by Marion Nestle
May 21 2009

Strong opinions about obesity

Investigators at the Harvard School of Public Health estimated the toll of behavioral contributors to early mortality.  Obesity, they say, is the #3 cause of death after cigarette smoking and high blood pressure.

Dutch researchers say smoking is what kills people.  Obesity just leads to disability.

The Robert Wood Johnson Foundation says schools could do something to help prevent obesity if they got their act together.  It provides a guide to doing so.

Adam Drewnowski, my colleague and friend at the University of Washington, says: if you want to understand obesity, take a look at what poverty makes people eat.

And Jeffrey Friedman, an obesity researcher at Rockfeller University tells Nature that obesity is neither an epidemic nor a disease of lifestyle.  It’s all in the genes and in evolution.

I say (see What to Eat): eat less, move more, eat plenty of fruits and vegetables, and don’t eat too much junk food!

  • Jessica

    Amen! I love your “food sense”, Marion!

  • Marion

    Dr. David Katz sends this comment about Friedman’s view that obesity is not an epidemic:

    “I am tempted to say more, but can’t suppress two comments:

    1) as the co-author of 3 editions of an epidemiology textbook, yes, obesity is epidemic. The fundamental definition of an epidemic has nothing to do with person-to-person transmission, nor with any absolute level of disease; rather, it is the occurrence of any condition at either unprecedented, or unexpected levels.

    2) the notion that since ‘only half’ of individuals with access to an egregious excess of calories are overweight, obesity is not fundamentally environmentally driven is almost shockingly naive. There are two fallacies in the statement.
    The first is that before everyone becomes obese, some people will. Applying the logic here to the sinking of the Titanic, one would have inferred at the midway point in the disaster when only half the passengers were wet, that the problem resided in that half of the passengers, rather than the ship. The obvious issue was that some would get wet sooner, some later, but all would ultimately be vulnerable to a dunking because of the fate of the ship. The second fallacy let’s call the ‘snap shot’ fallacy, the notion that statistics at one point in time are a meaningful indication of trends. In fact, Shiriki Kumanykia recently told us that we are, indeed, headed toward universal adult obesity (Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic. Obesity. 2008 Oct;16:2323-30). I would hope we could agree on efforts to fix environmental factors before, rather than after, universal obesity renders the issue of genetic variability entirely moot.

    We’re all in the same boat, just different parts of it. And it is, indeed, and alas, sinking!”

    –David L. Katz, MD, MPH, FACPM, FACP, Director, Prevention Research Center, Yale University School of Medicine

  • It’s funny how science makes something obvious to complicated. I agree with your sentiment about eating less and moving more. The question is WHY so many Americans find it impossible to follow this advice.

  • The question of why it seems so impossible to so many to “eat less and move more” doesn’t strike me as such a mystery. The 9 to 5 work life takes up an enormous portion of the day, is largely sedentary, and is most often located much too far from the residence to make walking or even biking to work an option. Food advertising bombards us all day every day from every possible source to eat more and eat poorly, and many live in neighborhoods that don’t provide very many healthy food options.

    The way we socialize also discourages the “eat less, move more” mindset – getting together with friends, we’re likely to go out to dinner (at a restaurant that will undoubtedly serve us each a doublesized portion), and then possibly continue on for drinks. So while it’s a perfectly logical approach – the best and probably only effective approach, really – it ends up being contrary to the way we’ve structured our lives, and it’s certainly the exact opposite of the way corporations would like us to behave.

  • The Adam Drewnowski link doesn’t work. Can you provide the title to the writeup or another link?

  • AD

    Gary Taubes and others have shown that there’s a lot more to obesity than “eating less” and “moving more.” In short, the science is ambiguous but higher carbohydrate consumption appears to be the primary cause of obesity even if groups like the AHA, and ADA are reluctant to concede as much.
    Also: it is politically popular, especially on the left, to encourage everyone to eat little to no meat for environmental and “health” reasons (even though there is good reason to believe that vegetarian diets are suboptimal for humans). But what if eating non-negligible quantities of meat and cutting down on cheap-to-produce grains (even whole ones) is a healthy way to eat, would people and organizations, especially on the left, accept such findings?

