Jul 25 2011

What’s Causing the Obesity Epidemic

There is no question that Americans are getting fatter. The CDC animated graphic tells the tale – state by state statistics of the percentage of population that are obese. The big question is, what’s causing it? There are three main hypotheses, which are not mutually exclusive. The first is that activity levels are down. People, especially children, are spending more time indoors in front of computer screens and TVs and less time outside running around. The second is that people are eating more calories. And the third is that the type of calories we are eating is playing a significant role. There are two main camps in this third group: those who blame fat consumption and those who blame carbohydrates.

I do not feel that the evidence supports the third group – blaming calorie type. This hypothesis is great for selling books advocating one fad diet or another, but there is just no convincing evidence that altering the type of calories consumed has a significant effect on weight. Certainly the low-carb craze has not caused a blip in the steady rise of obesity in the country, just like the low-fat craze failed to have an effect. You can argue that this is because not enough people actually adopted an effective diet. However, if book sales are any indication, millions of people tried low-carb diets, and they do not appear to have struck upon the secret of easy weight loss. The clinical data also shows that weight loss is generally a factor of total calories, not calorie type.

It is true that Americans are becoming more sedentary, and it’s hard to imagine that this is not contributing to some degree to the obesity problem. But the data is not clear. The evidence shows an overall association between obesity and greater time spent in sedentary activities. However, recent data suggests that obesity causes lower activity levels (at least in children), not the other way around.

So we are left with the primary factor in actually causing the obesity epidemic being an increased intake in total calories. Multiple independent lines of evidence point in this direction. First of all – if we simply calculate the total amount of food being consumed by Americans it looks as if we are consuming 500 calories per day per person more than we did in 1970. Further – that increased caloric intake completely accounts for the rising trends in obesity.

If we accept that increased caloric intake is the primary culprit, then the deeper question becomes – why are we consuming more calories? It could just be culture, it could be the “supersized” fast food industry, or it could be changing trends in eating habits. One factor often raised is the fact that families with both parents working have less time to prepare traditional meals, and therefore there is more reliance on fast food, eating out, and store-prepared foods – all of which tend to have more calories.

A new study supports the notion that eating out is a significant contributor to caloric intake. The study finds:

The study determined that increased energy intake (+179 kcal/day) by children from 1977-2006 was associated with a major increase in calories eaten away from home (+255 kcal/day). The percentage of calories eaten away from home increased from 23.4% to 33.9% from 1977-2006.

This study shows that kids are eating more calories outside the home, and this contributes to greater overall caloric intake. This does not necessarily mean that such food sources are inherently more caloric – it could just mean that kids have greater access to food outside the home and this is adding incrementally to their overall calorie intake.

However, restaurant portion sizes and overall calories have been creeping up over the years. Prepared foods also compete for tastiness, and that often results in higher calories (even when labeled low fat or low carb). To address this issue there is an increasing push for labeling calories on menus. I find this extremely useful. It’s difficult to be in denial about how many calories a restaurant meal may have when the calories are printed right there on the menu. This does tend to affect food selection and aids those who are trying to estimate their caloric intake.

A more aggressive public health strategy would be to regulate the food industry to reduce the number of calories in prepared food. Such draconian measures are not popular, but as our health care system strains under the weight of the obesity epidemic such measure may become more palatable.


There is still a need for more and better research into the many questions and sub-questions surrounding the obesity epidemic, but at this point, the evidence is pointing to increased overall caloric intake as the primary culprit. There are no easy answers to this problem, but it is becoming increasingly important that we find practical solutions.

105 responses so far

105 Responses to “What’s Causing the Obesity Epidemic”

  1. Gehackteon 25 Jul 2011 at 8:23 am

    Although I’m not American (albeit close enough to the north), I find a lot of people really cant get the calories in vs calories out thing.

    Im 6 feet tall and 125 pounds(male), so whenever I discuss these issues, I’m dismissed since I just have a “genetically high metabolism” (their words not mine). However I try to explain that I just don’t eat a lot (too little obviously) and that I walk/bike everywhere. However that doesn’t seem like a good enough explanation.

