Is food addiction the ever-elusive single cause of the obesity epidemic?  As a slightly pedantic sceptic, I must admit to finding this term somewhat illogical.

The official definition of addiction is: a persistent, compulsive dependence on a behaviour or substance.  To some degree aren’t we all persistently, compulsively dependent on food?  After all, unlike nicotine, gambling, alcohol and narcotics, we cannot live without it.  Preferably we need it at least three times a day, every day, for our whole lives.  Yet only a third of the population are supposedly at risk of having “food addiction”.   If broccoli was your preference, would that be labelled an addiction?

Don’t get me wrong – I’m not trying to belittle the justifiably valid concerns of those who feel completely out of control around food, and who legitimately see this as a reason for their own weight problems – I just don’t see these people being in the majority.  I was intrigued when I recently saw a notice on a bus advertising an Overeaters Anonymous meeting.  Perhaps this is something we will see more of, and hopefully, as with AA, it will be a very helpful framework for individuals in order to work though common issues towards recovery.

But does this loss of control around food (or more correctly, specific types of food) occur in isolation?  I’m no psychiatrist, but it would seem to me that underlying reasons for this type of behaviour would be multifactorial and complex.  Overeating is therefore a symptom, which sadly results in symptoms of its own, exacerbating a cycle of health problems.

I don’t think the complete loss of control around food, with a continuous drive to eat more and more around the clock is solely responsible for the obesity epidemic we face.  Most of us eat a little too much on a regular basis and are too inactive to balance
this intake of calories.  Over time this leads to a gradual increase in the waistline, until we are in a situation where more people are overweight than are normal weight within the population, and nearly the same proportion are obese.

If it helps people to examine what they’re eating and how active their lifestyle is to label themselves as a “food addict”, then so be it.  The only outcome I’m interested in is people getting healthier.  This involves solutions that enable all of us to take more ownership of our health and make wiser choices about what foods and drinks we choose to buy and consume, in what amounts, and how much we sit being inactive.  What do you think?

But the real kicker is what’s happened to our waistlines, despite all this apparent healthy change.  There’s no doubt about it – we’re all getting fatter.  Sadly, as is often the case, this trend disproportionately affects certain groups in the population, with obesity rates amongst Maori and Pacific peoples in particular, starting to scale to dizzying proportions.

While everyone agrees the reasons are multifaceted, a number of experts have provided commentary in the past week as to why this dichotomy is being seen, including (and I’m paraphrasing for the sake of brevity):

1. “It’s because people under-report what they eat in surveys” (Rod Jackson)

Yes, this has been documented in the literature, but in comparing like methodology with like methodology are we really likely to be recording our food intake any less accurately now than we were in 1997?  Even with an interviewer in our homes and going through our cupboards?  I’m not sure this is the only explanation.

2. It’s partly because we’re less active than ever before and the survey did not assess activity levels.

Certainly the basic energy in: energy out equation loop isn’t completed without an assessment of physical activity levels.  There is no question that sedentary behaviour is the elephant in the room with respect to obesity.  No matter how much we idolise our sporting heroes as a nation, the majority of us are more likely to sit on our backsides for most of the day.  Every day.  But, are we likely to be even more sedentary now than we were in 1997?  The 2006/07 NZ Health Survey found no change in regular physical activity between 2002/03 and 2006/07.  However, according to Professor Grant Schofield, our levels of sedentary behaviour are likely to be on the increase, with more hours of TV viewing, more sedentary jobs and greater car ownership/distance travelled by car in the last 15 years.  I don’t think we’ve heard the last on just how dangerous sitting can be for our health.

3. “It’s because our environment is too jammed with easily available high fat, salt and sugar foods” Robyn Toomath.

This is where we start to go around in circles, because the dietary intake data on the whole indicate we’re actually eating less fat and sugar.  In fact the only source of sugar which is growing in our diets seems to be fruit.  And in our fear of fat we seem to be switching to low fat dairy at the expense of retinol intakes and cutting out red meat to the expense of our zinc and iron intakes.  So are we reporting our intakes correctly? (… and the circular nature of this dicussion goes on).