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  • Marta Capasso

    I think part of the issue with obesity that is often missed that stands outside the oversized portions and lack of nutrional value in “cheap eats” is the psychology behind obesity. Yes 8-6 sedantary work schedules make it hard to fit in moving, but perhaps is also the impact of working longer hours that is making people emotionally burdened and resulting in higher food consumption. I often find people disregard the importance of psychology and overconsumption. Maybe we need to partially focus on happiness to curb the obesity epidemic and in conjunction with the temptation of junk food that is marketed to us on a daily basis.

  • I love what Brian Wansink says about obesity and junk food in “Mindless Eating”. I agree that if we all ate even a little more mindfully, we wouldn’t be as apt to plow through an entire bag of chips. Also, if we quit eating to satisfy ourselves emotionally and instead just ate for health and survival, we would be better off. This obviously points towards education, education, education!

  • One of the things that I’d like to see discussed more is whether obesity is a cause or a symptom. I.e., is the health issue carrying excess weight? Or is the real culprit a diet full of processed food high in refined carbs and less healthy fats?

    I’m sure the former isn’t benign (I’ve read that excess fat is not inert tissue, particularly wrt endocrine function), but with the latest focus on inflammation and CRP, it would seem far more useful to make diet the focus and not necessarily one’s BMI.

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  • Anthro

    AD – You give no citations to back up your dubious views.

    Thank you Dr. Katz for the rebuttal; I too, was taken aback by the statement on epidemic, but have often found myself wondering why a lot of people remain slim and even skinny in the midst of this epidemic. I don’t find your explanation fully satisfying–we may all get fat eventually, but would this be because the genes of the fatter people will prevail or because the socioeconomic factors that contribute to obesity will continue to affect eating habits?

    I agree with comments that lifestyle has much to do with obesity; people eat away from home much more than 30 years ago and they simply do not realize how many more calories they get in commercially prepared food. It’s hard to find salad without meat anymore and at salad bars you see people drowning their lettuce in dressings that are pure fat. People don’t realize how MUCH they have to “move” in order to burn off even 300 calories. I don’t think most people even know how many calories they usually consume. But this brings me back to the main point: Why do many people remain thin amidst all this? It has to have something to do with the basic mechanism of “feeding” as Freidman calls it; some people get full very quickly and others don’t it would seem. So does Dr. Katz think their is ANY validity to Freidman’s work. I noticed when reading the article that he has financial ties to pharma, but he does disclose them at any rate.

  • AD

    Anthro–On vegetarianism: there are few if any traditional diets that are vegetarian, and almost all peoples throughout history have gone to great lengths to acquire certain animal foods–seafoods, or particular animal organs. This is probably because the vitamins D3, K2-MK4, and forms of Vitamin A (the non-beta carotene form), among other nutrients, come almost exclusively from animal products and are very difficult to get from plant sources. I think it’s *possible* to be a vegetarian, but it’s not easy and it’s definitely not as “natural” as some people make it out to be (vegetable oils, flax seed oil and tofu, for instance, are highly processed foods–and the vegetable oils, in particular, are often rancid omega-6 bombs).
    One recent study concluded that contrary to popular belief, not only does red meat consumption elevate the risk of colectoral cancer, those who adhered to vegan and vegetarian diets:””Compared to those eating meat, vegetarians and vegans turned out to have an increased risk of colorectal (cancer in the colon or rectum). Risk in these people was 39 per cent higher than in meat eaters. They also compared risk of colorectal cancer in individuals classed as vegetarian (vegetarian and vegans) with non-vegetarians (eaters of meat and/or fish). Here, vegetarians had a 49 per cent increased risk of colorectal cancer.”
    And here’s a study showing that vegetarians have much higher concentrations of advanced glycation end products, which as you know, are very bad for one’s health long term:
    Finally, I was a vegetarian for a number of years and it made me less healthy. I am sympathetic to the ethical and environmental concerns of vegetarians and vegans, but I believe that humans adapted to require certain foods, including those from animals, regardless of what our consciences say.