    After some calorie counting, I found out I’m barely consuming my BMR. I dont dislike food, I just don’t snack, and I love food like salad and stir fries, and drink tea over anything like pop (although I have nothing against pop and have one every couple of days)

    So in conclusion, this will be one hell of an uphill battle, because people don’t like being held responsible for their own ill’s, and in my experience, will find any reason other then what actually makes you thin to become thin. As well as cast aside anything you do as a genetic pre-disposition, and not as a result of your actual actions. (disclaimer: I’m not saying there’s no genetic factors, but Im also implying its a drop of the bucket compared to your actual consumption)

    very frustrating.

  2. Rikki-Tikki-Tavion 25 Jul 2011 at 8:39 am

    In my opinion the theory that less movement isn’t to blame doesn’t sit well with the fact that we don’t have a similar epidemic in continental central Europe.

    We have McDonalds in Germany, too. In fact, the most calorie-rich we have are traditional German foods like sausages. Dry burgers with a little fatty sauce don’t compare.

    I see the root of all evil in the lack of infrastructure, and the overabundance of air conditioning in the summer. I once walked a mile through D.C. last summer and I met maybe 2 people on the way, who where rushing to their cars. Why did I walk a whole mile in the scorching sun? Because the public transportation is laughable.

    Americans are too used to a constant 20°C and they have no reason to go further than from their home/office to their car (such as a well-built subway system).

    I think the fact, that the epidemic is worst in the Midwest southern states corroborates here: There the temperatures are the most extreme and public transportation is generally worst.

    Further reading: http://en.wikipedia.org/wiki/Obesity_in_the_United_States

  3. banyanon 25 Jul 2011 at 9:22 am

    A simple but politically difficult partial-solution would be to eliminate the corn subsidies in order to drive up the price of meat.

    Corn subsidies have made the cost of raising lots of cattle or lots of chickens almost nothing. As the cost of beef has gone down, fast food chains have hit a floor in terms of price competition for a hamburger. So instead of making the burgers cheaper, they compete by making them bigger.

    That trend has left working families with the choice of spending $X on ingredients and putting in the time to cook and spending the same $X dollars on a big burger or big bucket of fried chicken without any time spent in preparation.

  4. BillyJoe7on 25 Jul 2011 at 9:31 am

    The comments are going to be full of personal anecdotes, so why not:

    In my mid twenties I was a 50kg (110lb) weakling.
    I took up running and eventually ran about five marathons in as many years, at the end of which I weighed 60 kg (132lbs)
    I guess that was all muscle.
    Then came the kids and no time for exercise and my weight increased to 70kg (154lbs)
    That was defintiely fat.
    When I again had the time to exercise, I took to walking and running through the local hills and dropped my weight to 65kg (143lbs)
    Which is ideal for my height.

    I can eat whatever I like and easily remain at this weight. However that means running for an hour every morning and walking and running throught the hills for 4-5 hours every Sunday. Luckily I love doing that, especially Sundays through the hills.

    On the other hand, over the past twelve months, my wife reduced herself from obese to skinny (like when I first met her :)) simply by cutting out all fast food and all snack food.
    She does not exercise. She hates it with a vengeance.

  5. daedalus2uon 25 Jul 2011 at 9:41 am

    I don’t think the data supports the idea that less movement is causing obesity. I appreciate that there is a strong correlation in many groups, but not in all. The one group where less movement can’t be causing obesity is in infants. Infants are not mobile. Infants can’t move. If infants are getting obese, it is not because their movement patterns have changed because they haven’t.

    Infants are not susceptible to marketing information. Infants don’t choose to go out to eat. Infants don’t choose their own food or prepare their own food, and mostly don’t feed themselves. Infants do self-regulate how much they eat by stopping eating when they are replete.

    I see the obesity problem as being due to a breakdown in the physiology of the signaling of when the person is replete. If the signal that one has eaten enough doesn’t get through, then one can continue to eat. If the signal to eat (hunger) persists after one has eaten enough, then one will be compelled to continue eating.

    The obesity problem has to be a “setpoint” problem. If one consumes 100 extra a day, then in 35 days there will be an extra pound of depot fat. In 350 days there will be 10 pounds and in 3500 days, 100 pounds.

    The signaling of energy status is largely through nitric oxide signaling pathways. Low NO is a signal of low energy status. Stress is a low NO state, consuming extra food during stress may be signaled through low NO. Acute fever is a high NO state, not consuming food during fever and illness may be signaled by high NO.

