Fatness and Obesity - Framing the Problem
The Big Fat Problem refers to both obesity and fatness, but I want to make a distinction from the start between those subproblems because while they overlap they don’t always go together.
For our purposes here, I am going to define obesity as a pathological condition of visceral body fat associated with various metabolic diseases. The problem of obesity is obviously closely related to the problem of fatness, it a subset of that larger problem. But a lot of people are fat without being unhealthy and a lot of people are unhealthy without being fat, so fatness itself is not necessarily pathological, even if we sometimes find it unappealing or undesirable.
The causes of fatness also overlap heavily with the causes of obesity, but in the case of obesity taken to an extreme pathological degree in a way that impacts our health as well as our aesthetics.
1. Different Kinds of Emphasis: Thriving, Health Risk, Fatness, Fitness
The distinction between obesity and fatness is important because we can sometimes do something beneficial for our health without necessarily making the big changes we might prefer to make in our appearance. People can also alter their appearance sometimes without necessarily improving their health very much. Focus on thriving, focus on health risk, focus on fitness, and focus on fatness are four different ways of thinking about these related problems. The situation is complicated by bringing fitness into the picture, as health enthusiasts understandably want to do. I suggest that it does make a difference to our long term success whether we approach the Big Fat Problem from the perspective of thriving, health risk, fatness, or fitness. Of the four kinds of emphasis, I suggest that long term success depends to some large degree on how much we focus on thriving in particular. Fatness, fitness, and health risk are important but they don’t motivate us robustly in the same sense as our desire to thrive.
2. The Obesogenic Environment
Since obesity was rare until relatively recently, and it is unlikely that significant changes in the stable aspects of our heredity have occurred in that period, it is generally assumed (with good reason I think) that the current prevalence of obesity is driven largely by changes in our environment. As opposed to the most heritable aspects of biology changing for example. The idea is that we have not become a new and fatter species (homo obesicus?), but we are still the same species living under conditions that create vulnerabilities for our existing genes.
Since it appears that prior to modern environments obesity was relatively rare, it seems reasonable to assume that the incidence of obesity is being driven by the relatively greater availability, variety, palatability, and reward characteristics of food, our relatively more sedentary lives, and perhaps some failure of our self-regulatory mechanisms to compensate for those environmental changes because of various changes in the way we live. Diet authors have made some far more specific claims and I want to address the strengths and weaknesses of those. But for now I just want to affirm that the “obesogenic environment” theory of obesity is probably a very good starting point for analysis. The idea is that our body is well tuned to tend to regulate itself under a variety of conditions, but we have created particularly extreme conditions for ourselves that in some sense bypass those regulatory abilities.
3. Mismatch Theory
Since the problems of obesity and fatness are very complex, I think it is helpful to find a way to think about them in a general way, to have an overall framework. The concept of an obesogenic environment provides us with a good start. For increasingly many of us our environment has come to bypass the ability of our body to regulate its storage of energy, resulting in the problem of fatness. That fatness in turn often becomes a problem for health, resulting in the problem of obesity.
Why has our environment become increasingly obesogenic? Perhaps the most general and plausible theory that brings the most observations together under a single umbrella is the mismatch theory. The mismatch theory says that human biology and human culture both evolve, but at very different rates. The genetic composition of organisms is refined over time by Darwinian processes for particular ways of adapting to environments. The epigenetic composition of organisms is altered by the environment and behavior of our more recent ancestors. When environments change very rapidly compared to those Darwinian effects on our genome, the previously adaptive functions of the organism can become maladaptive for the new environment . The mismatch model is most centrally about differences between Darwinian adaptations and current environments, but that doesn't negate the possible significance of other effects that may be important factors in obesity, such as epigenetic inheritance from our parents. This model is particularly helpful as a very high level organizing principle for a very large and complex set of factors that lead to metabolic disorders.
In a sense, human culture is a part of human biology, it is part of what allows us to survive, reproduce, and thrive, when it supports the needs of our biology. Since culture evolves more rapidly there is also a distinct possibility for culture to evolve in such a way that it no longer supports human biology in the same way. Our culture can outpace our genes in some ways, resulting in areas of mismatch between culture and biology.
Mismatch theory is very broad and very powerful, which also means we should be careful about applying it too casually. It would be easy to see every aspect of the obesity problem in terms of mismatch, whereas there may be factors that are better seen in other terms. However as a framework for troubleshooting, if we keep its limitations in mind, I think the mismatch theory provides us with our best starting point.
4. Problems of Comfort and Consumerism
During the latter 20th century we got increasingly fat and increasingly unhealthy at a rapid pace and it is useful to view that as a result of various aspects of our cultural environment changing rapidly compared to various aspects of our genome, which then becomes maladaptive for our current environment.
Given that framing of the problem, the big question becomes which aspects specifically of our culture and our genome are in conflict to cause the environment to become obesogenic? That’s where the most intense differences of opinion about The Big Fat Problem seem to arise. Did we get fatter because we started eating more grains? Did we become fatter because we started eating more sugar? Did we get fatter because the physical demands of our lives decreased to make us less active? Did we become fatter because more food is available and we just can’t help eating it?
Part of my framing of the solution is that people who succeed at maintaining a healthy weight after being obese have effectively created a local environment for themselves that protects them from the obesogenic aspects of their environment, and without forcing themselves to constantly fight their own biology or their own desires.
In order to create this sort of local environment, we have to understand what about our lives is most mismatched with our ability to regulate our energy storage. Is it the sorts of things we are eating? The activities we engage in? The nutritional quality available to us? The amount of food available to us? The way food is marketed to us? The level of stress in our daily lives? The amount of sleep we get? The kinds of bacteria that live in our body? These ideas have all been proposed and any and all of them (and more) can be argued to be plausible factors. I want to insert a caution here about being too confident that we have identified the problem by identifying any of these particular aspects of our environment. It seems to me that sort of thinking tends to lead to ineffectively narrow strategies.
One way of keeping our perspective on troubleshooting rather than false solutions is to frame the problem in a very general way. I’ve suggested that the obesogenic environment is one very general framing. Mismatch between culture and biology is a further refinement of that thinking. A third suggestion I would make is to view mismatch in terms of the twin overall trends in culture toward comfort and consumerism.
These dual trends of comfort and consumerism are both associated with affluence on a grand scale. As wealth has increased in various parts of the world, so has the availability and variety of food and the reduced need for hard physical work. At the same time, the economies that drive that wealth are typically themselves driven by constant efforts to increase profits by producing more at lower cost and selling more. These broad trends both have many problematic implications for a species that has evolved in various ways to prefer and exhibit efficiency in its use of energy whenever possible. This is, broadly speaking, where I think the mismatch problem becomes obesogenic. I suggest that these are the aspects of our environment that we have to be most careful to protect ourselves from.
