May 17 2012

Pondering the Weight of the Nation

I’ve been asked to comment on the HBO series, Weight of the Nation and everything that comes with it: the accompanying book, the auxiliary videos, the distribution plan to schools and other institutions, and the Institute of Medicine’s report, Accelerating Progress in Obesity Prevention.

Because I wanted to look at all of it before commenting, plenty of others have beaten me to it, among them FoodandTechConnect’s infographic summary,   Kerry Trueman on AlterNet and Michele Simon on Grist.

I don’t have HBO but got sent the press kit, the Weight of the Nation book, the disks, and the IOM report.  I watched all four hours of the HBO series, plus the “Rethinkers” video of kids working on a school lunch project in New Orleans (air dates), plus the IOM and HBO books, plus the website.

Overall, Weight of the Nation makes the size, scope, causes, and consequences of obesity alarmingly clear.

The talking heads—many of them my friends, colleagues, and former students—all had plenty to say about what obesity means on a day-to-day basis for individuals and its personal and economic cost to society.

The programs ought to convince anyone that obesity is a big problem and that something big needs to be done to prevent it.

But doing something big, the series makes clear, will be very difficult.

This may be realistic, but it is not inspiring.

We need inspiration.   That’s why I wish the programs had focused as much on social responsibility as they did on personal responsibility.

I wanted to see the programs take leadership on how government can help citizens reduce the social, economic, and business drivers of obesity.

That kind of leadership exists.  To see it in action, watch the video of the New Orleans school “rethinkers.”  Those kids wanted to improve their school lunches.  They got busy, dealt with setbacks, and learned how to make the system work for them.  They “spoke truth to power” and “held feet to the fire.”

Why aren’t adults doing the same?   Politics, the IOM report explains.  Although one of its principal recommendations is critical—Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice—its recommendations speak some truth to power but do little to hold feet to the fire.

The IOM report explains the political realities:

The committee’s vision takes into account the need for strategies to be realistic, as well as consistent with fundamental values and principles.  At the same time, however, having a diversity of values and priorities among them is itself a principle of U.S. society.

Potentially competing values and principles must be reconciled, for example, in considering protections needed for individuals versus the community at large or for the public versus the private sector.

Vigilance regarding unintended adverse effects of changes undertaken to address the obesity epidemic is also needed.

“Americans,” the report says, are accustomed to the current obesogenic environment, one “driven by powerful economic and social forces that cannot easily be redirected.”

It may not be easy to redirect such forces, but shouldn’t we be trying?

In 1968 the CBS documentary Hunger in America galvanized the nation to take action to reduce poverty and malnutrition.

The HBO series was equally shocking but I wish it had focused more on how we—as a society—could mobilize public distress about the poor quality of food in schools and the relentless and misleading marketing of sodas and junk foods that it so well documented.

But dealing with the need to address the social and economic forces that promote obesity would, I’m told, be considered lobbying, which the private-public sponsors of the series are not permitted to do.

Mobilizing public support for health is considered lobbying.  Food industry marketing is not.

FoodNavigator-USA.com columnist Caroline Scott-Thomas wrote about the HBO series:

As an industry journalist, I’ll be among the first to admit that industry is stuck in a very hard position here: On the one hand, it wants to be seen to be doing the right things – but on the other, what people say they want to eat, and what they actually do eat are often very different, and after all, food companies are in the business of making money.

But honestly, could industry do more to make healthy choices routine, easy choices? I think so.

Yes it could, but won’t unless forced to.

Without leadership, we are stuck doing what the food industry needs, not what the public needs.

Weight of the Nation did an impressive and compelling job of defining the problem and its causes and consequences.  I wish it—and the IOM—could have risen above the politics and pressed harder for strategies that might help people make healthier choices.

But—if the HBO programs really do help mobilize viewers to become a political force for obesity prevention, they will have been well worth the effort that went into making and watching them.