    As for the obesity and carbohydrate link, Taubes’s book is really the place to start, part three in particular. The book is fair and thorough and scientific (it is not a diet book). I found it quite persuasive, but the argument is long and detailed, so I’m not going to repeat it here.

  • AD

    Sorry about that mess of a second paragraph.
    What I meant to write was: One recent study concluded that contrary to popular belief, red meat consumption does not elevate the risk of colectoral cancer, especially compared to vegan and vegetarian dieters: “Compared to those eating meat, vegetarians and vegans turned out to have an increased risk of colorectal (cancer in the colon or rectum). Risk in these people was 39 per cent higher than in meat eaters. They also compared risk of colorectal cancer in individuals classed as vegetarian (vegetarian and vegans) with non-vegetarians (eaters of meat and/or fish). Here, vegetarians had a 49 per cent increased risk of colorectal cancer.”

  • Every time I hear this argument about “eat less, move more, eat plenty of fruits and vegetables, and don’t eat too much junk food!” I am reminded of suggestions to me when I was in elementary school struggling with academic competency. “Just try harder, you have lots of potential. You just really aren’t doing “enough.” Try harder and you will do better was always the message. It was at least 10 years after I was tested, before learning disabilities would became an accepted explanation for some of my learning struggles.

    These days I believe there are similar “unknown and unseen” explanations for obesity and other health issues. I have had a diagnosis of Celiac Disease since I was an infant (1946). Now, according to current diagnostic tools I no longer “test positive.”…so what does that really mean?

    Along with having lost my confidence in allopathic medicine to having sufficient solutions to current health problems, I also believe there are no magic bullets and that the obesity epidemic discussion/issue is related to many things seen and unseen, known and unknown.

    Like child sexual abuse, obesity is not an economic experience. Sadly, both issues cross all economic, social and political lines. We now know much more about who is at risk of sexual victimization. Hopefully, we will learn/discover what are a more comprehensive set of risk factors for obesity.

  • I do not believe the notion that carbs are making us fat. My husband who has battled his weight his entire life just started letting go of sugar and eating better. All the things you hear the health professionals tell you.

    We eat no frozen food (other than some frozen veggies), no processes foods (and if so it is miniscule) my husband gave up red meat and pork, my daughter and I are vegetarians on our way to being vegans. But get this…we live on carbs.

    What people freak out about is the processed carbs they are trying to avoid. You have to remember, I make my own bread, from my own wheat, we eat brown rice and plenty of potatoes. Recently my husband got to visit with some of his family who had the bypass stomach surgery. This person has recently put back on 25 pounds. While my husband has taken off that same amount.

    This family member asked how he did it and he told him that he had let go of sugar, and eats wherever he wants, minus the packaged, processed foods, and no fast food. The family member said, “I can’t do that…and you really eat carbs?” First off, it’s not that he can’t give it up, it’s that he doesn’t want to…big difference. And why does it amaze folks that we eat so many carbs in our house and we are all still thin. It’s the type of carbs you eat, not carbs themselves.

  • Jon

    Um, sugar is a carb? LOL Seriously, I’ve found the exact opposite situation, that when I ditch some carbs, I lose weight, because despite what vegans say, carbs do have calories. Fats have more calories, but people eat a lot more carbs than fats, and dumping fats for carbs requires you drop one gram of fat for every ≤2 grams of carbs you add, which requires more math than simply restricting calories in general.

    You can see this at any fast food restaurant. You get a large french fries and a 42-ounce soda with infinite free refills with any combo.

    Also, even the most balanced vegan diet depends on B12 pills.

  • Anthro

    AD –

    I really don’t know what you are looking for at this science-based site? Your references, beginning with Dr. Briffa, are not mainstream, peer-reviewed, or even well-documented. Briffa seems to be a supplement-pushing “media” doctor whose advice I would take with a large dose of skepticism.

    No matter how you slice it, the ONLY cause of obesity is MORE CALORIES IN THAN OUT. The amounts of protein, carbs and so on that the body needs are well established scientifically. It doesn’t matter whether the protein comes from flesh or beans or milk or eggs.