    Green leafy vegetables have a lot of nitrate (few tenths of a percent) which helps maintain the appropriate NO status the organism is trying to maintain. When physiology is trying to maintain a low NO status (as during stress), avoiding things that will raise NO status is to be expected; explaining the observations of avoiding green leafy vegetables (NO from nitrate), avoiding increased heart rate (high velocity blood flow increases NO production), avoiding sweating (ammonia in sweat is converted to NO/NOx by resident AOB biofilm (lost in modern lifestyle)), avoiding sleep (sleep is a high NO state).

    If the obesity problem is a setpoint issue, nothing except correcting the setpoint is going to fix it. The setpoint is too strong, it has to be to prevent organisms from starving. When the setpoint gets messed up, such that individuals can starve themselves, then you get eating disorders which have the highest mortality of any neuropsychiatric disorder. Trading obesity for an eating disorder is not an improvement.

  6. locutusbrgon 25 Jul 2011 at 9:43 am

    I have little doubt that Americans are getting heavier. I do think there is cause for debate as to how much. There was a change to the yardstick, BMI. I have noted that at both ends of the height spectrum there is a visible disconnect between categories and body fat percentage. You could argue that the US has a relatively unique population mix. The BMI scale is based upon world wide averages. Still other measures “BAI” show increasing obesity just not as great.
    I am also questioning the cultural, and genetic impact that a large increase in the Hispanic population has had upon these figures.
    I know from personal experience over the last decade, that poor nutritional choices are much cheaper than good nutrition. I have not done, due review of all data, and this is not my specialty. Still I think that the problem, and possibly the cause is dispersed among many factors. Always it boils down to calories in/out which is simplistic. In my opinion people like simple answers and easily identified factors, but that does not sit well with this problem.

  7. taustinon 25 Jul 2011 at 9:51 am

    The article you link to talks about increasing obesity rates from 1985 to today. I presume that, in this context, obesity is measured by Body Mass Index averages, which seems to be the current medical standard. But neither it nor you mention that, in 1998, the definition of obesity changed, and literally with the stroke of a pen, 25 million American who were not overweight in 1997 suddenly were in 1998. I’ve never once seen someone talking about the obesity epidemic who was willing to discuss that. It makes it hard to get meaningful data on the subject.

    Do you have any links to data on changes in actual average weights, rather than BMI categories? How much more do Americans actually weigh, in pounds, than they did in 1985?

  8. Dile T. Tanteon 25 Jul 2011 at 9:52 am

    My understanding is that genetics plays a role in obesity (as described in Wikipedia , for example). Is it possible that changes in the genetic makeup of our population as a whole could be a factor in the “obesity epidemic”?

  9. ccbowerson 25 Jul 2011 at 10:15 am

    Steve is right on on this topic. Although the data aren’t perfect, most studies looking at this issue do point to caloric intake as the primary factor (versus activity).

    It does make sense considering how easy it is to easy it is to consume calories that don’t impact satiety much (e.g. soft drinks and dessert), and how hard it is to ‘burn’ those extra calories. For example if someone decides to opt for a cheesecake from the Cheesecake Factory (you’d have to eat only half your entree to have room) you are looking at adding an extra ~1000 calories. You’d have to do a couple of hours (~2-3) of strenuous exercize to ‘burn’ that many calories. How easy is it to opt for the dessert versus hours of exercize? Do that 3 times a month and there is an extra pound (obviously its a bit more complicated than that, but it makes the point)

  10. amysrevengeon 25 Jul 2011 at 10:20 am

    Regarding calorie types…

    Strictly speaking, 1 calorie = 1 calorie, regardless of its source.

    I’ve been led to understand (and just accept without skepticism lol) that there is a secondary effect to calorie type that comes into play though.

    Calories from fat (and carbs) are less filling than calories from protein, and so you eat more of them.

    Dunno if it’s true – it’s just what I’ve been fed, so to speak.

  11. elmer mccurdyon 25 Jul 2011 at 10:21 am

    fwiw I think the theory behind low-carb was not that carb calories contributed more to weight gain, but that cutting carbs would make you less hungry and eat less as a result.

    Anyways, as a (very mild, diet-controlled) diabetic with a sweet tooth, I appreciated the sudden ubiquity of sugarless sweets. I miss those days.