  • http://www.FeedYourHeadDiet.com Ken Leebow

    Unfortunately, I think we are Obsessed with Obesity. While the show did discuss food, the problem is almost 100% about the food. And candidly, most people know they should eat more fruits and vegetables. The show should have shown that it is simple and easy to prepare and cook delicious fruit and veggie dishes.

    On a positive note, at least they did not chop off the heads of obese people.

    Ken Leebow
    http://www.obsessedwithobesity.com

    P.S. Why weren’t you in the documentary? You’re a movie star!

  • http://www.muchmorethanfood.com Bonnie Modugno, MS, RD

    I am not surprised the talking heads and experts only talk about the problem. It is the same at conferences, unless there is a drug involved.

    There are real solutions and opportunities to do this differently. , but when you are preoccupied with the goal (as medicine, big pharma and the insurance industry often are) the process is neglected, even ignored. ( My recent blog addresses more on this: http://muchmorethanfood.com/blog/do-americans-eat-too-damn-much/)

    At the root of the problem is a preoccupation with weight and pretending it is an effective bio-marker for risk. Thin people get sick with diabetes, cardiovascular disease, and cancer, too. They can be “metabolically obese”.

    In the meantime, thin people get a free pass to eat whatever they want. Everyone is preoccupied with treating folks who don’t. This creates an food environment that doesn’t work for anyone–and especially compromises people who already struggle with their weight. Why is weight (or body size) the litmus that determines what someone gets to eat?

  • http://www.eatwellmealplans.com Jennifer Cohen Katz RD

    As a nutritionist I encouraged my clients to view the doc to help chip away at their preconceived beliefs about eating behavior. Hopefully they heard that they should have easy access to fresh fruits and vegetables. Fresh fruits and vegetables should be affordable. They need to decode slick food advertising. They need to be advocates for their children both at home and at school. Etc.

  • Subvert

    Hmmm, maybe Americans’ time spent watching the documentary would be better spent actively walking around the block instead of rotting our minds in front of the TV?

  • http://www.deliciouspotager.blogspot.com Jennelle

    I imagined watching this documentary as someone completely new to this discussion. I think it did a great job from that perspective for introducing the issue in a way that was not “nanny-ish” or came off as “food police.”
    I thought the documentary reflected reality on the point that the obese and overweight people featured felt powerless to do something about their status. I took from it that many just don’t know where to start, and I think that’s true. At least based on the overweight and obese people around me. There is a lot of conflicting and confusing information about diet and nutrition out there, coming from seemingly expert sources. I was disappointed (and I haven’t watched the final part yet) there was no discussion of farm and agriculture policies and the role that those play in our obesity epidemic. But, it might have been too overwhelming for the average person who does not follow this issue to take all that information in. I’m all for wining society over by taking baby steps, as long as the conversation about this important issue continues.

  • Marion

    @Jennelle: keep watching. they do get to farm and ag policy.

  • Stephanie

    I am a parent activist on the issues of obesity and nutrition in my community and have utilized the resources of both the Rudd Center and the Alliance for a Healthier Generation .

    I wonder if, as a society, our fractured nature makes it hard for us to think in terms social responsibility? Nutritional guidelines, like the one developed by the American Heart Association, are very easy to understand. However, when I shared those with administrators at my son’s school I was met with complete defensiveness and denial. They did not want to hear that they needed to change or that they were doing anything wrong.

    I have a friend who frequently reminds me that food is love, and to tell our schools or community organizations that they aren’t feeding our children appropriate and healthy nutrition is to accuse them of not loving our children – and they do. They are loving our children to death.

  • brad

    At the risk of sounding like a shill for this book (I have no connection to the authors or publisher, I’m just a big fan), I highly recommend reading “Switch: How to Change Things When Change is Hard,” by Chip and Dan Heath. There are many useful approaches in this book, all of them tested and based on evidence, that can be applied to tackling obesity and its many causes. Early on in the book the authors cite studies showing that people preferentially focus on problems rather than solutions; one of their strategies involves avoiding our natural tendency to focus on learning why something’s not working and instead focus on drawing lessons from what’s working (what they refer to as “bright spots.” They provide case studies and examples of all these approaches in the field, and I have to say this is probably the single most useful and inspiring book I have read in the past 20 years. Anyone who wants to learn how to effectively bring about change — personal or political — can learn a lot from reading it.

