Resisting a challenging food environment

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!

The case of South LA, Obesity and the Meaningless Law

You may have heard about the 'absolute failure' of a fast food zoning ban in South Los Angeles, California.  The ban on new, stand alone - very distinctly defined - fast food restaurants did not lead to a loss of weight for city residents, in fact, overweight/obese rates went UP after the law was 'on the books.'

Notably, the rates of overweight and obesity went up for ALL of Los Angeles and LA County. According to the study authors (Sturm and Hattori), South Los Angeles residents - ones whose behaviors and weights were captured in the California Health Interview Survey- had a higher rate of overweight obesity to begin with and their rates increased faster - or to a higher degree - than either the whole of Los Angeles city or LA County (their behaviors and weights were also assessed through the survey).

Whether or not a ban on new fast food restaurants - and it was not a total ban - was a good idea is for someone else to argue, but whether or not the study results are conclusive or even meaningful falls into the bailiwick of this (increasingly infrequent) blogger.  Yes, I end up giving an opinion about the law, I can't help myself sometimes.

This LA Times article provides a bit of information, though it does not describe the study methods. I accessed the journal article, the abstract is here. My main interest was in how the researchers went about collecting their data and answering their research questions. Sturm and Hattori (2015), used two main sources of data. They used establishment/restaurant permit records from the Department of Health and existing survey responses from a recurring/repeating survey - the California Health Interview Survey.  The survey responses (people) could be categorized by city, county, zipcode etc, so the researchers compared results between 3 groups, only one of which, South Los Angeles, was 'exposed' to the new regulation.

The regulation didn't really do much, I mean literally - it didn't do anything.  Fast Food Restaurants (FFR) still opened in Los Angeles, new business rose about 2% in all three locations. So from time 1 to time 2 there were actually MORE not less places for residents (or commuters?) to eat foods that were likely very high in calories. Between the time that the law went into effect and when the researchers evaluated the survey respondents FFR patronage frequency and their BMIs a second time, the environment did not change 'for the better'. There were not fewer FFR at time two, but would that have mattered? Research has shown that even sit down restaurants, fast casual or otherwise, serve foods that are calorically dense.  All away from home eating is associated with excess calorie consumption - so a law that prevents a certain sub category of FFR from adding more locations might make sense on its face, the result won't necessarily - or likely - be lower weights for the people who live in that area,

With an understanding of what did and didn't happen as a result of the law - i.e., FFR locations did not decrease or remain stable, they increased - how can one say that restricting FFRs does not lead to less FFR patronage or less calories consumed.  The law was flaccid at best - the first outcome - a decrease in number of restaurants or restaurant density did not happen. There was NO change in the obesogenic environment - people had as many if not more options for calorie dense food as before the law. So the answer to the first question: "Does a law restricting FFR lead to fewer FFR?" is no. Therefore, we can't answer anymore questions! But lets say the answer was yes, that five years later there were less restaurants in the area; the second question is: "Did the law lead to less consumption of fast food - or even better, much better, did it lead to few calories purchased/consumed?"

Now, is this the right policy?  Banning restaurants?  In some ways, it makes sense.  If there isn't a FFR on every corner, then FFRs become less popular, less 'normal.' And if FFRs were the only source of our passive overconsumption of calories, fewer of them might change our intake.  But they are not - there are plenty of sources of too many calories. The goal, in my opinion, should be to get existing establishment to reduce the amount of calories - across the board - that they put out for sale.

NB. Another possible 'confounder' for South LA is that people may not eat where they live - so capping the number of fast food restaurants does not change behavior if people are not eating where they live. 

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Mom, you would be happy to know that I had three more paragraphs, but I realized I had already said what I needed to say so I deleted them.

Whose Responsibility Is It?

It is interesting to read the news of how countries besides my own (USA) deal with public health issues. This time it is Scotland. I caught a talk show last night that was responding to some recommendations that the Scottish National Party had released. I also found a newspaper story on line regarding the same issue.

The ideas and responses are familiar. Limit high calorie foods, especially fats and sugars, and pay attention to schools and the stores that are near to them. Limit the serving size of foods and put nutrition information on labels . Make those labels easy to understand.
The grocery and retail industries of Scotland responded with assertions that they are already doing these things voluntarily and that it should continue this way. One even said that the ideas from the government were NEVER going to get passed or followed because the companies that make the foods, all over the world, are not going to participate. Of course, there is more than one political party in Scotland, so getting them to agree on legislation aimed at reducing obesity will probably go as well as the USAs attempt to reform health care.

Before I point out a few things that caught my attention, let me tell you the broader goals of the SNP and why the Health Minister published the report.

First - the extent of the problem. Recall a recent blog that noted Mexico as having a higher rate of obesity than the USA - in Scotland, the word is that the only countries with worse weight problems are the USA and Mexico. In fact, the fear is that over 40% of adults will be obese in twenty years. It appears that about 20% or 150,000 Scottish children are currently obese.

Second - the proposal. Reduce calories consumed, increase physical activity, improve "behavior" at work, and target children early.

Now two or three things from me in response to what I heard and read.
When the counter argument is that the change has to be at the individual level by individual free will and choice, it is couched in the term "individual responsibility." I agree, but when the individual is NOT responsible than who is? Who pays for and suffers the consequences for the explosion of illness associated with being overweight and obese? Society (fat and not fat) does. [same as all society pays for tobacco illness] If the behavior affects the government (which is there to protect the people) then the government not only has a right to intervene, but a responsibility to do so.

The Health Minister of Scotland is Shona Robison, and she was quoted in press (Times Online-2/22/10) as saying that NO country had been able to get a handle on obesity and that Scotland needed to. She referred to the environment and how it actually encourages and promotes over consumption and makes weight gain almost "inevitable". To this I say what is becoming a Deirdre-ism, but true is true. We have got to make maintaining a health promoting weight socially possible and sometimes that requires legislation.

That does bring me to the one point I unequivocally disagreed with in the government's proposals. The idea of using expanded labels with the additional information of how much of a certain activity, like walking, would be needed to burn the amount of calories a person consumed in whatever product they were about to eat. It is not that kind of simple. I think they would be wise instead to educate, and yes, start with kids, on calories, nutrition and the body. If not, they are going to have to have three page labels explaining how variant and multi factorial the burning of calories can be.

You guys have it easy! Just use the many websites I have thrown at you over the last year!