5. The Pivotal Calorie - Quantity vs. Quality
I’ve offered a broad framing of the problem of obesity in terms of specific aspects of modern culture that are mismatched with our stingy biology and create an environment that tends to make us fatter. A final level of specificity in framing the problem is needed in order to come up with specific ways of changing our behaviors and environments to be healthier. To do detailed and specific troubleshooting of our own situation, we need to have an accurate sense of how cultural mismatch actually impacts our behavior, nutrition, and metabolism. What sorts of things should be looking at in order to understand how our environment is affecting us and make effective and useful changes?
Consider two facts about intake and fatness:
1. Population increases in obesity coincide with people eating more across those populations.
2. Individual increase in fatness does not always coincide consistently with people eating increasingly more.
A lot of wasted effort has been invested in arguing over which of these two facts is more important and a lot continues to be wasted.
Authors have devoted entire books to arguing about whether or not we should be monitoring calories or simply eating certain things vs. others.
The polarization over that question has far outstripped its usefulness, so for the record I want to try to put this question into some perspective here.
In recent years a number of authors have tried very hard to revolutionize our understanding of the problem of obesity by framing it as hormonal rather than in terms of energy balance. These authors argue that traditional weight loss solutions involving restricting calorie intake have failed because the problem is not one of how much energy we take in but of how our body uses that energy. The popularity of this view can be traced largely to Atkins, Taubes, and through most variations of the diet advice promoting high protein, high fat, low carbohydrate, low sugar, low glycemic, and “paleo” strategies (especially the animal-based ones).
Statistically, however, the first fact is undeniably the more important. When we look very closely at physiology for brief periods it appears that people can become fatter to some degree without eating more, but that does not seem to be a big part of the obesity problem at a population level. Some authors have denied that the second fact is even possible to any degree that impacts health, but I am going to stipulate the possibility here for the sake of argument.
I don’t think the problem of whether hormonal effects might make us more efficient at metabolizing vs. storing fat is terribly consequential, since the putative “fat burning diets” (usually high fat ketogenic diets) that people have heavily promoted are not sustainable for most of us anyway. Most of us don’t thrive on a ketogenic diet in the long term, so the claim that it is a solution to obesity has often been vastly exaggerated.
Further, for the more reasonable (less restrictive) versions of “hormone balancing” strategies, it doesn’t really matter whether they provide their benefit by altering metabolism or via helping us eat less.
What does matter is whether we are viewing the problem in a realistic way that lets us do useful troubleshooting. If I’m trying to lose weight or maintain a weight and I specifically avoid monitoring certain things because I’ve adopted a theory that disregards those, I could very well be ignoring very valuable resources. For example if I’ve adopted the view that “calories don’t matter” and I’ve committed myself to a particular diet, and I find that I’m gaining weight on it or that it is becoming increasingly hard to sustain, I’m not going to have any idea why I’m having a problem or what to do about it because I’m not monitoring important variables that I could be adjusting. I have to rely on the heuristics provided by the authors who promote that diet, and those are almost always anecdotal and based on selective experience of people who are similarly committed to that strategy. If I’ve adopted the view that “calories are the only thing that matter,” I could very easily find myself in the same unfortunate situation, not monitoring some of the variables that could be used to improve my success.
We sometimes draw simplistic and unhelpful conclusions from each of the above facts, resulting in endless and largely useless debates over whether quantity or quality of food matters most to obesity.
If we do follow these debates, seem at first to discern roughly two camps: (1) the “calories in/calories out” camp that seems to argue that the quality of food doesn’t matter and fatness is entirely about how much energy we take in and expend, and (2) the “metabolic advantage” camp that seems to argue that the amount of food we eat makes no difference to fatness so long as we eat the right sorts of things.
I’m not entirely sure whether anyone actually believes either of those extremes are true, outside of heated debates perhaps, but I’m pretty sure they are both exaggerations. Quantity and quality of food both matter to fatness and to health and thriving in general.
Since more obese populations eat more than less obese populations, we are often tempted to blame obesity on eating more and exhort each other to count calories and take in less food. Most attempts to simply eat less are a dismal failure in the long run.
Since we are relatively bad at monitoring our own metabolic energy dynamics and since those metabolic energy dynamics change significantly from one set of conditions to another, we are alternately often tempted to blame obesity on how the environment is “breaking our metabolism.” Broad attempts to fix our broken metabolism and to invoke “fat burning metabolism” by eating in a certain way have not resulted in real sustainable solutions for most people who attempt them.
An important part of the metabolic energy dynamics picture is activity.
Consider two facts about activity and fatness:
1. Population increases in obesity coincide with decreases in activity.
2. Individual increase in fatness does not always coincide consistently with people getting more activity.
Again, as with food quantity and quality, we find a lot of debate over the calorie in terms of activity. Do we need to move more or eat less, or just move and eat differently?
If we were to accept the extreme quantity argument about fatness, and extend it to activity, we seemingly would be saying that people just need to “burn off” more than the calories they take in, and weight loss would simply and reliably follow. Trying to burn off calories to regulate weight is typically a dismal failure. People feel compelled to exercise in ways they don’t enjoy just to compensate for eating and they come to resent it. They also very often tend to eat more to compensate for the exercise, defeating the whole purpose. So the simplistic form of the quantity argument doesn’t extend to activity either, even though there is no doubt that moving more expends more energy in general.
If we were to accept the extreme quality argument about fatness, and extend it to activity, we seemingly would be saying that specially designed exercise programs can alter our metabolism in ways that make us leaner without affecting our intake adversely. This is in line with what many people selling fitness products do claim in their advertisements, but it doesn’t seem to be a real obesity solution for most people either.
Analysis by researchers seems to so far implicate intake rather than exercise per se in the population incidence of obesity. Populations studied so far did not become fatter simply because they moved less. The quantity argument about activity has not been supported in that respect. However sedentary living is undoubtedly one of the factors that makes fatness a problem. Activity has consistently been shown to be an important factor in maintaining healthy levels of body fat and being sedentary (sitting a lot) seems to be an independent risk factor apart from simply not exercising. So a sedentary lifestyle does seem to result in us becoming poorer at regulating our body fat and maintaining our health, even if it is not specifically because of “burning less calories.”
The Big Fat Problem
The Big Fat Problem is that increasing fatness is very difficult to reverse both in individuals and in populations once the trend is established, and eventually leads to the potentially serious health implications of obesity.
