Every so often an article arrives at a new perspective that has the potential to influence us to reshape our thinking about a subject – maybe even influence our behavior. Today I’ve read and thought about just such an article; titled: Free will and the obesity epidemic, which was published in Public Health Nutrition on September 19, 2011. The article, written by two scientists at Cornell University, David A. Levitsky, a professor of both psychology and nutrition and Carly R. Pacanowski, a graduate student, states, “Food choice is an illusion.” Instead, they gave strong evidence that a set of environmental cues were more influential than personal choice.  These included ‘food primes,’ variety of foods offered, widespread availability of food, fat content of the diet, the number of people eating, the location of eating and food marketing as the main causes influencing individuals to consume more calories.

The article is long and there are several lines of argument, but getting from A to Z is clear. Their conclusions, I believe, can be a real benefit to all of us who are working to maintain our weight or trying to lose weight – and that is a majority of Americans and a growing number of individuals around the world. The authors reviewed many studies to build their arguments and broached a complex number of related issues; but if you’ve been trying to manage your own weight or helping others to manage weight for very long, you already knew that it would be fairly complex. If you’re interested in weight management you’ll not want to miss reading the entire review; but if you don’t have the time, I’ll try to condense the main points into this blog.

Increased intake or decreased exercise?

The authors begin by developing an argument that the obesity epidemic, which really began to soar in the 1980s, is due primarily to an increase in energy intake rather than a decrease in energy expenditure. This is, of course, speaking about the population of the U.S., not about individuals. As it turns out, there is a much stronger association between the prevalence of obesity and an increase in energy intake rather than a decrease in energy expenditure (exercise). (This does NOT mean that they recommend that increasing our exercise is not important!)

How much has intake increased?

Using a couple of different ways of answering this question, they propose that the population increased their intake by about 30 calories per day, on average, for each year, beginning about 1970 or 1980. That is certainly not many calories and the resulting weight gain of less than one pound per year would be imperceptible to the average person. But if you’re an average person, that could spell a 30 or 40 pound weight gain over a 30- to 40-year period and we can certainly see that.

Who controls our food intake?

A Gallup poll said that 89% of Americans believed that the food industry should not be held responsible for our overeating and increasing body weight. Therefore, the resulting belief is that Americans believe their eating behavior is totally controlled by their own will. Simply stated, we believe that the obesity epidemic is a result of being weak willed, lacking the will power to make healthy decisions. The authors report that forty-six percent of U.S. women and 33% of the males report that they are currently attempting to lose weight. If you look only people who are obese, the numbers jump to 70% of women and 60% of men who are dieting. And this is the sad part; the evidence is extraordinarily clear: losing weight by dieting is futile. The authors then share the rates for dropping-out of weight loss treatments (77% for standard out-patient treatments and 93% from commercial weight-loss programs.) They then share the dismal statistics regarding regaining how little weight is actually lost and how much is regained.

Willpower is insufficient to control eating behavior

The authors discuss the most effective techniques that lead to weight loss, namely gastric bypass surgery. Yes, it is the most invasive and risky, but no other treatment surgical, dietary or pharmacological comes close to producing as much weight loss. The point that the authors are making is that bypass surgery does not depend upon improved willpower, but upon the physical constraint imposed by the surgery, which limits the amount of food that can be eaten at one time.

Meal replacements which consist of commercial-grade, ready-prepared foods, packaged in smaller sizes than would ordinarily be served, work somewhat like a bypass surgery, but compliance seems to drop off and the patients return to their former eating environments. A commercial weight-loss group such as Jenny Craig averages about 90% dropout rates by the end of 1 year.

Medicines that reduce appetite work until the patients stop taking the medication, then unwanted weight begins to return.

In summary of present weight loss, the observation of the authors is that all successful methods require removing people from their ‘natural’ environment or modifying their environment by surgery, meal replacements, group reinforcement or medication. The point is that serious reduction in the patients’ freedom to eat whatever they want or whenever they desire it is removed. And they conclude, that in every case when the restraints are removed and people return to their pre-treatment environments in which weight regain is inevitable; weight quickly returns to pre-treatment levels or more.

