Obesity: Have We Lost the War?

IllustrationIllustration by Dave Mazierski

Illustration

Story by Marcia Kaye

Physician Alex Jadad was blissfully unaware of the whole issue of obesity — until it landed with an ominous thud in his own family.

Neither Jadad nor his wife had ever had a weight problem. But 13 years ago, they were dismayed to learn that their 10-year-old daughter Alia was being bullied at school for her weight. Other kids nicknamed her the Blue Marshmallow (she often wore a blue jacket) and taunted her with chocolate. As her self-esteem fell, her weight climbed. Soon Alia was beyond pudgy; she was obese.

If anyone should have had answers, it was Jadad. A physician who also holds a doctorate from the University of Oxford, he had just become the Canada Research Chair in eHealth Innovation and had been named by Time magazine as one of the six most innovative medical researchers in Canada. He would soon become a professor in the Faculty of Medicine and Dalla Lana School of Public Health. But today he laments, “Twenty years of medical education and nobody taught me anything about obesity.”

Obesity, together with a pandemic of chronic conditions including diabetes, is such a serious and growing problem worldwide that Jadad calls it one of the Four Horsemen of the Apocalypse (alongside the other destructive forces of environmental damage, violence and inequity). The World Health Organization reports that more than 1.9 billion adults are overweight (with a body mass index, or BMI, of 25-plus) or obese (with a BMI of 30-plus). There’s even a new term for this global epidemic: globesity.

In Canada, six in 10 men and almost half of women are overweight. So are nearly one-third of children ages five to 17, most of whom will grow up to be overweight or obese adults. The associated health risks include heart disease, stroke, diabetes, breast cancer, colon cancer, arthritis, depression and a host of other ailments, which add up to an estimated $7 billion in annual costs to Canada’s health care system, or a sobering $2 trillion worldwide.

It’s a puzzling epidemic. Our knowledge of nutrition keeps improving. Our understanding of the importance of physical activity keeps increasing. The links between obesity and ill health keep getting stronger. Why, then, do we keep getting fatter? And what can we do about it?

One of the problems is that, as desperate as we are for a magic-bullet solution, obesity is not a simple issue with a single identifiable cause. Eating more calories than you burn off is an overly simplistic view that doesn’t take into account the many factors that have come together over the past 30 years for the first time in human history.

Among them: the 24/7 availability of inexpensive, quick food; relentless marketing; socioeconomic inequities that leave poorer people unable to access or afford healthy food; our natural human attraction to fatty, sweet and salty tastes; our shared human evolutionary heritage, which like many mammals gives us bodies designed to store fat easily (particularly if we went hungry as children); a drop in home cooking and corresponding jump in processed foods and restaurants; supersized portions; sugar added to previously unsweetened products such as bottled pasta sauce; a move from physical jobs to sedentary ones; a proliferation of screen-based entertainment; hormonal disruption from too little sleep or shift work; side effects of medication, medical conditions and disability; babies born to overweight or smoking mothers; and excessive weight gain in infancy.

The links between obesity and ill health keep getting stronger. Why, then, do we keep getting fatter?

Obesity is so complex that the research has spread to a variety of disciplines, including microbiology, chemistry, endocrinology, genetics, psychology, sociology, anthropology, kinesiology and socioeconomics. “We’re building up our knowledge in a piecemeal way,” says nutritional anthropologist Daniel Sellen, Associate Dean of Research at the Dalla Lana School of Public Health and a professor in the Faculty of Medicine’s Department of Nutritional Sciences. “Scientists are each looking at one small part of the story, so it’s a challenge to understand that complexity and to translate that piecemeal science into clear public health messages and policies and programs.”

The result is bits of messages entering the public sphere. Many are incomplete, even downright contradictory. For instance, are we more likely to have healthy weights when we live in cities or in the country? Well, that depends. Some studies show that people in cities walk more and eat less fat, but other studies show that urban high-rises and public housing offer less access to fresh food, exercise facilities or safe places to walk or bike. Here’s another dramatic incongruity: the Mediterranean diet, based on vegetables, legumes, fish, nuts and olive oil, is touted as one of the healthiest ways to eat. But, according to a 2013 report from the International Association for the Study of Obesity, which country has the highest rates of childhood obesity in the world? Greece. And second? Italy. Whether due to an increasingly processed diet or genetic changes, we simply don’t know.

To address this fractured approach to obesity within academia, the Faculty recently formed the Centre for Child Nutrition and Health (CCNH). Led by researchers from nutrition, paediatrics, and family and community medicine, the Centre brings together scientists from around the university to find evidence-based solutions to the obesity crisis. Better yet, researchers are looking for ways to prevent children from becoming obese in the first place — in part by cutting through the confusion about how to eat, and reaching patients directly.