The problem is so difficult in part because it is a result of our biology being unprepared to compensate for the extremes of demands and temptations found in our environments. We can oppose it in various ways for a while, but long term success is relatively uncommon. The solutions offered to us tend to fall into conflicting extremes that work in the long term only to a very limited extent and lead to confusion and frustration.
What as individuals can we do about The Big Fat Problem?
What can be said about it that has not already been said?
1. We can emphasize thriving over aesthetics or risk or fitness. Whatever we do must be consistent with thriving amd not result in constant deprivation and distress for the sake of health or fitness or appearance.
2. We can learn to treat fatness as a developmental concern rather than a quick fix, since the long term is the more important and the more challenging time frame for addressing the problem.
3. We can learn to troubleshoot our own problem of fatness by better navigating the popular dialectics of quantity and quality or intake and activity
Thursday, August 06, 2015
Saturday, July 11, 2015
To me it seems critical that we get a realistic and accurate sense of the overall problem, since much of the difficulty is confusion regarding how to think of it in the face of seemingly conflicting information. I am going to offer my understanding of the scientific consensus as a framework.
For all the confusion we often have over various aspects of nutrition and fitness, I think there are a handful of principles that are particularly reliable based on the evidence we have so far.
The reason so many people around the world have been getting so much fatter so quickly is that they are taking in more energy than their bodies need in order to be nourished and satisfied. And they do this for reasons that they are mostly unaware of having to do with reward, preference, palatability, expectancy, reliance on cues, and satiety. Let's call this the mindless surplus intake theory of obesity.
As intuitive as it might seem at first, the mindless surplus intake theory of obesity doesn't have to be true. There could be other reasons for our growing fatness. Our bodies or environment might have changed to make many of us store fat more efficiently from the same amount of energy intake (the broken metabolism theory of obesity). A number of authors in recent years have promoted variations of the broken metabolism theory. The broken metabolism theory sounds scientific and some variations of it have been promoted with long lists of research citations or even with the limited blessing of some researchers, especially when it is combined with reasonable actionable advice as well. In general though it seems to me that the "broken metabolism" theory itself has been pretty thoroughly falsified as a primary driver of obesity. And that fact matters in some important ways.
Our bodies or environment might also have changed to make many of us more impulsive about eating and we have failed to compensate by exercising our willpower adequately (the gluttony theory of obesity). Similarly, our bodies or environment might have changed to cause us to be less motivated to move and we have failed to compensate by exercising our willpower adequately (the laziness theory of obesity). The gluttony and laziness theories are compelling to us individually because we have a strong intuitive sense of the importance of personal responsibility, and self-control is indeed a powerful factor in success across many endeavors. However the laziness and gluttony theories exaggerate the role of deliberate self-control in the myriad decisions we make every day about eating and activity. People successful at controlling their weight use their self-control not to make every decision deliberately but to create better habits for themselves and shape their environment to help them. It is not a failure of willpower that drives obesity. That fact also matters in some very important ways.
Our bodies or environment might also have changed to cause us to need less food while still eating enough to create a surplus (the inactivity theory of obesity). Activity levels contribute significantly to both health and obesity, and especially to the maintenance of healthy weight, but we know the driver of obesity is mostly intake and that just moving more without also cutting back energy intake doesn't reverse weight gain in the obese in general. This is almost certainly a major factor in both health and obesity, but it is clear from the existing evidence that it is not the primary driver of obesity. The trend in fatness corresponds far more closely to changes in intake than changes in activity. Also the experimental evidence shows activity being far more useful for maintaining weight loss than for simply "burning off calories" in most people, largely because we often tend to eat more to compensate for exercising.
In addition, more than one of these might be a factor. But from my reading of the evidence patterns, the primary driver of obesity is now clear. We have been taking in increasingly more energy than we need, mostly because we have been eating more than we would need to fuel our activities and nourish our minds and bodies. And we have been doing this for reasons that do not involve the specific discretionary macronutrients we eat most of (e.g. carbs vs. fats), do not involve us simply failing at deliberate self-control, and do not involve us having inadequate knowledge of which diets are best for weight loss.
What are these mysterious reasons for creeping intake if it is not eating too much fat or too much sugar or too much starch in particular as many authors have claimed?
- Our intake is regulated primarily by mechanisms of reward, preference, palatability, expectancy, reliance on cues, and satiety. We learn what to eat and how much based largely on stimulus cues, what we expect from food, how palatable foods are to us, and how they make us feel.
- Our reward and satiety mechanisms are optimized for regulating our weight under natural stimulus conditions by relying primarily on volume and weight of food and secondarily on energy content. We mostly tend to eat about the same volume of equally palatable and rewarding foods every day.
- Our metabolism is optimized for efficiency of energy storage rather than for maintaining a stable weight.
- We are bad at estimating how much energy we need in order to be nourished and feel satisfied.
- We are bad at estimating how much energy we are taking in in order to compensate for well-engineered distortions of reward and palatability.
- We have come to rely increasingly on cues in our environment to determine how much energy we need and how much we are taking in
- We have come to increasingly exploit our reliance on cues in our environment in order to market food and health and fitness products, and this distorts the cues we rely upon so heavily
- We have come to increasingly rely on strategies which overemphasize small or irrelevant metabolic effects, rely on outdated theories, rely on willpower, ignore the long term, and in general are unsustainable and make us feel like failures when we can't sustain them.
If my understanding of the scientific consensus is correct, the mindless surplus intake theory of obesity reflects it well and can be understood in more detail in terms of the satisfaction theory of intake regulation. This says that we eat mostly what satisfies us because of the way the reward and satiety mechanisms work in our nervous system rather than because of metabolic or nutritional effects. What gets "broken" in obesity in general is that we stop being satisfied with a nourishing amount of food and we keep eating even though we are taking in more than we need. The reasons for this have little directly to do with willpower or carbs or fats and everything to do with the mechanisms of reward, preference, palatability, and satiety.
- Why is the problem of obesity so damned tricky?
A lot of us are fat. Fatness increased dramatically in the 20th century, especially since the 1980's in the US. We don't like being fat in general. When it becomes extreme, body fat usually doesn't look good to us and can lead to health problems, diminished longevity, and restricted quality of life. Some distributions of body fat are worse than others for health or for appearance, but at some point it eventually looks bad to us and detracts from our lives.
