Manual Obesity: Your lack of wisdom will take you places you might not want to go

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We're just eating too much. I've been arguing otherwise.

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And one reason I like this hormonal hypothesis of obesity is that it explains the fat kids in Depression-era New York. As the extreme situation of exceedingly poor populations shows, the problem could not have been that they ate too much, because they didn't have enough food available. The problem then—as now, across America—was the prevalence of sugars, refined flour, and starches in their diets. These are the cheapest calories, and they can be plenty tasty without a lot of preparation and preservation.

And the biology suggests that they are literally fattening—they make us fat, while other foods fats, proteins, and green leafy vegetables don't. If this hypothesis is right, then the reason the anti-obesity efforts championed by the IOM, the CDC, and the NIH haven't worked and won't work is not because we're not listening, and not because we just can't say no, but because these efforts are not addressing the fundamental cause of the problem.

Obese to Beast

Like trying to prevent lung cancer by getting smokers to eat less and run more, it won't work because the intervention is wrong. The authority figures in obesity and nutrition are so fixed on the simplistic calorie-balance idea that they're willing to ignore virtually any science to hold on to it. The first and most obvious mistake they make is embracing the notion that the only way foods can influence how fat we get is through the amount of energy—calories—they contain.

The iconic example here is sugar, or rather sugars, since we're talking about both sucrose the white, granulated stuff we sprinkle on cereal and high-fructose corn syrup.

The answer she's given is "stop drinking sugar-sweetened beverages. Left unsaid is the fact that sucrose and high-fructose corn syrup have a unique chemical composition, a near combination of two different carbohydrates: glucose and fructose. And while glucose is metabolized by virtually every cell in the body, the fructose also found in fruit, but in much lower concentrations is metabolized mostly by liver cells.

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From there, the chain of metabolic events has been worked out by biochemists over 50 years: some of the fructose is converted into fat, the fat accumulates in the liver cells, which become resistant to the action of insulin, and so more insulin is secreted to compensate. The end results are elevated levels of insulin, which is the hallmark of type 2 diabetes, and the steady accumulation of fat in our fat tissue—a few tens of calories worth per day, leading to pounds per year, and obesity over the course of a few decades.

Last fall, researchers at the University of California, Davis, published three studies—two of humans, one of rhesus monkeys—confirming the deleterious effect of these sugars on metabolism and insulin levels. The message of all three studies was that sugars are unhealthy—not because people or monkeys consumed too much of them, but because, well, they do things to our bodies that the other nutrients we eat simply don't do. The second fallacy is the belief that physical activity plays a meaningful role in keeping off the pounds—an idea that the authorities just can't seem to let go of, despite all evidence to the contrary.

If we do exercise regularly, the logic goes, then we'll at least maintain a healthy weight along with other health benefits , which is why the official government recommendations from the USDA are that we should all do minutes each week of "moderate intensity" aerobic exercise. And if that's not enough to maintain a healthy weight or lose the excess, then, well, we should do more. So why is the world full of obese individuals who do exercise regularly? Arkansas construction workers in The Weight of the Nation , for instance, do jobs that require constant lifting and running up ladders with "about 50 to 60 pounds of tools"—and an equal amount of excess fat.

They're on-camera making the point about how the combination is exhausting. You can't last as long as you used to. In a country that places a big rhetorical premium on individual responsibility, we tend to not only do a lot of blaming the victim—we also seem to kind of enjoy it. In this lavishly illustrated piece we encounter families living in decent homes and owning nice appliances, Nike Airs, and cell phones—and they all eat terribly.

They consume greasy chicken gizzards, hot dogs, chicken nuggets, and tater tots. Judging from the pictures and videos, most people profiled are overweight.

A moment for introspection

With the exception of a family foraging for food, the eating scenes in this article are grim. This point has some merit—the federal government certainly subsidizes sodas and hot dogs far more than fresh fruits and vegetables. It only takes a quick scan of the June retail food prices —or taking a calculator to a chain grocery store—to see that for the cost of a pound of cookies and a pound of processed cheese you could buy a pound each of broccoli, tomatoes, oranges, bananas, potatoes, and rice.

Should we simply go ahead and blame the obese for their obesity? What a sweetheart. Of course, such a response not only makes one sound like a jerk, but is tragically short-sighted. We might begin this process by trying to understand diet as a psycho-socioeconomic phenomenon rather than as a matter of food access. Absolutely nothing about their lives is secure. Knowing that biology is behind a craving helps them to respond by making a different choice, Fitch says.

To help patients keep off their weight for the long term, many hospitals give patients the opportunity to continue their programs but at a less-intense level.

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Also, providers encourage patients to come back whenever they falter. Hospital medical weight-loss programs typically work hand in hand with surgical weight-loss programs because their services are so intertwined and because they want to give patients choices. Dietary, exercise, and behavior therapy; medication; and surgery are all different tools in the weight-loss toolbox, Fitch explains.

Bariatric surgeical patients still need dietary, exercise and behavioral therapy to succeed.

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Offering the full range of services produces economies of scale by allowing the various professionals to see both medical and surgical weight-loss patients. As a result, hospital weight-loss centers typically charge patients and encourage them to research whether they have coverage and submit a claim if they can.

In some quarters, the perception persists that obesity is a personal failing. Some patients are able to pay for services out of health savings accounts. At UAB Medicine, Garvey had discussions two years ago with senior leaders about the need for a multidisciplinary weight-loss clinic and for insurance coverage. The insurer covers UAB employees and is available to area employers.

Obesity: Your lack of wisdom will take you places you might not want to go

Garvey hopes the new American Association of Clinical Endocrinologists clinical guidelines will prompt more employers and health insurers to cover weight-loss care by providing a rational construct that treats obesity in the same way as other chronic conditions. While progress is being made toward accepting obesity as a chronic disease, much work needs to be done at the physician-practice level. We think obesity should be put on the same par with other chronic diseases. A September article in the journal Health Affairs lays out the Chronic Care Model in which providers and community organizations work together to optimize obesity treatment and to make healthy choices an easy option for residents.

Eat less and exercise more.