Fatness and Obesity: Framing the Problem

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?
Calories In


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.
Calories Out


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

Obesity - What is the real problem?

 

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?

 

1. 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.
2. 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.  
3. Our metabolism is optimized for efficiency of energy storage rather than for maintaining a stable weight.
4. We are bad at estimating how much energy we need in order to be nourished and feel satisfied.
5. We are bad at estimating how much energy we are taking in in order to compensate for well-engineered distortions of reward and palatability.
6. 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
7. 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
8. 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.

Can Blender Food Help Us Lose Body Fat?

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.   

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:

1. "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.

2. 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." [1] (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.  [2]  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." [3] 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).   [4] 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. [5]   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.  [3] 

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.  [6]  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.  [7],[8]    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.  [9]  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.  [10]

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.[11]    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: 

1. We enjoy them and find them palatable and satisfying  and expect them to be satisfying while still keeping them at low energy density. 
2. We do not make them energy-dense with sugars and fats, even "healthy" ones.
3. We use them to replace rather than just add more intake to higher energy density sources
4. They contain satiating ingredients such as high fiber carbohydrates and lean protein
5. We don't rely on them as our only strategy for getting good nutrition while taking in less energy

 References

[1](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

[2]  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

[3] (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

http://www.researchgate.net/profile/Jenny_Ledikwe/publication/7870238_Changing_the_Energy_Density_of_the_Diet_as_a_Strategy_for_Weight_Management/links/0f31752e8eb7a40544000000.pdf

 [4]  (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 and

Weight 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

[5]  (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

[6]   (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

[7]"Short Term Dietary Compensation in Free-Living Adults"

F. McKiernan, J.H. Hollis, and R.D. Mattes

Physiol Behav. 2008 March 18; 93(4-5): 975–983.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323337/

[8] "Dietary compensation in response to covert imposition of negative energy

balance 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
http://www.researchgate.net/profile/Peter_Murgatroyd/publication/13457513_Dietary_compensation_in_response_to_covert_imposition_of_negative_energy_balance_by_removal_of_fat_or_carbohydrate/links/0deec52cbd1ac48ea3000000.pdf

[9] (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
http://cibr.refrescantes.es/ka/apps/cibr/docs/06_2000_Solido_y_liquido_efecto_peso.pdf

[10] (2007) "Liquid calories, sugar, and body weight"

Adam Drewnowski and France Bellisle
Am J Clin Nutr March 2007 vol. 85 no. 3 651-661
URL: http://ajcn.nutrition.org/content/85/3/651.long

[11]  (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.

URL:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664987/?tool=pubmed

Book Review: Secrets from the Eating Lab

Book Review: Secrets from the Eating Lab by Dr. Traci Mann

Review on Amazon

How our well-meant attempts to address the health implications of our increasing body fat are making the problem even worse.

This is a very well written and uniquely informative book in a field glutted with opinions and weak and conflicting advice. It is not a how-to book on losing weight, although it has a few solid behavioral suggestions for making modest healthy changes. This is primarily an interpretation of much of the available evidence regarding obesity and health by psychologist who runs an eating lab at the University of Minnesota and publishes a lot of scholarly peer reviewed work in the field.

Although she is a researcher, Dr. Mann takes pains to distinguish herself from obesity researchers with a public health focus who are motivated to warn people about the dangers of increasing body fat. Her interpretation of the data is often the opposite in some ways from theirs, she sees the growing incidence of body fat and she sees the growing incidence of adult onset diabetes, but she reports that the link between body fat and health problems is far weaker than is implied by the rhetoric of most obesity researchers and much weaker than the popular impression has become. In addition, our efforts to fight obesity have, she concludes, actually become counter-productive because of the manner in which we typically attempt to fight our own biology by restricting calories and exercising in ways that increase our stresses and increase our preoccupation with food, and that both of these things feed back into exacerbating the original problem.

