If you have spent any time in the diet space, whether as a consumer or a professional, you have learned that it is a very confusing place, filled with competing ideologies about what to eat, conflicting scientific evidence about ‘bad’ foods and ‘good’ foods, food industry interests undermining pubic policy, and my favorite from personal experience, trying to get four dietitians and nutritionists to agree on essential public health diet recommendations – let alone a roomful of experts. Pile on caveats about cultural factors, sensory experiences, social customs and the dangers of creating more people with eating disorders (to name just a few more), and the reasons for a lack of clear and consistent direction about addressing the obesity epidemic become painfully obvious.
Today, Jennifer Levitz in The Wall Street Journal ledes with -
You aren't what you eat. You're how much...That's the message from a two-year National Institutes of Health-funded study that assigned 811 overweight people to one of four reduced-calorie diets and found that all trimmed pounds just the same. It didn't matter what foods participants ate, but rather how many calories they consumed…The message is that dieting may be "much simpler" than everyone thought, says Catherine Loria, a nutritional epidemiologist at the NIH and co-author of the study. Along with choosing healthful foods, "all you have to do is count your calories."
For people who are trying to lose weight, it does not matter if they are counting carbohydrates, protein or fat. All that matters is that they are counting something adds Tara Parker-Pope in The New York Times.
They are both referring to a study published in The New England Journal of Medicine this week. In the authors’ own words:
In this population-based trial, participants were assigned to and taught about diets that emphasized different contents of carbohydrates, fat, and protein and were given reinforcement for 2 years through group and individual sessions. The principal finding is that the diets were equally successful in promoting clinically meaningful weight loss and the maintenance of weight loss over the course of 2 years. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets. The diets improved lipid risk factors and fasting insulin levels in the directions that would be expected on the basis of macronutrient content. The study had a large sample, a high rate of retention, and the sensitivity to detect small changes in weight. The population was diverse with respect to age, income, and geography and included a large percentage of men. The participants were eager to lose weight and to attempt whatever type of diet they were assigned, and they did well in screening interviews and questionnaires that evaluated their motivation. Thus, the findings should be directly applicable to both clinicians’ recommendations for weight loss in individual patients and the development of population-wide recommendations by public health officials…Such diets can also be tailored to individual patients on the basis of their personal and cultural preferences and may therefore have the best chance for long-term success.
No doubt the vested interests, from diet book authors to ADM (the largest supplier of high-fructose corn syrup used in most sugared sodas and many other foods), will be trying to rip this study apart. However, from the vantage point of someone who has been involved with a number of public health approaches to weight loss, the words of Aaron Beck come to mind: Sometimes science is just the validation of common-sense. [And note that a nutritional epidemiologist is the one quoted as saying ‘it is simpler than we thought’ – who exactly is WE?]
Audience: Should we focus on children and adolescents and not tweens (the darlings of the past few years of these efforts)?
Products: How do we make it easier for people to count and track calories? We’ve had pocket-sized food calorie guides you can look value up in, or web-based systems that do the same. Food diaries to carry around with you or to complete online to detail everything (hopefully) that goes into your mouth. But these clearly have not been enough. What if you could just speak the food items into your phone and then have the calories automatically calculated and entered into a calorie app on your phone, or wirelessly sent to a web site, or appended to your personal health record?
Services: The study had people in counseling sessions over a 2-year period (Group sessions were held once a week, 3 of every 4 weeks during the first 6 months and 2 of every 4 weeks from 6 months to 2 years; individual sessions were held every 8 weeks for the entire 2 years). Anyone who has tried to do that in real life (I wish the authors had described their adherence strategy in the paper) knows the futility of doing this at scale. But, do social and mobile media offer ways around this. And what are the service experiences of participants that lead to long-term commitments to these efforts? Or is it all about the incentives that are offered?
Behaviors: How do we reposition calories against all the other factors that influence people’s food choices – convenience, taste, value (amount of food for the dollar), low fat, low carb, organic, pesticide-free? How do we make calorie counting and monitoring easy, fun and popular to do? Remember, we have about 200 opportunities a day to influence food choices.
Price: Do we revisit the fat tax idea for calorie dense foods with poor nutritional quality ? Tax supersized portion offerings in stores and restaurants? Offer incentives to employer managed food service programs that restrict the availability of high calorie food? Offer reward systems for people who successfully maintain food records or school children whose lunch selections fall within weight/age calorie guidelines? Subsidize health care provider prescribed weight loss counseling?
Place: Limit the proximity of fast food outlets (including convenience stores) to schools? Open school gyms and pools to local residents during after-school hours? Develop mobile apps that identify ‘healthy food choice locations’ based on your current location? Provide more point-of-choice programs? Offer more weight loss programs at drug stores?
Promotion: Putting calorie/serving information on the fronts of food packaging, shelf-labels or tags, and on fast service menu boards (see limits of that approach here)? Setting up SMS reminder systems of the ‘daily menu’ designed by the person on their diet website with other eHealth weigh loss tools to be delivered 30 minutes before planned meal times?
Most importantly, we need to understand what are the high leverage behaviors that are characteristic of the people who successfully lose weight. As the lead author of the study, Dr. Sacks, said in the NYT article:
The effect of any particular diet group [on weight loss] is minuscule, but the effect of individual behavior is humongous... We had some people losing 50 pounds and some people gaining five pounds. That’s what we don’t have a clue about. I think in the future, researchers should focus less on the actual diet but on finding what is really the biggest governor of success in these individuals.
And maybe some social marketers should be doing so as well. The bottom line: any low calorie diet leads people to lose weight – we just don’t know how they do it. But as we think about this as a public health issue, and not simply an individual one of a person trying to lose weight, we also need to be cognizant of the other key social determinants that are inherent in our dynamic obesogenic networks and systems.