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August 2021

Aug 30 2021
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Obesity Part 5: the GB Obesitas Action List

By About obesity, Body weight regulation, News, Obesity prevention, Online resources

In our blog series “Obesity -who is to blame?” in Part 1, we have talked about how obesity is a disease, in Part 2 how we move around, in Part 3 processed food and the term “bliss point” and in Part 4 the costs of obesityand an example from Chile of what can be done about the problems in real life. We have now put together a variety of measures that have been tried or proposed in different places around the world.

The idea behind this is this: Obesity is not the fault of the individual – it is obesity-sensitive genes plus our obesogenic environment that creates the disease. Dealing with obesity as the “responsibility of the individual” is therefore both unfair and ineffective. As far as prevention is concerned, society is already acting in situations which in principle are similar: traffic, alcohol, tobacco. We have traffic rules, car testing and driving licences; alcohol tax, age limits and warning labels. Now we need the same in our “obesogenic” society.

Preventing overweight and treating obesity are different things

Preventing overweight and obesity from occurring (=primary prevention) is just as important as treating obesity disease in those already affected (=obesity care) -but the two situations require completely different measures. Primary prevention requires preventive community intervention, obesity care requires medical intervention. Measures in the list that are preventive are labeled “(PR)” as in primary, measures related to the care of already established obesity are labeled “(HC -health care)”.

Medical decisions and measures (HC)

  • Obesity should be considered a common, chronic and serious disease
  • Obesity disease is thus a central and mandatory subject in all healthcare educations, this needs to include knowledge about how the disease occurs, its physiology plus nutritional education. (All these things are completely underdeveloped in Swedish healthcare education today).
  • Evidence-based national guidelines
  • Patient follow up database for non-surgical obesity treatment, corresponding to the surgery registry SOReg. (We must document what care measures we do, which ones work and which do not, etc. In spite of the fact that the weight management industry in Sweden alone has a turnover of SEK 300 million per year, there is currently no patient follow up register in place.)
  • Drug subsidy for modern obesity drugs. If obesity is a common chronic and serious disease, then of course the medicine costs must be treated as all other medications -with subsidy.
  • All children with isoBMI > 30 are referred to an obesity-competent team (mandatory for the caregiver, children with obesity risk living 14 years shorter lives than their normal weight friends), these children’s parents should be involved and supported (not blamed).
  • Activities suitable for FAR (physical activity on prescription) – procured by Sweden’s regions from gyms, wellness and fitness centers and associations and then offered subsidized to those prescribed FAR by the healthcare system

School and Youth (PR)

  • “Walking school buses” under municipal authority
  • Ban on fast food restaurants, soft drink vending machines etc. within 500 metres of and within schools
  • Mobile phone ban in school during all school hours including breaks (probably positive for both studies and activity).
  • Subsidies for ourdoor kindergartens and preschools
  • Guidelines+control of served food at preschool and school: -educational meals, nutritional content and portion sizes; and training in nutritional science for all staff.
  • Playgrounds with roofs that are a little more comfortable when the weather is bad.

Society (PR)

  1. Sugar tax (18% tax on high sugar drinks in Chile),
  2. Black Dot labels on foods high in sugar, salt, calories or saturated fats (i.e. up to four black “dots” per food). Foods with several Black Dot labels are sold in separate sections inside the stores.
  3. Ban on ads for high-processed junk food and sweets aimed at children, ban all TV advertising for this type of product from 06:00 to 22:00 every day.
  4. Prohibition of mascots or toys for children associated with junk food, e.g . Tony the tiger at Kellogg’s or KinderEgg.
  • Ban on sweets, soft drinks and unhealthy snacks within 15 feet of the checkouts in shops
  • Water dispensers outside all grocery stores
  • Accessibility requirements for stairs (not just escalators and elevators) in all public environments (“points of decision prompts” -signs showing the way to the right choice).
  • Guarantee of at least five public areas for physical activity within a 500 metre radius of housing in all urban areas.

Do “everything at once”

None of the above listed measures alone will have a sufficient effect on society to make a difference. We need to implement many of the measures in parallell at the same time and on a large scale. Different actors in society need to work together, led and supported by policiesand legislation. We need to monitor which measures are effective (and which are not)but avoid getting “stuck” in decision making regarding what should be prioritised or not before we even get started. The efforts will, of course, in several cases cost money. At the same time you can expect society to also save the money from increased public health – and consider that overweight and obesity already cost Sweden a staggering SEK 48.6 billion per year and 3400 deaths.

