During my recent visit to Canada, I had a chance to meet Dr. Yoni Freedhoff, an obesity expert for Evidence Network.ca and an assistant professor in family medicine at the University of Ottawa. He is also the founder and medical director of Canada's Bariatric Medicine Institute, so I figured he knew a thing or two about patient engagement when it comes to reducing obesity. What he had to say was somewhat surprising and could be useful for people who are struggling to lose weight or helping others who are.
TL: Must people be engaged in changing their behavior to lose weight?
YF: I'm a lot less enthusiastic about behavior change if weight loss is the whole driver of the exercise. It can't be relied on as the sole source solution. Not everyone is interested in change. Life is difficult. We are not in this mess because people are lazy. There's not an epidemic of laziness or gluttony.
TL: Why is life more difficult?
YF: Advertising has changed our lives, especially regarding food. It's become the touchstone of our lives. There's no event too small that doesn't encourage us to eat. Plus, there is the normalization of convenience. The ubiquity of food has been a subtle, slowing growing change. Food is always around us.
TL: What's the evidence we are eating more?
YF: We have been eating more calories per day per person among all age groups since the 1970s. We're eating about 500 calories more per meal.
TL: How does this have to change?
YF: We have to normalize eating less, not eating more. So far, this has been a behavioral change in the wrong direction. We have to educate parents that eating more is not okay for them or their kids.
TL: Has cooking gone out of style?
YF: It's normal to cook by mixing bottles, boxes and jars of processed food together. It's now normal to eat out a lot. I am more likely to meet someone who eats out three or four times a week than someone who eats out two times a month. There's so much temptation beckoning us.
TL: So then, given all these influences on eating behavior, is society putting too much blame on people for being overweight?
YF: We are in effect telling people who should eat less to stop eating. It doesn't work. People need to come to the realization that it's not abnormal to have a healthy body weight. I am opposed to vilifying obesity.
TL: What happens if we continue on this path of increasing obesity?
YF: The scenario is frightening in Canada. It will be the crumbling of health care as we know it, and this will be staring us in the face in 10 or 20 years. The costs of treating people will be enormous.
TL: How do we move away from the "blame the victim" framing to something more effective and constructive?
YF: We are going to have to make changes in the food industry, and it won't be easy. There was an initiative here two years ago to create awareness that we were consuming too many sugary drinks. They are totally unnecessary for life and are responsible for seven to eight percent of all calories being consumed by North Americans. The Coca Cola people from Atlanta came up. Suddenly the conversation changed from consuming too many empty calories to taking away our personal freedoms.
TL: What about that argument about personal freedom? It's persuasive.
YF: We have an acceptable bias against obesity. It allows the food industry to say obesity is all part of individual choice, so we've come to believe obesity is a matter of choice.
TL: Given the clout of the food industry, when is societal change likely to happen?
YF: When the cost to society from diabetes and weight-related illness is greater than the cost to politicians from speaking out against the food industry.
TL: Then you believe in taxing sugary beverages?
YF: Yes. We need a government to say "sugary drinks are not cool."
TL: Until that happens, what should be the approach to obesity and too many calories?
YF: We don't have a gold standard for weight reduction. People need to live their lives, and there comes a point when they can't eat less and exercise more. We've gotten ourselves into the problem of trying to make them achieve A+ lives when we should be aiming at Bs. People should choose the healthiest diet they can enjoy. This is not about guilt, shame or telling everyone that we should all be skinny. The upstream problems are about cooking and the lack of skills. It's about changing societal norms.
Freedhoff says that we can't lick the obesity problem one person at a time. There must be buy-in from the community. It's that thing about population health versus the health of the individual. The U.S., too, has a long way to go.