  • Anthro

    I just returned from the supermarket with a couple of bags of fresh produce. While I was there I saw a number of morbidly obese people, all of whom were buying very cheap, very fatty sausages, large, heavily frosted cakes, large packages of large cookies, crates (literally) of soda, bags of chips, and so on.

    I also noticed some packages of ground chicken and turkey that listed nutrition information on the FRONT of the package– in reasonably large type. When I saw that four oz. has 180 calories, I passed–also I’m a vegetarian, but I was thinking of getting it for the spouse. I was the only person even bothering to look at this stuff, the others being busy with the sausages and hot dogs.

    Most of the produce is now already cut up and put into even more useless, landfill-clogging plastic containers (the ones used at this market are not recyclable in our city), at a considerably higher price than the whole product. Is this stuff a reasonable value if you consider all the waste of something like a pineapple or cantaloupe? It gets more expensive every week to procure fresh fruit and veggies, but if you cut your calories in half (as I did) and don’t eat meat, well, I think I spend less than most people in the long run.

    Well, the point is (and I DO have one), I don’t see any responsibility at all, personal, social, or corporate. How can so many people be so ignorant of why they are so large? People “struggle” with their weight we are told–not really, they just refuse to consider that they eat too much, and choose way too many obviously fattening foods.

    I actually feel a little bit sorry for some of the food producers who do put the calories on the front (but not the number of servings or a realistic serving size–but whose responsibility is it to know a serving size?) or make low-salt products and then no one buys them.

    I know how long it took me to realize that even though I have eaten “well” all my adult life, I was simply eating too much for my body and metabolism. It ain’t fair at all that other people can eat more than I can and not get fat, but accepting that was one of the first steps. I eat at home 95% of the time, and that helps as well.

    Everyone must do their part, personally and in the community. Products will change to meet demand–or disappear if no one buys them! That leaves the teevee and its glut of advertising to be held accountable and that’s the one I don’t see budging. I killed my television years ago and have never been sorry. Yes, yes, I watch Netflix on the computer or iPad, but no commercials for me, thanks.

    We need to mandate a huge program of PSA’s (Public Service Announcements) to counteract crap food advertising and ban it outright on any kind of children’s programming. That would be the RIGHT THING TO DO. I won’t hold my breath.

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  • Charlie L

    As someone who had been morbidly obese most his adult life until fairly recently (see http://www.marksdailyapple.com/a-primal-comeback/), I was disappointed that a low-carb or Paleo nutrition perspective wasn’t explored in any meaningful depth in this documentary to help balance the conventional calories-in-calories-out paradigm. One major factor ignored in this documentary is that the conventional advice on weight loss itself may be unwittingly complicit in contributing to the obesity epidemic, especially if it hasn’t worked for many people in the long-term and on multiple occassions. So far, it’s worked more for the processed food and dieting companies than actual people. Instead, calories-in-calories-out is often assumed to be gospel and if a person has failed to lose and keep weight off long-term, society (including the skinny-but-never-been-obese nutrition experts) pretty much assumes that the obese person is a lazy glutton who lacks enough motivation to become healthier. There are consequences for conventional advice not working for many people for so long beyond just the abstract, academic point of simply being wrong.

    Another commenter mentioned earlier the book “Switch” by the brothers Heath. Perhaps if the documentary’s aim was to help inspire or motivate others instead of dwelling on the negatives (as we seem to be naturally inclined to do–i.e. think of the local evening news), the focus could have been on formerly obese non-celebrities who managed to keep weight off long-term (and not via drugs, surgery, extreme exercise, or being locked up in a hospital setting as part of a 9-month leptin study), then try to decipher common things they did to remain that way. A parade of normal to skinny nutrition experts is always good, but it adds another dimension when people can identify with real people who have actually been there and back.