  12. locutusbrgon 25 Jul 2011 at 10:25 am

    ccbowers makes a very good point. I think that 185 lb male has to run 8 miles at a 12 mph rate to equal the calories in 3 slices of pepperoni pizza. A lot of people can easily eat three slices of pizza. Only a small percentage can run 8 miles at all. Our bodies are very efficient machines and you can easily out eat calories expended. Activity is important for overall health but fails to be main factor in obesity.

  13. Steven Novellaon 25 Jul 2011 at 10:44 am

    taustin – that point comes up a lot, but it is just factually incorrect. The definition of obesity has not changed, and the cutoff of a BMI of 30 is consistently used in the CDC graphics I linked to. The cutoff for “overweight” is what changed, to bring the CDC definition in line with the WHO definition.

    I write about it in detail here: http://theness.com/neurologicablog/index.php/obesity-denial/

  14. Geoffrey Charleson 25 Jul 2011 at 11:59 am

    This study:


    seems to support your conclusions.

    However, popular media’s reporting on this study seems to somewhat contradict them:



    Or, perhaps I, a layperson, misunderstood the study, and the media is actually correct?

  15. KeithJMon 25 Jul 2011 at 11:59 am

    Dile T. Tante, there isn’t any way for a genetic mutation to suddenly appear to a large percentage of the population in a single generation. You’d need serious evolutionary pressures (like, a mass die off of everyone who doesn’t have the gene) or a tiny,tiny population to have a change sweep through a population that quickly, and even then one generation isn’t long enough for the genes to pass down to anyone but the children of the original mutator.

  16. steve12on 25 Jul 2011 at 12:25 pm

    I try to keep my scientist hat on here, but it just keeps falling off for personal reasons.

    I have trouble keeping my weight down Ideally I’m 6″ 205 LB , which is what I was in college when I was a swimmer. Now I do triathlons, and I really have to watch my weight – I’ll go up to ~220 after Xmas if I don’t.

    Ya know why? Because I ate like a pig! Then I don’t (and I train) and I lose weight. Problem solved – it’s called thermodynamics. I’m sure we could refine the relative contribution of each of the 3 factors above, but in the end people have to stop stuffing their faces with Taco Bell and Ice Cream. I do agree that US agra policy allows people to hitch up to bigger feed bags for less cash, and should be changed, but people in America have to stop eating at some point and do something else.

    Just look at the choices obese people make IN THE GROCERY STORE. We’re not talking about reaching for something they’re going to eat now, this is planning. And they plan to drink soda and eat chips – a lot of chips.

    The only relevant science I see is how we can change beahvior – because that’s the problem.

  17. etatroon 25 Jul 2011 at 1:03 pm

    Steve – I agree with your assessment in general. I also agree with your prescription.

    However, I run into an argumentation problem when I discuss this issue with others.

    There’s an assertion or belief that someone’s weight or health is their own business and them choosing to eat unhealthy food and gain weight is not MY (or OUR) problem, it’s theirs, so it’s not my place to tell them what to eat or do. Government interventions like regulating (which has become an evil word in US lexicon) the food producers to insist on lower calorie food would be seen as a governmental overreach, and the “nanny state.”

    To bring people around to agreeing with prescription (or proscription?), you’d have to bring them around to a mindset of collective well-being, collective governance, responsibility to your neighbor, a concept of the “public good,” or “public welfare.” It’s very difficult to do, I often quote the Preamble of the Constitution, “promote the general welfare,” is one of the purposes for forming a government. At this point people shut down and it’s all about ‘stealing their freedom to choose.’

    Perhaps changing the discussion to children might help because they cannot choose. Most reasonable people agree that they are marketed to very heavily to desire consuming high calorie, low nutrient food, and if we can agree to regulate tobacco and alcohol marketing to children, maybe we can agree the same on food. Perhaps that’d be an incremental step.


  18. Enzoon 25 Jul 2011 at 1:25 pm

    Activity is important for overall health but fails to be main factor in obesity.”

    Well said by cc and locutus. Though I suppose activity coupled with diet has to be the main contributor when combined. Plenty of people burn a higher-than-average number of calories in vigorous daily exercise yet their diets would not be considered calorie-heavy when compared to an average diet. The same type of person (heavy exercise) can still be overweight when eating an average diet. I guess it’s also a matter of what weight your body stabilizes in once you’ve settled into a routine of physical activity and diet.

