’s tools and showed <a href="https://www.ncbi.nlm.nih.gov/pubmed/9336560">sustained weight loss</a> even two years later, the first intervention to avoid <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862452/">the “V” shaped weight loss curve</a> of obesity treament: losing weight during the treatment, then rapidly regaining it thereafter. </p>
<h2>Moving from dieting to rewiring</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214322/original/file-20180411-543-1q54xh1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Knowing what is healthy to eat is not enough to lose weight.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-woman-having-bowl-salad-while-571231624?src=IzSyLcuUeEu5RqzXJ1LdNQ-1-12">Wavebreakmedia/Shutterstock.com</a></span>
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<p>As obesity causes both personal suffering and a budgetary health care crisis, perhaps it’s time to reinvent the wheel. Our relentless pursuit of changing what we eat without changing the brain’s habits that cause the stress that promotes overeating and regain needs updating. </p>
<p>Using brain-based methods to make it easier to push away from the table and eat healthy could help turn around the nation’s obesity epidemic and, on an individual level, make it easier to peel off those extra pounds and enjoy our summer weekends at the beach.</p><img src="https://counter.theconversation.com/content/94615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laurel Mellin, Ph.D. directs the non-profit organization, The Solution Foundation, which provides public health information about the science and tools of Emotional Brain Training. She is the president of EBT, Inc., which conducts clinical certification programs for health professionals and interventions to the public.</span></em></p>New weight loss approaches seek to switch off the brain patterns that drive overeating and weight regain. Here’s how that works, and how it could help you.Laurel Mellin, PhD, Associate Professor Emeritus of Family & Community Medicine and Pediatrics, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/917042018-04-11T10:45:09Z2018-04-11T10:45:09Z3 research-based things a doctor says should be part of your weight loss efforts<figure><img src="https://images.theconversation.com/files/212696/original/file-20180329-189810-1pjhn65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman exercising on a stationary bike. Exercise is an important component of weight loss, most experts agree.</span> <span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Imagine that you are running a company, but you cannot get to your goal because all of your good workers keep quitting.</p>
<p>For 30 years, your response to this problem has been to criticize the workers and say they are stupid and weak for quitting. As a result, you never reach your goal. You don’t change your formula or alter your plan, just keep blaming and shaming the workers for quitting. </p>
<p>If you did this, your failure rate would remain unchanged over time, of course, and you would never reach your goal. </p>
<p>In the same way, hundreds of thousands of people fall short of their dieting and weight loss goals every year, and the incidence of obesity <a href="http://www.soard.org/article/S1550-7289(15)00296-8/pdf">continues to rise</a>. The fitness industry’s answer to this has been to continue on as planned and blame the soaring failure rates on the people themselves, creating a culture of <a href="https://www.huffingtonpost.com/2013/12/16/fatmicroaggressions-fat-shaming-tweets_n_4453060.html">overt and subtle fat-shaming.</a></p>
<p>Now, imagine that you do some research at your company, and you find out that folks keep quitting because the carpet smells like garbage, the office is way too hot and the desks are in disrepair. If you hope to eventually get to your goal, you would almost certainly address the factors that are leading to attrition of our workers, right? </p>
<p>The same thing goes for <a href="https://www.clinmedjournals.org/articles/ijsem/international-journal-of-sports-and-exercise-medicine-ijsem-1-026.php?jid=ijsem">weight loss</a> in 2018. Science has shown us why “workers” are quitting. They quit because their ability to perform exercise is limited, they don’t sleep enough and they don’t eat for change. Just as your company needed to stop ridiculing the workers for quitting and instead change the carpet, furnace and desks, the fitness world should resist the urge to fat-shame and instead focus on exercise capacity, sleeping and recovery. </p>
<p>I have studied weight loss and obesity for many years. The issue of overweight and obesity grows more pressing each year, as <a href="https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html">84 million people are now considered pre-diabetic</a>. While they are in a pre-diabetic condition, they can still avoid the debilitating consequences of the disease. But once they become diabetic, health problems cascade as a result of this serious disease. The same is true for heart disease, arthritis and many other obesity-related conditions. </p>
<h2>Exercise</h2>
<p>People must <a href="http://spectrum.diabetesjournals.org/content/30/3/157">exercise enough</a> not only to burn calories for weight loss but to keep weight off. Simply put, if a person can walk for only five minutes today, he or she cannot expect to be successful on a program that calls for four days of exercise beyond that amount each time, tomorrow. Thus, the initial goal of any intended weight loss transformation should be to first increase one’s exercise capacity to a critical point, called the <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.4960130809">catching point.</a> </p>
<p>Once this capacity is reached, <a href="https://www.cambridge.org/core/journals/proceedings-of-the-nutrition-society/article/effects-of-exercise-and-restrained-eating-behaviour-on-appetite-control/EF3EA40F13BB2777A50CB771E15F15B9/core-reader">food preferences will change</a>, metabolic rates will increase and patients will have a real chance to follow an exercise regimen that results in a significant amount of calories burned. </p>
<p>An <a href="https://www.unm.edu/%7Elkravitz/Article%20folder/ExerciseMot.pdf">“in-shape” person</a> is much more likely to be successful with a new diet and exercise program than a sedentary, overweight person. As a result, step one must be to increase this capacity and to get there. </p>
<p>The other two tenets of recovery are equally critical: sleep and diet. </p>
<h2>Sleep</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212699/original/file-20180329-189816-895aai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Restful, plentiful sleep is key to weight loss, research suggests.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-young-woman-sleeping-while-lying-547906330?src=ykrjfAS8BH7cQJTN1wDPJg-1-46">Volka_R/Shutterstock.com</a></span>
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<p>Thousands of articles and many books have been written on sleep as it relates to brain function, brain waves, thinking, memory, mood, etc. <a href="http://www.medical-hypotheses.com/article/S0306-9877(11)00180-0/fulltext">The role of sleep in physical metabolic change</a>, though, is missing from most diet attempts. </p>
<p>Simply put, sleep is the time that the body changes. Structurally, our bodies are making molecules during sleep that follows exercise which will do useful things for us such as strengthen our muscles, lower blood pressure, neutralize inflammation and increase our metabolism.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951287/">Sleeping enough will also make us eat less</a>. Functional MRI scans of the brain show that people are far more interested in eating when they are sleep-deprived. Moreover, <a href="https://www.forbes.com/forbes/welcome/?toURL=https://www.forbes.com/sites/alicegwalton/2016/11/02/the-vicious-cycle-of-sleep-deprivation-and-overeating/&refURL=https://www.google.com/&referrer=https://www.google.com/">sleep-deprived people</a> are more driven toward unhealthy foods when given the option. They also have increased levels of gherlin, the hormone that makes us feel hungry, and decreased levels of leptin, the hormone that makes us feel full. And, in multiple studies people have been shown to actually eat more food and actually gain more weight when sleep-deprived, and population-based studies have shown increased BMIs in people with fewer sleep hours. </p>
<h2>Eating for change</h2>
<p>Often, people err when they try to lose weight by restricting calories at the beginning of their efforts. <a href="https://theconversation.com/new-medical-advances-marking-the-end-of-a-long-reign-for-diet-wizards-88463">Restricting calories</a> leads to a host of responses from the body that induce food-seeking behavior and cause people to “quit” their diets. A recent study of a large group of people suggests that <a href="https://www.nytimes.com/2018/02/20/well/eat/counting-calories-weight-loss-diet-dieting-low-carb-low-fat.html">people should not count calories</a> at all but instead pay attention to the quality of the food they eat, refraining from sugar and processed foods and instead eating lots of fruits and vegetables.</p>
<p>We can’t make changes in our body’s structure without the appropriate nutrients on board. If, while we are sleeping, our bodies set out to make the changes we want and there are no nutrients with which to do so, there will be no transformation. The specific nutrients necessary for recovery and optimization of our <a href="https://theconversation.com/dont-hate-your-gut-it-may-help-you-lose-weight-fight-depression-and-lower-blood-pressure-77453">microbiome</a> have been well-described during recent years and should be added to our intake (vs. restriction) until a critical point of clean eating is reached. </p>