The book starts off ripping into both the commercial diet industry and the focus of a lot of articles by doctors and obesity researchers by announcing that their "3 pillars" are all simply false:

1. That some diets work for losing weight

2. That some diets are healthy for losing weight

3. That obesity itself is deadly 

Among the central and most compelling aspects of this book is where Mann observes that our ideal body image often tends to be outside of the range that we can reasonably sustain. And this becomes confused with health concerns and fed by commercial interests. We could transform our bodies potentially through diet and exercise, but at the cost of altering or entire lives in the service of that goal and experiencing extended self-denial and obsession with food.

And the clincher for her argument is that all this self-denial and obsession would be mostly serving our aesthetic ideal rather than actually improving health. She finds that according to best available evidence upon close inspection mortality is not significantly improved by losing weight, unless you are already extremely obese and still have a long life ahead of you. The population in that category is far smaller than the one targeted by both the diet and fitness industries and most obesity researchers.

Mann finds that diets consistently fail in two ways: (1) only a tiny percentage of dieters retain their weight loss, regardless of which diet it is, and (2) even when people lose enough weight to satisfy the goals of improving their risk profile, they rarely lose enough to satisfy their aesthetic preference. This means that according to the person themselves, their diet failed even when for health purposes it succeeds. Our aesthetic goals trump our health goals for the purpose of satisfaction with the diet.

If we should want to attempt small changes that help us regulate our own eating so we can maintain a sustainably lower body weight, Mann offers several well-tested behavioral suggestions along the lines of "nudges" that help us avoid being triggered to eat excessively.

I think her principles seem sound and her use of evidence is compelling. I do have one criticism of her otherwise superb and unique exposition though. She argues for a set point model of body weight regulation that maintains our weight within a fairly narrow range but she doesn't really address the obvious question of why people are statistically getting fatter if we are so consistent at maintaining our weight in such a narrow range.

 

She puts most of her focus on obesity not being as deadly as it appears except at the extreme, and she explains why people can't simply diet away unwanted body fat, but she doesn't at all dive into the reasons for our growing bodies. That's a big topic and it isn't her area of research so I can understand leaving it to others to try to explain, but for me it left a logical hole in her argument that begs to be filled and should have been addressed with at least some general thoughts.

Book Review: The GenoType Diet

The GenoType Diet: Change Your Genetic Destiny to live the longest, fullest and healthiest life possible

By Catherine Whitney (Author), Peter J. Dr D'Adamo (Author)

[Review based on Kindle version]

From my Amazon review:

"... is it plausible in general that metabolic traits cluster along with personality traits, and that these clusters imply different health regimens? Of course it's possible. I'm strongly disposed from my own experience to think there are personality traits that lead us to construct particular rough kinds of niches, and it makes sense that these might have distinct metabolic patterns. But does the author get it right that eating Turkey vs. Chicken or Beef vs. Pork for a particular type really is a difference that makes a difference? That part needs more research."

The question this book raises in my mind is whether the author's GeneTypes significantly improve the guesses we make about the best nutrition for us as individuals, compared to just knowing our medical risk factors and knowing our rough somatotype.

This book takes off from the author's previous writings about how blood type can predict a cluster of traits that include individual response to nutrients, and modifies it into a 6 part theory of types. The 6 part model is given an evolutionary rationale and the author links metabolic differences, personality traits, and speculation about ecological niches where those traits and metabolic differences might be especially adaptive. The resulting categories are so clean and tell such a compelling sort of story that they seem to invite accusations of similarity to fortune telling. But if they're right, then this would a pretty cool system, wouldn't it? At least in theory.

• The Hunter: Tall, thin, and intense, with an overabundance of adrenaline and a fierce, nervous energy that winds down with age, the Hunter was originally the success story of the human species. Vulnerable to systemic burnout when overstressed, the Hunter’s modern challenge is to conserve energy for the long haul.

• The Gatherer: Full-figured, even when not overweight, the Gatherer struggles with body image in a culture where thin is “in.” An unsuccessful crash dieter with a host of metabolic challenges, the Gatherer becomes a glowing example of health when properly nourished.

• The Teacher: Strong, sinewy, and stable, with great chemical synchronicity and stamina, the Teacher is built for longevity—given the right diet and lifestyle. This is the genotype of balance, blessed with a tremendous capacity for growth and fulfillment.