    My personal opinion is that the epidemic probably has a lot to do with individual fullness levels being pushed. I wonder if part of the epidemic is simply a cultural reaction to increased portion size as Steve alludes to. You get more so you tend to eat more, even if the food is considered healthy. Eventually one becomes used to getting more and so even when you cook yourself, you eat more. This coupled with routine snacking, etc.

  19. daedalus2uon 25 Jul 2011 at 1:29 pm

    There are two aspects to food choice, what to eat and how much to eat. Both choices are controlled by physiology. With access to a large variety of different foods with sufficient nutrients, deficiency disorders are very rare. What this tells us is that humans spontaneously self-select a diet that provides enough of each nutrient that they require. What this implies is that the physiology of the self-selected diet process somehow compels selection of the “right” foods in the “right” amounts to avoid deficiency disorders.

    Wild animals must also have physiology that results in self-selection of a diet with sufficient nutrients. Wild animals are not conscious and self-aware, so the self-selection of diet does not need to occur at the level of consciousness.

    If people are eating too much of the wrong kinds of food, there must be a problem with the physiology of the self-selected diet process.

    I appreciate that people don’t want to appreciate that it is physiology that compels consumption of which foods and how much, and that instead it is some sort of “free will” and that people who eat such that they are obese have a deficiency of the right kind of “will” that whose who are not obese do not lack. We know that what ever that type of “will” is, it is instantiated by physiology.

    The NEJM article is interesting. It shows that people who self-select certain foods also self-select to eat too much of them. To me, this strongly suggests that there is a problem in the diet selection physiology. If the diet selection physiology was skewed only in terms of quantities eaten, I would expect to not see diet choice skewed toward high carbohydrate and high glycemic index foods. There is such a skewing, to me that implies that physiology is skewing food selection to facilitate achieving and maintaining a high blood glucose level. A high blood glucose level is characteristic of high stress, and characteristic of the fight or flight state.

    Under conditions of stress, people eat “comfort foods”, which typically are sweet, to recapitulate the archetypal placebo of being nursed. Is the desire to eat something sweet when under stress an example of a dietary self-selected food to facilitate raising and maintaining a high blood sugar as an adaptive stress response? If so, then telling people who are stressed to not eat what relieves their stress is not going to work very well and may even be counterproductive.

  20. Rikki-Tikki-Tavion 25 Jul 2011 at 1:35 pm

    There’s a fault in your logic here: You assume, that in order not to get fat, you would have to burn all the calories you eat by walking. But that’s not the case. People get fat because they have a (sometimes slight) surplus in their calorie intake, say 50 ckal/day, not because they eat three slices of pizza more than they burn. That surplus accumulates over years and people get fat. If they walked for a kilometer or so a day, they can burn a decent surplus.

    If you want to lose weight quickly (different matter) it would be smarter to swim if you have a pool near your home or work. The water drains the body heat and thus makes the body consume calories without you really having to do much. Of course additional movement helps.

  21. steve12on 25 Jul 2011 at 1:40 pm

    @Erick – couldn’t agree more

    “At this point people shut down and it’s all about ‘stealing their freedom to choose.’’

    This is a big part of the problem. I don’t want to get into politics too much, but farm subsidies somehow fit into the smaller gov’t model while non-mandatory public health campaigns are Tyranny. We need to fix this.

    In the end, people need to take in fewer calories, and that’s pretty much that. But let’s face it – Americans don’t do moderation that well.

  22. steve12on 25 Jul 2011 at 1:59 pm

    But Daedalus, for most people, our selection bias is always going to be toward high calorie foods because of the relative rarity. In “the wild”, if you found a gallon of ice cream, you should eat the whole thing! All that fat and protein is precious.

    And the same physio drives are present in Europe and America. Obviously culture drives are not free will, but that end of the whip is not putting food in one’s mouth. And people with high locus of control always do better at things like weight loss and keeping weight off.

    And I do think we have free will at the ecological level that we actually live in, though I realize that this is an invitation to an intractable debate:

  23. SARAon 25 Jul 2011 at 2:02 pm

    Speaking form A LOT of personal experience: I used to weigh 400lbs and have been overweight since elementary school. I have tried just about every fad, scam or legitimate program there is.

    At age 33, I finally had a gastric bypass. I lost weight BECAUSE I TOOK IN LESS CALORIES.
    I didn’t exercise. I ate less.
    I didn’t watch fat or carbs – I ate less.