<p>In summary, the three things missing from most diet attempts are the appropriate exercise capacity, the right amount of sleep and a plan to eat for recovery and change. Implementing these elements to most plans will allow folks to stay engaged long enough for healthy habits to “catch.”</p><img src="https://counter.theconversation.com/content/91704/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Prologo is the founder of The Catching Point Transformation (<a href="http://www.catchingpoint.com">www.catchingpoint.com</a>).</span></em></p>The success rate for weight loss is small, suggesting that a new approach is needed. Here are three things to consider, one of which you may be overlooking.J. David Prologo, Associate Professor, Department of Radiology and Imaging Sciences, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/922512018-03-02T11:45:09Z2018-03-02T11:45:09ZWill holding the cheese and chocolate milk on Happy Meals make a difference?<figure><img src="https://images.theconversation.com/files/208136/original/file-20180227-36677-198i8iu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Happy Meal with chocolate milk and cheeseburger at a Brandon, Miss., McDonald's.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-McDonalds-Happy-Meal-Changes/25f6c7f7a8b2461287862d53008044b5/1/0">AP Photo/Rogello V. Solis</a></span></figcaption></figure><p>McDonald’s recently <a href="https://www.healthiergeneration.org/_asset/h4xjlv/McDonaldCommittment.pdf">announced a major commitment</a> to improve the nutrition quality of its kids’ meals. Globally, at least 50 percent of Happy Meal bundles, which include a main dish, side and drink, will meet nutrition limits on calories, saturated fat, added sugar and sodium set by McDonald’s. In the U.S., the restaurant will use strategies such as not listing cheeseburgers or chocolate milk on Happy Meal menus – but providing the items if customers ask – to meet this goal. </p>
<p>This commitment is a positive step, but reducing children’s consumption of nutritionally poor fast food will require much more.</p>
<p>I have spent 10 years studying fast-food kids’ meals marketing and nutrition. My research and that of others demonstrate an enormous challenge for parents to select healthy options when the environment inside fast-food restaurants makes the unhealthy options so much more appealing. </p>
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<h2>Fast food: Children are lovin’ it</h2>
<p>Improving the nutrition of fast-food kids’ meals is important to public health. Childhood obesity rates have skyrocketed over the past four decades, <a href="http://pediatrics.aappublications.org/content/early/2018/02/22/peds.2017-3459">with no improvement</a> in recent years. In the U.S., 58 percent of children ages 6 to 8 and 41 percent of preschoolers are overweight or obese. </p>
<p>Sugary drinks are a big problem, but so is fast food. Despite recent introductions of healthier items, <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_Summary.pdf">nearly all fast-food items,</a> including on kids’ meal menus, exceed recommendations for maximum calories, sugar, saturated fat and/or sodium in a meal for children. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_Summary.pdf">Fewer than 3 percent of kids’ meal bundles</a> offered by top fast-food restaurants, including McDonald’s, meet the industry’s own standards – set by the National Restaurant Association – for healthy meals for kids. </p>
<p>Furthermore, on any day, <a href="http://www.bridgingthegapresearch.org/research/powell2012_ajpm/">one-third of children</a> consume fast food. And on days they eat fast food, <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/1389390">children consume 126 additional calories</a>, and more sugar, saturated fat and sodium. </p>
<p>Support for mandating healthier kids’ meals is growing, as local communities enact laws setting nutrition standards for kids’ meals. The <a href="http://baltimore.cbslocal.com/2018/02/26/baltimore-kids-drinks-bill/">Baltimore City Council</a> just approved legislation requiring healthy drinks as the default in kids’ meals, <a href="http://www.foodmarketing.org/wp-content/uploads/2017/04/NationalMovement.pdf">following the lead of other cities</a>, including Davis, California, and Lafayette, Colorado. </p>
<p><a href="https://www.healthiergeneration.org/mcdonalds_report/">Over the past five years,</a> McDonald’s has done more than most fast-food restaurants to voluntarily improve the nutritional quality of its kids’ meals. In 2013, it reduced the size of french fries in Happy Meals and added a healthier side, such as apple slices or yogurt. In 2014, the restaurant initiated a policy to remove sugary sodas from kids’ meal menus and only list healthier drinks, including milk, chocolate milk and 100 percent juice as options. </p>
<p>McDonald’s also has more at stake. The <a href="http://www.uconnruddcenter.org/files/Pdfs/FACTS-2017_Final.pdf">company spent US$33 million advertising</a> Happy Meals in 2016. Children aged 2 to 5 viewed, on average, 2.7 TV ads for Happy Meals each week, while 6- to 11-year-olds saw three ads. Notably, children saw more ads for McDonald’s Happy Meals than for any other food brand in 2016, and the company placed more than 10 times as many ads on children’s TV networks (e.g., Nickelodeon or Cartoon Network) than any other fast-food restaurant. </p>
<p>This marketing works. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_2010.pdf">In a survey of parents,</a> 41 percent said their child asked to go to McDonald’s at least once a week, while 15 percent of parents of preschoolers reported that their child asked to go every day.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208149/original/file-20180227-36680-16k8ncz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A 3-year-old girl appears to enjoy her Happy Meal. Kids like her often ask their parents to take them to McDonald’s.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/auckland-nov-12-2017little-girl-naomi-753590665?src=dZRCOTFWbf3FdAjONumXiQ-1-5">ChameleonsEye/Shutterstock.com</a></span>
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<p>Persuading parents to say “yes” to their children’s requests is also part of McDonald’s marketing strategy. <a href="http://fastfoodmarketing.org/media/FastFoodFACTS_Report_2010.pdf">When advertising to parents,</a> trips to McDonald’s and Happy Meals become a way to make children and parents happy. Public relations campaigns announcing nutritious options in Happy Meals also support this strategy. In a recent survey that has not yet been published, my research group found that 80 percent of parents said they had purchased lunch or dinner for their children under age 12 from McDonald’s in the past week. And two-thirds said they would take their child to McDonald’s more often because of the restaurant’s healthier kids’ meal policies.</p>
<p>Yet despite positive attitudes about healthier Happy Meals, unhealthy sides and drinks with Happy Meals persist. In our 2016 survey, we asked parents who reported purchasing a Happy Meal for their child what drink they received; 42 percent answered that they received a soda. This proportion has not changed since 2010. In addition, 64 percent reported that they received french fries, while 31 percent did not receive a healthy side. (Happy Meals come with two sides.) Furthermore, 18 percent of parents purchased an item, such as dessert, plus the Happy Meal for their child, and 25 percent did not purchase a kids’ meal at all. Notably, parents were more likely to purchase Happy Meals and healthier drinks for preschoolers than for older children.</p>
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<h2>The tantalizing smell of fries</h2>
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<img alt="" src="https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208152/original/file-20180227-36696-16v3vbf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Nothing smells quite like french fries cooking in hot oil, and the aroma can be a powerful trigger.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/delicious-french-fries-taken-out-hot-320193203?src=B0SkemvOAeGjGUpPhuX9wg-1-30">Whiteaster/Shutterstock.com</a></span>
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<p>Parents decide whether their child gets apple slices and milk or french fries and soda with Happy Meals. But research on consumer choices shows that making the healthy choice in this situation is difficult, even for adults. Consider the environment inside a fast-food restaurant: the smell of french fries, the prominent soda fountain with soda brand logos, the images of ice cream and large burgers on posters and menu boards. These cues all trigger desire for these unhealthy but highly appetizing choices. </p>
<p>Studies by <a href="https://www.journals.uchicago.edu/doi/full/10.1086/684364">behavioral economists</a> also show that simply offering healthy options alongside unhealthy options is not enough to increase consumers’ selection of healthy option.</p>
<p>However, offering healthier drinks and sides by default – and only providing unhealthy options upon consumer request – significantly increases the likelihood that consumers will accept the healthy items. Disney theme parks use this approach with their kids’ meals. <a href="https://www.journals.uchicago.edu/doi/full/10.1086/684364">An evaluation of their policy</a> demonstrated high acceptance of healthier options. </p>