- Just Theories are Well Communicated and Popular but Wrong
If we find fat so problematic, why haven't we simply found good solutions for it and begun to apply them? Most people can lose some body fat temporarily by some combination of depriving themselves of some particular kinds of preferred foods, trying to force themselves to eat less, and trying to force themselves to be more active. Most people end up going back to their original body fat levels, or greater, after a few weeks, months, or years of that effort. There is no lack of simplistic just theories about why this is happening:
Fat people are just lazy and not exercising enough self-control over their eating and exercise
Fat people are just gluttons who eat too much
Fat people are just eating too much carbohydrate
Fat people are just eating too much starch
Fat people are just eating too much sugar
Fat people are just eating too much fat
Fat people are just maintaining their weight at a genetic set point
Although each of those ideas is wrong in its own particular way, and they are each perhaps partly right in some sense, it is the just part that is most wrong of all. The just theory is a special kind of problem in itself that is part of the reason fatness is so difficult to address.
Here's my central claim: scientific consensus is not just a matter of certain opinions winning out over others, the problem of obesity is understood in broad form as a scientific consensus even though many the details are complex and some of our knowledge of the factors is undoubtedly incomplete. There is a rough scientific consensus about various aspects of obesity across fields of physiology, nutrition, psychology, neuroscience, and medicine. It is not just the confusing mess that appears in popular media.
I also claim: this consensus understanding is not what is published in most diet, fitness, and weight control books. In fact, a sizable number of popular books on diet and weight control conflict dramatically with the scientific consensus, but are marketed as if they were new and revolutionary new findings. This has contributed heavily to the confusion and so added to the problem.
B. The Scientific Consensus is Poorly Communicated
In the stories that journalists tell to try to communicate their own interpretations of the obesity and health research, they have often engaged the science compellingly but not faithfully. We now know some very useful things that are not well communicated, or are even ignored or denied by popular authors with their own agendas, or get lost in the media confusion:
- The theory that people can control their weight by exercising self-control at each eating or activity decision is simply wrong.
No one has that much self-control against an environment that constantly tempts them. The psychological study of self-control reveals that variation in impulsiveness is indeed a factor in all sorts of problems, including obesity, and that people can often learn skills to compensate for impulsiveness, but these do not rely on individual acts of self-control. Self-control is always finite, and we successfully compensate for impulsiveness by not just exercising self-control in each decision, but also even more importantly by altering our environment and altering our habits so that we reduce the need to exercise our always finite capacity for self-control.
- All of the theories of specific macronutrients causing us to become fat are simply wrong.
The theories of metabolic advantages of particular diets (low carb, low fat, vegan, paleo, etc.) have all been falsified scientifically so far. Obesity is in general at the population level not caused by everyone's metabolism being "broken" by certain foods nor is it "fixed" by eating certain foods.
We know for a fact for example that low carb diets do not cause people to lose weight by any special "fat burning mode" as is often claimed in popular diet books. We know that simply eating a lot of fat or a lot of sugar while keeping energy intake constant does not cause us to gain more body fat. We know for a fact that the theory of obesity being caused by insulin levels rising due to eating too much starch or sugar is simply wrong. People become fat when they take in too much energy regardless of the source and they lose body fat when they take in less energy regardless of the sources they eat less of.
That doesn't mean people respond equally to every kind of diet. It's just that the reasons are not metabolic. The reasons have to do with reward, satiety, and sometimes individual differences. But the metabolic differences between different macronutrient strategies is based on thinking that has already been tested and falsified.
Also this wouldn't have to be true necessarily. It isn't a logical necessity that foods have no powerful differential effect on absorption and conversion to fat and fat storage. It's not just a matter of thermodynamics or conversation of mass and energy. It is possible that our biology might have allowed us to take in some kids of nutrient, extract energy or chemicals from it, and excrete most of it without gaining body fat. But it turns out to be false. The reason is not conservation of mass and energy, the reason that our biology is particularly efficient in using nutrients and in storing the surplus energy.
We might truly have discovered some differential metabolic effects that prevent us from processing certain foods into fat (and that is exactly what many popular authors have claimed) but … it turns out that it doesn't seem to be true in general, and certainly not as a reliable way to lose body fat permanently. The small differential effects of nutrients on metabolism are sometimes used to good effect in short term efforts at bodybuilding and fitness, but they are not a reliable approach to obesity in general.
- Consequently, No macronutrient restriction strategy is a best practice diet for everyone.
Framing the problem of fatness as if we need to choose between popular branded diets is more often part of the problem than part of the solution. Branded diets are generally based on a particular just theory.
Debates over low carb, low fat, low sugar, low starch, low glycemic, high fiber, vegan, paleo, and so on are mostly based on asking the wrong question: "what specific food is making me fat?"
Cutting out problematic "trigger" foods can be helpful for particular people, but not for metabolic reasons. Also cutting out entire classes of food can help at least temporarily lose weight. This is also not for metabolic reasons. This is because we tend to reduce intake more than we compensate, at least for a while, when we cut out entire classes of food.
Some of those strategies work better than others in the short run. But it turns out with those macronutrient restriction strategies that it really doesn't matter which class we chose to cut out in the long run.
People who successfully reduce intake by restricting carbohydrates and people who successfully reduce intake by eating vegan or by eating "paleo" are all losing weight because they are taking in less energy, not because of metabolic advantages.
So long as we can sustain the calorie deficit with that strategy, we lose body fat. That's wonderful for the people who end up with a strategy they can sustain, and we can find some success stories for many different strategies. Strategies that restrict entire classes of nutrients end up being unsustainable for most people in the long run though and the claims often made about any of these having unique metabolic advantages for weight control have been soundly falsified.
- People do not regulate their weight to a particular inherited set point.
This is the opposite problem from the panacea solutions. This one reinforces our tendency to give up. Fatness and leanness often run in families, but not because our genes have a built in weight that we are fated to maintain. It is because of all of the various factors that go into activity, reward, impulse control, individual metabolism, and habit formation, how those interact with specific environments, and because we often inherit things in addition to our genes. Animals in their native ecological niche tend to regulate their weight very tightly and people who try to lose weight often end up back at the same weight. But these are as much a result of stable aspects of their environments as stability in their weight regulation. When we re-engineer out environments we end up altering weight regulation. The efficiency of our biology and the stability of our dispositions are powerful factors in making obesity a difficult problem but they do not make it impossible to solve.
I'm going to try to do more than just add my own personal just theory to the already confusing and conflicting list. What I'm going to try to do is navigate the available evidence to show what is going on and make sense of why the problem is so difficult and what people are doing when they do manage to succeed.
- The Backlash Culture Against Obesity Does More Harm Than Good
So the "obesity epidemic," as it has often been called, has led to a culture of backlash against fatness. By that I mean a commonly shared negative attitude toward fatness and toward fat people. We have mobilized mightily against the problem in all sorts of ways. Some of those have unfortunately probably made the problem worse.