Can you come up with more smart measures to prevent obesity? Get in touch with us and we can update the list!

Feel free to share!

Aug 30 2021
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Food labelling Chile

Obesity -who is to blame? Part 4

By About obesity, Body weight regulation, Food and drink, News, Obesity prevention, Online resources No Comments

In Sweden we have laws and regulations!

We have traffic legislation: we drive on the right, we have to take a test for a driving licence, have the car inspected regularly, drive sober, wear a seat belt and comply with speed limits. We even have special traffic police. The cars themselves are made increasingly safe, they are also crash tested.

We also have alcohol legislation; with age limits, Systembolaget, alcohol tax, warnings in alcohol ads. Tobacco is the same: age limits, warnings on packaging, tobacco tax and recent ban on smoking in outdoor dining areas. Drugs are completely criminalized.

 

Why do we have all this?

Couldn’t people just “take responsibility” and discipline themselves?

We have it because we know that without all this, people would be in harm’s way:

In Sweden, 324 people died and 2195 were seriously injured in traffic in 2018 (Swedish Transport Agency). Approximately 12,000 people die from smoking each year, while 100,000 fall ill with smoking-related disease (National Board of Health and Welfare/Public Health Agency of Sweden). About 2,000 people die as a direct effect of alcohol per year, in addition, alcohol caused just over four percent of the total burden of disease in 2017 (data from the international global burden of disease(GBD) project).

Society/the government thus chooses to take responsibility for the population as a group through legislation, to steer it in the right direction. One can have political opinions on the details of the above, but no one would want to abolish all the laws and regulations. Right?

 

How much does overweight and obesity cost? More than you know

At the same time, obesity disease causes at least 3,400 deaths in the country per year. The total cost of overweight is SEK 23.4 billion per year, obesity an additional SEK 25.2 billion (report IHE). Every other adult Swede is currently overweight or has obesity(Public Health Agency of Sweden).

In response to this overweight and obesity epidemic, Swedish society is currently doing -what?

Almost nothing. (Well, we have a 15-year age limit if you want to buy a can of Red Bull and there are certain rules for what advertising to children may look like.) If we translate this approach to traffic, it would be equivalent to having right-hand traffic -but forget the rest (driving licence, speed limits, alcohol, seatbelt, traffic lights)…

We have petrol, alcohol and tobacco taxes. “Fetmainitiativet” (the obesity initiative) proposed a Swedish sugar tax, but this was dismissed by the then responsible minister,who instead wanted to see a “holistic approach”. There is still no sign of this “grip”.

On the contrary, we are unbridledly exposed to advertising of high-processed foods, snacks and sweets almost everywhere. (Public service even allowed Melodifestivalen to have pure junk food as its main sponsor this year). In my large supermarket at home you have to step 20 steps(!) from the checkout to get out of the “zone” with nothing but sweets, chocolate, chips and snacks -there is now even a mini shelf at the checkout between the merchandise band and the customer with small pieces of chocolate (just at eye level for accompanying children). No warnings, no age limits. Nothing.

The same government and society that otherwise impose traffic rules, age limits, extra taxes and warning labels choose to watch passively while the population becomes increasingly exposed to highly processed foods that we know lead to obesity disease. So now we as citizens are suddenly supposed to “discipline ourselves” and take responsibility ourselves, apparently?

This is unreasonable and in every way illogical. In addition, the problem already costs us 3400 deaths and SEK 48.6 billion every year. (Let that sink in).

 

Then why doesn’t anyone do anything?

No one “knows” exactly, but let’s speculate:

Do people realise that obesity is a disease, or do they think it is a poor lifestyle choice made by the patient? Considering Swedish healthcare professionals are basically not educated about obesity disease at all, then how much do our politicians and decision-makers know? Do they think high-processed food is harmless? How strong is the food industry’s own lobbying (quite strong, one might suspect)? How much public opinion is there to help people avoid overweight or obesity?

 

The Four Black Dots

In the next part of the series we will list our proposals for society measures, but you will get a little sample here: in Chile you have a pronounced overweight and obesity problem (75% of the adult population is overweight or obese). Since 2016, there has been an action plan in place to tackle this at the community level. The reason for this: Senator Guido Girardi, who is also a trained physician.

Chile has introduced a number of interesting reforms in this area:

Soda tax: sweetened beverages have an 18 percent tax.

