Once-Weekly Semaglutide in Adults with Overweight or Obesity, 2021, Wilding et al

I have the answer;

It's because food exists.

I start the day nauseous. I don't eat, only drink.

After a few to several hours I eat, from that point on I get hungrier and hungrier, and by night time I am ravenous.

It doesn't matter how much control I exert - and I exert quite a bit or I'd be eating all the time, it still happens.

It doesn't matter if I am full, if I ate an excessive meal only 30 minutes before, it doesn't matter if I have eaten so much it hurts, that it's difficult to swallow, if I can feel food that whilst swallowed hasn't actually made it all the way down. I am ravenous, while there is food in front of me I will keep eating it.

This is not 'ideal'. Clock watching to see if it's reached an allowed time to eat yet, not being able to eat enough to stop being ravenous, near constantly having to put less on my plate than I would like, or use little bowls instead of standard sized ones. Not 'ideal'.

The problem is food, that it exists.

Fortunately humanity seems to have a plan to cure the existence of food, by making things a bit too warm, or wet, for it to be produced affordably.

Just got to wait, they're sorting it out.

 

I'm hungry most of the time. I have no idea why.

 

I don't think I am the one moralising to be honest! I maintain my weight by episodes of strict diet about once every three years and with enough exercise to keep me from putting on weight when the season permits (which I find is about 15,000 steps a day). Exercise consistently makes a difference and when I diet I predictably lose weight at about two pounds a week. I realise that not everybody can do that but it makes no sense to say that diet and exercise are no good. They work extremely well for a very large number of people.

Obesity is almost entirely explained by food availability. In the 1950s it was very rare to see anyone obese in the UK. Obesity became common in the USA and then the UK.

 

Obesity is mainly a product of food prices vs income ...availability has something to do with it, as has the fall in manual labouring jobs but price is the main one.

https://www.bbc.co.uk/news/business-45559594

Fresh fruit and veg proportionately though now cost more. Automation has driven the cost down of some things far more than others (cauliflowers are still cut by hand in the field for example)

lower calories more exercise is clearly the mechanism for lowering weight. The problem is that cheap food (based on flour, palm fat, air, water and sugar) isn’t good for suppressing appetite (protein and fibre are).

edit: I’ve added in a report that looked at food prices over time. I’m sure no one is interested or necessarily wants to waste valuable energy reading it ...but for food nerds it might be of interest.

https://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9580.pdf

also 1950’s and rationing etc ...doesn’t explain the shape of the curve of rising obesity and obesity mapped shows a fairly clear link to poverty and income

 

A couple of maps that show obesity vs affluence

 

That seems to me closer to home than food prices. I am pretty sure that most obese people I pass in Tesco have spent a lot more on their food than we have - with trolleys full of ready-mades, meat, which we rarely eat, and huge bags of crisps and biscuits. I think the main problem is coping - which is maybe why people in poor areas are more likely to be overweight - nothing really to do with the price of food. I think at least part of the solution is likely to be reducing the never ending displays on shelves groaning with sugar-packed goodies. The sweetened fizzy drink aisle takes up about twenty times more than the wholemeal bread flour shelf, which provides about a third of all my calories.

 

The space dedicated in store is directly related to the consumption of the goods not the other way around. Every transaction at the till goes to range reviews via EPOS (till point data) and each item will have a weekly rate of sale which is monitored weekly if not daily by the category manager. If the rate of sale is too low it is cut from the range. In short ...if people didn’t buy the stuff it wouldn’t have as much space allocated. That’s my experience of 30 years doing range reviews with Tesco any way. Each range is given a full range review every year or two so to imply that the retailers are somehow pushing this stuff to consumers by the space they allocate is fundamentally wrong.

the price is definitely the main driver but as mentioned obesity has many drivers. The main issue is to bring healthy food prices down to a level that is affordable and to encourage people to eat a more balanced diet with a more appropriate amount of fibre in it. There is a vicious cycle at play.

people shouldn’t be punished for treating themselves, but it is a balance thing. Simply banning so called junk food or putting up the prices with taxes is not the answer...they need to bring the healthy stuff down. There is also an education piece and more help cooking in schools etc etc. But fundamentally if it’s all too expensive you are banging your head against a brick wall.