    The key isn’t the diet – most of them will work if you stick to them, because under all the blather – they are generally lower calorie diets. .

    The issue is sticking to a diet. That issue is far more complex. That is why we have an overweight society. You will find the majority of people understand that they need to eat less. But most don’t do it consistently. Lack of will power – caused by psychological, physical and social issues. A nice blend of those in various forms and degrees is what is stopping us.

    Knowledge is good, but it won’t stop people from eating.

  24. ccbowerson 25 Jul 2011 at 2:09 pm

    “It shows that people who self-select certain foods also self-select to eat too much of them.”

    That probably is true, but the conclusion from that is far from clear. Part of it is that some foods are easier to eat more calories (therefore easier to overeat). Similar to a ‘resolution’ analogy, an extra scoop of ice cream verus a few more blueberries will have different impacts on caloric intake. Also peoples’ food choices tend to go hand in hand with attitudes about foods (therefore behaviors) and other lifestyle factors that may impact weight.

  25. mufion 25 Jul 2011 at 2:11 pm

    I have family and friends who are overweight, if not obese, and I trust them when they tell me that a life of calorie-counting is a miserable one; i.e. that it’s preferable to try to make peace with the perception of “being fat” and to live as healthily as possible from that standpoint (e.g. by making efforts to increase physical activity and substitute more nutritious meals for less nutritious ones, but without necessarily ever achieving a recommended BMI).

    Of course, that resolution won’t make all of the health risks of added weight just go away. But it’s easy for me – as someone who eats and exercises in an intuitive and spontaneous way, while somehow always maintaining a recommended BMI – to say that it’s all about caloric inputs vs. outputs when I never have to worry about either.

    That said, I did read a book a few years ago by consumer behavior professor Brian Wansink, called Mindless Eating: Why We Eat More Than We Think, which suggests other techniques for reducing one’s calorie intake besides counting. Still, easier said than done.

  26. rezistnzisfutlon 25 Jul 2011 at 2:55 pm

    I have to disagree that food choices don’t make a difference and its simple cals in v. cals out. I’ve been a physical trainer for many years as well as competed in bodybuilding competitions, and not to get too anecdotal or argumentative from authority, the types and distribution of calories consumed plays just as much a role in body composition as does the quantity of calories consumed on a daily basis. Primarily, and put rather simplistically, it’s because what we consume has a direct effect on the endocrine system and the endocrine system governs the human body.

    As a skeptic myself, I follow the scientific literature on fitness and nutrition pretty closely, and what I’ve observed is that there’s a big disconnect between what studies are performed by the scientific community and what is applicable to everyday life for ordinary individuals, especially in regards to fitness and sports nutrition. Most of the research currently available in nutrition is in the field of dietetics, where the emphasis is on proper and adequate nutrition for inpatient and outpatient healthcare, not on healthy individuals and athletes, and there are even fewer long-term studies of specific nutrition regimens. For instance, look up journal submission on how protein consumption effects renal function, and you’ll get 20 articles on how it effects kidney patients to 1 incomplete, inconclusive and short-term study on healthy populations.

    How do the food choices affect health and body composition? For example, a person who eats a consistent diet of high-GI, heavily processed carbs along with generous portions of fats will have constantly elevated insulin levels, often well past where myocites, etc, have become insulin resistant. The carbs will spike insulin levels while the fats slow gastric emptying to the point where the digestive system is extending release of glucose into the bloodstream, keeping insulin levels high. On the other hand, a person who all but eliminates fats from their diet will have reduced hormone function as hormones are produced from dietary fats.

    Truth of the matter is, most people have no idea what they’re eating, how much, and the effect food choices have on their system. In fact, most people have next to zero knowledge on nutrition and fitness, period, and that’s evident with the obesity epidemic today. I’ve had countless clients tell me they had no idea they were consuming so much after I had them keep a food journal for a week, and by simply keeping a journal, they learned a tremendous amount about foods, nutrition and the role it plays in their life.