<p>Publicizing healthier Happy Meal options while also offering unhealthy options raises concerns about potential “health halo” effects. Research has shown that depicting <a href="https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/exposure-to-healthy-fast-food-meal-bundles-in-television-advertisements-promotes-liking-for-fast-food-but-not-healthier-choices-in-children/FB446383F6AD78401F8DAEE3ABBF499C">more nutritious kids’ meal items</a> in fast-food commercials does not increase children’s selection of healthier items, but it does increase their reported liking of fast food generally. Advertising for unhealthy food, such as cookies and fruit drinks, using nutrition messages increases <a href="http://onlinelibrary.wiley.com/doi/10.1111/ijpo.12257/full">children’s beliefs that these products are healthy</a>. <a href="https://foodpsychology.cornell.edu/sites/default/files/unmanaged_files/health_halos-JCR_2007.pdf">Studies with adults </a> have also shown increased calorie consumption and purchases of unhealthy fast-food sides resulting from health halo marketing messages. </p>
<p>Finally, <a href="http://www.uconnruddcenter.org/healthierkidsmeals">a recent evaluation</a> of McDonald’s healthier kids’ meal side and drink policies revealed inconsistent implementation at individual restaurants. In some cases, menu boards still showed french fries and sugary drinks as kids’ meal options, and counter personnel continued to suggest these items with kids’ meal orders. </p>
<p>McDonald’s new commitment to set nutrition standards for Happy Meal bundles is a positive first step. However, I believe the restaurant must do more to prove its commitment to children’s health and supporting parents. Healthy Happy Meals should be the most appealing choice for children, the most convenient choice for parents, and the only Happy Meal options available at their restaurants. McDonald’s could also, in my view, stop advertising directly to children as young as 2 years old so that parents can make the decision about if and when to introduce their children to McDonald’s.</p><img src="https://counter.theconversation.com/content/92251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Harris has received grant funding from the Robert Wood Johnson Foundation and Healthy Eating Research to examine fast food marketing and nutrition of kids' meals. </span></em></p>McDonald’s recently announced it will make its Happy Meal, which accounts of about 15 percent of all sales, healthier. Will it make kids healthier? That’s unclear, but it could lower parents’ guilt.Jennifer Harris, Professor of Allied Health Sciences, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/890602017-12-26T14:40:37Z2017-12-26T14:40:37ZWhy your doctor may not be able to help you lose weight<figure><img src="https://images.theconversation.com/files/200270/original/file-20171220-4980-3r8mu7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Woman in a doctor's office. Overweight people often turn to doctors for help, but doctors often do not know how to help.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/overweight-woman-having-consultation-doctors-office-721562377?src=QxJuG9L6N4HiJuXnk5ad0Q-1-74">Africa Source/Shutterstock.com</a></span></figcaption></figure><p>Obesity was <a href="https://www.cdc.gov/obesity/data/adult.html">designated a disease</a> in 2013 by the American Heart Association and American Medical Association. Obesity, defined as a body mass index of 30 or higher, had long been identified as a health condition, but its designation as a disease underscored its role as a risk factor for leading causes of death, such as heart disease, Type 2 diabetes, stroke and many cancers. </p>
<p>Given that <a href="https://www.cdc.gov/nchs/fastats/body-measurements.htm">nearly 40 percent of Americans are obese</a>, you might think that primary care physicians, the front line of medical care, would be actively engaged to help patients lose weight. Counseling on a healthier lifestyle has long been under the purview of the PCP.</p>
<p>The United States Preventive Services Task Force, an independent panel of experts, further solidified the physician’s role in engaging patients in weight loss efforts when it recommended in 2003 and again in 2012 that physicians should screen “all adults for obesity and <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-screening-and-management">offer or refer patients with a BMI of 30 kg/m2 </a>to intensive, multicomponent behavioral interventions.” </p>
<p>Unfortunately for patients with obesity and our society, PCPs have been largely silent in their response to the obesity epidemic. </p>
<p>As a PCP myself, and a health researcher, I’ve studied how primary care has been engaged in helping our patients lose weight. Unfortunately, we’re not doing so great. Losing weight is difficult, and my studies suggest helping patients lose weight isn’t any easier. </p>
<h2>High weight, low response</h2>
<p>One of my studies revealed that <a href="http://prowellness.vmhost.psu.edu/wp-content/uploads/obesity_epidemic.pdf">only 6 percent of visits</a> include counseling for weight, a decrease from 8 percent of visits during the prior decade.</p>
<p><a href="http://prowellness.vmhost.psu.edu/wp-content/uploads/obesity_epidemic.pdf">Rates of counseling</a> for diet and exercise have also decreased, with greater declines seen in patients with the most to benefit from healthy lifestyle change, including those with hypertension, diabetes, and obesity. Further, a small minority – 9 percent – of PCPs are performing the majority – at 52 percent – of all <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429525/">reported weight counseling</a>. In addition, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429525/">most PCPs </a>– 58 percent – failed to perform any weight counseling during patient visits across study years.</p>
<p>There are real reasons PCPs have been less than engaged in counseling patients about weight loss. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831634/">Physicians are pessimistic</a> that patients can change, physicians have time limitations, and physicians’ training and skills for counseling are thought to be inadequate. Until recently, physicians weren’t reimbursed for time spent counseling, either.</p>
<p>Also, PCPs often do not have time due to an <a href="https://www.ncbi.nlm.nih.gov/pubmed/18830762">increasing number of clinical items</a>, including diseases, medications, and tests, addressed during adult primary care visits. Further, doctors don’t have the tools. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200272/original/file-20171220-4973-y4l18t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Busy doctors in an office. Primary care doctors often are so busy that they do not have a lot of time to spend with patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-doctors-busy-working-office-using-672381052?src=eq2YB1T9uSwLv1yCVxWSqg-1-25">Fancy Studio/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>It’s not because doctors aren’t capable but rather because <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726879/">few tools exist</a> to help PCPs counsel patients. Weight loss programs within the primary care setting are relatively ineffective. Also, there are only a handful of prescription medications available to PCPs to prescribe, with several withdrawn from the market due to <a href="https://www.webmd.com/diet/news/20101008/fda-rejects-weight-loss-drug-meridia#1">safety concerns</a>. Multiple medications have recently been introduced to help with weight loss, although there is a known delay in prescribing uptake.</p>
<h2>Patients pay attention to their doctors</h2>
<p>Recent policy changes have attempted to overcome at least the barrier of lack of reimbursement for counseling. In 2012, Centers for Medicare and Medicaid implemented coverage for <a href="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1142.pdf">intensive behavioral therapy for obesity by PCPs</a>. Further, the implementation of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4187299/">Patient Protection and Affordable Care Act</a> expanded this coverage to all adults by requiring health insurance carriers to cover this and other recommendations, at no expense to the patient. </p>
<p>This does not guarantee success, however. In fact, the medical community does not yet have data about whether Medicare and other insurer coverage of the intensive behavioral counseling benefit will actually help patients lose weight and maintain it. </p>
<p>Although the new reimbursment provides a structure and payment code for visit frequency, there remains a need to understand how best to implement such counseling within the primary care setting, even if studies show that counseling is effective. Further, a <a href="https://www.cbsnews.com/news/shortage-of-primary-care-physicians-could-threaten-patient-care/">looming primary care shortage</a> calls to question if a workforce will even be there to see current patients, much less add up to 20 additional visits for the one in three who have obesity.</p>
<p>But PCPs may be able to help patients address their weight in other ways. A study my colleagues and I did of national data found that patients who were overweight and obese were <a href="https://www.ncbi.nlm.nih.gov/pubmed/24743008">more likely to report successfully losing 5 percent</a> of their body weight in the past year if their doctor had simply told them they were overweight.<br>
Although barriers such as an awkwardness to even discussing a patient’s weight in the clinic remain, PCPs may be better equipped to provide this straightforward, yet powerful, information during a clinic visit. </p>
