There is an intense media focus on the arrival of a new class of Anti Obesity Medications (AOMs) and a robust national discussion to clarify their value (“bang for the buck”) given the mix of positives (significant clinical benefits) and negatives (side effects, weight regain on stopping, and high price tag).
In this blog, we provide a brief background on the rise of ultra-processed foods (UPFs) in our American diet and culture and their critical impact on our basic hormonal biology and contribution to the US obesity epidemic.
Why do we have a national obesity crisis?
One of the major reasons for our high rate of obesity (42% nationally) is that obesity is basically an “upstream issue”, strongly reflecting our recent modern US culture and built environment. Our national healthcare response to this growing obesity crisis since the 1970s has been to provide Americans with ineffective (and costly) strategies. Traditional medical and behavioral obesity programs in the US have been bogged down by what has turned out to be a flawed national dietary prescription for obesity. This was a low fat (“fat is bad”), calories in vs. calories out treatment approach, influenced heavily by the controversial Federal (USDA) guidelines in 1980. This view of obesity has been widely adopted by our national institutions, including highly influential US feeding programs (WIC, Programs for the Elderly, School Lunch Programs), our national Health Professional Associations such as the American Medical Association, American Heart Association, and Academy of Nutrition and Dietetics, US Military health programs, national scientific advisory committees, Federal and State regulatory agencies, and our US corporate food producers. There is awareness now that the 1992 USDA food pyramid and related coordinated Government push for this dietary approach has fostered a widely-held medical view among doctors and dietitians on the clinical front line that the keys to achieving weight loss and good health are:
- avoiding or minimizing dietary cholesterol (eggs, shrimp) and fats
- counting and limiting calories
- exercising to burn calories
- eating smaller meals and adding snacks throughout the day to reduce blood glucose swings and control hunger pangs
- exerting more personal willpower
- showing greater personal accountability
Unfortunately, Americans following this approach over 50 years have mostly experienced demoralizing hunger and frustration and a lack of sustainable weight loss results despite considerable time, money, and personal effort. Today, approximately 130 million Americans are defined as obese (BMI >30) and 50% are predicted to become obese by 2030. These statistics tell us to stop and rethink our strategy.
The new biology of obesity
Scientific knowledge in obesity advances continually and provides us with important breakthroughs that (if we embrace them) will lead to fresh hope and a clearer understanding of the problem. Incorporating these findings will allow for more effective management of obesity as a national crisis. These insights are often slow to reach patients and doctors. For example, recent cellular, animal, and clinical research by Robert Lustig, MD and his colleagues conducting newly focused obesity research helps us understand the important interplay of modern life with our basic human hormonal, metabolic, and immune systems. These systems have been misunderstood and underestimated to date for their importance in driving up our obesity rates.
Traditional obesity programs have largely focused on calorie intake and exercise but this has been a mistake based on this new science. New studies pinpoint the critical role of insulin (a powerful gut hormone) in systematically driving up fat storage in the human body when blood glucose levels are chronically high from our modern diet. We need to leverage these new scientific findings on the role of insulin in fat storage, as part of a fresh start for our obesity management strategies in the US where we systematically measure and then manage the real clinical biological drivers of obesity (insulin levels and food quality not just calorie intake and exercise).
Modern ultra-processed foods (UPFs)
While obesity does have a genetic component, our habits and environment are the most powerful factors in creating the modern obesity problem. Research shows that the diet of Americans today is comprised 73% “ultra processed foods” (UPFs). UPFs include highly-refined carbohydrates, including sucrose (white table sugar) and high fructose corn syrup (HFCS), and industrial obesogenic chemicals added to modern packaged foods and sweetened drinks. Americans today are basically surrounded by the wrong foods and drinks that have been created by a powerful food industry informed by insistent federal policies (including those emerging from the USDA food pyramid) and we all are paying the (biological) price. These UPFs are ubiquitous in our daily lives and heavily marketed to us. Factory sugars were creatively added to our foods in part to replace the recently reviled dietary fats. UPF products were unknown in pre-industrial times but today they drive-up blood glucose levels, insulin production, and blood lipid levels (triglycerides) causing insulin resistance and chronic bodily inflammation. Bottom line: the dramatic shift in our national diet towards UPFs has been a silent driver of the obesity epidemic, and unfortunately, this message is not getting into our current national AOM debate. We appear to be stuck with the old message of “cutting calories and increasing exercise” as the way out of obesity. This message must change to align with our new research breakthroughs.
