As the years have progressed and research findings amassed,
it has become obvious to most people – experts and non-experts – that obesity
is not caused by one thing. However, certain factors seem to have a greater
impact on whether or not a person consumes more calories than they need or burn
than others. For example, genetics have less of an impact than lack of physical
activity. And a combination of risk factors intensifies the impact of any one.
For example, a genetic risk, not exercising (or being sedentary), being female
and using antidepressants is a perfect storm for gaining weight.
The risk factor that my research and my public health
efforts focus on is the environment – the food environment, which I define as
anywhere we make a decision about what to eat immediately or what to buy to
cook or eat at home. Within this huge
food decision space, individual level factors (knowledge, stress, social and
family norms, income) interact to make it harder for some to ‘resist’ what is
sometimes called a toxic or obesogenic (obesity causing) environment.
To advance my goals – reducing caloric excess in the
population - I support policy that aims to change the environment. Policy that
changes the space where we make so many food (and beverage) decisions. I have
spoken a lot about information policy, but that doesn’t directly change the
environment (indirectly it could lead restaurants to supply lower calorie meals
through a change in recipes or serving sizes). Strategies/laws that directly
change the environment would include the failed NYC serving cap on sodas. Other strategies, softer ones some will say,
fall into the category of ‘choice architecture.’ In other words, someone (and
this someone can be a contentious issue) decides that in order to help a person
choose the healthier (? – definition pending) option, this healthier option needs
to be easier to access or displayed more attractively than the non-healthy one.
For example, instead of the huge display of 50 cent white bread at the front of
the store, the owner places a display of whole wheat bread. Strategies that I
am particular enamored with include taxes (price manipulations), zoning
restrictions (do we need 10 fast food restaurants w/in a mile of a neighborhood
or school?), and advertising constraints (do transit busses really need to
advertise 2 dozen donuts for the price of 1?). The point of these efforts is to
change perceptions about food consumption and the pressure to consume more food
than we need. The changes of what is normal developed in response to our
environment over the past 30 years. We have new social norms.
Changing the environment means reducing the amount of or
display of ‘desirable’ foods.
I hadn’t realized that what I was talking about is also
called ‘desire reduction.’ In other words, if the things – no the triggers -
that lead us to overconsume calories are taken away, then our desire to
overconsume is reduced. Take my donut example. If the ads for donuts are taken
off the bus, then this might reduce my desire to go buy donuts. Certainly, if
your work place bans junk food at office meetings, this would reduce the desire
to eat those junk foods. I like these strategies because they attempt to
reverse something that happened without our asking it to happen. The
environment changed around us and what was normal changed. Now it is ‘normal’
to be served supersized meals. It is ‘normal’ to sit for hours. It is ‘normal’
to drink a 20 ounce sugary beverage or an 8 ounce glass of wine. And pushing
back against the new normal in our social context is often met with shock and
disapproval. Still, this push back, this resistance, is yet another strategy –
an individual level strategy that some people promote. I am not convinced.
The ‘new’ term for this type of individual level strategy or
intervention is ‘desire resistance.’ I became familiar with both of these terms
(desire reduction and desire resistance, but not the concepts) only recently,
when I read an article by Dutton, Fontaine and Allison (abstract
here). I am a pretty big fan of Dr.
Allison, he is the co-director along with Dr. Fontaine, of the Nutrition
Obesity Research Center at the University of Alabama, and I pay attention to
what he has to say. This is one of the few times I disagree with him.
In their discussion of desire resistance, the authors offer
this example of the skills an individual might need to posses in order to resist their ‘internal
desires’ or ‘external challenges’ (eg those brownies someone left in the break
room):
“Desire resistance skills include
strategies such as self-monitoring, meal planning, asking for social support,
wearing a physical activity monitor, cognitive restructuring, making a public social
commitment, and preparing oneself to
anticipate, tolerate, and accept feelings of deprivation when they are encountered.”
I understand that the authors are advocating for both desire
reduction and desire resistance, but desire resistance, to me, is going back to
the individual focus that others have already found to be extremely challenging.
Programs that work at this level usually do not produce lasting change. Yes,
there is some evidence that teaching people to count calories or plan their
meals will work for the short term and maybe in the long term, for some people,
but it is rare. In my experience and in the literature, finding people who can
actively, consistently and perpetually resist this 'in your face, food pushing
society’ is unusual. I AM one of those people, so if I am against desire resistance as an
obesity prevention strategy, it’s worth noting!
This idea of resisting cues to eat calorically dense foods
or drinks, or any food or drink when you are not hungry, reminds me of the time
I spent teaching people how to resist the trigger to smoke a cigarette when
they were trying to quit. What worked the best was when there were LESS
triggers. In other words, successful quitters are more likely to be around others
who did not smoke, work and recreate in smoke free environments and live in a
‘space’ where smoking is not ‘normal.’ The environmental changes – and taxes on
tobacco – have done far more to assist in smoking cessation than all the desire
resistance programs!
It’s also ironic to me that in the Allison article, where the
authors introduce the desire reduction and desire resistance terms, that they
also point to the 2010 Recommendations from the US Surgeon General regarding
obesity prevention as misguided. They note that most of the strategies are in
the desire reduction category, as if that were a bad thing. I see it as a
response to the years – decades – of efforts that did not include the
environment at all. Still, in the end, the authors suggest that both strategies
– reduce desire by modifying the space and increase resistance by teaching
skills – be employed. And in their closing comments they make a valid,
important point. The same point is true with smoking or in their example,
managing anger, and it is: there is no world in which all temptation or
triggers will be absent at all times. In those situations where temptations
exist, a person will either indulge, relapse or resist.
Personally, I plan to do a little indulgence in a few days….
Thanksgiving here I come!