    I am an anthropologist and I can assure you that the idea that pleistocene people (which is what we are, as well) ate a lot of meat is false. Our species (or a closely related proto-species) most likely began consuming flesh by scavenging bits of it from other animals. Even when we got to hunting it ourselves, it was not a significant part of our diet which consisted mostly of nuts, berries and other plants collected mostly by the women. It is true that meat may be responsible for a growth spurt in the development of the brain, but again–that doesn’t mean we were eating huge quantities of flesh. We are omnivores, but that term doesn’t specify what the ratio of meat to non-meat foods should be. By the way, anthropologists often use the term gatherer-hunter rather than the usual hunter-gatherer to make clear that the emphasis was on collection of plant foods

    Anyone can choose to be vegetarian and for a lacto-ovo, there should be no problem at all getting sufficient protein. Vegans CAN get adequate nutrition, but will need B-12 supplementation (the ones I know break down and eat a bit of cheese now and then and do just fine). Eat flesh if you like, and enjoy, but stop with the pseudo-scientific references when you are addressing a scientifically literate audience.

  • AD

    Anthro–In the event that you missed the citations on the Dr. Briffa article, they are:

  • Alicia

    I find it very hard to react to the ‘problem’ of obesity in an objective way. While it may be difficult to argue that extra weight and, most especially, a diet of processed foods correlate with poor health in general and a variety of specific conditions, I am always prone to rush to the defense of any researcher trying to prove that obesity is not the problem we believe.
    In all honesty, this is less because I think that their research comes closer to the truth than that of the many spreading the gospel of thin – than because I am deeply dismayed by the tone of most of the voices which sing their hymns. More often than not, someone makes mention of watching those around them, specifically those around them who are overweight, eat. They mention gobs of salad dressing, enormous platters of cheese-spangled pasta, kegs of soda, and the revolting image of the swollen bellies consuming them. Their disgust is so clear, and so creul, that my sympathies rush to anyone who will argue with them.
    Fat people are not gluttonous slobs stuffing their faces at all hours. They are not ignorant, thoughtless consumers (since when is it ‘normal’ to know the calorie count of everything you eat, anyway? Isn’t the latest trend to ‘eat like great grandma’ who certainly never counted points?). They are not morally weak. They are not your inferiors.
    They are just fat.
    Much, much too often, health is used as a blind to hide haughty esthetic judgments. Until obesity is viewed with the moral neutrality of, say, polio, it will be difficult for health and nutrition professionals to make real headway in treating it.
    You simply cannot tell by looking at someone if they eat their veggies and exercise. I know many large people who do. I can feel minds saying “yes, but they eat too much and don’t exercise enough”. Again, you don’t know anything about these people, other than their weight.
    Diet and excerise may work, in the strict sense, but since only a tiny fraction of people are able to committ to these programs for life, we must begin to hunt for other solutions. After all, if everyone on the Titanic is getting wet, the problem is clearly the Titanic and not the passengers. Being too stubborn in the belief that all fat people need to do is eat less and move more blinds us to finding a real, viable solution to a problem which is affecting a large percentage of the population – and not just the stupid, lazy, gluttonous percentage.

  • AD

    (Apologies for my sloppy commenting and that accidental 3:21 comment.)

    First, “mainstream” is not necessarily the same as correct. The relevant question is: does the evidence stand up to scrutiny?

    The citations for that article are here:
    1. Truswell AS. Meat consumption and cancer of the large bowel. Eur J Clin Nut 2002;(suppl 1):S19-S24
    2. Key TJ, et al. Cancer incidence in vegetarians: results from the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford). 2009;89(suppl):1S-7S
    3. Alexander DD, et al. Meta-analysis of animal fat or animal protein and colorectal cancer. Am J Clin Nutr 2009;89:1-8

    Draw your own conclusions.

    I think the question of protein sources for vegetarians is probably misguided, and that they should be more concerned with the quality and sources of fat and fat-soluble vitamins. You mention vitamin B12, but what about K2-MK4, vitamin A, or DHA and EPA or D3? I’m not anti-vegetarian, but it’s probably a sub-optimal way for humans to eat. I am highly skeptical of veganism, but enough people are willing to experiment with their own bodies that we will soon enough understand the long-term consequences.