<p>This does not, however, address the need for effective weight loss programs following the identification of patients with obesity. </p>
<h2>Changing our approach</h2>
<p>Overall, despite the recognition of obesity as a chronic disease, we doctors still don’t treat it this way in the clinical setting. Clinically, if we do help patients engage in weight loss efforts, we then stand back and watch as they regain weight, and then try to re-engage them in additional weight loss efforts. Of patients who lose even 5 percent of their weight, our work has shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/20479763">2 in 3 will regain</a> weight within one year.</p>
<p>It’s important for us PCPs to start thinking about better approaches. We wouldn’t treat someone’s high blood pressure with a medication for only a year and then scratch our heads as to why their blood pressure is high again two years later. </p>
<p>Weight loss is incredibly difficult. Unlike smokers who are trying to quit and can just throw out their cigarettes, people with obesity can’t simply throw away all of their food. Patients with obesity need to identify a new relationship with food, and understand how to have a healthful diet, and not just a diet to help one lose weight. </p>
<p>PCPs have an important role in helping patients with obesity identify the need to lose weight and then make lifestyle changes in order to do so. We just need to find ways to better engage both PCPs and patients to avoid our silent response to this epidemic.</p><img src="https://counter.theconversation.com/content/89060/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Kraschnewski receives funding from Patient Centered Outcomes Research Institute (PCORI), National Institutes of Health, and Commonwealth of Pennsylvania Department of Health. </span></em></p>We turn to doctors to treat cancer, addiction and high blood pressure. And, they have a lot of training and tools to help us. Why is that not so with obesity?Jennifer Kraschnewski, Associate Professor, medicine, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/884632017-12-26T14:37:01Z2017-12-26T14:37:01ZNew medical advances marking the end of a long reign for ‘diet wizards’<figure><img src="https://images.theconversation.com/files/199767/original/file-20171218-27607-p7u70a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Wizard of Oz promised results he could not deliver but was convincing in his presentation. Diet wizards have done the same for decades. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/tom-margie/">Insomnia Cured Here/Flickr.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>For many years, the long-term success rates for those who attempt to lose excess body weight have hovered around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990387/">5-10 percent</a>. </p>
<p>In what other disease condition would we accept these numbers and continue on with the same approach? How does this situation sustain itself?</p>
<p>It goes on because the diet industry has generated <a href="http://www.sciencedirect.com/science/article/pii/S014067361461744X#cesec80">marketing fodder</a> that obscures scientific evidence, much as the Wizard of Oz hid the truth from Dorothy and her pals. There is a gap between what is true and what sells (remember the <a href="https://www.npr.org/sections/thesalt/2015/05/28/410313446/why-a-journalist-scammed-the-media-into-spreading-bad-chocolate-science">chocolate diet</a>?). And, what sells more often dominates the message for consumers, much as the wizard’s sound and light production succeeded in misleading the truth-seekers in the Emerald City.</p>
<p>As a result, the public is often directed to attractive, short-cut weight loss options created for the purposes of making money, while scientists and doctors document facts that are steamrolled into the shadows. </p>
<p>We are living in a special time, though – the era of <a href="https://www.nature.com/articles/nrgastro.2013.119">metabolic surgeries and bariatric procedures</a>. As a result of these weight loss procedures, doctors have a much better understanding of the biological underpinnings responsible for the failure to lose weight. These discoveries will upend the current paradigms around weight loss, as soon as we figure out how to pull back the curtain.</p>
<p>As a dual board-certified, interventional obesity medicine specialist, I have witnessed the experience of successful weight loss over and over again – clinically, as part of interventional trials and in my personal life. The road to sustained transformation is not the same in 2018 as it was in 2008, 1998 or 1970. The medical community has identified the barriers to successful weight loss, and we can now address them. </p>
<h2>The body fights back</h2>
<p>For many years, the diet and fitness industry has supplied folks with an unlimited number of different weight loss programs – seemingly a new solution every month. Most of these programs, on paper, should indeed lead to weight loss. At the same time, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08397-6/abstract">the incidence of obesity continues to rise at alarming rates</a>. Why? Because people cannot do the programs. </p>
<p>First, overweight and obese patients do not have the calorie-burning capacity to exercise their way to sustainable weight loss. What’s more, the same amount of exercise for an overweight patient is <a href="https://www.nature.com/articles/0803052">much harder</a> than for those who do not have excess body weight. An obese patient simply cannot exercise enough to lose weight by burning calories.</p>
<p>Second, the body will not let us restrict calories to such a degree that long-term weight loss is realized. The body fights back with <a href="http://mannlab.psych.umn.edu/">survival-based biological responses</a>. When a person limits calories, the body slows baseline metabolism to offset the calorie restriction, because it interprets this situation as a threat to survival. If there is less to eat, we’d better conserve our fat and energy stores so we don’t die. At the same time, also in the name of survival, the body sends out surges of hunger hormones that induce food-seeking behavior – creating a real, measurable resistance to this perceived threat of starvation. </p>
<p>Third, <a href="https://www.scientificamerican.com/article/how-gut-bacteria-help-make-us-fat-and-thin/">the microbiota in our guts are different</a>, such that “a calorie is a calorie” no longer holds true. Different gut microbiota pull different amounts of calories from the same food in different people. So, when our overweight or obese colleague claims that she is sure she could eat the same amount of food as her lean counterpart, and still gain weight – we should believe her. </p>
<h2>Lots of shame, little understanding</h2>
<p>Importantly, the lean population does not feel the same overwhelming urge to eat and quit exercising as obese patients do when exposed to the same weight loss programs, because they start at a different point. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">French fries and chocolate milkshakes affect people differently. Some are tempted by them, and others are not.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/chocolate-ice-cream-glass-cup-whipped-346034765?src=2d7C-LrAcTRnSveGXLCSDA-2-48">Sheila Fitzgerald/Shutterstock.com</a></span>
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</figure>
<p>Over time, this situation has led to stigmatizing and prejudicial fat-shaming, based on lack of knowledge. Those who fat-shame most often have never felt the biological backlash present in overweight and obese folks, and so conclude that those who are unable to follow their programs fail because of some inherent weakness or difference, a classic setup for discrimination.</p>
<p>The truth is, the people failing these weight loss attempts fail because they face a formidable entry barrier related to their disadvantaged starting point. The only way an overweight or obese person can be successful with regard to sustainable weight loss, is to directly address the biological entry barrier which has turned so many back.</p>
<h2>Removing the barrier</h2>
<p>There are three ways to minimize the barrier. The objective is to attenuate the body’s response to new calorie restriction and/or exercise, and thereby even up the starting points. </p>
<p>First, surgeries and interventional procedures work for many obese patients. They help by minimizing the biological barrier that would otherwise obstruct patients who try to lose weight. These procedures alter the hormone levels and metabolism changes that make up the entry barrier. They lead to weight loss by directly addressing and changing the biological response responsible for <a href="https://www.nature.com/articles/nrgastro.2013.119">historical failures</a>. This is critical because it allows us to dispense with the antiquated “mind over matter” approach. These are not “willpower implantation” surgeries, they are metabolic surgeries. </p>
<p>Second, medications play a role. The FDA has approved <a href="https://www.medscape.com/viewarticle/876411">five new drugs</a> that target the body’s hormonal resistance. These medications work by directly attenuating the body’s survival response. Also, stopping medications often works to minimize the weight loss barrier. Common medications like antihistamines and antidepressants are often <a href="https://academic.oup.com/jcem/article/100/2/342/2813109">significant contributors to weight gain</a>. Obesity medicine physicians can best advise you on which medications or combinations are contributing to weight gain, or inability to lose weight. </p>