• The Explorer: Muscular and adventurous, the Explorer is a biological problem solver, with an impressive ability to adapt to environmental changes, and a better than average capacity for gene repair. The Explorer’s vulnerability to hormonal imbalances and chemical sensitivities can be overcome with a balanced diet and lifestyle.

• The Warrior: Long, lean, and healthy in youth, the Warrior is subject to a bodily rebellion in midlife.With the optimal diet and lifestyle, the Warrior can overcome the quick-aging metabolic genes and experience a second, “silver,” age of health.

• The Nomad: A GenoType of extremes, with a great sensitivity to environmental conditions—especially changes in altitude and barometric pressure, the Nomad is vulnerable to neuromuscular and immune problems. Yet a well-conditioned Nomad has the enviable gift of controlling caloric intake and aging gracefully.

If the model is right, it is a pretty remarkable and perhaps revolutionary approach to making better guesses at how to improve our own nutrition based on our biochemical individuality. The evidence for its plausibility seems reasonable, but there is still little evidence validating the particular categories here.

Full review on Amazon here.

The argument for a SANE diet

This is the second in a series of commentaries on the ideas promoted in Jonathan Bailor's book "The Smarter Science of Slim."

This one presents my own spin on his argument for a SANE diet as an effective long term strategy for counteracting the trend toward obesity and obesity-related chronic illness.

In addition to recommendations for brief, infrequent, high intensity exercise to counter insulin resistance and reset metabolism, Bailor promotes what he calls a SANE diet. This is an acronym for satiety, "aggression", nutrition, and efficiency. Rather than duplicate his explanation, I'll just summarize by saying this refers to the quality of food rather than the quanitity, and takes a number of different quality factors into consideration. This note is intended to present my version of the argument for a mixed collection of quality factors in an anti-obesity strategy.

1. Human biology tends to regulate its body weight in a very narrow range for long periods under a wide range of natural and ancestral environments.

I came to understand this well over a decade ago and in my opinion the evidence base for it has grown rather than being seriously questioned in any significant way. This model does have a potentially misleading aspect to it in practice. Many people seem to assume that a body weight set point means different people are predisposed to different body weights. That is only partly true. The set point model does not assume a fixed value, it assumes that we tend to regulate our weight within a narrow range for long periods of time. It is obvious that the body fat set point changes over time, otherwise creeping obesity simply wouldn't happen. The issue is not whether the set point can change, but whether (and how) we change it in the other direction. The forces on it appear to be asymmetric.

My 1998 article on body fat regulation, showing the weak understanding I had at that point of the specifics but I think accurately depicting the concept and showing its historical origins and scientific rationale.

There have also been a number of helpful popular press articles expanding on the dynamic set point concept and its relation to weight loss plateau.

Obesity expert Arya Sharma discusses the set point concept and a unique theory of how it works.

2. Increasingly throughout the contemporary world, a combination of global economic drivers and local environments has created conditions that defeat the biology of weight regulation and cause body weight to creep upwards, resulting in an "obesity epidemic."

A recent Lancet special issue on obesity gave a summary of the current perspective on factors in obesity.


3. Clinical studies suggest a role for dietary glycaemic index (GI) in bodyweight regulation and diabetes risk.

There are a number of lines of evidence leading to the conclusion that glycemic index plays a central role in weight regulation through glucose homeostasis. I singled out this article because it also describes why some of the implications of that conclusion are controversial.

4. The effect of lowering GI is a dynamic change to metabolism, not a static linear dropping of weight because the body adapts to the loss of energy in order to maintain its set point. Static models of calories in vs. calories out do not take the effects of metabolism into consideration and therefore do not accurately predict weight loss.

Even though glycemic load is an important factor in obesity, we can't just cut out starches and sugars without making any other change and expect to keep losing weight. We will tend to compensate in other ways because of the significance of metabolism in weight regulation. As a result it is now considered essential to consider metabolism in predictions of weight loss rather than just calorie balance.