Why is chronic hyperinsulinemia and insulin resistance important to the US obesity epidemic?
High insulin levels as a result of UPFs not only tell every cell in the human body to prioritize fat storage but also over time impair basic human leptin brain signaling from our fat cells to the brain (creating leptin resistance) or the false message to the brain that there is insufficient fat storage in the body. Chronic hyperinsulinemia and insulin resistance have resulted largely from chronically high levels of dietary glucose and fructose seen in UPFs. Effectively, we are thwarting our natural metabolic and hunger/satiety feedback systems from working properly with UPFs and our current eating habits. Relatively few experts and lay people discussing the problem of obesity today are aware of the biological chaos caused by modern UPFs in our US diet or the science showing that switching out UPFs for foods and drinks closer to their natural state is a dynamic treatment pathway to healing and good health.
New research also shows that UPFs strongly stimulate hedonic pleasure and continued eating habits by manipulating our basic human biology including our natural dopamine reward pathways that shape daily behaviors to seek even more sugar and other processed carbohydrates and that create food cravings and food addictions. To compound the problem, not only has the quality of our food dropped, but our typical meal, snack, and drink portion sizes and the frequency of daily eating and drinking has skyrocketed up compared to 50 years ago to now eating and snacking approximately 5 times per day. We are effectively missing the natural “quiet times” between meals our ancestors enjoyed that allowed our biology, including insulin levels, to reset and reduce a drive towards fat storage and obesity.
Hunger is also very important for us to understand properly when considering the high failure rate of traditional obesity programs. Most people, old or young, will not tolerate feelings of hunger and deprivation for any period of time, even if motivated to try new ways of eating, as hunger is a powerful natural driver of human behavior that easily overrides well-intentioned dietary change plans (using food diaries to track patterns, goal setting to provide a fresh focus of action, feedback and coaching, behavioral nudges and rewards to build change momentum, getting encouragement from others).
Helping Americans with their daily habits to replace UPFs with minimally processed foods closer to their natural state and consume healthy drinks closer to water than sugar sweetened and chemically altered versions will be an enormously important goal for our national obesity strategy. Raising awareness of today’s range of healthy and unhealthy choices in modern daily life (at supermarkets, restaurants, and corner stores, and during family celebrations, holidays, and social events) will be critical to solving the obesity challenge and empowering patients and families. Innovations to provide healthy meals and food supplies are emerging that could provide valuable health benefits if combined with coaching and support that address each individual’s root human and environmental issues related to obesity.
A whole person obesity solution is critical
Once we understand that the clash of basic human biology with modern culture and lifestyle has been a major contributor to our modern obesity epidemic, we must remember also that many people struggle with many daily life, work, social, family pressures, and health inequities that can get in the way of any healthy lifestyle change plans. People can be helped in practical ways with these issues to ultimately create a deeper plan more likely to succeed in the long term. Depression, anxiety, economic stress, competing life priorities, the reality of long held cultural and personal preferences, the presence of structural racism and discrimination, food insecurity challenges, poor health benefits and care coordination, obesity stigma, and other social realities can all create barriers to reducing obesity and achieving better health if these are not systematically assessed and managed. We have the technology and scientific knowledge to get at these root issues as a starting place to solve the obesity problem.
A modern obesity management program must capture each individual’s “personal story” on life related to obesity and build this story into a whole person obesity treatment plan that is part of a long-term view of the patient’s health journey. To solve the US obesity crisis we need to learn from our mistakes and take a whole person view of the problem and invest in smarter solutions and not simply repeat the strategies of the past that have not worked. It is a humbling journey of discovery for all of us to learn from our past mistakes and enthusiastically adopt new knowledge and insights. It is critical to do this work so that we create a brighter future for 130 million Americans living with obesity today.