Susceptibility to food cues

Based upon several studies the authors state; “One of the most powerful of these cues is portion size. The amount of food people consume at a meal is determined to a large extent by the amount of food placed on the plate in front of them.” They also cite a 2005 study published in the journal Physiological Behavior, co-authored by Levitsky titled "Imprecise control of energy intake: absence of a reduction in food intake following overfeeding in young adults<.” The outcome of the study points in the direction that there is very little evidence that our bodies correct for overeating by reducing intake at a later meal.

Even larger packages of food give us a cue to increase intake and if we think that others have eaten more, it may stimulate an increase in intake, too.

Based upon the research reviewed, the authors believe that the increase in portion size may be one of the major causes of the obesity epidemic. Based upon a 2002 study, the authors say, “…. the food industry has been increasing portions sizes in supermarkets and restaurants, especially in fast-food establishments, for the past 40 years, a time when the increase in obesity has been observed.” The surprising observation is that the amount served at home also has increased, at least at the same rate as in restaurants. The point that they’re making is that people’s estimation of a normal-sized portion has been increasing. The author’s conclusion is that we are ‘learning’ from subtle environmental information acquired by advertising, food products and food establishments. We don’t consciously even realize that we’ve established a new ‘social norm’ for food portions.

Next they argue that the more variety available at a meal, the more food consumed. They cite work done by Brian Wansink, whose research about this subject, we have cited in past blog articles. Even something as simple as jelly beans – the greater variety of colors – the more eaten.

They discuss how the variety of foods available to the public has increased over the past 30 years; but most of us who have eaten at buffets, know only too well how much more we eat if variety is available.

The authors share evidence that the amount of dietary fat available to consumers has increased significantly since the early 1980s. They say that the “food industry has compounded the effect of dietary fat by adding more fat to foods that are served outside the home in restaurants and fast-food establishments.” They continue with calculations that show that it is clear that the higher amounts of fat from food prepared outside the home, is enough to explain the obesity epidemic.

In addition to dietary fat, two other variables that all seem to contribute to eating extra calories are: (1) eating with a group. (2) watching food commercials.

The ultimate conclusion of the observations about the various stimuli (portion size, food variety, fat content, social facilitation and television watching) is that people are usually unaware that they are being carefully lured to consume slightly more energy than they would without the stimuli. They say, “Unawareness of seductive stimuli is at the very heart of the obesity epidemic. The stimuli are subtle and stealthy; we do not notice their influence on our behavior because their effects are small and produce imperceptible changes in our daily weight.”

Food priming

If the food cues listed above were not enough, there is even a more insidious mechanism that causes us to be vulnerable to environmental stimuli; it’s called priming. So the billboards, the Internet, newspapers, magazines, subways, buses, pens, bags, etc. combined with the food cues – large portioned, energy-dense, inexpensive foods, have created the “perfect storm” for an increase in obesity. Priming cues are so powerful that they can make us feel like looking for something to eat—right away.   We are even commanded to do so – “obey your thirst”.

Stopping the obesity epidemic

The end of the article offers some ideas (tools for self-regulation) to help with managing the obesity epidemic.

• One is to stop living under the illusion that we are free to control our feeding behavior in the current food environment, to subject ourselves to the barrage of food primes that relentlessly make us eat a little more food than what was normal even a year or so before.
• Become aware of the effects advertising.
• A third idea is daily weighing and weight recording. Weight monitoring has been shown to be an effective mechanism to increase awareness of what is being consumed. The recommendation to weigh daily has traditionally been widely advised against in the nutrition community. Although imprecise because of fluctuations in body water, gastrointestinal contents and tissue glycogen stores, to name a few, it has been shown to be successful in studies cited in this review article. It appears that daily weighing gives people a means to detect small changes in their weight. The weighing provides (1) frequent biofeedback about the battle to resist environmental food primes (2) experience in successfully returning to the previous weight, which reinforces the behaviors that caused the weight change or maintenance (3) observation of success in maintaining weight enhances feelings of self-efficacy and sense of being in control of one’s weight.