5. Solely manipulating GI in isolation has a diminishing return over time in weight loss because the reduction of calorie intake tends to slow metabolism and because of changes in potentially confounding dietary factors such as fiber content, protein content, palatability, and energy density.

This is a continuation of the previous claim, based on the evidence gathered from trying to control weight solely by reducing glycemic load.

6. CONCLUSION: An individual nutrition strategy that replaces high GI foods by taking energy density, palatability, fiber, protein, energy density, ad other factors into account can more successfully use a reduction in glycemic index to control body fat by improving fat metabolism, slowing or stopping the accumulation of insulin resistance, and reversing the upward creeping of the body fat set point..

None of that is particularly surprising scientifically as far as I know. The set point model of weight control has been standard in both human and animal research for a long time, it is not at all controversial among obesity and physiology researchers. You simply have to take metabolism into account when considering how the body absorbs, utilizes, and catabolizes nutrients and energy. You can't just assume that everything we take in minus some estimate of what we are "burning" is going to be an accurate model of body weight fluctuation.

The part where there is still room for argument is the specific causal sequence, and that has some additional implications. There's an old conundrum in psychology research: "do we cry because we are sad, or are we sad because we cry?" The answer seems intuitively obvious but it turns out that both causal models are partly right because there is a feedback look from our behavior to the way we feel.

There is a similar conundrum in obesity research. Do we get fat because we eat too much and don't move enough, or do we eat more and move less because of the effects of obesity. Again it turns out that both capture part of what is really going on. We do gain weight when we eat more and move less, at least in the short term before our metabolism starts to regulate our weight back to normal. But the thing that causes our weight to more permanently creep upward is the changes to our metabolism over time. And those hormonal and cellular changes make us less good at burning fat and better at absorbing it, changing our body fat set point over time.

Todd I. Stark
Nov 20,2011

Dietary fads, fictions, factions, and facts

This is my first post in a series of planned commentaries based on my reading of Jonathan Bailor's highly recommended book, "The Smarter Science of Slim."

This first commentary is my perspective on the history of the issues and how I perceive they have been resolved scientifically so far.

The Low Carb Revolution

Years ago, Dr. Atkins shocked popular culture and infuriated proponents of low fat diets with the claim that people could lose weight and reduce their risk of heart disease by minimizing the mainstay of the typical diet, carbohydrates, replacing them with proteins and fats.

This was a controversial claim not only because low fat diets were popular at the time but also because in emphasizing a low carbohydrate diet, Atkins was claiming that we could be healthy with minimal amounts of important dietary elements like fiber and the nutrition we get from vegetables. He was opposed by the people who promoted an ever higher proportion of vegetables in our diet and who encouraged us to minimize saturated fats, which were long widely thought to increase the risk of heart disease and obesity. At the same time, a lot of people argued that obesity can and should be sensibly addressed with the reasonable commonsense approach of eating a little less and moving a little more: get active and cut back a little on calories each day.

Two Battles Emerge

This turned into two polarized contests of opinion in popular culture.

First, there was a conflict between the folks who think quality of food is important in weight control and those who think that emphasis is misplaced, that we should just measure calories in and calories out. The implication of the food quality view: eating more of some things and less of others should affect our weight over time without making constant efforts to otherwise monitor and control our intake by counting calories. The implication of the calorie balance model: just eat a few calories less and move around a little bit more to burn a few more calories and you will lose weight consistently.

Second, among those who consider the quality of food to be important, there was the battle of the low-carb lobby vs. the vegetable lobby. Should you eliminate carbohydrates because of their effect on metabolism, or should you eliminate saturated fats because "fats make us fat" and raise blood cholesterol?

As is often the case in polarized positions it seems from our perspective today that both sides (in both contests) got some things right and both sides got some things wrong.

Calorie Balance vs. Metabolism: The Result

The standard and consensus view of obesity among researchers is that passive overeating is the best overall description of the cause. It is widely accepted, though not universally, that the amount of caloric energy we take in plays a causal role in obesity. Further the standard and consensus view is that this results from a combination of global economic factors and local environmental factors (the "obesogenic environment").