The four Black Dots. If a food item is unhealthy in terms of sugar, salt, caloric content or saturated fat respectively, each of these categories results in a black stop-shaped label being put on the packaging. The customer can thus directly see if an item has zero, one, two, three or, in the worst case, four black dots. The effect is obvious and immediate: no more guessing what the small print in the table of contents really means, and extremely difficult for the producer to get around the problem via misleading advertising or the like.

Result: accompanying children often point out to mom or dad themselves that they don’t want food with black stop signs on -and the industry self-adapts to avoid the black labels. (Read more in the New York Times atricle.)

– ban on junk food advertising on radio and television between 6 a.m. and 10 p.m.

– ban on mascots and cartoon characters linked to junk food (e.g. Tony the Tiger at Kellogg’s).

So it is possible to make changes -if only the will to do so is there.

In the next blog section we will list our suggestions for action – follow us!

/Carl-Magnus

Aug 28 2021
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Obesity -who is to blame? Part 3

By About obesity, Body weight regulation, Food and drink, News No Comments

On a normal day…

On the burger joint’s drive-thru: the taste of hot fresh grilled burger, a little sweetness from the dressing and bread, salty fries, bubby cola flavor from the soda -just what I needed now! (This is what a bliss point tastes like, see below!)

At the same time, at one of our info meetings: “obesity is of course my own fault, no one has forced me to eat this much…”

Meanwhile, in a social media comment field: “fat people have themselves to blame, no one has forced them to put all that rubbish in their mouths…”

At the same time, in a boardroom: “… we see excellent growth in all markets, especially the Nordic market has developed favourably since we…”

Is all this connected? And if yes, then how? We’ll talk about that today.

 

Bliss Point

Let’s start with the meal we descibed. Now it was a Burger Meal of some kind, but might as well have been a microwave lunch, sweetened drinking yogurt or a Friday snack in front of the TV: here we need to learn about the term “Bliss Point”. The following quotes are from Svenska Dagbladet’s article series on obesity the other week:

“Bliss point is a term that describes the proportion of sugar but also fat, salt and other flavors, which is maximally alluring to our reward system. If the point is exceeded, we feel disgust because it becomes too sweet or too salty. But all the way up to the “disgust point”, the product gradually becomes increasingly attractive. The term bliss point has been used in the food industry since the 1970s when it was explored in detail.

An important discovery was when sugar, fat and salt are combined, the respective disgust point is raised and the product instead becomes super rewarding. For children, the disgust point is just over 25 per cent sugar, for some up to 36 per cent. That’s just over twice as high as for adults, and explains why products aimed at children are often made sweeter.

In addition, some ingredients can shift the disgust point upwards for other ingredients, thus increasing consumption, such as sugary soft drinks together with salty snacks.”

 

Bliss Point: the perfect combination of sweet, salty, fat

So it’s no coincidence that a Burger Meal looks the way it does – it’s the perfect, super rewarding, combination of sweet, salty and fat that releases the most rewarding neurotransmitters (endorphins, dopamine) in our brains. Once there, the various companies have gradually increased portion sizes and thus the profits – compare a burger meal in 1950 against today in the first picture, or how, among other things, our “Friday in front of the TV” habit has increased Swedish potato chip sales in the second picture:

And so the “no one has forced me” reasoning tags along, doesn’t it? This food is scientifically expert designed to produce as much reward hormones as possible in our brains every time we eat(!).

 

Study: High processed food -weight up

This spring, a very well-crafted study on just that was published by Kevin D. Hall in Cell Metabolism (“Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain…”). 20 adult participants, weight stable with BMI around 27, were stayed at the clinic for two weeks. They were randomized to either eat high-processed food or unprocessed food. They could eat as much or as little as they wanted. The result? Those who lived on high-processed food ate an average of 508 kcal more per day than the others, through eating more fat and carbohydrates, but not protein. After the study period, those who ate high-processed food had gained an average of 0.9 kg, those with unprocessed instead lost an average of 0.9 kg! See also the chart in the title image of the blog here above.

The study has, quite rightly, already received a great deal of attention. And note that these were weight-stable study subjects who did not have obesity, yet it becomes so obvious in just two weeks.

So you see, it’s all connected! Developing overweight/obesity is not the individual’s “fault”, our food society is today like an ingeniously rigged minefield with “bliss points” everywhere. (And so far, the government is doing nothing about this basically, but more about their responsibilities in the next blog section).

 

Big business

So to the boardroom we mentioned in the beginning: who are these companies?