What is clear is that academics feeding policy from a medical point of view have singularly failed to gain traction and this is mainly because they don’t understand how the food supply chain actually works. I realise that many people would like to blame someone for this situation, however I think it will cost more money and effort than governments have previously devoted ...one thing is for sure the motley crew at Queeen Mary’s and public health England have failed spectacularly to move the dial. And part of this is their dogmatic focus on reformulation not price, advice and education.

With regards to fizzy drinks, sugar consumption of these has been declining for at least 10 years (way before the sugar tax) whilst obesity has been rising so it’s probably worth looking at the actual sales rather than observations in store.

these are general comments about obesity in general and not about pwme.

 

I've been a fat teenager --- too thin --- fat ---
I came across Michael Mosley's recommendation, i.e. extending your overnight fast, and Tim Spector's advice on increasing fibre & avoiding super processed foods. So porridge in the morning and try to have my evening meal a bit earlier - due to my poor time management it's often later. 70% chocolate time now!

So yes I agree with diets but I reckon the simple one Michael Mosley recommends, and a bit of Tim Spector; a lot of the others have no supporting evidence - a bit like recommendations for ME/CFS research.

 

Now that can't be right can it, because they are just related?

But that is my point. I am not suggesting that the drinks shelves are deliberately made longer than the sales justify. Just that this stuff is on sale. The cause and effect is: On the shelf > bought. I realise that if you reduced the number of items of a particular product you would have an empty space. But that is not the only option. One option is not to stock the item. That might reduce income but we are interested in people's health, not Tesco's income.

I don't really see that the price of nourishing food is the issue. Chicken, milk and eggs are good protein and cheap. Potatoes are cheap and so are carrots. Bananas are pretty cheap. I eat masses of bread and jam which seems to keep me perfectly healthy. Vast amounts are spent on alcohol. Food is surely much cheaper than it was in the fifties and sixties - all sorts of food.

I cannot get my head around the idea that people are eating too much because they cannot afford stuff. Surely if they ate a bit less of the bad stuff they could afford some of the good stuff? I can see why that is hard to handle, as Trish says, but I find it hard to see how pricing is the solution.

 

My diet is just cutting down on everything. One piece of toast for breakfast instead of two. One slice for lunch instead of three. No teatime snack and no second helping for supper. It isn't difficult I don't think.

 

I can stick with Michael Mosely's advice i.e. increase the overnight fast. Also, his advice was eat what you want; although I modify that to tilt towards stuff with less sugar in it - e.g. porridge is amazing since it keeps you feeling full for much longer.
I'm not great on the eat less thing though - pity since it would help.

 

Yes, my point was relating to the amount of shelf space, which is directly related to how many units are sold each week and the replenishment of shelf gaps twice a day. So to use your example if there is stock on shelf of wholemeal flour and it’s there when you come to buy it (pandemics aside) then it’s space allocation is right. If people buy more it will be given more space in the next range review. Equally if people bought less the shelf space would decrease. The food retailer doesn’t dictate what people choose to buy. They can however incentivise with price and promotions (for which there is additional space in store).

Aisles of soft drinks (with around 65% of the space being no sugar drinks) though represent what is sold.

so the point is, how do you shift what people put in their baskets which I think is the point we agree on ? The main drivers for this are price and promotion to encourage trial of something new and to encourage the shift permanently with repeat purchase. Well that is the main tool that Retailers have at their disposal. That and to develop new products in their own label portfolio. Problem with new products is the cost price of the food and the wastage on things that have a short life (particularly with the pressure on food waste). People have to buy it to make it work. And now that most consumers are spreading their shop in more than one place the basket size is dropping making new products less certain.