    Unfortunately, most of what people get for “nutrition education” comes from television via paid advertisements, which accounts for the junk supplement and so-called super food industries being multi-billion dollar industries. What the government gives in health class is woefully inadequate and grossly outdated (food pyramid anyone?) and what’s being taught at many universities in dietetics isn’t applicable to a healthy population. Dr. Novella, perhaps you could corroborate this, but some of the physicians I’ve spoken with have told me that they receive very little nutrition and fitness education in medical school, and unless someone specializes in it, retain very little of what they learned during that time anyway. It’s amazing some of the terrible nutrition advice medical practitioners have given to clients of mine (assuming what the clients were reporting accurately represented what the physicans actually said).

    Not to belittle medical science as I have great respect for the amount of education and training most professionals receive, but I believe that their nutrition training is truly lacking. All one has to do is visit a hospital and see the state of physical fitness the workers there possess, it’s in line with the general population! These people should be serving as examples by maintaining healthy lifestyles. But, that’s just my opinion.

    So, I’ve made it somewhat my position that education is key. Separating what’s real from the myriad junk science, advertising, and bad advice that gets passed word-of-mouth (everyone’s an expert it seems when it comes to fitness and nutrition). Just like with, well, pretty much everything else, people should verify what they’re being told by educating themselves independently when claims are made, and for the most part those giving advice should be able to back up what they claim with some sort of evidence, and freely present further corroborating literature on the subject.

    I’ve heard many, many discussions and opinions on why there’s such a problem with obesity, so I’ll throw in my 2 cents to this one. I think it’s a complex issue that has more than one factor. I think that in general people are far less active than they used to be, consume way too much of the wrong kinds of calories, aren’t educated enough on the subjects of fitness and nutrition, and are bombarded with the wrong kinds of information all day long by advertising media who’s primary goal is to take their money. Most people also don’t have the willpower to give up their unhealthy lifestyles. Also, very unhealthy, tasty, cheap, and convenient foods are readily available anywhere, whereas healthy foods tend to be a little more expensive and require more effort to prepare.

  27. ccbowerson 25 Jul 2011 at 3:46 pm

    “I trust them when they tell me that a life of calorie-counting is a miserable one”

    I don’t think that the lesson here is that calorie counting is the specific solution for most people. Its not practical for most since most people don’t want to live in such a regimented way (me included).

    The important thing is to recognize that increased intake of food calories is the major problem for weight, and portion control (via whatever mechanism) and/or changes to what is eaten are the approaches that should be taken. How best to do this is another large question, but individual should go with whatever appears to work given their circumstances.

  28. ccbowerson 25 Jul 2011 at 3:56 pm


    Many people think the way that you do, and what you are saying isn’t that far from what the average educated person thinks. You have some good points which are true, but the relevant current evidence does not support your conclusion that its all about “wrong kinds of calories.” Sure there are likely many factors, but the evidence pretty clearly supports the increase caloric intake as the major factor (versus activity) in regards to weight. That does not mean that cardiovascular fitness is not important for other reasons, but that is another question.

  29. Bronze Dogon 25 Jul 2011 at 4:03 pm

    I’m currently trying to cut down on portions, myself. For cooking frozen food, I usually have a compulsion to fill up my toaster-oven’s tray. I’m going to resist that urge.

  30. Steven Novellaon 25 Jul 2011 at 4:18 pm

    rez – to be clear, weight is all about total calories in vs out. But other health parameters, like glycemic control and heart healthy, are affected by other factors. Athletic performance can also be influenced by food choice – as that is not about just being healthy but pushing the body to physiological limits.

    For the average healthy person, all the endocrine, metabolic, hunger issues do not seem to make a significant different to weight control, which is dominated by total caloric intake and activity level.

  31. jt512on 25 Jul 2011 at 4:49 pm

    Steve, regarding your last comment, I agree with you that change in body weight is strictly a function of caloric intake vs caloric output. However, there’s a question of how these two variables are regulated. Clearly, hunger drives caloric intake, so a diet that is more satiating will tend to lead to lower caloric intake than one that is less satiating. In other words hunger matters, and there is certainly evidence that the composition of the diet effects hunger.


  32. Rikki-Tikki-Tavion 25 Jul 2011 at 4:50 pm

    In the end, you’re right of course. In=out+weight gain , that’s thermodynamics. But it gets tricky when you factor in, that “in” and “out” are mutually dependent. If you take in a few calories before you get active you can perform better and thus burn more calories, possibly compensating the initial added calories. Conversely, if you eat very little, your body saves energy, lowering the dieting effect.

    I don’t have time to research this right now, but I think it’s backed by studies.