Well, it’s Nestle (including Mövenpick and Dreyer’s ice cream, PowerBar, NesQuick, KitKat, Smarties), Pepsico (including Tropicana, Mtn Dew, Gatorade, 7Up, Pepsi, Pizza Hut, KFC, Taco Bell), Unilever (including GB Glace Group, Ben&Jerry, Knorr, Becel), Coca Cola (Fanta, Sprite, Monster, VitaminWater, etc.) -add the companies Mars, Kellogg’s, Kraft, McDonald’s, Restaurant Brands Int groups (including Burger King and Tim Horton’s), Orkla Foods (OLW m.m.) and a couple more and you have the majority of all processed foods in your own store at home.

This is big business –nothing is left to chance. Including our taste buds and reward systems.

A hefty cynicism can be found in these large companies’ product ranges: the same companies that have had full control of “bliss points” since the 1970s, and are actively contributing to our ongoing obesity epidemic, are engaged in -you guessed it! -the weight loss industry: a quick Google search shows a market report on the globalWeight Loss and Obesity Management marketand finds some familiar companies listed there -Coca Cola Co., Nestle, Pepsico, Unilever, Kellogg’s…

So the same companies that create our highly processed, bliss point-optimized foods make sure to then also offer weight loss methods and make money off us once more, so to speak.

We can only imagine how perfectly orchestrated these companies feel that it is, when the consumers who suffer healthwise from weight gain only blame ourselves -or each other..!

The next section will be about society, government and politics. What should they be able to do to help us out of this? What have other countries already done and succeeded in? Follow us!

Aug 28 2021
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How does our way of getting around affect our health?

Obesity -who is to blame? Part 2

By About obesity, Body weight regulation, Obesity prevention No Comments

In Part 1 of our series, we talked about why the individual with overweight or obesity is constantly held personally responsible for their situation -even though obesity is a geneticly and hormonally controlled disease and not a of lack of character, or poor personal lifestyle choice. If you missed the part 1, you’ll find it here. In short: genes sensitive to obesity are the prerequisite for developing obesity, our community environment determines how many of those with sensitive genes then develop the disease.

If our increasing problems with obesity in society are not the fault of the individual, but the result of how we created our society – who or what is it that contributes to this? We’re going to start unraveling that now, starting with how we get around in everyday life:

Transport from A to B

When I went to school in the ’70s and ’80s, 90% of the pupils walked or bicycled to our school. Nothing strange about that. These daily movements burned perhaps 300-600 kcal per day. Spread over 38 school weeks of 5 days, it was actually 57,000 – 114,000 kcal in a year – just this little everyday routine. Kids don’t really do this today, do they?

We don’t see the road to school as really safe anymore – so schoolchildren today are increasingly being given a ride by mom and dad. Safer -yes maybe -but thereby you miss the 300-600 kcal listed above. If we add that during breaks or leisure time you don’t automatically play football, climb around at the playground or chase each other in general – we’ve invented smartphones and tablets with games and social media in it – then we’re starting to have a very passive everyday life for our children.

The Public Health Agency of Sweden and Generation Pep presented data on the subject at Almedalen Week last year: obesity prevalnece today is 20% among children in Sweden, the proportion of children cycling to school has halved since 1990 -while average caloric intake has increased by 200 kcal per day (!).

Microtransports

On to youth and adulthood. The same phenomenon can be found here, but in partly different guises: what was before natural was to walk -run if you were in a hurry! Or cycle distances in everyday life of 500 meters to a kilometre or two has today been given the trend term “microtransport”. The technology behind it is efficient rechargeable batteries that power Hoverboards, Segways, electric skateboards, electric mopeds, electric scooters and e-bikes – the latter, as you know, even had government subsidies until very recently(!). What they all have in common, of course, is that they are new, cool, easy to get around with, often have quite impressive both maximum speed and range -but you burn zero or minimal calories.

“Riding is easy and fun. It’s easier than learning how to ride a bike, and more fun than walking on tiny feet… Get the App”

The quote is borrowed from one of the most common electric scooter companies, many of you see these every day in our cities. Their slogan is ‘catchy’ isn’t it? ‘Tiny feet’ suggests that you can probably try it at early ages..?

Any of you who have continued (like me) to be childish enough to like animated movies? Remember humanity in Pixar’s (amazing but dystopian) Wall-E? If not, check the clip here,you’ll soon understand where I’m going with this.

What should we do to combat overweight and obesity?

Society itself must do more. There are very good examples of organised projects, such as the “walking school bus” in France where children are accompanied to and from school, or here at home by the fantastic work that is already taking place in Friskvårdsgruppen Halland – read more here!