<p>Third, increasing <a href="https://www.ncbi.nlm.nih.gov/books/NBK404/">exercise capacity</a>, or the maximum amount of exercise a person can sustain, works. Specifically, it changes the body so that the survival response is lessened. A person can increase capacity by attending to recovery, the time in between exercise bouts. Recovery interventions, such as food supplements and sleep, lead to increasing capacity and decreasing resistance from the body by reorganizing the biological signaling mechanisms – a process known as retrograde neuroplasticity.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=466&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=466&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=466&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=585&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=585&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=585&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Strength conditioning builds muscle mass, which can help increase capacity.</span>
<span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/_tools/imageViewer.cfm?id=180&c=2&r=0">Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Lee Kaplan, director of the Harvard Medical School’s Massachusetts Weight Center, captured this last point during a recent lecture by saying, “We need to stop thinking about the Twinkie diet and start thinking about physiology. Exercise alters food preferences toward healthy foods … and healthy muscle trains the fat to burn more calories.” </p>
<p>The bottom line is, obese and overweight patients are exceedingly unlikely to be successful with weight loss attempts that utilize mainstream diet and exercise products. These products are generated with the intent to sell, and the marketing efforts behind them are comparable to the well-known distractions generated by the Wizard of Oz. The reality is, the body fights against calorie restriction and new exercise. This resistance from the body can be lessened using medical procedures, by new medications or by increasing one’s exercise capacity to a critical point. </p>
<p>Remember, do not start or stop medications on your own. Consult with your doctor first.</p><img src="https://counter.theconversation.com/content/88463/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Prologo is the founder and CEO of The Catching Point, LLC (<a href="http://www.catchingpoint.com">www.catchingpoint.com</a>). </span></em></p>Dieting fads have been around for more than a century, but none of them has been shown to curb obesity long-term. The good news is that scientific evidence is revealing treatments that do work.J. David Prologo, Associate Professor, Department of Radiology and Imaging Sciences, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/859582017-12-26T14:36:57Z2017-12-26T14:36:57ZWhy are so many of our pets overweight?<figure><img src="https://images.theconversation.com/files/194418/original/file-20171113-27625-iwl68r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pet obesity often says more about an owner's relationship with their pet than the animal itself.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/large-longhair-grey-color-cat-laying-358973213?src=A-I4kd2YoNGDHf5B8pON8w-1-26">Susan Schmitz/shutterstock.com</a></span></figcaption></figure><p>When I looked at my appointment book for the day, I thought something must be wrong. Someone who worked in the fitness industry was bringing his cat in to the Tufts Obesity Clinic for Animals. Did he confuse us for a different kind of weight management clinic? Is he looking to get muscle on his cat or maybe kitty protein shakes? </p>
<p>I was utterly surprised when I called for my appointment in the lobby and an athletic man stood up with an almost 20-pound cat! I asked if I could speak bluntly with him. Why does someone who clearly knows a lot about keeping healthy need to bring his cat to a veterinary nutritionist? What would he say if the cat was one of the people he helps to keep fit every day? Our conversation then went something like this…</p>
<p>“Well, I’d tell her, suck it up, buttercup. Do some kitty pushups and no more treats!” </p>
<p>“Well, I have to ask, then, what’s stopping you from doing this with your cat?” </p>
<p>With a worried look of guilt on his face, he replied, “Well, Dr. Linder, I mean… she meows at me…”</p>
<p>This was the moment I realized that I was treating pet obesity all wrong. I needed to focus less on the pet and more on the relationship between people and their pets. That’s what’s literally cutting the lives short of the dogs and cats we love so much. </p>
<h2>An obese pet isn’t a happy pet</h2>
<p>As with humans, <a href="https://www.cbsnews.com/news/dog-cat-obesity-rate-continues-to-rise/">obesity in pets</a> is at epidemic proportions. Over half of the <a href="https://doi.org/10.1111/j.1748-5827.2010.00933.x">dogs</a> and <a href="https://doi.org/10.1016/j.prevetmed.2012.05.006">cats</a> around the globe battle the bulge. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=537&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=537&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=537&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=675&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=675&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194416/original/file-20171113-27612-1oudtp9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=675&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Don’t fall for those puppy dog eyes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dog-licking-tongue-252628372?src=ydyYdBWDiVPmopqL9WHWpQ-1-93">Liliya Kulianionak/shutterstock.com</a></span>
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<p>While overweight pets may not face the same social stigma as humans, medical and emotional damage is being done all the same. Obesity in animals can cause complications in almost every system in the body, with conditions ranging from <a href="https://www.ncbi.nlm.nih.gov/pubmed/9621878">diabetes</a> to <a href="https://www.ncbi.nlm.nih.gov/pubmed/11767921">osteoarthritis</a>. </p>
<p>Owners often say they don’t care if their pet is “fat” – there’s just more of them to love! It’s my job to then let them know there’s less time to provide that love. A <a href="https://doi.org/10.2460/javma.2002.220.1315">landmark lifespan study</a> showed Labradors who were 10-20 percent overweight – not even obese, which is typically defined as greater than 20 percent – lived a median 1.8 years shorter than their trim ideal weight counterparts. </p>
<p>Another <a href="https://doi.org/10.1016/j.tvjl.2011.09.015">study</a> shows that obesity indeed has emotional consequences for pets. Overweight pets have worse scores in vitality, quality of life, pain and emotional disturbance. However, the good news is those values can improve with weight loss.</p>
<p>Furthermore, humans struggle to succeed even in the best conditions – and so do pets. <a href="https://doi.org/10.1371/journal.pone.0184199">In one study</a>, dogs on a weight-loss program were only successful 63 percent of the time. </p>
<h2>Showing love through food</h2>
<p>So where exactly is the problem? Are foods too high in calories? Are pets not getting enough exercise? Is it genetics? Or do we just fall for those puppy dog eyes and overfeed them because they have in fact trained us (not the other way around!)? From my experience at the pet obesity clinic, I can tell you it’s a bit of all of the above. </p>
<p>It seems veterinarians and pet owners may be a little behind the curve compared to our human counterparts. <a href="https://doi.org/10.1001/jama.293.1.43">Studies show</a> that it doesn’t really matter what approach to weight loss most humans take – as long as they stick to it. But many in veterinary medicine focus more on traditional diet and exercise plans, and less on adherence or the reason these pets may have become obese to begin with. (This should be easy, right? The dogs aren’t opening the fridge door themselves!)</p>
<p>However, the field is starting to understand that pet obesity is much more about the human-animal bond than the food bowl. In 2014, I worked among a group of fellow pet obesity experts organized by the American Animal Hospital Association to publish <a href="https://doi.org/10.5326/JAAHA-MS-6331">new weight management guidelines</a>, recognizing that the human-animal bond needs to be addressed. Is the pet owner ready to make changes and overcome challenges that might slow down their pet’s weight loss? </p>
<p><a href="https://doi.org/10.1017/S0007114514002335">One interesting editorial review</a> compared parenting styles to pet ownership. As pet owners, we treat our cats and dogs more like family members. There’s a deeper emotional and psychological bond that was not as common when the family dog was just the family dog. If vets can spot an overindulgent pet parent, perhaps we can help them develop strategies to avoid expressing love through food. </p>
<h2>A healthier relationship</h2>
<p>Managing obesity in pets will require veterinarians, physicians and psychologists <a href="https://doi.org/10.1016/j.jcpa.2017.03.006">to work together</a>. </p>
<p>Many veterinary schools and hospitals now employ social workers who help veterinarians understand the social aspect of the human-animal bond and how it impacts the pet’s care. For example, a dog owner who has lost a spouse and shares an ice cream treat every night with their dog may be trying to replace a tradition they used to cherish with their significant other. A social worker with a psychology background could help prepare a plan that respects the owner’s bond with their pet without negatively impacting the pet’s health.</p>