It is also a standard and consensus view among obesity researchers and physiologists that body weight is regulated by metabolic factors (via chemical messengers) that are not not related to the number of calories we take in and the number of calories estimated for the activity we perform.

What the calorie balance model captures: our biology doesn't violate the laws of conservation of mass and energy. Eating less and catabolizing body mass for energy does cause us to lose body mass. Eating more and demanding less energy utilization does cause us to gain body mass.

What the metabolism model captures: The calorie balance model clearly predicts that our body weight should consistently fluctuate according to the overall energy balance between what we take in and our activity. This is demonstrably not the case both from common experience and controlled studies. The prediction of the calorie balance model only apply for a short time and then our body changes internally to absorb food differently and to use it differently for energy. Our appetite and subjective energy levels are also changed. This is collectively expressed as the body regulating its mass in various ways around a relatively stable point.

The common experience of a "weight loss plateau" coincides with the concept of a "weight set point" around which our body maintains itself in a narrow range over time.

When we simply eat less, we lose weight for a little while and then the loss slows down and eventually stops and tends to reverse itself into return to baseline weight and sometimes even gain above that original level.

Further, the signficance of metabolism implies that quantity of energy taken in and demanded is only part of the causal model. Metabolism is affected differently by the specific foods we eat over time and the specific kinds of activities we engage in, not just or even primarily the total amount of energy involved. The metabolism model better captures the importance of food quality than does the calorie balance model.

Low Carb vs. Veggies: The Result

Given the consensus view that metabolism is an important factor in weight control and that the kinds of food we eat are an important factor in metabolism, we arrive at the second battle, over what it means to eat higher quality food more conducive to health and fighting obesity.

What the low carb lobby got right and the vegetable lobby got wrong: saturated fat isn't itself an important cause of heart disease and obesity. You can consume reasonable amounts of fat, including saturated fat from animal sources, and still have a very healthy diet.

What the low carb lobby got wrong and the vegetable lobby got right: The low carb lobby deals with the problems of insulin response in a gross and overly restrictive way by choosing proteins and fats over carbohydrates in general rather than balancing them and eliminating high glycemic carbohydrates. This makes levels of fiber too low and eliminates important sources of nutrients and often crowds out vegetable nutrition sources using animal ones. This is probably healthier than the typical high glycemic diet, but not nearly optimal. Minimizing carbohydrates is a bad strategy because we get many nutrients from carbohydrates, especially vegetables.

What both the low carb lobby and the vegetable lobby both got right from the start: Sugars and starches as a mainstay of our diet are killing many people. Insulin resistance is a precursor to type 2 diabetes and is associated with and exacerbated by a high glycemic diet as well as by obesity. Starches are high glycemic.

The low carb lobby recognizes the role of high glycemic foods in obesity and chronic illness but they generallize it too far to all carbohydrates as an overly restrictive and overly simplified strategy.

The vegetable lobby is too concerned with the role of animal fat in nutrition and focuses on that rather than the more important distinction of higher glycemic vs. lower glycemic carbohydrates and a more balanced diet.

Saturated fat doesn't itself cause heart disease or obesity. Combined with a high glycemic diet, saturated fat exacerbates the problems caused by constant massive triggering of the insulin response because of a combination of factors:

(1) fats plus sugars tend to increase appetite dramatically,

(2) fats have a high energy density compared to their nutrition,

(3) saturated fats in particular have no protective effect for heart disease compared to omega-3 from polyunsaturated fats.

People tend to lower their risk of heart disease when they switch from saturated to unsaturated fats. This is one of the strongest arguments for eliminating saturated fat from our diet. However it turns out that this benefit is probably not because saturated fats cause heart disease. It is more likely because unsaturated fats have a protective effect compared to saturated fats.

Lowering glycemic load allows us to use nutrients more effectively, to metabolize all fats more effectively, and tends to reduce the risk of heart disease and obesity far more than reducing saturated fats.

So what works?