I would love to know what you make of all of this.  It would be great to get a discussion going.  Just insert a comment below (if there are no comments yet you need to click on the no comments box in order to make one).

I do believe after many years of courtship and conflict, the various groups of stakeholders in the ever-expanding waistlines of New Zealanders are finally approaching engagement.  There’s not a lot of tangible evidence of productive engagement yet, but the scene is set.

[The cynic in me is bearing in mind that using the above definition, engagement can mean both betrothal and battle...]

Last week I attended the popular Edgar Centre for Diabetes Research and Prior Policy Centre’s Who Cares About New Zealand’s Waistline? seminar held in Wellington.

Much of the discussion was not new – but the format was.

As Professor Jim Mann explains here, the event was designed to portray evidence and practice from several of the key “actor groups” previously identified by the United Nations as influencing the health of populations.  The “actor groups” chosen to contribute at this event were Food Industry, Government, Civil Society Organisations, Schools & Families, Media and Workplace.

Researchers were asked to present the case for evidence-based action in each sector and each sector was asked to respond with what has been and what could be done in New Zealand.

I was particularly struck by the lack of hard evidence for any one intervention within each “actor group” having a major impact on obesity rates (with the exception of better town and transport planning).  Although every group demonstrated tangible evidence that they’re doing their bit – some better than others – within each area.  And no-one can deny that the combined effect of many coordinated interventions involving many different actor groups would likely be substantial, if any such research project existed to provide the hard evidence.  Presently it’s an ambitious dream, but monitoring action and research in this way on an annual basis will hopefully show progress.

Tariana Turia impressed us all with her personal and compassionate concern for the issues.  You can read her speech here.

Professor Grant Schofield from AUT was bold enough to admit that people don’t want to hear public health messages.  He suggested we need to re-frame the problem/issues into solutions/benefits/outcomes our audiences can relate to.  This was also backed up by sentiments expressed in the media session by Lorelei Mason and Jim Tully about what consumers want.

Re-framing the issue is something done particularly well by the private sector.  Engaging in marketing and business tactics used successfully by the private sector are exactly what could make the difference to public sector campaigns.  In a recent inspirational TED presentation by Melinda Gates, she stated (of the need for aspirational marketing in health) “…<health agencies> assume when people need something we don’t have to make them want it”. It’s very true.

Which brings me back to the need for real engagement between all actor groups to engage New Zealanders in the issues.  The main point I took from the research outcomes presented was that working away diligently in silos is not likely to trim our waistlines one iota.

Well done to Professor Jim Mann and his team – who did a lot of the legwork to pull together the programme.  It was a refreshing approach.

It got me thinking that scepticism vs denialism is another way of describing a theme often addressed in this blog.  I consider myself a sceptic – meaning that I take an objective approach to the evaluation of claims – but I also find that a bit of commonsense goes a long way.  Deniers, on the other hand, have a position (or end goal) staked out in advance, and sort through the data employing “confirmation bias”.  This is defined by New Scientist as “the tendency to look for and find confirmatory evidence for pre-existing beliefs and ignore or dismiss the rest”.  Whether sceptics agree or disagree, we can debate the issues like grown ups.  Dealing with denialism feels more like trying to rationalise with a toddler having a tantrum.

It’s easy to think of denialism as an old fashioned notion, driven by zealots such as anti-evolutionary theorists or those who believed the Earth was flat.  But no – denialism is alive and well in our modern world.  We’ve all heard of climate change and vaccination deniers.  New Scientist provides useful perspectives on these examples, as well as deniers of the ill health effects of tobacco, the existence of AIDs and those who believe pandemics such as swine ‘flu are developed and released by pharmaceutical companies.  I can add more examples to this list based on personal experience in the food and health area.  Those who are convinced that:

• obesity is caused by single foods or beverages (and that this is a conspiracy of global food companies).
• anti-tobacco tactics directed to certain foods are the best option to combat obesity.
• specific approved food additives or ingredients cause illnesses ranging from autism to cancer (and that this is a conspiracy of both food companies and food safety organisations).
• there are no adverse health effects of high salt diets at a population level.
• it’s acceptable to deliberately design research studies to prove a point or handpick research results to suits their means, rather than taking a more objective view.