The problem you have is that the food industry is a commercial supply chain with many suppliers and high retail competition (most shoppers shop at 2 or 3 different food retailers). Are you proposing that someone should decide what people are allowed to buy centrally and restrict sale of goods?

and what rule would you apply? On what basis is someone allowed to buy or sell something?

Suppliers make stuff, retailers sell it, consumers buy it or not...that’s the model here and everywhere else.

Given that the food industry is one of the biggest, if not the biggest manufacturing sector we have in this country, regulating supply as suggested seems a little unrealistic. How would that even work? Nationalise the whole food industry including all 7000 food manufacturers ? ...fine a retailer that sells too many cakes?

If Tesco decided not to list say a mr Kipling angel slice multipack for instance ...would the consumer just not buy it from Asda instead? Almost certainly ...so you would have to ban mr Kipling angel slices from sale everywhere. I’m sure premier foods would have something to say about that, particularly as it isn’t harmful if eaten responsibly. Sounds like it gets into the realms of competition law.

wouldn’t it be far easier to offer some sort of incentive for consumers to eat more healthily whilst raising awareness on healthier choices to improve balance and at the same time make healthier convenience foods cheaper? I don’t have a problem with shifting unhealthy foods to more expensive prices to reduce volume, but you need to ensure that the alternatives are affordable and as attractive, particularly the convenience options at the low end of affordability.

The problem is people are also time poor. This is driven in part by household incomes shifting to dual income over the last few decades. Comparing a raw chicken breast to breaded chicken nuggets for example The nuggets win on both price (half the price of raw) and convenience. You can play that out for sausages and burgers too. It’s far cheaper to buy cake than make it at home too...because the manufacturer has economy of scale?

in terms of overall income, the poorer you are, the more likely you are to be eating less fresh food (including fruit in particular) and eating more of the low quality processed food. This is a factor of income (where proportionately you are spending more of your income on food ..around 40% at the lower end). The other factor is the higher cost generally of convenience food. Cooking to save money just isn’t an option for some. Some people also don’t have the cooking facilities if they are in temporary or shared accommodation etc. Even the more well off have to resort to convenience options. A large proportion of people are not confident cooks either regardless of income.

Why everyone eats less healthily comes down to choice (viable alternatives) and the price of convenience food.

A manufacturer can make healthier versions of things, introducing fibre for instance, however these are often a lot more expensive than the version before. So this is the nub of the issue. How to make healthier food that is the same price as the unhealthy version and if it is more expensive, how do you incentivise people to buy and try it?

encouraging people to cook at home from raw ingredients is not the answer to the wider problem. Many people decided to cook from scratch at home during lock down (mainly cake ironically) but many many more didn’t bake but ate big bars of dairy milk. Interestingly net alcohol consumption went down over lockdown. I doubt people will continue cooking from scratch once lockdown measures ease because they will become time poor again.

Embracing convenience foods as part of the solution rather than demonising them (as often happens in the press) seems to be a sensible route forward. Encouraging substitution as well may have legs, but that would require an expensive government comms campaign and some joined up thinking across defra and public health agencies.

I think to illustrate what a cul de sac the U.K. has got itself into you only have to look at the PHE sugar reduction targets. Anyone that knows anything about baking or chocolate-making knows it’s pretty difficult to remove sugar from those things let alone 20%. Doesn’t stop academics publishing papers showing variance in calories and nutrients across biscuit and cake types (that paper boiled down to a rich tea biscuit has less calories than a chocolate hob nob so everything can be reformulated to a rich tea biscuit). When challenged, a member of the Queen Mary’s academic ‘advisory group’ suggested manufacturers use fresh courgette in bakes to lower the sugar ...unbelievable (the moisture content would make that product impractical to distribute, probably quadruple the costs and make it potentially unsafe so that it would probably have to be chilled so it rapidly becomes a non -cake).

I think medical people should work more collaboratively with the food industry and perhaps we might make more progress.