    I’m also not advocating a high-meat diet. But I do think some meats are very good for people, and that there is a politically motivated anti-meat bias that is not firmly rooted in science or tradition.

    Secondly, the calories in calories out as the cause of obesity hypothesis just isn’t particularly well-supported by the research. If you are aware of *experiments* that robustly defend, by proving causality, your supposedly iron-clad hypothesis, please post it in the comments.

    Taubes goes into great detail explaining how insulin prevents the body from using body fat as fuel, and how carbohydrate consumption elevates insulin levels. High levels of carbohydrate consumption means constantly elevated insulin levels, which means the body is more often storing more fat rather than mobilizing it. Eating fat and protein, by contrast, elevate insulin minimally thus allowing the body to mobilize body fat for usage as fuel. As he notes in the epilogue, “Consuming excess calories dos not *cause* us to grow fatter, any more than it causes a child to grow taller.” That is, we need to consider the regulatory function of hormones, and the way in which hormones respond differently to different types of calories to properly understand the causes of obesity.

    To state my biases: If I were to recommend a diet it would include some combination of: meat (especially seafood, and organ meats, and avoiding factory farmed corn- or soy-fed animals), vegetables, fruits, nuts, and some dairy.
    It would limit: most processed foods, legumes, grains, and sugar (including those silly “healthy” alternatives like agave or cane sugar).

    My primary influences: paleo-anthropology, human culture, Gary Taubes, Weston A. Price, Michael Pollan, and Alice Waters.

  • AD

    I agree with Alicia that the moral condemnation of the obese is misguided and a little cruel, though I do think obesity is something that people should avoid for reasons of health and, yes, even aesthetics (it is simply not fun to be fat, nor does anyone like to look or feel fat, nor are many attracted to those who are fat). We shouldn’t mock those who struggle with obesity, but we also shouldn’t stand by idly accepting that it is just the way they are.

    There is some evidence that the obese eat more because they are literally starving. A non-obese person with normal insulin levels can access fat stores for energy between meals. An obese person, by contrast, suffers from permanently elevated insulin levels that prevent them from drawing on fat stores for energy, and driving them to crave glucose as a source of energy, which causes them to store more fat, and further elevate their insulin levels.

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  • Razwell

    Obesity is a serious, chronic medical condition of fat cell dysregulation. Gary Taubes’ greatest contribution towards understanding obesity is his overwhelmingly strong case against the classic caloric model of obesity.

    The conventional caloric model of obesity cannot explain:

    *WHY we have a worldwide epidemic of obese 6 month olds

    *WHY we have extreme poverty and malnutrition going hand in hand with obesity

    The classic caloric model of obesity is a theory born of logic alone, and completely ignores the data.

  • I think Obesity is a society-mediated “eating disorder/food addiction” fueled & enabled by it’s “pimps” the 1.Mass Marketing of Agribusinesses AND 2.Political Parties who receive funding for their campaigns & lobbying money from #1.

    In the 1950’s through 60’s…for instance..did you see the kind of “obsession” with food tat you see today?
    Did you see the “varieties” of junk foods on the shelves in such an expanded array?…
    Did you see such a massive “money making machine” in this country around soda and chips?…really now? come on…in the 1960’s?? we would have laughed about it!There were not that many choices!We would have had one bag in the house, no one would have thought twice about it…and there were no OBESE EPIDEMICS THEN. think about it folks…we were NOT OBSESSED ABOUT FOOD in the 60’s I was there, I KNOW!!

  • Amanda

    I believe obesity is caused partly by a dieting mentality among other lifestyle factors (such as urban sprawl and sitting at a computer all day for work). Sure, this may sound contradictory, but realisitically Americans are more food obsessed than ever! Thanks to pressure from the social media in addition to glorifying the dieting way, Americans have gained weight since they are no longer in tune to the signals their body gives them. I think it may be helpful to encourage people to STOP dieting, and actually pursue physical activity they love and the foods that make them feel great! Maybe if more attention was given to this sentiment (and education on how to reach this sentiment), we may actually reverse this epidemic. However, if health professionals, educators, and media personnel continue to encourage dieting and encourage reaching a designated number on the scale, then I am afraid our culture is pretty much doomed.