Your typical denier often has the public’s sympathy because they’re the “underdogs, fighting the corrupt elite”.  They often occupy the moral high ground for this reason.   And the media love the extreme viewpoint they offer so they have a natural public stage.  Regulators, businesses and governmental organisations do not have the luxury of being able to handpick evidence to suit.  They have to be objective, so they often come off looking non-committal, or at worst, defensive, when facing denialists in public.

In my digging around for material on this subject I also found this delightful quote by Richard Asher, published in The Lancet in 1959.

“It is important to realise that ideas are much easier to believe if they are comforting and that many clinical notions are accepted because they are comforting rather than because there is any evidence to support them. Just as we swallow food because we like it, not because of its nutritional content, so do we swallow ideas because we like them and not because of their rational content.”

I believe this rings especially true today and I’d love to hear some more examples of denialism that you’ve come across.

A recent evaluation of the zoning strategy employed by authorities in Los Angeles, banning new fast food establishments in order to address the excessive obesity problem in South Los Angeles, indicates that strategies like this are unlikely to achieve their goals.  The main reasons for this failure are outlined at the end of this posting.

There is an assumption both in the US and NZ that so-called “toxic food environments” exist, in which poor and minority neighbourhoods are overrun with fast-food chains, causing higher obesity rates.

While the majority of fast food may not be nutrient dense, it is conceivably less obesogenic than food eaten at full-service, sit-down restaurants in the US.  This is because it is less calorie-dense, due to greater portion control and a shorter “food exposure time”.  In American sit-down restaurants the serving sizes were found to be 2-4 times greater than recommended, and in this environment people are more likely to also order dessert and be topped up with free sugary drinks throughout their stay.

There are some big differences between the US and NZ.  Most obviously, our much maligned intake of soft drinks does not come anywhere near the gallons consumed per capita in the US – especially by teenagers and young adults.

I propose that the great kiwi institution of fish and chips – still the country’s most eaten takeaway, is probably more obesogenic than many fast food chains.  A piece of battered fish and standard scoop of chips from one of these places is enough to feed my whole family – for several days sometimes!

But most importantly, as the L.A. study illustrates, we just have too much food around us all the time.  Establishments providing meals are only one small part of a food environment where it’s possible to indulge our taste buds ceaselessly if we so desire.  In my opinion it’s this constant nibbling (or scoffing) that’s by far the biggest problem – even more so than what’s being eaten.

Findings of the L.A. zoning evaluation study:

1.    Upon analysis there were actually fewer fast food outlets in South LA per capita than in other parts of L.A.
2.    There was a much higher density of small grocery stores (I guess similar to our dairies) in South L.A. compared to other parts of L.A., and a lower density of large supermarkets.
3.    Discretionary calorie intake, higher in South L.A. than other parts of L.A., was mainly from foods and beverages widely sold in non-food establishments as well (eg, vending machines, car washes, bookstores, laundromats, offices, etc).
4.    The proportion of the population having the recommended number of fruit and vegetable servings per day, or getting the recommended amount of exercise was no different in South L.A. compared with other parts of L.A.
5.    People in South L.A. were more likely to walk or take public transport to do food shopping, while this is unreported in other parts of L.A.

Politics might be about people, but at the end of the day it is the fiscal health of our country and the impact an issue has on that health that is guaranteed to exercise the conscience and therefore policy direction of our government.

Obesity is the perfect example of this.  One of, if not the main reason obesity has become a major political issue during the past decade is the cost to New Zealand now and in the future.  But in identifying this problem what have we tangibly done to address it?

For almost a decade we have seen an enormous amount of time used in consulting, planning, lobbying and networking, in order to decide how we can help people overcome all of these issues that apparently are absolutely no fault of their own. Note the “how we can help”.