The backlash against fatness might have been a good thing if it had led to a problem solving culture that recognized the biological, psychological, cultural, and economic dimensions problem realistically, helped us understand it, and began providing realistic solutions. Obesity researchers have sometimes attempted to offer realistic solutions, especially focusing on preventing obesity in children where we can potentially have the most effect.
But realistic problem solving is definitely not most of what has happened so far. What we have instead is:
- The problem remains: most people who try to lose body fat end up going from diet to diet or from one exercise program to another , succeed for a while, and then give up. Eventually many give up on the problem entirely as hopeless. In effect, we often give up on ourselves. This is especially true when we buy in to the popular misconception that obesity reflects a simple failure of willpower. Fat people are often stigmatized as lazy and they feel like failures, which generally makes the problem worse rather than better.
- The food industry exploits the situation by creating and marketing niche "diet" and "health" products that supposedly address the problem but which rely on outdated theories, popular misconceptions, and strategically selective interpretations of research. The market for high density rewarding "diet" foods for example was created to exploit medical advice to eat less food by eating less fat. The advice was oversimplified and the new market for diet foods probably added to the problem significantly by exploiting it. Their goal is selling more food product rather than improving health, which most often turn out to be conflicting priorities. They become part of the problem by flooding us with false solutions and misleading information.
- The fitness industry exploits the situation by creating complex dietary and exercise programs that are oriented to short term bodybuilding or fitness goals and then marketing those as solutions to obesity.
- Popular authors tout their range of idiosyncratic interpretations and solutions, each trying to make sense of the confusion but they mostly end up increasing it. Popular diet just theories by journalists and doctors very often end up inadvertently creating even more confusion.
So the backlash culture in these various dimensions, far from helping to lessen the problem, has exacerbated and perpetuated it in several specific ways:
- It increases the difficulty of the problem for individuals psychologically, by fostering confusion and then discouragement and self-loathing. By emphasizing willpower in unrealistic ways, and relying on solutions that require extraordinary short term efforts, we make people less able to succeed rather than more able to succeed in the long run.
- It adds to choice confusion when we try to make decisions and are led astray by the marketing of product rather than decisions in our own best interests. Unless things like "diet foods" and "bootcamps" and "extreme weight loss" are themselves actually viable solutions to obesity (which they are not in general) they become new sources of both confusion and discouragement.
- It reinforces the epistemological problem of cynicism. Thinking we are all scientific experts who are well situated to simply choose between the popular diets and popular theories that seem most plausible to us prevents us from learning from the actual research and prevents us from moving toward more realistic solutions. We become easy prey for every scheme that comes along.
D. Science Cynicism and Overly Broad Mistrust of Expertise
Journalists writing about the problem of obesity have responded to this ongoing confusion by either claiming we don't know what causes obesity or by trying to promote a particular new finding. The problem is very complex in some ways, but it is very misleading to say that we don't know enough about it to move toward better solutions. The journalists who say we don't know the answer are a minor concern though, they are at least sincerely trying to be good communicators of the science and clear up the confusion. The ones who are really dangerous are the grandiose prophets of false information.
What we usually have is a theory that catches the interest of the journalist and then they confirm it by gathering information and telling stories that reinforce their own theory. This is a compelling and powerful way to communicate, but it offers no assurance that they are getting the science right. And while we sometimes find out about truly revolutionary ideas this way, as it turns out, these "sciencey" storytellers are most often getting as much of the science wrong as they are getting right.
These "sciencey" journalists often end up asking bad questions and then we end up talking about the wrong things. I think this is a big part of the problem and the reason I have written this book. I hope to describe what we know about the problem of fatness without falling into the common trap of arrogance and confirmatory bias, but of course I can only argue my own perspective. I could be wrong about the scientific consensus, but I will do my best to communicate it as faithfully as I can.
The unconstrained confirmatory bias by journalists wouldn't be so bad by itself in some cases, since they do sometimes bring information to light that was not previously well known. At least some people would benefit from some of this information. But these folks often then read some scientific literature to try to bolster their articles and books and I feel they often do a hatchet job on it. They can't reconcile their idiosyncratic theories with the existing evidence so they start claiming that the evidence that conflicts with their own theory was due to "corrupt researchers." This ad hominem strategy has been a highly successful one for some authors, but it is an unfair way to argue and much worse, it plays into general cultural cynicism of science. That part is extremely bad for the rest us. It means we perceive the science as arbitrary or a matter of choosing sides based on what sounds plausible or what seems to work for some people. It feeds the popular trend for imagining that everyone is naturally capable of evaluating scientific evidence by virtue of "common sense."
What often happens, I believe, is that we end up mistrusting expertise, which is in itself a very serious problem. That fact that we find so many false or misleading claims of expertise makes the problem of finding, trusting, and interpreting legitimate expertise even more of a challenge. Nutrition and health sometimes involve on complex technical knowledge and interpreting rich patterns of seemingly conflicting evidence. This kind of interpretative skill and knowledge is not something we possess as part of our "common sense." It is something that requires not only understanding "critical thinking" in general, but also requires domain-specific knowledge in the specific fields in question.
The backlash culture and especially cynicism of real expertise has fed bias and arrogance by various popular journalists who then set the tone for popular conversations in unproductive ways. Although they may have a lot of charts and graphs and selectively cite and interpret a lot of research, rarely do journalists engage the research deeply and competently and systematically and put it into context. Rarely do they make a distinction between different kinds of evidence and different quality of evidence in order to do a skilled job or drawing general conclusions from the existing science.
The biggest problem with many of these popular authors is their grandiosity. They think they've discovered a pattern that everyone else has missed or they have some limited success with some people and they proclaim to the world that they have the solution. Grandiosity exploits uncertainty and cynicism to produce cults of misinformation that are self-perpetuating and extremely difficult to address with reasoning and evidence.
Summary of Why the Big Fat Problem is So Tricky
Summary of broad factors making the Big Fat Problem so nasty:
Class of Factor
Associated Bad Thinking
We tend to think in terms of simple actionable heuristics we can act upon when we make decisions. What food is causing me to get fat, so I can stop eating it and lose weight? What foods should I eat to lose weight instead? Our need for actionable heuristics makes us especially vulnerable to just theories, and just theories of complex outcomes are typically wrong.
"Obesity is just a matter of eating more of … or eating less of …"
The science is often distorted into oversimplified advice. The scientific consensus relies on expertise to understand and is hard to communicate in terms of actionable steps so it gets lost in the confusion of just theories. We end up systematically asking the wrong questions and arguing without regard to the existing patterns of evidence.
"One study constantly contradicts the previous one, so it's all really useless information, we should just pick the authors we agree with and follow their advice"
Our collective cultural assault on fatness has led to a backlash culture that makes things worse and leads to additional problems.
