A Turkey’s Leap: A philosophical entry on Thanksgiving, obesity and healthcare

A turkey sitting in each oven basking and browning under the heat, cornucopias filled with roasted colours of autumn, the aroma of pumpkin, cinnamon and a hint of nutmeg shrouds each house, the table set and sides are ready – mashed potatoes, Brussels sprouts, cranberry sauce and gravy. Family, friends and loved ones gather together for a time of giving thanks and celebrating another fruitful year. On the same note, this day is also a celebration in a shift how we view obesity.

Not many of us know, but about one year ago today, the Canadian Medical Association declared recognition of obesity as a chronic disease. The issue was brought forth under the the precedence that this recognition would precipitate a shift in thinking: from obesity as just a lifestyle choice to a medical disease with an obligation to treat it as we would diabetes, or hypertension – because it is not just a “lifestyle choice”.

We all know that weight loss is not that easy. This month its Atkin’s, next month it’s the Juice Cleanse, then Jenny Craig or Dr.Bernestien, and let’s not forget Paleo or Raw, or Paleo-Raw diet which promises becoming Neanderthin – it’s a never-ending trial of restrictive to more restrictive in hopes of keeping the tummy off. It’s removing social events from the schedule and replacing them with $$$ elite memberships at the gym to receive personal training. By the end of the first 2 weeks it’s 5lbs off, then 20lbs slip off by week 16 but by the end of the year, we’ve gained a net worth of 10lbs and our bank accounts have lost a few too many digits. It was stress, try to juggle work and raising three kids, between dad being diagnosed with Alzheimer’s and soccer practice, there’s no time to sleep well, let alone cook meals.

The other night, I had the privilege of attending Dr.Arya Sharma’s talk at the Canadian Obesity Network YVR chapter evening. He spoke of this issue and gave me a new set of eyes. He had mentioned that behaviour modification has a success rate of 5-10% for sustained weight loss. It felt like I swallowed a rock. As a registered dietitian and a passionate health advocate, did he just belittle everything my profession had stood for? Clearly, nutrition counselling has not been effective. Seemed quite simple really, logical physics, right? We eat less and move more and the weight should come off. But then he went on to describe the body’s mechanism to fight against this caloric deficit which appeared to be the golden rule of weight loss: “Energy input vs. Energy expenditure”. Not that simple… our bodies, biology tries to mitigate this deficit we are creating with less input and increased activity (output). This is known as ‘physiology’, the interaction between biology and physics. Did you know that when we’ve created this energy deficit, our bodies reduce thermogenesis, slows down the overall metabolic efficiency and hormonal changes begin – leptin, a satiety hormone is reduced whereas ghrelin, a hormone stimulating appetite and hunger is increased. These are just the small tweaks our biology makes to fight against our will to shed the weight. This wasn’t all news to me, in fact, I was also aware that adipose (fat) tissue when increasing, does so both in size and in numbers, however, when fat loss occurs, it only does so in size. Perhaps this would be one of the reasons why re-gain is so little of a challenge. Dr. Sharma introduced the notion of ‘micro-scarring’ of neurons that regulate hunger and satiety in the hypothalamus (key homeostatic regulator of eating behaviour). This process was called ‘reactive astrogliosis’, an inflammatory response where the neurons become permanently inaccessible to new synapses – in lay terms, this is the mechanism by which our body determines a new set point when weight gain occurs. The most heart-wrenching news is that no diet, exercise, medication or surgery can undo this ‘scarring’. Kind of makes sense now, why only 5-10% of behaviour modification results in sustained weight loss, and I guess how the weight-loss business is the best kind to be in – returning customers.

So what now, it appears impossible to lose the excess weight and keep it off. You must be thinking “she had mentioned celebration” but there seems to only be morbid news, and it only gets worse when you read on. Contrary to what you may be thinking, there is most definitely something worth celebrating here, because we know more about obesity and how it works today than we did ever before. It’s only the tip of the iceberg but we are moving in the right direction, just a little slow in progress. One year ago today, when the CMA declared recognition of obesity as a chronic disease, we took a leap.

It is our hope that this declaration would stimulate more attention to efforts at prevention, and to help mobilize more funding and resources to its research and treatment. That recognizing it as a health condition would reduce stigma by the public and healthcare professionals, improve insurance coverage for obesity-specific treatment and improve training in obesity for healthcare professionals. It is too easy to romanticize obesity, to see people living with obesity as inherently lacking will, and to let fall through the cracks of the healthcare system. So on behalf of the public and dietitians: to all doctors, general practitioners and all health care professionals, please hear our plea to take all ownership of this chronic disease. Next time a patient or client walks into our office, do not send them out the door with no support other than the words ‘to eat less and move more’, treat it as we would hypertension, or diabetes. Educate them in the factors affecting their health, empower them with knowledge and self efficacy and encourage behaviour change through resources and support; show empathy and let them know that they’re not alone and that the primary healthcare system recognizes a need for treatment and that they can take their health into their own hands with the right strategies and tools.

Today, we know that obesity is not just lifestyle choice, but genetics, mental health, environment, social structure, food system, and politics all have a role to play in the precipitation of obesity. What exactly the mechanisms are still need to be explored, but we know that there is no ‘one-answer’ and hence no ‘silver bullet’. And that means there’s a call to action on a multidisciplinary level and treatment plan. It no longer is the responsibility of the dietitian to ‘fix’ obesity, but we are and continue to be a keystone player in the support system for the treatment plan and weight management. It is not that there is no hope for weight management with modified behaviour change, but on the contrary, learning the way our physiology works in response to food and eating, we can learn the skills and identify strategies to take the reigns and prevent obesity or manage the weight. Counselling skills, motivational interviewing, nutrition expertise and establishing a foundation of trust bridging between the client and primary healthcare. We are not the food police or the source of diet plans, but we are someone you can confide in to seek expert evidence-based advice on nutritious, mindful, intuitive eating habits to live a healthy life.

Here are some FYIs from the National Weight Control Registry, the largest prospective investigation of long-term successful weight loss maintenance database which tracks over 10,000 individuals with detailed questionnaires and annual follow-up surveys to examine behavioural and psychological characteristics. They found that though there is variety in how members kept the weight off, of those who were able to: 78% eat breakfast every day, 75% weigh themselves no more than once a week, and 62% have less than 10hrs of screen time a week, 90% exercising, on average, about 1 hour daily. Clearly, there is something about what we eat and do on an everyday (lifestyle) basis that has a role in weight management.

Lest us not forget that the original definition of obesity is ‘a condition characterized by the excessive accumulation and storage of fat in the body’, hence the very foundation of the condition is related health concerns, not weight, size nor BMI. And speaking of ownership, I encourage fellow RDs to step up to the plate and advocate for healthy eating habits to prevent obesity. After all, the best treatment is prevention.

Other than the beautiful meal you may have shared, I hope this was something else for you to chew on. Wish you all a warm and Happy Thanksgiving!

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