Robust nutritional research may in fact be taking place, but the public is not well served by it, says Dr. Mike Evans, who was recently appointed by the Centre as Canada’s first Chair in Patient Engagement. Too often, he says, the media will latch on to a study’s findings about a single nutrient — fat or carbs, gluten or salt — and the take-home message becomes skewed, rarely portraying the larger picture. For instance, the low-fat craze has demonized all fats while ignoring sugar. Nutrition advocates tout “superfoods” but ignore balanced diets. Evans says, “We get nudged a lot towards bad eating decisions. You see that sign in the coffee shop for the high-fibre, low-fat muffin. Yes, it’s better than a sweet white muffin, but it still has 450 calories. One of our questions at the Centre is how to nudge people from mindless overeating towards mindless healthy eating.”

Evans, a professor of Family and Community Medicine, has become a YouTube star with a series of short animated videos on personal health topics. His viral YouTube channel has had an astonishing 12 million views worldwide.

“I feel strongly that the university has a key responsibility to be a knowledge resource for the community,” says Evans. “People are solving their problems in new ways — shouldn’t we support that?”

Another physician on the front lines of the obesity crisis, Ottawa’s Yoni Freedhoff (MD ’99) uses social media to reach opinion leaders with his message that obesity is a societal issue, not just an individual responsibility. To that end, he’s taken on a very public watchdog role, calling out food manufacturers and institutions for their role in the obesity epidemic.

“Telling someone to ‘eat less and exercise more’ is as useful to an overweight patient as ‘cheer up’ would be to a person with depression,” says Freedhoff. A pioneer in non-surgical bariatric medicine, the Faculty of Medicine alumnus deploys an army of nutritionists, personal trainers and psychologists to customize weight-management plans for patients.

 When faced with a flood, Freedhoff says, we need more than swimming lessons; we need levees, and some of these must come from government. For instance, in June the Government of Canada announced proposed changes to nutrition labels for packaged foods, including more information about sugar. It’s a welcome change, but as happened with tobacco control, packaging changes are only one small part of the solution.

“Nutrition labelling will help, but the big improvements have to be system-wide,” says U of T Professor of Nutritional Sciences Mary L’Abbé. These could include a national school food program, restrictions on advertising of low-quality food to children, subsidies for healthy food and a tax on junk food. Mexico, with one of the world’s highest obesity and diabetes rates, last year added a tax on sugar-sweetened sodas, fruit drinks and energy waters. Consumption dipped, but critics argue beverage companies have the option of simply absorbing the cost and dropping their prices.

Scientists are each looking at one small part of the story, so it’s a challenge to understand the complexity.

Academia has a major role to play in obesity prevention. That includes ensuring the funding for studies is transparent and without strings. “One of the proudest things we can say about Canadian research, and U of T in particular, is that most of our scientists’ funding comes from philanthropic or public sources,” says Sellen. “We have greatly reduced most types of bias, and our research is well-known to be of high quality.” He also advocates a two-way knowledge exchange, where universities not only educate the public but learn from them. “Many of the solutions are in people’s homes and communities. Scientists don’t have all the answers.”

Freedhoff questions whether university medical schools have taken obesity seriously enough. “Where medicine fails is addressing lifestyle,” he says (and Jadad agrees). “I graduated from U of T in 1999, and I learned more about conditions that I will never see in my practice than I did about nutrition.” While he says today’s young doctors are more attuned to preventative measures, he’d like obesity to be a larger part of the curriculum, with the emphasis on health, not weight.

That message has been heard at U of T, where a major curriculum overhaul is underway. It’s understood that nutrition and exercise are the cornerstone therapies for the prevention and management of chronic disease, says Nutritional Sciences Professor John Sievenpiper, who is leading the overhaul. “The biggest improvement will be in reinforcing the existing nutrition and exercise curriculum in key areas relevant to family medicine and general paediatrics,” he says. “But we plan to do a better job of weaving lifestyle education into new learning objectives.”

As for Alex Jadad, the physician whose young daughter was obese, a radical revamp of the family’s lifestyle habits helped Alia achieve a healthier weight and become the vibrant, happy 23-year-old she is today. Her father says, “Obesity is one clear example, among many, of how our financial, political, medical, communication and alimentary systems are turning against us. Academia must now lead the way, moving us from third-person singular — he or she has a problem — to first-person plural. It’s about our survival.”