  • brad

    @Charlie: I remember a point in the HBO documentary where they asked a bunch of obese people what diets they’d tried. Many of them said, over and over again, “Atkins,” “South Beach,” and other low-carb diets, and I remember one of them said that low carb had been the most effective for him. But then, one after another, they all said, “but then I regained all that weight I’d lost.”

    There’s a lot of evidence that low-carb is the most effective way to go if you’re aiming for rapid and significant weight loss. And it makes intuitive sense that low-carb is easier for some people to sustain over time than other diets because it tends to be more satiating. But it doesn’t seem to be better than any other diet in the long term: like most dieters on any diet at all, the majority of dieters who follow a low-carb diet tend to eventually gain back the weight they lost. We all know exceptions and most people who are motivated to post comments on blogs like this in defense of low carb are themselves the exceptions. We don’t generally hear from the millions of people who are the rule, not the exceptions. I think we heard from a sample of them in the HBO documentary.

    The other thing that’s striking to me is that you saw obese people who successfully lost weight by eating less and moving more, or by reducing fat in their diets without necessarily reducing carbs. It reinforces the conclusion that any diet can be effective, but some diets work better for some people than others. But I think for most people the actual diet matters less than their food environment and psychological cues.

    Another one of the Heath brothers’ maxims in “Switch” is to “script the critical moves.” This means we’ve got to identify the points at which people who follow a diet start to abandon it and drift back to their old ways, figure out why they do so, and develop effective ways to help them stay the course. Pretty much anyone can lose weight once they decide to get serious about it (which is another critical point in the equation), but it’s far more challenging to keep it off as the months stretch to years and the years stretch to decades. We’ve got to find the keys to that kingdom.

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  • Charlie L

    @Brad – I’m a very big fan of “Switch” and find it influential in how I think in retrospect about my experiences in losing and keeping off a significant chunk of weight (and body fat). I think a documentary focus on what successful long-term dieters actually do (e.g. non-celebrities who aren’t paid millions of dollars to lose weight, who didn’t have surgery, drugs, or do extreme amounts of exercise) would help “focus on the bright spots” (a Heath maxim), which would in turn clarify paths to success better (another Heath maxim). Think of it like a real people version of “7 Habits of Highly Successful Non-Celebrity Dieters” instead of an exception vs. the rule dichotomy. Unfortunately, since we’re so attuned to thinking that big problems (like obesity) require extraordinarily big, drastic solutions (think Biggest Loser, or My 600 Pound Life, or Weight loss surgery, diet pills, etc…) that we forget about the pockets of success that don’t fit such conventions of thinking, which may help out actual everyday people. Plus, it doesn’t help that the media, diet, food, and drug industries profit from such a belief that big problems require drastic solutions.

    I also think that if the calories-in-calories-out model works long term for some people that they ought to stick with what works for them, but the reality is that it hasn’t worked for many obese people. Of course, the blame usually falls on the dieters themselves instead of the advice they’ve tried to follow several times to the same long-term conclusions, but perhaps it’s time to re-look the advice being given as well. Unfortunately, the HBO documentary proceeds as if calories-in-calories-out is gospel. I just think a calorie (the amont of heat–i.e. energy–it takes to reduce something, like food, to ashes, in a lab setting) is a poor way of looking at human metabolism, giving a false sense of simplicity and separation from the nuances of millions of years of evolution.

    I think of it like this: if calories-in-calories-out is like building bridges, and many, if not most, bridges still collapse after 30 or 40 years, it would be long overdue to rethink how we advise bridge building. From a pragmatic viewpoint, drivers don’t fail bridges; bridges fail people when they don’t help most people arrive from point A to point B safely. It would be crazy to blame the drivers or their cars to explain why those bridges still collapsed. But with calories-in-calories-out dieting, this is exactly what we’re doing. The HBO documentary doesn’t do much to challenge such insanity.