But otherwise, we probably can’t expect smartphones, tablets or electric small vehicles to disappear -of course they won’t. They’re great -sometimes!

But they have physical inactivity – and therefore the risk of weight gain – as an obvious side effect. We need to understand that. We need to make our children understand that. Just because something exists, and can be used, doesn’t mean we have to do it all the time, does it? Next time – take a walk from A to B instead, all changes start there, with the first step you take.

/Carl-Magnus

In the next part,we knock on the door of probably the biggest culprit in our obesity epidemic – the food industry. Follow us!

 

Aug 28 2021
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Obesity -who is to blame? Part 1

By About obesity, Body weight regulation No Comments

I have been meeting patients with obesity for many years and talked to several thousand patients with obesity or overweight. What strikes you consistently, both in the affected individual and in the reactions they tell you about from their environment or previous healthcare experiences -is the discussion of guilt.

Whose fault is it… and why is it so important?

Whose fault is it that you suffer from overweight/obesity? Whose fault is it that you don’t fix the problem yourself by “moving more and eating less”? Why do patients, their surroundings and healthcare (!) over and over again fixate on the issue of who is to “blame for the problem” of overweight/obesity? We never do it in other situations?

Someone who falls, has a fracture and has to be treated in the hospital – doesn’t get cross-examined about “risky behavior” by their loved ones or their treating orthopaedic surgeon before the fracture is even casted? Someone who is stressed at work, regularly drinks alcohol, doesn’t have time to exercise -and now develops angina; the environment does not point the finger at him/her for the “sloppy lifestyle”, delaying or even refusing(!) treatment for the person to first “get their act together”..? No, the heart disease patient immediately gets the proper examination and then the most modern medications. A conversation about the alcohol, stress and lifestyle choices during the care period, too, of course, but not with a “blame yourself” attitude linked to it. And why? Because both fractures and coronary artery disease are diseases. And we have the right to treatment for our diseases, right?

Now it is just that obesity is also a disease, classified as such by, among others, the United Nations. WHO and American AMA. It’s not a poor lifestyle choice by a less intelligent person who lacks character, it’s a disease.

Who is at risk of developing obesity, and how many people are affected?

Obesity in society develops in two stages: the first step is whether you are at risk of getting the disease obesity at all or not – this is determined by your genes. If you have genes that are sensitive to our obesogenic (obesity-inducing) environment, then you are at risk. Step two is how many of those with sensitive genes who then develop the disease. It is determined by our daily environment – that is, our community. More about this in part 2 of the blog series.

Time to wake up – the earth is round, not flat -obesity is disease, not laziness

Why do we continue to stigmatise, discriminate and bully people with obesity? A strong part-explanation is ignorance. Obesity is a complex, hormonally controlled disease – but very few know about this.

Within Sweden’s healthcare educations – including the medical program! Nothing is basically being taught about obesity. Zero. Nothing. Let that sink in.

And if you don’t know anything about a condition and then meet this particular condition every day, what are you going to do? Well, you have to make something up. Hence the most common prescription “you have to move a little more and eat a little less, so…“. The idea behind this phrase is that the body is like an unintelligent machine without built-in defense mechanisms – if you feed the body with less energy but burn more, it shrinks -as simple as that.

The problem is that science has known since at least the 1990s that it is not that simple – the body has its own idea of what weight it wants, a so-called “set point for body weight” in the brain. If you starve your body, it still remembers what the set point was before you lost weight and now your body is defending itself! (if you want to know more -read here,look here or here). It’s 100% biology. 0% morality, will or character.

The earth is round, not flat. But society or health care has not understood that. -yet.

Time for change!

If you’re suffering from obesity, hear this! It’s not your fault. You’re a perfectly normal person! You live in a large body because you have genes sensitive to obesity. Need support? Contact the National Association of HOBS – they will be happy to help you.

You who bully others for their obesity –stop immediately! Have a close look in the mirror instead: what makes you bully others? What right do you have to judge someone for a disease? Do you also judge other people for other diseases?

If you work in health care, you know what a ghrelin or leptin molecule is, or what they do? No? Then you need to do your homework -it is not acceptable to be ignorant of something as common and serious as obesity. Have you ever prescribed “move more and eat less”, or “you have to lose weight”? That is not evidence-based care. You must read up – feel free to contact us if you need help to move forward.

Next part of the blog series

… it is about who can actually be held responsible for us having an obesity epidemic on our hands. And it’s not individual people with obesity – it’s completely different factors. Follow us!