Wednesday, June 26, 2013

Inviting debate - what do we do about overweight and obesity?

Recently, I received an email from Run Stop Shop who are promoting the 'infographic' (a new term for me) below. You can also see it on their site here. It's the sort of thing I am happy to share, because it presents facts and figures in an easy to grasp way, drawing on the published literature rather than anything more subjective or biased.

State Of Australia's Health Infographic
Source: Run Stop Shop


As some of you know, I work in health and medical research, and more specifically, in mental health research. If you work in mental health research, you learn early on that good research takes weight status / Body Mass Index into account, because it is so strongly associated with depression in particular and mental health difficulties in general - at least in females. This relationship is generally accepted as being bi-directional: mental health problems are likely to predict overweight/obesity just as much as overweight/obesity predict mental health problems (see this study and this study for examples).

There are a few things we know about overweight and obesity. It's increasing in prevalence, obviously. It's increasing particularly dramatically in childhood and adolescence. It's associated with a whole range of physical health problems (as the above shows, cardiovascular disease and Type 2 Diabetes in particular) as well as mental health problems, social problems, disordered eating (particularly binge eating), and distress about weight. Again, these effects are more pronounced for females than for males.

We also know that not everyone who is overweight or obese has these difficulties. Weight, like so many other things, is meant to normally distributed. Remember the bell shaped curve you learnt about in maths? There will always be some people who are classified as "overweight", just as there will always be some people who are classified as "underweight". We aren't all the same height. We don't all have the same shoe size. Variation is normal. Being overweight isn't always bad, or a result of overeating, or a sign of medical problems. In older men, being slightly overweight actually seems to be protective. It gives people more reserves in case of infection or illness - it may be healthier than being a "healthy weight"! In other age groups and in women, the health consequences linked to overweight and obesity seem to be linked, mostly, to obesity. We lump overweight and obesity together but they have quite different consequences for our health.

There is also a lot we don't know. The main thing is how to fix the problem. Dieting does not generally work, and in many cases will make things worse. Psychological treatments are better than commercial diets, but still quite ineffective in the long term. We are now at the point where national guidelines in Australia recommend weight loss surgery (bariatric surgery) as a serious treatment consideration for postpubertal adolescents and adults with obesity.

What about prevention? Surely that is the best place to start? Well, yes. Of course. But how? There is some great research on environmental contributors to overweight/obesity, and we know that environments where walking and cycling are easier, playgrounds are more available for children, fast food outlets are not scattered at regular distances, and fresh nutritious food is readily available are all positive. We also know they're not likely to be enough.

The truth is, weight is a complicated thing. It is influenced by genetics. We are, to a certain extent, evolutionarily designed to eat when food is available and store fat in case it becomes scarce in the future. We have created so many labour saving devices, modes of easy transport, and foods of immense calorie density that we have surprised our bodies and left them unprepared for this latest evolutionary challenge of too much, not too little (although outside of Western societies of course things are still reversed). Many of us have lost the skill of eating to genuine physical hunger, as opposed to the many other reasons that can prompt us to eat today. You are also more likely to be overweight or obese if you live in a socially disadvantaged area. It's social, too.

I don't have the answers, and writing this post is not about giving them to you. I did, however, have even more cause to think about these issues this week because I recently finished reading The Heavy: A mother, a daughter, a diet by Dara-Lynn Weiss. Some of you may remember her as the author of the highly controversial article published in Vogue in 2012, when she wrote about placing her 7-year-old obese daughter on a strict calorie controlled diet. The public backlash was huge. The book explains things in more detail.

Professionally and personally, I don't promote dieting. I actively discourage it. Dieting in teenagers predicts weight gain not loss. It is the most reliable predictor of binge eating and other eating disorder symptoms. I think eating according to the healthy eating guidelines is a good stance to take. I am fond of moderation, balance and staying away from extremes. I wish we could all focus a bit less on weight. I like studies showing that regardless of weight status, good nutrition and physical activity are associated with positive health outcomes.