  • John Durkin

    In the past two years I lost 30 kg of body weight, after been overweight and obese for many years. I did it after my doctor told me on my 50th birthday I would be diabetic, have high blood pressure, gout, and need to put me on meds for the rest of my life (I am 52). I realized that calories in/calories out was the only realistic way of managing my weight. It took about 18 months to get me BMI below 25, into normal range. Now I manage day to day to keep the result, and am trying to achieve and maintain a BMI of around 22-23. I also just achieved a life long dream of running a marathon in under 4 hours. Also, no meds.

    My point is that calories in calories out was the only way this worked. It was as simple as a spreadsheet (which I used at the beginning, but switched to a iPhone/net app later). Exercise was also essential. Also understanding personal calorie balance is eye opening – I still have a hard time believing my male body only requires about 2,200 calories a day.

    There are so many distractions and temptations. Its true we are bombarded with food messages, most of which are aimed at getting us to buy some of most processed and calorie dense foods. I found that my craving for junk/processes foods declined over time and now I crave seasonal fresh fruits and vegetables. Seems almost like a miracle.

    Also, lifestyle change is very hard. I had to wipe out all social or business events that involved food for 2 months at the beginning of my “diet” to keep the calorie balance. Working exercise into my schedule was difficult at first, but now its routine.

    Its really difficult for most people to make the lifestyle change necessary to reduce calorie intake to lose weight. If this TV program and campaign result in even a few people waking up to the realities of calorie balance and adjusting their life style, then its very much worth the effort. I think HBO is doing a great public service.

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  • Stuart Katsh, MS, RD

    As a fellow Registered Dietitian (RD) I am disheartened, sickened and simply disgusted that the HBO series Weight of the Nation BARELY mentioned the profession of RDs. They did not mention what our profession does, they did not interview or include RDs in the special. In fact we were barely mentioned.
    RDs are the nutrition experts! We are the only ones who are educated and licensed to practice and to be reimbursed from insurance companies for the practice the science and art of nutrition.
    RDs are the only MEDICAL profession that is fully qualified to practice the science of nutrition – not MDs, not NPs, not RNs, and certainly not almost all of the people involved in the thousands of weight loss books/schemes/plans
    No other medical professionals have the training to educate people on how to eat for health, for illness, for disease, and how to correct and prevent obesity
    RDs were BARELY touched on in the HBO series.
    I certainly do not want to assign blame for this to anyone but I feel I must. Perhaps it was the ignorance of the people who made the series. Or perhaps, and more likely the fault of our governing body The Academy of Nutrition and Dietetics (AND). THEY should have known about this documentary. If they did not they are not doing their job. AND has never done what I and many of my friends who are fellow RDs feel they should do which is HEAVILY PROMOTE and EDUCATE the public and medical profession on THE ROLE AND BENEFITS OF A REGISTERED DIETITIAN.
    The series lacked this and I am disgusted by this. My mother was an RD starting in the late 1930s. From her stories, little has changed in the public’s knowledge of the role of an RD. This series missed the true opportunity to help people by showing much more interactions between client and RDs and what RDs do.

    For information on what it takes to become a nutrition professional, an RD please go to http://www.eatright.org/BecomeanRDorDTR/content.aspx?id=8143

    Thank you foe reading this and listening to my opinions.

  • brad

    @Charlie: you make a lot of good points and I agree 100% that a documentary that follows a number of people who’ve successfully lost weight and kept it off long-term would be a useful follow-on to what we saw in “The Weight of the Nation.” In fact there’s at least one study that has been following a group of successful dieters long term.

    Some researchers argue that low-carb/high protein diets boil down to calories in/calories out, because people who lose weight on those diets are actually consuming fewer calories than they did before, it’s just that the calories they consume are embedded in foods that are more satiating and also don’t lead to spikes in insulin. You can achieve some of the same effects with a diet rich in whole grains, which are metabolized gradually and there’s no spike. If you look back at historical wheat consumption in the United States, for example, you find that Americans’ consumption of wheat during most of the 1800s was close to double today’s level and yet we had no obesity epidemic back then. Sugar is a different story.