"Being fat is really bad, stop being so lazy! Just do this… "
Journalistic arrogance and widespread science cynicism exploit the problem of ubiquitous expertise
"We're all scientific experts, including me! Forget the scientific consensus, this sounds like a good way, follow me!"
"Sciencey" storytelling journalism
Poor science communication
"Telling stories about research and researchers is a great way to learn the science! The details of weighing evidence are boring and irrelevant and people aren't able to handle it."
Industry interests driven by economic and business concerns that often end up conflicting with public health or individual interests of consumers
Economically Driven Consumer Culture
"People citing research in their ads and branding their products for health are generally offering valuable new choices for us."
Saturday, June 13, 2015
I use the blender for weight control as do a lot of people, but I've been very careful about tracking my results and I've found that I've had varying success using the blender as a weight control tool. I think I've discovered some of the reasons for the variance. I'm not interested in motivational stories or anecdotes or testimonials or selling recipes or blenders here, I'm interested in the specifics of what makes the blender a useful tool for weight control and what makes it less useful in some cases.
Gail R. Goldberg*, Peter R. Murgatroyd, Aideen P. M. McKenna, Patricia M. Heavey
and Andrew M. Prentice
British Journal of Nutrition (1998), 80, 141–147
DP DiMeglio and RD Mattes
Am J Clin Nutr March 2007 vol. 85 no. 3 651-661
The main ingredients in a smoothie intended for weight control are fruits and vegetables. Protein powders often figure in recipes but I want to consider them separately because in most cases they are not used for weight control specifically. There are exceptions to that such as protein-sparing fasts, but it is the fruits and vegetables that most advocates of blender foods are talking about for the most part.
In general we think of fruits and vegetables as healthy. Not much to argue with there, but I want to first examine the basis of this idea so we have a clear understanding of what we are talking about because in this case the details matter and not just the general principle that fruits and vegetables are mostly very healthy food.
In general we tend to accept the assumption that fruits and vegetables are healthy compared to most of what most people eat. The most convenient and least expensive foods and ones we value most tend to be the least healthy in general. Compared to those, fruits and vegetables are clearly more conducive to good health.
There are two important points of contention though:
- "Smoothies" often contain ingredients for flavor that are not just blended fruits and vegetables and maybe some protein powder. They can contain a lot of added sugar, and significant added fats because those often make the drink a lot more appealing. However that is a concern mainly if you buy commercial drinks or if you are careless about the recipes you use.
- There is also evidence that drinking food can sometimes have completely different effects on satiety than eating it. This is a much more important concern to me and one that I want to examine in more detail. The tricky part is that the effects of drinking calories can be good or bad depending on other things.
For the moment let's assume we are intelligently blending fruits and vegetables, and that the resulting drink is healthier in most ways than commercial soft drinks. That assumption is probably not too much of a stretch. The question I'd like to address is specifically whether we can generalize that adding daily smoothies to our diet can improve our ability to regulate our weight, whether it can be a detriment, or whether it tends to be a neutral or indeterminate factor.
First, let's get a scientific handle on fatness. The problem of obesity at a population level has a lot of complicated aspects and the biology of metabolism is also very complex, but advocates of various products and services have often used that complexity to distract us from what are fairly simple overall facts of the matter. So let's start by taking a very simple high level cut at the problem of human fatness from a biological perspective.
Kelly Brownell, an expert in nutrition and weight disorders, describes the overall situation as clearly as any problem description can be stated:
"The simple story is that biology seeks out an energy-dense diet, the environment provides it, and we have runaway obesity."  (p. 35)
This is sometimes known as the "mismatch" framework because it reflects our observation that our environment has become less well matched over time with our biology in some ways. We have made great strides in exploiting the widespread animal evolutionary selection for efficiency in the form of preferring an energy dense diet when it is available. We seek out sugar, fat, variety, and the flavors we associate with fats and carbohydrates especially. Our cultural environment exploits this in selling food. That's the simple truth of why so many of us are fat. Our stable biology preferring energy dense foods provides a vulnerability that our environment has come to exploit.
Obesity, or runaway excess fat tissue, is relatively uncommon outside of humans, the companion animals of humans, and the animals domesticated by humans. In general when animals have equally palatable or equally unpalatable choices of different macronutrients, they tend to balance them pretty well rather than becoming malnourished or overnourished. Under conditions of their natural environment, animal preferences in food tend to serve them well most of the time, just as we would expect. Weight is regulated in a very stable way under those conditions. Animals evolved to eat in a way that helps them survive in their natural habitat, by taking advantage of the food sources available to them.
The bad news is that something relatively uncommon in nature is now very common in human environments: abundance in the form of an amount and variety of energy dense foods that was very rare in earlier times. The seemingly good intake regulation animals do in natural environments, where scarcity is the rule, is easily overridden by simply making greater amounts and greater variety of foods available of the sort we tend to prefer.
We are not wired to regulate our weight, we are wired to thrive in natural environments by strongly preferring energy dense foods in order to take advantage of them when we find them, and there is apparently no natural mechanism that effectively compensates for that preference by eating less of them under those conditions.
In experiments with rats, the preference is so strong that they eat themselves into protein deprivation when either more fats or more carbohydrates or both are provided than proteins.  Rats may seem pretty far removed from us in some ways, but the pattern is suspiciously familiar in human environments as well. Greater availability of higher energy density foods leads to eating more of those and neglecting other sources of nutrition, to the detriment of our health.
So we don't need to look at a lot of complicated issues in nutrition to see why fruits and vegetables are offered as favored foods for weight control. However I think we do need to be suspicious of whether simply adding more of those to our diet will have the desired effect of competing successfully with the higher energy density foods that make us fat. Will drinking more green smoothies lead to eating less loaded fries and mega burgers and drinking less gargantuan soft drinks? That's the promise of the blender as a weight control tool, at least in the ads for smoothies and blenders and smoothie recipes.
We have clear-cut evidence that fruits and vegetables are in general less energy dense and yet are still satisfying sources of nutrition compared to most of the food that comprises the average American diet. The strategy of reducing energy density in general has been supported by research and argued by leading experts in weight regulation such as Barbara Rolls :
"A growing body of laboratory-based, clinical, and epidemiological data suggests that low-energy-dense diets are associated with better diet quality, lower energy intakes, and body weight. Dietary energy density can be lowered by adding water-rich fruits, vegetables, cooked grains, and soups to the diet, and by reducing the diet’s fat content."  p. S98
So the argument for replacing at least some portion of our energy dense foods filled with added sugars and fats with satisfying but far less energy dense foods like fruits and vegetables appears to be very defensible, so long as we are also somehow still getting the nutrients we need that might not be easily found in fruits and vegetables. The advocates of smoothies rarely suggest that they should entirely replace other foods with smoothies, so that doesn't seem like a big concern to me so long as people are not relying entirely on smoothies for their nutrition.