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<p>At our obesity clinic at Tufts, physicians, nutritionists and veterinarians are working together to develop joint pet and pet owner weight-loss programs. We want to put together a healthy physical activity program, so pet owners and their dogs can both improve their health and strengthen their bond. We also created <a href="http://www.petfoodology.org">a pet owner education website</a> with additional strategies for weight loss and pet nutrition.</p>
<p><a href="https://doi.org/10.1016/j.cvsm.2014.03.004">Programs that strengthen and support the human-animal bond</a> without adding calories will be critical to preserve the loving relationship that is the reason why we adopt our pets, but also keep us from literally loving them to death by overfeeding. Hopefully, we can start to chip away at the notion that “food is love” for our pets.</p><img src="https://counter.theconversation.com/content/85958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Linder has received research or speaker funding from Jane's Trust Foundation, the North American Veterinary Community, the Mark Morris Institute, Royal Canin New Zealand, and Clinician's Brief in the past year. </span></em></p>More than half of dogs and cats around the globe are overweight. Are well-intentioned owners to blame?Deborah Linder, Head of Tufts Obesity Clinic for Animals, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/866012017-12-26T14:36:54Z2017-12-26T14:36:54ZOur fight with fat: Why is obesity getting worse?<figure><img src="https://images.theconversation.com/files/199353/original/file-20171215-25993-51v4qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman exercising. Thousands of people will be doing the same this week in an effort to lose weight, a perennial resolution.</span> <span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/resources/upload/images/press/ImageGallery/JPEG/122.jpg">UConn Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Gyms across the country will be packed in the new year with people sticking, however briefly, to their New Year’s resolution to lose weight. Most of them do not know that the cards are stacked against them and that weight loss is much more complicated than working out and not eating dessert.</p>
<p>Years into the obesity epidemic, millions of Americans have tried to lose weight, and millions of them have failed to do so long term. </p>
<p>It’s so serious now that <a href="https://www.cdc.gov/nchs/fastats/body-measurements.htm">close to 40 percent of Americans are obese</a>. The average woman in the <a href="https://www.washingtonpost.com/news/wonk/wp/2015/06/12/look-at-how-much-weight-weve-gained-since-the-1960s/?utm_term=.e9755d26095c">United States today weighs about 168 pounds</a>, or roughly the same as an average man in 1960.</p>
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<span class="caption">President John F Kennedy and First Lady Jacqueline Kennedy Arrive at Inaugural Ball on Jan. 20, 1961.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:President_John_F._Kennedy_and_First_Lady_Jacqueline_Kennedy_Arrive_at_Inaugural_Ball.jpg">Abbie Rowe/White House Photographs John F. Kennedy Library</a></span>
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<p>Not that guys’ waists haven’t ballooned, too. Men have gained on <a href="https://www.cdc.gov/nchs/fastats/body-measurements.htm">average nearly 30 pounds</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/15544194">since John F. Kennedy’s inauguration</a> in 1961.</p>
<p>From 1976 to 1980, <a href="https://www.cdc.gov/nchs/data/hus/hus02cht.pdf">just under 1 in 7 American adults, or 15.1 percent, were obese</a>. </p>
<p>Now, despite people’s concerted efforts, obesity is at its highest level ever, with about <a href="https://www.cdc.gov/nchs/products/databriefs/db288.htm">40 percent of U.S. adults and 18.5 percent of children</a>, considered obese. This is itself an increase of about 30 percent, just since 2000 when roughly <a href="https://www.cdc.gov/nchs/data/databriefs/db219.pdf">30 percent of American adults were obese</a>. </p>
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<p>The U.S., and increasingly the world, is in the grip of a real epidemic – the seriousness of which is lost in our obsession with diets. One study estimated an additional <a href="https://www.ncbi.nlm.nih.gov/pubmed/21872750">65 million obese Americans</a> by 2030, and increased medical costs between US$48 billion to $66 billion a year.</p>
<p>As an endocrinologist, I study obesity and treat people with obesity every day. Here are some things I see, and some things I see that could begin to address the problem.</p>
<h2>Costs across the board</h2>
<p>Obesity, defined as a body mass index of at least 30, is about far more than vanity. It impairs quality of life and exacerbates health risks involving many medical conditions in children and adults. Obese people incur <a href="http://journals.sagepub.com/doi/pdf/10.4278/ajhp.120905-QUAN-428">more medical costs, live shorter lives and miss more work </a>than their thinner counterparts. </p>
<p>The health risks include gallbladder disease, osteoarthritis, gout, sleep apnea, polycystic ovarian syndrome, cardiovascular disease and a broad spectrum of cancers, such as pancreatic, liver, breast and kidney cancers.</p>
<p>Obesity also leads to metabolic conditions such as hypertension, Type 2 diabetes and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387293/">nonalcoholic fatty liver disease</a>, which has long been overlooked as a life-threatening consequence of poor eating habits. This disease was rare until 1980.</p>
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<p>The medical costs associated with obesity are enormous – and growing. One study estimated the annual medical care costs of obesity in the United States in 2008 dollars at <a href="https://www.ncbi.nlm.nih.gov/pubmed/22094013">$209.7 billion</a>. To put that in perspective, consider that that’s almost half the amount of the estimated <a href="https://www.thebalance.com/current-u-s-federal-budget-deficit-3305783">federal deficit</a> for fiscal year 2018. About 1 in 5 health care dollars are spent to treat obesity-related illness.</p>
<p>The costs are also high to individuals. Compared with normal-weight individuals, <a href="https://www.ncbi.nlm.nih.gov/pubmed/19635784">obese patients spend 46 percent more on inpatient costs</a>, 27 percent more on outpatient care and 80 percent more on prescription drugs. </p>
<h2>A sickness of American society?</h2>
<p>Obesity’s roots are in American culture, from the stress of the workplace to the onslaught of food advertising, to our tradition of holiday overindulgence. The taste buds of our youth are raised on junk food and sugary treats, habits that follow children into adulthood.</p>
<p>American society is structured around productivity and long work hours. This leads to unbalanced lives, unhealthy lifestyles and unhappy people. Stress and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542973/">lack of sleep can contribute to obesity</a>.</p>
<p>For many families struggling between paychecks, the foods that make the most financial sense are the processed, packaged, fatty choices serving up the most calories.</p>
<p>Meal portions at restaurants have sharply increased in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447051/">recent decades</a> as well. The percentage of our food budget spent on out-of-home dining climbed to <a href="https://www.ncbi.nlm.nih.gov/pubmed/18309297">46 percent in 2006, up 20 percent since 1970</a>. The temptation of unhealthy food greets us on every street corner, in our breakrooms and at our favorite supermarkets. We Americans are eating too much yet we can’t seem to reverse it. Why? </p>
<p>Some blame the epidemic on the advent of the microwave and the growth of fast food options since the 1970s. Also, our <a href="https://www.ncbi.nlm.nih.gov/pubmed/21525258">food choices</a> have changed, with food industries mass market fattening foods to children. </p>
<p>Americans are more sedentary <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4524881/">than we were decades ago</a>. Our lives are tied to computer screens, big and small, in both our jobs and our homes. Our children are now raised on hand-held devices that serve as surrogate playmates in a world where “playing ball” is more likely to be done via internet connection than the actual playing field.</p>
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<h2>Blaming the victim?</h2>
<p>Many of us invoke “willpower” in our fight against fat, blaming and shaming ourselves and others for not losing weight. While many people have lost weight in the short term, they struggle to break the cycle of food addiction and unhealthy food choices. Yet scientists have learned that this is not about a shortage of willpower but about an abundance of physiological factors that make the body hold onto fat.</p>
<p>Patients standing alone with just their willpower and the latest diet to guide them invariably face great difficulty against a complex disease like obesity. <a href="https://www.nature.com/articles/ijo2017287.pdf?origin=ppub">Going it alone may be a barrier</a> to appropriate treatment options, such as behavioral modification counseling, anti-obesity drugs and <a href="https://asmbs.org/patients/bariatric-surgery-procedures">bariatric surgery</a>.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21247515">Weight regain</a> is common, as structured diets are hard to follow over the long haul. The body resists long-term calorie restriction by sending signals to our brains that trigger a craving for food, making diets prone to failure.</p>