    But I agree with your main point, which is that we all have choices when it comes to making diet and lifestyle changes to lose weight (or avoid gaining weight in the first place), and not all of these choices work equally well for all people. I don’t think there’s a universal solution: what works for me won’t necessarily work for you and vice versa. There may need to be a bit of trial and error. For some people, counting calories is highly effective (though I can’t imagine it can be sustained by most people over decades, because it’s tedious and requires sustained discipline). For others switching to a low-carb diet works best; others might have more success becoming a vegan (I’m fascinated by the vegan bodybuilders and professional athletes out there, who provide living counter-arguments to claims that a diet devoid of meat makes us weak and sickly).

    In the end, I think almost any diet will work; the trick is 1) finding a diet that will work for you, and 2) finding and sticking to a diet that will provide a healthy balance of nutrients and is sustainable over a lifetime.

  • Deev

    @Stuart, obesity is a behavioral problem, and RD’s know absolutely nothing about human behavior. Ask them about obesity and they’ll tell you that it’s due entirely to people overeating in response to low blood sugar. Their solution is to get people to eat all day long –tiny, unsatisfying meals and snacks to help “regulate” the insulin response. Never mind that by doing so, people who are hyper-responsive to the presence of food and to food cues (the stuff that actually triggers urges to eat) never get a break.

    No, according to RD’s, none of that matters… not the fact that obese people have perturbations in neural reward circuitry, not the fact that food addiction is a real phenomenon with distinct physiological mechanisms, not the fact that our brains are wired to eat food when it’s there (some people are acutely more sensitive to this than others), and because of the fact that food is everywhere, people eat it. Nope, no consideration of any of that.

    I was obese since early childhood and saw many a dietitian… None of their advice was helpful because it didn’t address the cause of my overeating. It wasn’t until graduate school, where I began doing research on the effect of conditioned stimuli in the environment, and on the neurophysiological effects of hyperpalatable food, that I understood what the problem actually was.

    I’ve since lost 150 pounds, no thanks to my dietitians. I eat two meals a day, no snacks, and feel fewer compulsive urges to eat as a result. Because I come into contact with food less often, my appetite is triggered less often. It feels like a miracle.

  • Suzanne

    @ Stuart Katsh, MS, RD – I can thank an RD for believing the big Academy of Nutrition and Dietetics sanctioned lie that I can eat a high carbohydrate diet (100 plus grams per day) and maintain my blood glucose at levels conducive to managing my Type II Diabetes.

    It isn’t possible, and the professional organization advocating and credentialing you is sponsored by grain-based agribusiness and the pharmaceutical industry. This affiliation does not invoke trust.

    I had to by trial and error, research, and networking, learn to treat myself through nutrition.

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  • Elaine Boston

    Another perspective of the obesity problem the consideration that food can be an addictive substance for people. An artictle here, http://www.alternet.org/health/155549/addiction_and_america, discusses the addiction perspective that the HBO series did not address.

  • Maureen

    Watching this series has reminded me of something that has bothered me for years: why does the government control the farming industry through subsidies and then distribute all of that excess production to the nutrition programs around the nation, including schools and nursing homes? I was a food service director of a large nursing home for several years and was required to participate in the excess subsidies program. NOTHING that was provided to our facility was fresh; nearly everything we received was fatty or loaded with carbs. It is food designed to quickly provide calories and fat to undernourished people. Peanut butter, cheese, white flour, salmon, canned apricots, beef, etc…. that’s what we received. Great stuff, but hardly what a well balanced diet is comprised of.

    What if…what if…what if – the government got out of the subsidizing of these products and instead focused on underwriting the fresh, local farms of our communities? What if BIG companies were excluded from the subsidy program and only small, family owned local farms could participate?

    I know that the school lunch programs in my state all depend on the federal subsidy program for a large portion of their food supply. This is where the heart of the failure lies. We have to change it all.

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  • http://www.nutritional-supplements-health-guide.com Oktay

    Quality of what we eat shapes our health, and it looks like the quality will not get any better as long as the world food system is controlled by these corporates.