What dietary strategy best lowers our risk of chronic illnesses and obesity? Do they all fail equally? Do different people respond differently to different regimens?

It turns out that individuality is a real factor, both biochemical and psychological, and learning to make the principles work in your own life and for your own biology is critical. Still, there are also some general principles that we can rely on as a very good start.

The low carb strategy often works for as long as people can manage to maintain it and is healthier than the typical diet but it is not optimal for health and most people find it hard to sustain and eventually have health problems or fail to sustain it. It is not balanced nutritionally, it is too severe in limiting valuable and healthy vegetable sources of nutrition.

A vegetarian strategy often works at least for a while and is also healthier than the typical diet but it is also difficult for most people to maintain and as a general strategy it is too severe in limiting valuable and healthy animal sources of protein and what for many people are satisfying sources of texture and flavor in animal fats.

Taking what they both get right and eliminating what each gets wrong, we end up with:

1. Avoid high glycemic carbohydrates as far as possible or only under very specific conditions.

As a mainstay of our diet are a primary cause of both obesity and chronic illnesses via their effect on our response to insulin and our ability to absorb and metabolize nutrients. In other words, these commonly accepted processed products of agriculture cause a "clogging" of our metabolism over time that defeats our evolved ability to regulate our own metabolism. High glycemic carbohydrates are not essential for health and we tend to become dependent on them in various ways so minimizing them is an important first step to better health. There are specific strategies you can use to minimize their negative effects if you want to use them for athletic reasons or because you can't bear to eliminate them from your life entirely, but you have to be wary of how often you do this and the timing of it.

2. Balance the remaining nutrients between proteins, low-glycemic carbohydrates, and fats.

Compared to high glycemic foods, these categories all contain many healthy and valuable sources of nutrition.

Why a balance? In addition to just having a variety of nutrients of different kinds as well as a variety of tastes and textures to make eating more satisfying, there are also some specific nutritional reasons.

A diet of too much fat and too little protein and carbohydrate fails because fat contains relatively little nutrition compared to its energy density and tends to crowd out our intake of fiber important to digestive health as well as various nutrients. A diet of too much fat also fails because we have to eat a lot of it to make us feel satisfied in lieu of protein, fiber and water because of its low nutritional density.

A diet of too much protein fails because it avoids fiber and avoids important sources of vitamins and minerals and because it requires us to limit our protein sources very severely. It is also unhealthy to take in extreme amounts of protein. You can live on a high protein diet for a while if it isn't too high, but it isn't optimal. Temporary protein-sparing fasts are effective and popular among some athletes.

A diet of too much low-glycemic carbohydrates (taken to an extreme this would basically be a vegetarian diet that not only minimizes starches and sugars, but also seeds, nuts, and soy) is not really something anyone seriously recommends or practices as far as I know, but if they did it would fail because it would not have adequate protein sources to sustain health and would be relatively unsatisfying. Even strict vegans eat vegetable protein and fat sources, they just avoid animal sources. A diet with a huge amount of low-glycemic carbohydrates is perfectly healthy and sustainable so long as it also includes a reasonable amount of plant fat and protein sources.

The lesson here is just to mostly eat natural foods while avoiding high glycemic carbohydrates rather than striving for extremes of individual components. Avoid high glycemic foods and otherwise eat to satisfy your hunger. The specifics of satisfying our hunger are important however, balance is important in order to get a good combination of fiber, protein, water, nutrition, taste, texture, and other factors to satisfy us.

3. Take advantage of the "Paleo" principle but don't be limited entirely by it

I think the principle behind "Paleo" diets is basically correct, that our metabolism seems to be tuned by evolution to process natural animal and plant sources of nutriton that we could hunt or gather, and has not adapted yet to our dietary preponderance of processed agricultural products. This is another way of saying that high glycemic carbohydrates (the main category of highly processed and cultivated foods in our diet: the wheat, corn, potato, and rice products) are a very bad thing to emphasize all of the time.

