FedUp with determining the "Cause of Obesity"

Small Graphic I made to identify factors that influence food intake/energy balance and contribute to obesity. By no means is this complete. Click to enlarge, might need to (command + to see enlarge)

The 101 Nutrition course that I currently TA for has provided me with a lot of insight into the college student mind. One of the lab exercises I have the students do is to go up to the chalkboard (they still exist!) and write down all of the factors that influence what they choose to eat. It's always funny to see the 8 words that get written on the first pass, and then to see the whole chalkboard get filled up as conversation progresses, as students begin to think deeply about all of the overt and subtle factors that have influenced their food choices, eating behavior and weight status.

I relay this story because I think it ties into a lot of relevant issues in modern day nutrition. I just saw the documentary, FedUp, the other day, and while I think it raised a lot of interesting points/questions, the focus on sugar was overly reductionist for me. There seems to be an incessant need to employ a reductionist line of thinking in nutrition; this is evidenced by the low-carb, low-fat, anti-saturated fat, anti-grain, etc etc movements. When it comes to obesity, there's been just as many conjectures to what drives the pandemic: lack of access to fruits and vegetables, too high a consumption of sugar/fat/starch, personal choice/lack of will power, industry influence, dietary guidelines. The lists go on and on. There was a really great post on this over at PloS blogs - see here - by Beth Skwarecki that I would highly encourage everyone to read. Another really interesting study - see here - came out arguing that simple economics and the cheap cost of food has driven the obesity epidemic. For any who think that sugar has caused the obesity epidemic, consider that USDA data shows that between 1970 and 2010, the average American increased their calorie intake by ~450 calories. 42 of these calories are accounted for by caloric sweeteners, over 360 are accounted for by added grains and oils. FedUp could've easily been a conspiracy theory story about grains and oils, but the authors chose sugar, because it's something that already has a negative perception in the media. Let's not even start on the variation in sugar intake that's not reflected by average means....

We know that energy imbalance is the cause of the obesity epidemic. What drives energy imbalance? A lot of things - I've attempted to identify broad categories in the graphic above. I initially started to make some bubbles bigger than others but devil's advocate wasn't having any of that (Netflix docs would the biggest *nervously jokes*).  One thing getting the perspective of teaching several hundred college students has taught me is that the factors are different for everyone. This seems like common sense, but there is still this need to be a reductionist. Reductionism distracts from actually addressing the problem, and ends up becoming a "no, this is the bigger issue" game, instead of acknowledging that what drives obesity is a heterogeneous mix of factors that may or may not be mutually exclusive, and that these factors may or may not affect different individuals or populations in different proportions. 

That all being said, public health campaigns kind of rely on reductionism - what's one issue that can be focused on? At this point in the obesity pandemic, we're caught in a vicious cycle. Consumers buy food products, many that aren't promoting health/normal weight status. Food companies produce food products, often without having individual health as a priority. We have abysmal health literacy rates, and nutrition/culinary education. Many consumers perceive health foods as expensive, lacking taste and/or requiring too much time to prepare. Accessibility to foods/food insecurity remains an issue for many. The solution to breaking the cycle is a deeply polarized debate, inherently intertwined with how one sees the role of government: 

1. Top Down Approach - Government regulation and policies to regulate nutritional quality, change food subsidies/environment, regulate food corporations - this is a lot of what the FedUp approach takes

2. Bottom Up Approach - Educate consumers, use market push to change food environment.

Which is the answer? I like to take a moderate perspective and say that we need both approaches, to some degree, and to address issues that pervasively underly as many issues as possible - I've expressed before that I feel simplistic efforts like sugar taxes will likely fail, without addressing issues of education and accessibility (unlike smoking, you've still gotta seek out alternatives and eat). Just taking a top-down approach leaves you with the debacle we saw with school lunches - see here. We've already seen booming health/natural/organic food markets due to an increased awareness of the link between nutrition and health/disease. We saw some changes to the Farm Bill because of this, with the organic industry winning out- see here. (sadly, organic isn't exactly my idea of winning or addressing any tangible health issues). Increasing nutrition education is really the crux of the solution for me, and I think this is what FedUp was addressing without saying it; it was educating consumers, albeit with some pseudoscience.  As much as I would love the food industry to change their products, there's just too much money involved and the entire food economy is built on this - that's what I got out of FedUp too: the food environment is stacked against you, and all you can do right now is to educate yourself and buy 'real' food. It's a shame FedUp didn't promote true nutrition education, as they end the movie with putting kids on sugar detoxes that they can't keep up. This isn't to put all of the responsibility on the individual, but to acknowledge that companies, no matter how large or small, have to make money, and will pursue making money, and that is by selling products that their research shows consumers will buy (unless we're moving to a state of larger government control, this is how markets work). Consumers have a lot of power, and empowering (not blaming) them can make a difference. It'd be great to see some top-down policies that encouraged nutrition education, and increased the ability of registered dietitians to be employed (AKA receive compensation) in non-hospital sectors - I'd rather see RDs providing this than 'functional medicine' quacks. 

Mine is just one perspective. I thank myself daily that i'm not professionally in public policy. 

*Sidenotes about the film - i'll keep adding more as I remember them:

1. Insulin is a satiety hormone outside the context of hyperinsulinemia - see here. The film blatently got this wrong. Amylin, another satiety hormone, is released alongside amylin.

2. The way Dr. Allison was portrayed was horribly biased. He is a well-established, great researcher - see here. and his research just doesn't fit the film's mantra, so it was portrayed terribly.

3. The research Lustig was quoted on Fructose is in the context of pure fructose overfeeding - for a good read on the whole 'sugar is toxic' issue see here.

4. Another of their experts, Dr. Mark Hyman, is a big proponent of pseudoscience, like doing cleanses to get rid of 'toxins' - see here.

5. The science of food/sugar addiction is far from having a consensus opinion, despite how it was portrayed in the movie - see here. 

6. Continuing with the bad insulin science, the movie states that artificial sweeteners illicit an insulin response. This is not true. Even the most recent, very, very conservative review on artificial sweeteners - see here - notes that Saccharin, Aspartame, Acesulfame-K, and Sucralose don't stimulate insulin responses. Stevia actually has been found to lower postprandial insulin levels relative to sucrose and aspartame - see here. I'm all for moving off soda towards something like unsweetened green tea, but not acknowledging the role artificial sweeteners can play in reducing sugar consumption, when making a movie about the dangers of (what should have been excess) sugar consumption is a shame, and only confusing consumers.

Further critiques of the claims in the film can be found here: http://www.foodinsight.org/Press-Release/Detail.aspx?topic=Correcting_the_Fed_Up_Record