And yet, Dara-Lynn relayed how focusing on general healthy eating didn't really work in their case. Her daughter, like many others out there, did not seem to have an 'off' switch when it came to food. Reducing her energy intake to a level that would halt weight gain and reverse obesity was tough, and restrictive. It did, over a year, work - in the short term at least, her daughter is now a healthy weight and functioning well. We could argue over the different ways it could be done, but clearly some parents are faced with a tough situation in helping their children eat appropriate amounts for their energy needs. Other parents face the opposite dilemma - children who could benefit from eating more, but don't show interest in doing so.

Again, I don't have the answers. My message is usually that healthy eating and regular exercise are what we need to focus on, in a balanced and non-extreme way: the kind of way that includes lots of fruit and vegetables, but also chocolate and cake on birthdays. A way that involves real rather than 'diet' food. I take the stance that weight will then take care of itself. Some of us will be an average size, some thinner, some larger. Clearly, though, it isn't as simple as that for many people out there. The above diagram highlights that. So what do we do?

I'd love to hear your thoughts.

Some references, for those of you who care about such things:

32 comments:

  1. LOVED loved loved this post Kari!

    I so agree with you about dieting and moderation- but despite having that knowledge I still end up caught in the diet trap, restricting, feeling deprived and overindulging *face palm* ah well, just got to keep trying my best to eat whole foods in correct portions and have some treats I guess.

    About 'healthy weight' I've always been big, even as a baby my father complained about how much heavier I was than other babies my size/age. BMI and suggested weights depress me. My personal trainer actually gave up telling me them and tried to stop me weighing myself and went by body fat percentage, waist measurement/pants size and my overall health rather than worrying about the norm so that I would keep lifting heavy weights and enjoy it rather than letting the increasing numbers get to me.

    I really appreciated the references with links too. Thanks so much for sharing :) xxx

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    1. I am so glad that you liked this Claire, and thanks so much for sharing your perspective. I'm really glad you have a personal trainer who is sensible enough to know numbers aren't everything and BMI can't take into account everyone's unique physique! It does go to show how much our world has become fixated on weight to think how many people might avoid lifting weights because the number they weigh on the scale goes up when they gain muscle mass.

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  2. I've just switched to Intuitive Eating after basically dieting since I was 17 years old. I was very overweight as a teenager and genetics and environment definitely do play a role in it. Knowledge however also plays a role and I think you can increase your knowledge and not become too obsessed. I think it is more around teaching people to listen to their bodies and look more at why they are eating not always what they are eating.

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    1. Thanks so much for your thoughts Jan. I think you make a great point - no matter what, knowledge is going to be key because without that, how could we possibly make informed choices? I'll look forward to following how you go with intuitive eating because it's an approach that so many of us have lost but so many of us could probably benefit from!

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  3. Great post Kari- so much wonderful information. Obesity is a huge issue in the US right now. Some people are even considering it a disease. For some people that could be true, but in a reality I think a lot of people are just lazy. I love my husband for example, but he has gained about 30 lbs so we were married in 2009. How has he done that? Eating junk food, fast food and literally doing no exercise. To him his weight gain is obviously not a disease because he is just lazy. Lazy, lazy, lazy. Drives me NUTS!

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    1. I had to chuckle at this - sometimes we do need to take a step back and just say well, if we eat that way, we are going to weigh that much and call things for what they are ;) It must be hard for you being so active though, to see him not join in something you're so involved with!

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  4. Oh such a complex issue to address. I am a fan of infographics and this is a useful one. Neither E nor I am into exercise so it is something I am aware of but it is so much easier in summer than winter - but we are lucky that parks are close by to walk to. Harder is that we don't have so many friends who live locally but the longer we have lived in the area the more local connections we make which allows us to walk more and be in the car less. I can't wait until Sylvia is at a school she can walk to. Though I am sure it will bring new challenge when she is at school and getting more independent.

    Teaching kids to eat well is tough when you spend time at the supermarket with all its glittery lures but at least we can have more control over our kitchen - it makes me laugh when sylvia is being sneaky and gobbles down a cherry tomato from the bench or nibbles an apple rather than getting her teeth into something else that shouldn't be left about.