But are we really any further forward?  Do we have a decisive road map on how, in the medium and long-term, we can address these issues, or the very least the confidence in our convictions that we are making some in-roads?  Certainly there has been some progress but often these are specific and isolated outcomes.  I also know that the food industry (I freely admit my own involvement within the food industry) has done a huge amount to “assist”.

It now seems that our new Minister of Health is calling for greater focus on putting the money directly into fixing the problem and the word is that we want actions and outcomes not plans and pontification.  But what will this mean in the area of obesity?  Fat camps or social welfare benefits for people who are the right weight only?

If we look at our US counterparts who are also taking a fresh and very serious look at these matters there could be some lessons to be learnt.  A recent address by President Obama, to the annual American Medical Association conference highlights the key strategies needed to “fix” the US health system and if we listen carefully the situation really is dire.

Most interestingly President Obama specifically identifies greater investment in preventive care “so that we can avoid illness and disease in the first place” as the second most important focus for his administration in order to get the health system back on track.

It only comes second because the first area to tackle is that of a more efficient and integrated record keeping system. It seems that in America there is far greater success tracking a Fedex parcel than a person’s medical records.  It also results in significant cost blowouts right across the system.

The most refreshing aspect of his focus on preventive care is that it directly links to personal responsibility – listen to his words.

“That starts with each of us taking more responsibility for our health and the health of our children. It means quitting smoking, going in for that mammogram or colon cancer screening. It means going for a run or hitting the gym, and raising our children to step away from the video games and spend more time playing outside.

“It also means cutting down on all the junk food that is fueling an epidemic of obesity, putting far too many Americans, young and old, at greater risk of costly, chronic conditions. That’s a lesson Michelle and I have tried to instill in our daughters with the White House vegetable garden that Michelle planted. And that’s a lesson that we should work with local school districts to incorporate into their school lunch programs.”

President Obama predicts that within a decade one of every five dollars earned will go towards health care.  In thirty years (when our own children will be working) one in three dollars will be spent on health care.  The future cost of health could potentially be the undoing of a modern society’s financial stability.

What I found particularly interesting was the fact that the US health system costs US$2 trillion every year and they apparently spend 50% more per person than the next most costly nation.  Despite that over 100,000 people a year die from medical misadventure.

So it is up to us as individuals to take responsibility for their health and the future health of their own children. To me it is a flash of the blinding obvious.

So to the question posed in the title.  Whose responsibility is it anyway?  Surely it is everyone’s?  So let’s park the blame game and get on with doing our bit.  But let’s do it for ourselves first!

While Tony Ryall argues that work in the areas dropped from the previous health targets is still important, I can only assume it’s not quite important enough to be a targeted priority.

The way we eat affects our health as a nation enormously – and in more ways than just our physical health.  I don’t think anyone would disagree with that.  What seems to be up for debate is where the responsibility lies for what and how people eat.

When Tony Ryall says that DHBs should not be held accountable for ensuring people eat their fruits and veggies, I tend to agree with him.  When public health experts say that people need a supportive environment to make healthy choices, I also agree with them.  Surely as a community we all need to play a part in creating a supportive environment, including the DHBs.  While the teams of experts within DHBs are doing a great job, they can’t achieve this on their own.

Most major food manufacturers and marketers are voluntarily taking significant steps to improve the nutritional compositition of their products and are playing their part in recommending responsible dietary consumption.  Having said that, some food manufacturers and retailers could definitely focus more on improving the nutritional content of their offerings.  For example, my local café serves very indulgent meals to its regular customers and it’s hard to find a menu item that doesn’t provide more fat/salt and/or sugar than what is desirable on a regular basis.

But people vote with their stomach when it comes to food choice, and those prioritising their physical health over everything else are sadly few and far between.  Making fruit and vegetables available, tasty, accessible, desirable, easy to prepare and affordable is the real task at hand, and no one should expect DHBs alone to be held accountable for this – just because they have to pick up the bill for obesity.  We all need to be accountable, but the Minister’s announcement may not help to underscore the importance of this.