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By Duane D. Freese : BIO| 26 Jul 2020
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"Simplify, simplify, simplify," admonished 19th Century writer/philosopher Henry David Thoreau.

Considering his roots, you might think The New England Journal of Medicine (NEJM) would take a bit of his advice before giving its own advice about how to deal with obesity.

Instead, a message that most people can grasp came not in an article and commentary in the esteemed journal last month but from a California girl.

Katherine McPhee, the runner-up on this year's Fox TV's American Idol, disclosed in a June interview with People magazine that she had suffered from bulimia for five years. Only last October after she had been selected as one of the 24 Idol finalists did she seek help, realizing that the binging and purging -- which she did up to five times a day -- was taking a toll on her vocal chords.

What she found out in treatment was that such activity also could end up killing her. And what was she taught in how to deal with her condition?

"I learned that there's no such thing as a bad food," she said. "If you look at a doughnut, people think it's a fattening food -- why? Because if you eat it you'll get fat? No, you'll get fat if you eat 10 doughnuts."

Pretty simple advice, informed by the wisdom of those who have had to deal with eating disorders: Don't brand and eliminate foods, moderate your intake of them. And if you can't stop either overeating, or gorging and purging -- i.e. becoming anorexic or bulimic -- find out why. Seek help.

In place of such simplicity to deal with obesity, the NEJM wrapped itself in a modern affliction -- trying to use the law to get people to exercise more and eat less.

"Obesity," declares the headline over the journal's June 15th Health Policy Report by Michelle Mello, David Studdert and Troyen Brennen, "The New Frontier of Public Health Law."

In it, the writers claim two "triggers to action" for more government regulation -- "a scientific base and social disapproval" -- both are "now in play with regard to obesity."

Among the problems faced by those seeking regulation, though, is that "there is no food-related equivalent to harm from secondhand smoke; and no one has shown that foods have physically addictive properties," and the "notion that consumers, young and old, can choose freely from a marketplace of ideas remains strongly rooted." Nonetheless, undercutting "the antipaternalism argument is the use of these products by children."

From this the authors divine a workable strategy for more regulation:

"First, initiatives are most likely to gain acceptance if they focus on children and adolescents." Second, states need to experiment with regulations, although "[c]areful evaluation of state initiatives is needed." Thirdly, "[a]dditional research on advertising and obesity may help build the case for regulation" of children's advertising. Fourth, industry should be motivated to self-regulate "improving the healthfulness of foods sold." And, finally, "the initial regulatory strategy should concentrate on improving public awareness of the role of the food industry and the food environment -- the social, physical, and economic conditions that affect access to healthful and unhealthful foods -- in contributing to the nation's obesity problem."

"Over time," the authors conclude, "a greater understanding of the environmental influences on food choices should create the ideological conditions for further regulation." But such "progressive laws are unlikely to be implemented until the dominant cultural mores are sufficiently favorable."

It's all a bit complicated -- defining good and bad foods; developing good and bad food punishments, making people feel guilty about what they eat and restaurants feel guiltier, or fearful, about what they sell -- so it no doubt will keep these advocates busy for years to come. And if they succeed, we'd all lose weight and feel great.

Or not.

A recent study by the National Institute of Mental Health found that nearly one out of four cases of obesity is associated with a mood or anxiety disorder. In addition, genetics plays a role in much obesity. And finally, most people who lose weight only regain it -- weight cycling -- which research suggests may not be so bad for obese individual's health, but is not good for normal weight people.

Meanwhile, there is another epidemic going on -- involving 10 million people with eating disorders such as Ms. McPhee's.

The National Institute of Mental Health notes that 90 percent of those suffering these eating disorders are young women, age 15 to 24. It estimates that between 0.5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime, with the mortality rate among people with anorexia estimated as 0.56 percent per year, or approximately 5.6 percent per decade -- 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population. An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime. Many of those with one of these illnesses develop behaviors and characteristics of the other.

As with obesity, genes appear to play a role in eating disorders. A new study of twins by researchers at the University of North Carolina estimates that "56 percent of the liability" for developing anorexia nervosa was determined by genetics.

But "environmental" factors also come into play. As Sandy Szwarc noted in a TCS series in 2003, "Among the causes for them listed by the Eating Disorder Referral and Information Center of the International Eating Disorder Referral Organization and the American Academy of Pediatrics (AAP) are:

  • cultural pressures that place extreme value on thinness and obtaining the perfect body.
  • persistent messages encouraging dieting.
  • a history of being ridiculed because of size or weight.
  • preoccupation with eating and weight.
  • unrealistic expectations for achievement."

The NEJM and other actors in the Public Health Law campaign might take a lesson from Kate McPhee if they are really intent on doing good -- Don't obsess about foods and people's weights; encourage moderation. And help people find out if they have an eating disorder -- be it undereating, overeating, binging and purging, or whatever -- and encourage them to get help.

Not that they will follow such simple advice. For Thoreau also noted, "As for Doing-good, that is one of the professions which are full" -- and usually with people who just don't know when and where to stop.

In the meantime, have a doughnut -- but just one.

Duane Freese is TCS Daily deputy editor.

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