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    1. I like to think of exercise as having two categories, the formal / planned type and the incidental / general movement type. I'd say if you're walking and going to parks, you may well be getting plenty of the latter :-) Mr B is a bit like that too - he doesn't get my interest in running at all and can't fathom gyms in the slightest, but he is probably still more active than many people who do formal exercise a few times a week and nothing in between.

      I'd also say that if Sylvia is sneaking tomatoes and apples, you are doing something very right indeed!

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    2. We definitely do far more of the incidental exercise than formal exercise - it is a matter of trying to make sure it is built into our lifestyle which I guess is why walking to school and walking to local events and parks is important.

      I was thinking about this and how so many houses are now built with such small backyards - we make sure there are large rooms inside if possible but build or extend over backyards. Not like my childhood when we had a football oval out the back as just part of our yard - though we lived on a big country block so probably had more than city kids even then. So I think public planning is important to ensure that kids can walk places and run about somewhere else. Just one thought on obesity solutions.

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    3. Someone I work with focuses on that kind of environmental influences on health and it is such a fascinating research area - makes me wish I'd gone down that path myself! I agree with your thoughts entirely. I was interested to hear that if you ask children, the vast majority want to walk to school. It seems that design is a big factor in that, and of course parks and ovals are key too. I wish some health people would go into planning!

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    4. I worked with some people who were into social determinants of health and it is a really important area of research but so so so complicated that it makes you giddy

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  5. Thanks for sharing this infographic, and your thoughts! And though it's specifically about Australians, I know the figures would be super similar for Canadians too. And thanks for making the distinction between overweight and obesity. I agree with your sentiments that regardless of what weight you are, the focus shouldn't be on losing it, but rather eating healthy, wholesome food (with some exercise thrown in there).

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    1. Whoops, I accidentally replied with my band account, ha ha!

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    2. Multiple accounts is always a challenge ;)

      Thanks so much for your comment and for taking the time to share your own thoughts! It sounds like we have very similar ideas on the issue :)

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  6. Look, this isn't usually the type of topic I'd click through to on blogs, particularly "healthy eating" blogs, but knowing that you work in this area I knew it wouldn't be the fat-shaming victim-blaming individualistic take to the issue that I'm so sick of seeing written by privileged white people in female-we-love-stevia-blogworld, so thank you for that. A well-considered piece. And now I'm going to eat more pecan pie. x

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    1. You have no idea how much I appreciate that you clicked over - not so much for the clicking over itself (although that is very lovely too!) but that you trusted I wouldn't be in the fat-shaming victim-blaming privileged blogger camp. Thank you :-)

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  7. Wow Kari - you have written this soooooooooooooo amazinly awesome! :-) Good on you for being brave enough to post this. I think it can be a bit of a tabo topic - people don't like to talk about their weight! Maybe I sound bias but I believe I switch towards a more plant-based diet would do our nation incredibly good - weight wise, mental health wise & many others (as you know!). Yet I'm also aware that it won't solve all the problems. I think BMI is over-rated because everybody is so very very different and while some people can easily maintain their weight in what is considered an normal weight range, others struggle to put on weight & others struggle to lose just because of their body type! I agree that dieting doesn't work but in being honest I am also someone who struggles to have an 'off switch' but I notice that my off switch seems to work automatically when I'm eating no processed foods! Sounds like you have an interesting job too! Oh and as a side note - I think its all very good to encourage people to exercise but in reality some people just find it plain boring & all the exciting types of exercise seem to cost a fortune! $15 for one class is ridiculous if you ask me! It means it can't be done regularly unless you self-motivate which those who need it most will often struggle with! (wow that got long - sorry, and very mis-matched just random comments!) :-)

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    1. Thanks so much Sandy! I relate to not having an 'off switch' too in many ways - Mr B jokes about how much fruit I can tuck away! - and like you find that eating a vegan diet means that my eating largely takes care of itself. I am pretty much guaranteed to get nutritious food even if I also get a lot of other things too ;)

      I know what you mean about exercise being expensive too. I'm really glad I discovered running as something I love, because whilst the shoes are expensive, per run it is a really cheap activity. I know it isn't for everyone though and if you don't find an activity you love, it is tough.