I’ve been a proponent of daily weighing for decades. I realize that there is a huge contingent of nutritionist who believe that daily weighing has too much potential for stimulation of eating disorders and emotional eating. But I find it a useful tool to prevent me from going too far down the path of weight gain. When Vic (Dr. Grandpa) needed to lose weight after his diagnosis of diabetes, he began daily weighing too. He posts his weight on the WeightBot smart phone App, which gives him valuable data. He quickly learned what happens after eating at a restaurant (water weight gain due to excess salt) and how much time is involved in recovering (2-3 days). He’s been through 7 holiday seasons and has learned more and more skills for reducing the predictable weight increase, and reducing the damage quickly. He does this by watching his weight graphs. He has learned which eating episodes cause weight gain and which lead to weight loss.

For me, the most important value of daily weighing is that I become aware of a gaining trend prior to a large weight gain. Having had to lose a significant amount of weight in the past, I know that I’d like to avoid having to go through that again.

• The authors suggest that we separate ourselves from the current environment by physically restricting the capacity of our stomach (gastric bypass surgery) or portion-controlled meals, or by providing ourselves daily reminders of changes in our body weight. They conclude that constant vigilance and dietary restraint are essential.
• One way of accomplishing dietary restraint is actively inhibiting what and how much is eaten. The authors say, “Those who do not dress in their armor of restrained eating live under the illusion that they have the freedom to choose what foods they eat and how much.

The authors go on to say that we are influenced by “… what the food looks like, what others around us are eating, what we think others consider a normal portion to eat, the price of that food, the ease of obtaining food, the speed of obtaining the food, how much time we have to eat, and many other factors which have yet to be discovered. A complex network composed of these factors determines our caloric intake. In combination, these factors are so powerful that, unless we are restrained by surgery or structured eating plans, or by a dedication to prevent future weight gain (restrained eating), we become vulnerable to all stimuli presented, mostly by commercial interests who have learned to effectively use these techniques to encourage us to eat a little more, increasing year after year.”

• “Learning that we can control our weight through adjustments in intake may not only have a direct positive effect on weight, but may also act indirectly by strengthening a sense of control over body weight and health.”
• The authors point out that the solution to the obesity epidemic is that we must consume less food. And that reduction in food intake will not be temporary, but a sustained way of life. They say, “Such a solution will not be taken passively by the food industry.”  Already they are suing the government for “restriction of free speech” in their massively successful food advertising to children.

The authors say that the way to control the power of the primes is to either (i) restrict the capacity to eat with gastric surgery or (ii) limit access to food by portion-controlled rations or by boycotting types of foods. For those of us, who are not struggling with a decision to have gastric bypass surgery, then it is probably the road to learning how to serve ourselves reasonable portions, restrict certain foods from our frequent choices and completely boycott others.  In my experience, the road to success is built upon numerous decisions made as a result of numerous learning experiences, which is why I chose the word “road.” It is a journey; it is not a destination or a diet. It is the reverse of how the food industry changed our thinking about when, where, and how much to eat.  They did it step by step, here a little and there a little.  And the epidemic of obesity, overweight, and chronic illnesses that accompany their accumulated successes demands both our individual efforts, and social and political action.  The road back is worth it. The end of dieting for me lead to much better weight management – fewer and smaller weight variations.

From our previous articles:

A few tips from Controlling Your Home Environment may be helpful in beginning to design a safe environment; as the article reviewed today suggests, the environment (primes) are key. Suggested Rules for Buffet Table Navigation may give you some ideas for ways to structure your eating environment especially during the holiday buffets.

As you begin to stock your pantry with foods that are healthy, serve yourself smaller portions, monitor your weight and progress, and recognize primes that are cuing you to eat more than necessary, you have begun to design behaviors that will support the management of healthy weight and reap the health benefits that weight management delivers. In your own ways, you might also consider how to hold the food industry to higher ethical standards in their quest for ever increasing profits, and to find local, natural alternatives to their carefully primed temptations.