Replacing some of our energy dense convenience foods with less energy dense fruits and vegetables certainly seems reasonable. So we might well agree in principle that adding fruits and vegetables to our diet can help regulate our weight. But does it actually work that way if we simply add fruits and vegetables to diet otherwise filled with convenience foods? Do we actually start eating less of other things if we somehow get ourselves to eat more fruits and vegetables? Or do we end up just adding more "healthy" calories on top of what we already eat?
The question is not just the trivial one of whether forcing ourselves to eat tons of veggies temporarily prevents us from eating a cheeseburger, or whether that would be a good strategy. The question is whether adding fruits and vegetables in some enjoyable way actually helps us eat less of other things in the long run in a way that causes us to take in less total energy. That would be a legitimate aid to weight control.
Or are green smoothies a minor convenience that still relies on brute force self-control to replace the more attractive foods we crave?
And if eating more fruits and veggies does help, does it still help if the fruits and vegetables are eaten as a liquid? There is a real possibility that it might make a difference. These are the real questions I want to explore.
Phrased this way, many of the vast complexities of nutrition and metabolism are mostly irrelevant. What I want to know is whether smoothies can actually help with weight control, which means the ultimate deciding factor is whether adding them to our diet causes us to take in less energy overall, without taking other measures. That's a strongly stated but relatively common version of the claim made for why smoothies are supposed to be useful for weight control.
Fruits and vegetables are low in energy density mostly because of their high water content and their low fat content. Their fiber content contributes as well, but to a lesser and more variable extent. The low energy density due to high water content and low fat content also seems to be the primary reason why fruits and vegetables are relatively high in satiety (we tend to compensate for eating them by eating less later) as well as satiation (we tend to find smaller amounts satisfying and stop eating sooner).  p. 6
If fruits and vegetables are generally useful in regulating our weight, the best argument I can find is that they replace higher density nutrition with lower energy density nutrition without motivating us to eat more to compensate. If we ended up more hungry a few hours later as a result of taking in less energy dense foods now, we would still be relying on our willpower to lose weight and the fruits and vegetables would not actually be helping us lose weight in the strongly stated sense.
So do fruits and vegetables have this effect of helping us take in less energy while not compensating later?
And do they still have this effect if prepared in a blender first?
In the latter 20th century, the rate of obesity rose dramatically and unexpectedly along with the amount of money we spent marketing and buying convenient foods that are very high in added sugars, added fats, enhanced flavors, portion sizes, and energy. It is very unlikely that this was a coincidence. We started eating more because foods that exploited our preferences became more readily available and appealed particularly to our decision making by appealing to our taste preferences and our preference for economic value. Nor did we compensate for the increased intake by moving more. If anything technology changes have led us to move less and exert less physical effort in our daily lives. As a result the environment came to overwhelm our ability to regulate our own weight.
Popular theories that preferentially blame fats or carbohydrates for obesity are mostly missing the point. We became fat when we started eating more of everything, and we did that because of increased availability of high energy foods that suit our natural preferences, not simply because fats or carbohydrates are fattening.
The crux of the problem of fatness is increased intake, not whether we eat "healthy" foods. That's why the question of whether fruits and vegetables help us eat less is crucially important. We eat more now across all of the major food groups, not just the "unhealthy" foods, so we can't lay the blame for obesity entirely on those. The increased intake that led to increased obesity included fruits and vegetables, not just French Fries and soft drinks. Adding fruits and vegetables to our diet in general as a population has not by itself magically pushed out junk food or reduced our overall calorie intake, and there is little population evidence to suggest that it should. The evidence that simply adding fruits and vegetables to our diet would compensate for overeating is not terribly compelling at a population level. But what about experimental evidence?
Considering how commonly it is recommended, there is surprisingly little direct evidence regarding the effect on weight control of adding fruits and vegetables to our diet. Most research where higher energy density foods were replaced with fruits and vegetables was relatively short term and also included explicit instructions and assistance in avoiding compensating for the added calories. So we don't really know whether (or how much) adding fruits and vegetables really helps us eat less or helps us eat less in a later meal. We strongly suspect it is at least a factor though because low energy density foods do tend to result in both higher satiety and higher satiation. The fiber content of those foods may also play a secondary role.
For the most part when we are not relying on external cues for how much to eat and we make use of internal sensation, it is the weight and volume of what we eat that makes the difference in how much we eat rather than the amount of energy it contains or the glycemic loading, so long as it has the right sensory properties that we experience it as substantial food.  Surprisingly, since so much diet advice mentions glycemic index, it does not appear that carbohydrate content or glycemic index are reliable predictors of satiation or satiety compared to energy density and fiber content. For example, boiled potatoes, which are relatively high in glycemic index, are also particularly satiating.
The available evidence from intervention studies seems to support the idea that adding fruits and vegetables to meals can assist in weight control by adding water and fiber and reducing energy density, increasing satiation and satiety, and helping us to eat less overall while still getting good nutrition. Supporting this idea, restricting high energy density foods while allowing unlimited amounts of fruits and vegetables has sometimes been a successful weight control strategy. 
This doesn't necessarily tell us that that adding fruits and vegetables to our diet causes us to eat less of other things, but it does tell us that we tend not to overeat fruits and vegetables, which suggests that many people find them either relatively satiating or relatively unpalatable. So it leaves the door open to the possibility that they can be useful for weight control for those who do find them palatable as well as satiating.
So let's assume for now that fruits and vegetables do help us with weight control by helping us eat less of other things. That being the case does this still apply when the fruits and vegetables are prepared in a blender?
The answer to this might seem obvious depending on how you think about satiation and satiety. The counter-intuitive reality though is that some foods increase in satiety when in liquid form and some foods decrease in satiety in liquid form. The case is most clearly established for high sugar drinks, which have been unambiguously established to have very low satiation and satiety and are believed by obesity researchers to be an important contributor to obesity. The case is more equivocal for liquid meals that also contain more satiating ingredients such as fiber and protein. In those cases, the variation in outcomes may be because the behavioral context plays a crucial role in their effect on intake.
First, on the plus side, the water content of foods is one of the main things that increases how well they satisfy our appetite. This happens by increasing their volume and their weight. When you make a soup out of ingredients, you are getting both a greater weight and greater volume of food than when you eat the ingredients without the liquid, and in general that tends to increase the satiation of the same food without increasing the energy intake. More interestingly, and more surprisingly, it can also increase the satiety of the same energy-equivalent of food, causing us eat less later.  For foods that are already satiating, adding water while still making them palatable and perceived as food, tends to increase satiation and satiety.