In general the principles behind paleo eating agree with those proposed here, however they also focus on a rationale that can be misleading, which is why I consider it a fad even though it gets things mostly right. Trying to guess what our ancestors might have eaten and in what amounts is not nearly as useful a way to figure out what is healthy as just applying general principles and nutritional research results. By all means it makes sense to look to Paleo recipes and products as candidates for making it easier to maintain good nutrition. Also it is convenient and useful to imagine whether something could be hunted or gathered to know whether it is a nutritional source likely to be compatible with our metabolism.

Just don't limit yourself to the principle that we can only eat what our ancestors ate or elaborate arguments about the Pleistocene lifestyle. You have more options which you can intelligently apply to use modern foods and still be healthy.

4. Don't expect restricting calories to help you in the long run if you are eating poorly.

If you stop eating competely, you eventually die because your body eats its own tissue to try to meet its energy requirements. So when we talk about calorie restriction we aren't talking about not eating. We are talking about changing the timing of when we eat and eating less in a given period relative to what we would normally eat. We might eat less in a given period than we otherwise would, or we might eat nothing for a specific period of time. There are many strategies for calorie restriction. Some of them have a place in athletic performance and some of them can also have a place in a health regimen, but we have to be careful about how we go about it and how much we rely on it.

Sometimes the most reasonable approach is not the best. Portion control and light or moderate exercise seem perfectly reasonable and have been long recommended as a treatment or prevention for obesity. But for the vast majority of people they don't work for this purpose. Our metabolism and appetite conspire to maintain a stable weight against our efforts to make small reasonable changes in how much we eat and how much we move. We have to more directly influence our appetite and metabolism to deal with obesity. Simply eating less of the same things we are eating does not neccessarily help because it does not address the metabolic causes of our problems.

Fasting, as opposed to portion control, is a more potentially valuable and effective health strategy. This is because it can help you learn how to better control cravings, and can help you get your body fat lower than you could reasonably get with frequent eating and for longer periods. Some evidence suggests that fasting itself might trigger healthy changes in the body, although these are hard to distinguish from just the benefits of controlling body fat and eating more healthy overall. Fasting is much more difficult to do effectively, much less sustainable, and much less effective and healthy when combined with a high glycemic diet.

Your best bet is probably to eliminate high glycemic carbohydrates and get the hang of eating well first, then try fasting as an additional strategy if you want to, to make it even more effective and sustainable.

5. Don't just load up on "low fat" foods. But do emphasize lean protein sources over fatty ones.

By the best evidence available now, it seems that reducing fat by itself plays virtually no role in controlling obesity or chronic illness. Nutritionally, fat should be considered "neutral" or "filler" compared to good nutritional sources like non-starchy vegetables and good protein sources like seafood, lean meats, and egg whites. The problem with a "low fat" strategy is that if you go out of your way to avoid fats, you will also tend to replace the missing energy with starches and sugars.

If you could eliminate fats without replacing them with high glycemic foods, this strategy would probably work a lot better. Lean protein sources are an important part of modern nutrition, not because fat is bad, but because protein is so valuable. Fatty protein sources are really fats, not proteins, so they should be considered filler in your diet, rather than assuming they are good sources of protein. You have to eat an unreasonable amount of fatty protein sources to get enough protein to be valuable for satiety and nutrition.

6. If you find yourself eating something high-glycemic, at least mitigate its effects with fiber and protein and avoid fat under those conditions.

The effect of food on our insulin levels is the primarily culprit in obesity and many chronic diseases. However this glycemic effect is not just a result of what individual foods we eat, it is result of their combined effect on the amount of glucose circulating in our blood. There is no way to simply counter-act the glycemic effect short of avoiding high glycemic foods entirely but you can reduce it by lowering the combined glycemic effect by increasing the amount of fiber and protein you eat along with high glycemic foods. If you are going to indulge in high glycemic food, you can reduce the damage it causes by avoid simultaneous eating of fats (which boost appetite strikingly when combined with starches and sugars) and eat lean protein and good fiber sources with the high glycemic foods instead.

Note: This article was inspired by Jonathan Bailor's highly recommended book, "The Smarter Science of Slim."

Todd I. Stark
Nov 20,2011