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  8. Oh, that's very sobering isn't it! I think parents need to take responsibility for what they feed their children but also, schools are forcing primary school children to be so much more sedentary by refusing to allow them to run around, removing sports programs to replace them with Mandarin lessons etc. Then in high schools, when I was at school sport was compulsory and now it's optional. Playing sport in school creates habits of continuing to exercise later on in life and it's time schools concentrated less on academic results on more on teaching a healthy lifestyle (but everything in balance of course it's just the pendulum has swung too far)! There's so much more to say but I'll leave it there xx

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    1. It is quite amazing how much physical activity has been side lined in schools. I will confess to hating physical education as a child and teenager, but I am quite sure it was good for me to do it! I also with that I'd had physical education that encompassed things I might have enjoyed - like you say, habits of exercising are things we should learn young and I'm sure there are activities for all of us, just like I'm also sure netball and hockey and the like are not mine. Thanks for sharing your thoughts :)

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  9. Oh I didn't know you worked in mental health research - must be fascinating! I know that I NEED to eat healthy AND move daily as well as being medicated to stay balanced. It's crucial. If I eat crap I feel like crap, no ifs or buts about that one.

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    1. Movement is super essential for me too Lou :) Eating healthy makes a massive difference as well, but if I don't exercise in the morning it is far more of a struggle for me to feel good and energised throughout the day. I'm glad I discovered that because I often think how I'd be a completely different (less happy and less healthy!) person if I didn't know it.

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  10. Great post Kari! It is such a complex issue. I worry about my young man often as he eats out very regularly and I know that everything he buys is basically junk. We have tried to educate him about nutrition and provide him with good food at home (the majority of the time) which is about all that you can do really. I'm also concerned with the number of very young children that are obsessed with sitting behind a TV, console game or computer rather than running around outside like we did when growing up. I really do fear for the health of the younger generations.

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    1. I think there must be a time for all adolescents and young adults when junk food is far more 'normal' than their parents would like! I like your points about trying to educate and provide good food at home though, and as you say, that's really all you can do. I also share your concerns about the amount of time children now spend at screens. I'm sure it doesn't do their eyes any good either! The fact we now have 'fitness' games for gaming consoles highlights how far we've come from the days children just played outside. These days of course many families don't even have easy access to space to play outside - or are too scared that their children will come to harm at the local park. There are so many changes and challenges!

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  11. This is such a wonderfully written post, Kari! Oh boy...the battle with obesity. The solution is simple. Simply eat less and move more. However, just as you've mentioned, there are so many different factors involved (genetic predisposition, socioeconomic status, the environment, psychological well-being...) that poses such a great challenge in addressing this epidemic. I had completely the opposite problem. For many years, the numbers on that darn scale defined me. I binged, starved, binged, and managed to keep my weight at 85 pounds (I'm 5'5) w/o even moving. My body was very used to being in starvation mode and that was a lot of fun (I felt so cold that even my insides felt frigid..hard to explain the feeling, my breath smelled oh so lovely, my cycles disappeared, I was losing hair...). It was not an easy battle to fight but one I needed to face and win for myself and for my family. I stopped focusing on numbers, BMI, all of that and diverted that attention to eating more mindfully and listening to my body (not easy but can be done w/persistence and lots of prayers!). You're right. Everyone's different and while BMI is important as a reference, but should not define anyone.

    As I'm studying to be a Registered Dietitian (my 10 mo. internship starts this August! ahh), I'm becoming more and more interested in childhood nutrition. One way to combat this epidemic is to start early. Oftentimes, when mothers feed their children, they think "oh my child won't like this bc it's too bland, mushy, doesn't taste good.." when it should be the child who makes that decision. Of course, if he/she doesn't like it the first time, just keep offering it. Parents can really shape the development of childhood preferences. Why not try to get your child to love carrots, broccoli, sweet potatoes rather than french fries and cookies? If a family member is wanting to lose some weight, the whole family needs to come together and help make that goal a reality. Having meal times together as a family around the table rather than starting at the tv screen, texting; getting rid of junk food; cooking more often...If everyone can just take baby steps in becoming mindful eaters, the future won't look so dismal.