<p>Because of the frustration of failure, many people are simply giving up on slimming down, making obesity an accepted social norm. One study has shown a declining percentage of <a href="https://www.ncbi.nlm.nih.gov/pubmed/28267846">men and women trying to lose weight since 1988</a>, perhaps due to a lack of motivation after failed efforts.</p>
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<h2>Fixes</h2>
<p>Even so, we’re making some progress battling this epidemic. Studies show obesity appears to be plateauing in Caucasians, <a href="https://www.cdc.gov/nchs/products/databriefs/db288.htm">though not in ethnic minorities</a>. But the numbers are already so high, “plateauing” seems more euphemistic than hopeful.</p>
<p>Scientific research has shown that the fixes are not about dieting, however. The solutions are complex and will take time and resources. Patients need more support than they are receiving.</p>
<p>Clearly, our country needs a greater systematic effort in the realms of public health, the government and industry. For starters, our political leaders should make combating obesity a top priority. Our nation faces many challenges, and the obesity epidemic has fallen to the bottom of a long list of health care problems. </p>
<p>Schools could play a role. Students should receive additional education in schools on good eating habits and how to control stress. </p>
<p>As someone who sees this devastating illness every day, I believe that health care insurers need to be more willing to pay upfront to manage obesity before it becomes a much more expensive disease to treat. Given the structure of health insurance now, physicians simply cannot spend the time needed with patients to properly communicate and educate.</p>
<p>Studies have shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28063213">many insurers exclude treatments</a> for obesity.</p>
<p>Each of us needs to become an advocate for a healthier way of life. Adults can start by teaching our youngsters about good dietary habits, by insisting on a better balance in the workplace, and by demanding more accountability from the food and health industries, and our government. Doing that will help ensure a brighter and healthier future for our children.</p><img src="https://counter.theconversation.com/content/86601/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Cusi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite the efforts of millions of Americans, obesity rates continue to climb. Why is it so hard to lose weight and to keep it off? It’s a lot more complicated than just pushing back the plate.Kenneth Cusi, Professor of Endocrinology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/825652017-12-26T14:10:05Z2017-12-26T14:10:05ZWhy walking with your doctor could be better than talking with your doctor<figure><img src="https://images.theconversation.com/files/199477/original/file-20171215-17848-xncibk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man who is overweight walking alone in a park. Walking with a doctor could be helpful for overweight patients. </span> <span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/resources/upload/images/press/ImageGallery/HighRes/276.jpg">Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Gyms across the country will be packed this week with people vowing to “get moving” to lose weight this year. </p>
<p>Much of the effort will be for naught. And, in fact, some of it could lead to injury and frustration.</p>
<p>Currently, <a href="https://www.cdc.gov/obesity/resources/strategies-guidelines.html">Centers for Disease Control and Prevention exercise guidelines</a> call for all individuals to do 150 to 300 minutes of moderate-intensity exercise per week, or 75 minutes of high-intensity exercise per week. In addition, the CDC recommends two days of strength training, or muscle strengthening, for obese people. </p>
<p>I am a physician assistant and exercise physiologist from the Lifestyle Modification Clinic at UConn Health. Current recommendations seem extremely unrealistic, considering <a href="http://dx.doi.org/10.1016/j.amepre.2010.12.016">less than 10 percent</a> of all individuals meet these criteria for exercise, even without the resistance exercises. </p>
<p>We’ve lost the focus on using the guidelines only as guidelines, and not individualizing an exercise prescription for our patients. We need to be smarter about prescribing it, and here’s why. </p>
<h2>A customized approach</h2>
<p>The medical profession has learned a few things in recent years about exercise and the obese and those who have become diabetic as a result. All exercise is not created equal, and neither are its benefits.</p>
<p>For those who want to burn fat, aerobic exercise is important. Fat metabolism is greatest <a href="http://ajcn.nutrition.org/content/72/2/558s.full">during aerobic exercise</a> which is achieved during moderate intensity exercise.</p>
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<img alt="" src="https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=437&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=437&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=437&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=549&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=549&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199478/original/file-20171215-17857-8rtf1y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=549&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Aerobic exercise class.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/aerobic-exercise-gym-746423404?src=n8UoK0KCIACkVlLYD-Zjew-1-8">Cultura Motion/Shutterstock.com</a></span>
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<p>Type 2 diabetes is due to insulin resistance, so the <a href="http://dx.doi.org/10.1056/NEJMoa020194">exercise that is more effective to increase insulin sensitivity </a>is more specific to the duration of the exercise than the intensity. </p>
<p>But overweight and obese people may not be able to do either of these without injuring themselves. The Hippocratic oath, whereby doctors pledge to first “do no harm,” gets lost with the prescription of exercise with most individuals. The risk of injury and noncompliance should be the first two things when discussing an exercise routine. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/870782">risk of injury</a> for all individuals, especially of the lower extremities, such as plantar fasciitis and knee pain, is up to four times greater doing high-intensity exercise, such as jogging compared to moderate intensity, such as walking. Obese individuals are at even greater risk.</p>
<p>The risk of injury drives noncompliance, especially with higher-intensity exercise. Educating patients about the benefits of breaking up <a href="http://dx.doi.org/10.2337/dc11-1931">prolonged sitting</a> throughout the day has been shown to improve insulin sensitivity for diabetics which will help motivate them to start making little changes to start. This will allow them to make realistic changes and even those will have benefits. </p>
<h1>Walking the walk</h1>
<p>Understanding the importance of exercise, you would assume that physicians spend a lot of time counseling on exercise. </p>
<p>However, in 2010, <a href="https://www.ncbi.nlm.nih.gov/pubmed/22617014">fewer than 31 percent </a>of physicians recommended physical activity for overweight and less than 47 percent for obese people during an office visit. This was an increase, however, from fewer than 17 percent for overweight and 35 percent for obese in 2000. </p>
<p>This could be partly due to how health care providers are educated, with less than <a href="https://doi.org/10.1123/jpah.2014-0316">20 percent of medical schools</a> in the U.S. even requiring one class in physical activity or exercise. <a href="https://doi.org/10.1123/jpah.2014-0316">More than half </a>of the physicians trained in the United States in 2013 received no formal education in physical activity and may, therefore, be under prepared to properly advise about exercise.</p>
<p>Exercise has been shown to reduce the risk up to 50 percent for all people from becoming diabetic, and since obese individuals are at greater risk, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762932/">they would benefit the most</a>. For physicians, the challenge is how to help obese patients understand this and help them become more active. </p>
<p>The first thing is to educate our health care professionals during their medical education on exercise physiology and the medical importance of physical activity which will help them give an appropriate exercise prescription. </p>
<p>It has been shown that the more the <a href="https://www.ncbi.nlm.nih.gov/pubmed/10810947">physicians focus on exercise</a>, the more likely patients will exercise. </p>
<p>Also, the more we doctors go into our “patient’s lifestyle” and find ways to get them moving more and being respectful of them, the more successful they will be. We need to get outside of our box of guidelines and listen to our patients. An example would be to go for a walk during their visits.</p>