 

IMO.
I agree with the timing ( some time after the 1950's) but not simply availability as the culprit. All manner of non-food chemicals have entered our food system. We really don't know how the many chemicals that are in our foods will affect us over the long term. And there are so many of them.

It's more difficult to stay away from foods with chemical additives the more you are either unwell or financially insecure or also other reasons. Having a clean diet is the privilege of those who can afford someone to cook for them if they're busy or who can afford the time money and energy to do so themselves.

 

I am not suggesting anything particularly, I am simply saying that I cannot see the price of good nutritious food as the problem. The problem is availability of harmful foods. And restriction of harmful things is very much part and parcel of our system. You cannot buy tobacco, except with huge taxes at specific outlets. You cannot buy caustic soda to clean drains except at special outlets. You cannot buy acetone at all now. You cannot just buy prescription drugs. You cannot buy cannabis. You cannot buy Chinese medicines containing lead and arsenic, at least in theory. The list goes on for ever. The foods that are the problem are highly contrived addictive substances produced by specialised manufacturing processes that really only serve to shorten people's lives. We got used to these foods in the 1960s when most people had not formed an addiction. We now see that addiction is a huge problem, just as addiction to air travel is destroying the planet and so on.

How you deal with that best I do not know but the example of the shelf length is easy. Just do not stock fizzy drinks. And it is not that retailers are forced to stock these. Some stock a lot more than others and the proportion of obese people walking around different shops varies markedly..

Chicken is nutritious and cheap. If suggest have more chicken content for the same price then it must be even cheaper to have nugget sized pieces with less of whatever is supposed to be bad about nuggets. Surely the objective is to help people lose weight - if what is preventing that is commercial interest that needs to change.

 

Well the main problem is that a fizzy drink or chicken nugget is not harmful if eaten as part of a balanced diet. It’s the quantity eaten and balance in the diet that’s harmful, so you can’t draw parallels with tobacco or prescription drugs. Prescribing food is unrealistic for all the reasons mentioned.

there is also quite a bit of evidence to show it’s not as simple as one ingredient over another (added sugar consumption going down while obesity rising etc) but that’s a whole other unpicking of misinformation.

the only real compelling correlation is amount of calories consumed has gone up and so has obesity so overall calories consumed have to come down and we know that rebalancing diet to include more fibre and protein in place of carbs and fat improves satiety. So it’s about balance not restriction.

 

There is of course more to the story. Our lives have become more and more sedentary. Children play video games and watch tv instead of playing outside. Office jobs where people sit all day. Long commutes to and from work implies less time for exercise, and less time for cooking. Convenient food is therefore more appealing.

I read somewhere that obesity is linked to inflammation and that once that settles it is much harder to get out of.

 

We will have to agree todisagree. Basically I think it is about addiction to highly contrived products that never sued to exist - like potato crisps and McDonald's.

I don't think obesity has anything to do with inflammation. That sounds like one of the current popular myths in medicine. The problem is addiction. It certainly is for me.

 

The timing of obesity is much much later than the 1950’s (in fact in the EU when additives were starting to be actively removed) 1980’s on wards. In terms of type II diabetes it is later still (shows a rapid upturn from the late 1990’s)



in terms of additives the attached that appeared in nature is interesting. We do know what goes into food (has to be put on the label etc), it’s whether there is a combination/cocktail effect that may be worth exploring. Obviously there are fundamental differences to how additives are regulated across the world. I think Canada is more like EU (precautionary) than USA (generally regarded as safe unless someone really challenges the status quo) but I’m not sure?

https://www.nature.com/articles/s41598-020-60948-w

the list from the report figure (figure 4) shows around 300 of the permitted additives. This shows that citric acid and ascorbic acid are pretty high up. Driven by soft drinks.

whilst it cannot be ruled out the total calories consumption and imbalanced diet (driven by processed foods in and out of the home) argument is more compelling I think. But it is complicated with a lot going on.