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    1. Thanks so much for your comment and thoughts Min! I love how you have turned your own health (and indeed life) around - it is a really hard thing to do and you show that while it's tough, it can be done and it brings worthwhile benefits! I also like your thoughts about shaping children's eating habits. Since when did a 5 year old get to dictate their diet anyway?! I certainly accepted what I was provided with at that age and parents have the potential to play a huge role. "Baby steps in becoming mindful eaters" is such a lovely phrase too - I agree entirely :-)

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  12. It's difficult to write usefully in response to this, because I am exactly the sort of person who should be trying to lose weight (overweight, family risk of type 2 diabetes), but if I start thinking about it and putting focused effort into it, I quickly descend into a spiral of utter self-loathing and depression which I suspect is worse for me than the excess weight is (I love the bit where stress messes with your blood sugar, too. Just what I need).

    (And I've just deleted most of what I wrote after that, because here comes the spiral!)

    I do think, though, that while it's a good idea for schools to encourage physical activity, there needs to be an emphasis on non-competitive physical activity, too. I went to a very sporty school, and because I was slow and un-co-ordinated, I got to spend around eight hours a week being either the person who was letting her team down or the person who was coming humiliatingly last - and it wasn't for want of trying. And this was not forgotten for the rest of the week. I've learned now that I quite like yoga (it doesn't hurt and I'm not 100% terrible at it), and that swimming and cycling can be enjoyable on those days when my body doesn't decide I need an evil knee or intense dermatitis, but growing up associating physical activity with humiliation and, frequently, pain, does not encourage one to embrace this as an adult.

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    1. I'm so glad you did write in response Catherine. Your first paragraph highlights exactly why it isn't as simple as telling people to just eat less! I think a spiral of self-loathing and depression is absolutely worse, or at least no better!, and we need to find ways where health encompasses everything - physical and mental and also just practical.

      As I alluded to in my reply to Hotly Spiced above, I was a bit the same with sport at school. I hated it for most of the year because I have no coordination either, am not physically strong, and hated team sports where winning was valued and I clearly wasn't going to contribute to that outcome! I wish we could have had more options - I'd have been perfectly happy to be active, but I will never be someone who is good at ball sports. Thank goodness these days I'm not forced to do the activities I don't like.

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  13. Wow! What a difficult topic!
    I sympathised totally with Catherine above, at school I hated sports, was a lot on the unco side and just slightly chubby (everyone else was skinny in those days ;)

    With a good diet and some moderate physical activity I am now probably considered reasonably thin. I would have hated to be pushed to exercise more as a child because I was already very self conscious! My daughter has the same body shape as me and the same lack of skill in the exercise department. She does enjoy being outside and playing and I think that is a much better answer. Good diet and outdoor play. Not computers and tv. Hopefully through good diets skills this will help balance the weight issue.

    Just my thoughts, A rubbish diet with lots of exercise isn't going to bring a healthy outcome.

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    1. I think being outside and playing goes a very long way. I was a very active child but not into school sports at all (the uncoordination stick hit me too) - but I climbed trees and rode my bike and swam and was just outside a lot. I also think exercise is only a small part of the picture too, and like you say, a rubbish diet with lots of exercise isn't a good approach either!

      Thanks for sharing your thoughts :-)

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  14. Kari such a great post, as it's brought about discussion and I do love a blog that invites discussion. Long term solutions, oh I have no idea, I really don't... I do think a lot our problems stem from our fast food nation- quick fix- convenient food obsession. So many contributing things to a global issue though.

    as for diets...pffft.

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    1. Thanks for chiming in, and for making me smile with your diet reference. You sum it up perfectly :-)

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