<p>Patients walking with their doctors can help doctors assess patients’ fitness levels. Health care providers can assess whether patients have any limitations such as knee or back pain. They also can explain the difference between aerobic and anaerobic exercise, which is best done by explaining the “<a href="https://www.cdc.gov/physicalactivity/basics/measuring/index.html">talk test</a>”. If you can talk but not sing while exercising, you are maintaining aerobic metabolism, which burns fats and is good for weight loss. If you are unable to say more than a few words without pausing for a breath, you will then be exercising anaerobically and burning sugar.</p><img src="https://counter.theconversation.com/content/82565/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brad Biskup does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health care providers often recommend exercise to overweight people as a way to lose weight, but that often does not work. Injuries can occur, and frustration can mount. Can walking with them work?Brad Biskup, Coordinator of Lifestyle Medicine Clinic, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/866042017-12-26T14:09:56Z2017-12-26T14:09:56ZWhat thin people don’t understand about dieting<figure><img src="https://images.theconversation.com/files/199111/original/file-20171213-27593-1yg6afh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A plate of fattening food is harder for some people to resist than others. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/breakfast-french-toast-highcalorie-meal-fried-392210401?src=SPYSxqYQtEtLcx9Zv-2xpw-3-22">Milan Gordic/Shutterstock.com</a></span></figcaption></figure><p>Diets do not work. </p>
<p>The scientific evidence is clear as can be that cutting calories simply doesn’t lead to <a href="http://psycnet.apa.org/record/2007-04834-008">long-term weight loss</a> or <a href="http://onlinelibrary.wiley.com/doi/10.1111/spc3.12076/full">health gains</a>.</p>
<p>We suspect most dieters have realized this by now too. And yet, here they are again, setting the same weight loss goal this year that they set last year. </p>
<p>The only people who don’t seem to appreciate this are people who have never dieted. It’s particularly hard for them to believe because it doesn’t square with their own eating experiences. </p>
<p>Take Nicky, for instance. She eats sensibly much of the time, with some junk food here and there, but it doesn’t really seem to affect her weight. She’s not a dieter. She is Naturally Thin Nicky, and it’s not surprising that she believes what she sees with her own eyes and feels in her own body. Nevertheless, Nicky has it wrong. </p>
<p>We are researchers who have been studying why diets fail for a long time. We have seen that diet failure is the norm. We have also studied the <a href="https://www.sciencedirect.com/science/article/pii/S0195666314003560">stigma</a> that heavy people face, and witnessed the blame game that happens when dieters can’t keep the weight off. From a scientific perspective, we understand that dieting sets up an unfair fight. But many Nickys we’ve encountered – on the street, in the audience when we give talks, and even fellow scientists – get confused when we say dieting doesn’t work, because it doesn’t square with their own observations.</p>
<h2>An unfair fight</h2>
<p>Nicky thinks she’s thin because of the way she eats, but actually, <a href="https://jamanetwork.com/journals/jama/fullarticle/359582">genetics</a> play a huge role in making her thin. Nicky gets all the credit though, because people see the way she eats and they can’t see her genes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199281/original/file-20171214-27562-1b8vr37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman wearing a crown and taking a selfie. Thin people sometimes think they deserve credit for having willpower to resist high-calorie food, when in fact other factors play a role.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-caucasian-girl-golden-crown-above-744920752?src=CBx7JApn2sl5umM15McUIg-2-24">N-defender/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Many heavy people wouldn’t be lean like Nicky even if they ate the same foods in the same quantities. Their bodies are able to run on fewer calories than Nicky’s, which sounds like a good thing (and would be great if you found yourself in a famine). </p>
<p>However, it actually means that after eating the same foods and using that energy to run the systems of their body, they have more calories left over to store as fat than Nicky does. So to actually lose weight, they have to eat less food than Nicky. And then, once they’ve been dieting a while, their <a href="http://www.nejm.org/doi/full/10.1056/NEJM199503093321001#t=article">metabolism changes</a> so that they need to eat even less than that to keep losing weight. </p>
<p>It’s not just Nicky’s genetically given metabolism that makes her think dieting must work. Nicky, as a non-dieter, finds it really easy to ignore that bowl of Hershey’s Kisses on her co-worker’s desk. But for dieters, it’s like those Kisses are jumping up and down saying “Eat me!” Dieting causes <a href="http://www.sciencedirect.com/science/article/pii/S1053811912011408">neurological changes</a> that make you more likely to notice food than before dieting, and once you notice it, these changes make it hard to stop thinking about it. Nicky might forget those chocolates are there, but dieters won’t. </p>
<p>In fact, dieters like them even more than before. This is because other diet-induced <a href="http://www.sciencedirect.com/science/article/pii/S1053811912011408">neurological changes</a> make food not only taste better, but also cause food to give a bigger rush of the reward hormone dopamine. That’s the <a href="http://www.sciencedirect.com/science/article/pii/S0149763407000589">same hormone</a> that is released when addicts use their drug of choice. Nicky doesn’t get that kind of rush from food.</p>
<p>And besides, Nicky is full from lunch. Here again, dieters face an uphill battle because dieting has also changed their <a href="http://ajpregu.physiology.org/content/301/3/R581.short">hormones</a>. Their levels of the so-called satiety hormone leptin go down, which means that now it takes even more food than before to make them feel full. They felt hungry on their diets all along, but now feel even hungrier than before. Even Nicky’s regular non-diet lunch wouldn’t make dieters full at this point. </p>
<h2>Where’s your willpower?</h2>
<p>People see Nicky and are impressed with her great self-control, or willpower. But should it really be considered self-control to avoid eating a food when you aren’t hungry? Is it self-control when you avoid eating a food because you don’t notice it, like it or receive a rush of reward from it? </p>
<p>Anyone could resist the food under those circumstances. And even though Nicky doesn’t really need willpower in this situation, if she did need it, it would function quite well because she’s not dieting. On top of everything else, dieting disrupts <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/impaired-cognitive-functioning-during-spontaneous-dieting/047B2389EBB0E325595FC82959C6D153">cognition</a>, especially <a href="http://www.sciencedirect.com/science/article/pii/S0195666305000802">executive function</a>, which is the process that helps with self-control. So dieters have less willpower right when they need more willpower. And non-dieters have plenty, even though they don’t need any. </p>
<p>And of course, even if Nicky were to eat those tempting foods, her metabolism would burn up more of those calories than a dieter’s metabolism.</p>
<p>So Nicky is mistakenly being given credit for succeeding at a job that is not only easy for her, but easier than the job dieters face. </p>
<p>The cruel irony is that after someone has been dieting for some time, changes happen that make it hard to succeed at dieting in the long run. It is physically possible, and a small minority of dieters do manage to keep weight off for several years. But not without a demoralizing and <a href="http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html">all-encompassing battle</a> with their physiology the entire time. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199311/original/file-20171214-27583-1s04mj9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A woman shopping in the produce department of a grocery store. People who are overweight often must learn to like healthy foods.</span>
<span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/resources/upload/images/press/ImageGallery/JPEG/410.jpg">UConn Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<p>It’s easy to see why dieters usually regain the weight they lose on their New Year’s resolution diet, and we have the following suggestions for when that happens: If you are a Nicky, remember the self-denial these dieters have subjected themselves to and how little they were eating while you treated yourself to decadent desserts. Be impressed with their efforts, and grateful that you don’t have to attempt it. </p>
<p>If you are a dieter, remind yourself that you aren’t weak, but that you were in an unfair fight that very few win. Change your focus to improving your health with exercise (which doesn’t require weight loss), and resolve to choose a different New Year’s resolution next year. </p>
<p><em>Traci Mann is the author of “<a href="https://www.npr.org/sections/thesalt/2015/06/01/411217634/in-eating-lab-psychologist-spills-secrets-on-why-diets-fail">Secrets from the Eating Lab</a>.”</em></p><img src="https://counter.theconversation.com/content/86604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Traci Mann has received grants from the National Institutes of Health, NASA and the USDA. </span></em></p><p class="fine-print"><em><span>A. Janet Tomiyama receives funding from the National Science Foundation and the Robert Wood Johnson Foundation. </span></em></p>Dieting is a setup. The act of dieting causes physiological changes that make it hard to continue dieting successfully. Here’s how the body fights back when some people try to lose weight.Traci Mann, Professor of Psychology, University of MinnesotaA. Janet Tomiyama, Associate Professor, Psychology, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.