The same effect is not seen simply by drinking water with a meal or before a meal as when the water is part of the food. Hunger and thirst are regulated separately in the body, the satiating effect of fluids are because we experience the food as heavier and higher volume (and as food!), not simply because there is more water in our stomach.
Blending fruits and vegetables into a drink obviously increases the water content, and they are already satiating, so we have reason to suspect it might increase the satiety and satiation. Assuming we experience it more as food rather than more as water. So the case for losing weight with green smoothies seems plausible scientifically.
On the minus side, we don't seem to regulate our own intake as well with a liquid diet as we do with a solid food diet.
Under controlled conditions, where we are not inundated with abundance, variety, and other cues that tell us eat more, we tend to regulate our intake from one meal to the next during the day to eat relatively the same amount from day to day, and we also seem to regulate out intake to some extent from day to day. This is especially true of the volume of food we eat, but under some conditions it is also true of calories.
Given the same weight and volume of solid food, we also tend to eat more or less from meal to meal to take in about the same amount of energy every day. In experiments, secretly adding more calories to the same amount of food each day results in people eating less in subsequent meals. This phenomenon of energy-specific satiety is sometimes known as dietary compensation. , The argument against liquid diets is based on the finding that dietary compensation seems to be much weaker with liquid meals than with solid meals.  However this is mostly based on findings regarding fruit juices vs. fruit and sugary drinks vs. sugary solid foods, and almost entirely based on liquid vs. solid carbohydrate intake. Liquid diets have also been used successfully for weight control under some conditions. 
This means that different forms of a food (at least a carbohydrate) can alter its satiety and satiation, and the liquid form of carbohydrates in general seem to bypass our tendency to compensate by eating less. With fruit for example, the case is quite clear, the liquid form is considerably less satisfying to our hunger when used as a "preload" just before eating. As usual, the energy density plays a big role, and fiber plays a smaller role, but simply drinking calories rather than eating them seems to have an independent effect on satiation as well. This may be due to structural factors involved in eating and digestion or it may be due to expectations we have regarding how satisfying the food will be and the context in which we are eating.
We probably don't expect fruit juice to satisfy our hunger as well as fruit, and that may in part be why it doesn't. Do we expect smoothies to satisfy our hunger? That might tell us whether they can serve us in weight control by helping us eat less in total.
One strategy for eating less is sequencing. Starting a meal with a low energy density food (as an appetizer or "pre-load") seems to reliably help us reach satiation with less total energy intake, but starting with solid low energy density food seems significantly more effective than starting with liquid low energy density food, regardless of fiber content. This is in direct contrast to the popular advice to drink water prior to eating in order to fill up. That seems relatively ineffective even if we replace the water a high fiber carbohydrate drink.
Using a blender to conveniently add fruits and vegetables to our diet seems a reasonable strategy for weight control, by providing satisfying nutrition at lower energy intake, but the way we use it probably matters a lot. It appears that blender meals are best used as weight control aids when:
- We enjoy them and find them palatable and satisfying and expect them to be satisfying while still keeping them at low energy density.
- We do not make them energy-dense with sugars and fats, even "healthy" ones.
- We use them to replace rather than just add more intake to higher energy density sources
- They contain satiating ingredients such as high fiber carbohydrates and lean protein
- We don't rely on them as our only strategy for getting good nutrition while taking in less energy
(2004) Brownell, Kelly and Katherine Battle Horgen, "Food Fight: The Inside Story of the Food Industry, America's Obesity Crisis, & What We Can Do About It." McGraw-Hill
 Michael G. Tordoff (2002) "Obesity by choice: the powerful influence of nutrient availability on nutrient intake"
American Journal of Physiology - Regulatory, Integrative and Comparative Physiology Published 1 May 2002 Vol. 282 no. 5, R1536-R1539 DOI: 10.1152/ajpregu.00739.2001 URL: From http://ajpregu.physiology.org/content/282/5/R1536
 (2005) BARBARA J. ROLLS, PhD; ADAM DREWNOWSKI, PhD; JENNY H. LEDIKWE, PhD "Changing the Energy Density of the Diet as a Strategy for Weight Management" Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION, May 2005 S98-S103
 (2004) Barbara J. Rolls, Ph.D., Julia A. Ello-Martin, M.S., and Beth Carlton Tohill, Ph.D., M.S.P.H. "What Can Intervention Studies Tell Us about the Relationship between Fruit and Vegetable Consumption andWeight Management?" Nutrition Reviews , Vol. 62, No. 1 January 2004: 1–17 URL: http://www.researchgate.net/profile/Barbara_Rolls/publication/8674390_What_can_intervention_studies_tell_us_about_the_relationship_between_fruit_and_vegetable_consumption_and_weight_management/links/5405d2cb0cf2c48563b1ba87.pdf
 (2005) Tohill, Beth Carlton, "Dietary intake of fruit and vegetables and management of body weight," World Health Organization , ISBN 92 4 159284 2 URL: http://www.who.int/dietphysicalactivity/publications/en/f&v_weight_management.pdf
 (1998) Barbara J Rolls, Victoria H Castellanos, Jason C Halford, Arun Kilara, Dinakar Panyam, Christine L Pelkman, Gerard P Smith, and Michelle L Thorwart Am J Clin Nutr 1998;67:1170–77.
"Volume of food consumed affects satiety in men" URL: http://ajcn.nutrition.org/content/67/6/1170.full.pdf
"Short Term Dietary Compensation in Free-Living Adults"
F. McKiernan, J.H. Hollis, and R.D. MattesPhysiol Behav. 2008 March 18; 93(4-5): 975–983.
 "Dietary compensation in response to covert imposition of negative energybalance by removal of fat or carbohydrate"
Gail R. Goldberg*, Peter R. Murgatroyd, Aideen P. M. McKenna, Patricia M. Heavey
and Andrew M. Prentice
British Journal of Nutrition (1998), 80, 141–147
 (2000) "Liquid versus solid carbohydrate: effects on food intake and body weight"International Journal of Obesity (2000) 24, 794±800
DP DiMeglio and RD Mattes
 (2007) "Liquid calories, sugar, and body weight"Adam Drewnowski and France Bellisle
Am J Clin Nutr March 2007 vol. 85 no. 3 651-661
 (2009) Julie E. Flood-Obbagy and Barbara J. Rolls "The effect of fruit in different forms on energy intake and satiety at a meal" Appetite. 2009 April ; 52(2): 416–422. doi:10.1016/j.appet.2008.12.001.