    Also, an unpealed apple, for example, takes more energy to digest than it provides. You can use that to trick your body into going into the high energy mode.

    I share rezistnzisfutl’s opinion that research on the topic seems to be lacking, although I’m by no means a body builder.

  33. nybgruson 25 Jul 2011 at 5:00 pm

    I suppose I can contribute to the anecdotes here as well:

    I was a very skinny kid, right up until I started elementary school. Then I had access to extra food (which was usually chips and other junk, of course) and peer pressure. When mom packed me lunch, which was usually healthy and well portioned, I was made fun of. I would trade lunch items, or just not eat it and get chips and snacks. So by the 2nd grade I was a bit chubby. It just kept compounding year on year. And of course, once you get used to certain foods you want them at home and I made my mother buy them, often over protest. They then became used as incentive to do chores, schoolwork, get good grades, etc.

    By high school I was obese. I finally settled into a 6 foot (183cm) frame and weighed about 225lbs (103kg), give or take. I tried dieting, and it didn’t work. I once got really bad bronchitis and could barely eat for almost 2 weeks. I dropped a LOT of weight. I swore I would keep it off. I didn’t. I was even part of the swim team and water polo team (because my parents made me) and regularly attended practice, swimming, running, and lifting (not very well mind you) but still fat.

    In college I ballooned up – even more access to food. I went up to around 250lbs (112kg). At one point I started playing a lot of raquetball and dropped down to about 205 and looked pretty decent. Then right back up to 250 two terms later. And that is the way I stayed. I was actually convinced that I was “big boned” and so I was chunky but not FAT. I was given a shirt that was a medium and was certain that no matter HOW much weight I lost I’d never fit into it, I was just not the right frame.

    Then I had a skiing accident and dislocated both my knees. Unable to walk for almost a month, something in my head clicked and I realized if I was this fat now, if I couldn’t walk for a while, I’d be a whale. So I changed my diet. I went hardcore Atkins – thinking that would be best. I dropped 15lbs in a month without being able to walk. Then I decided to start cycling to rehab the knees and try and exercise more. I fell in love with it, and was cycling 7 days a week. In 4.5 months I dropped almost 80lbs. I was so thrilled with it, that I became a really avid cyclist. I was putting in 300 miles+ per week, plus running, lifting, and surfing (I learned to surf and loved it).

    Back then, I actually really had to monitor what I ate, because as Dr. Novella said, I was pushing myself to the limits. I became extremely lean (even had a 6-pack for a while), and if I didn’t eat enough and right, I could feel it.

    Now, I still cycle a lot and I run to the hospital when I need to be there, but I don’t exercise like I used to. I also don’t eat like I used to. I basicallye at whatever I want, throw in a fair bit of greens, even have some dessert…. but I eat VASTLY less than I used to.

    And that is all it was. When people would ask me how I lost the weight, I said, “I ate a LOT less and exercise a LOT more.” They never like that answer. But it holds true. Over the holidays I barely exercised and ate like a pig because I was back home (and I drank a lot of beer because we have two kegerators with 2 taps each so yeah….). And I gained 18 pounds in 3.5 months. Then I got back to school, started my regular schedule, and dropped right back down to my previous weight in about 6 weeks. All because I ate normally again.

    Also, when I do eat an exorbitant meal, I actually do go for that 5-10k run or put in 50-60k on the bike the next day.

    My take is that certain diets can help keep you from eating more calories, but mostly it is the regimen. The problem is people think of the diet as a means to an end, and then when they reach their target weight they stop. And then they get fat again. What they don’t realize is that the diet can’t merely be a means to and end – it has to be a lifestyle change. It was the basic lifestyle and food and exercise choices that got you there over YEARS. Doing a diet for 6 months and then going right back to the way you were beforehand doesn’t work. It CAN’T work. But that change is crazy hard. I know from personal experience. But once you do it, hopefully you can sustain it. It has been 4 years next month since I first lost the weight and I have never been above 195lbs in those 4 years (I usually hover around 180). But that is because I consiously changed the way I THINK about food and exercise.

    Anything else (like good calories vs bad calories, carbs are bad, fat is bad, meat is bad, whatever) is just a delusion to distract you from the real problem – how you eat is bad.

  34. BillyJoe7on 25 Jul 2011 at 5:27 pm


    “I think that 185 lb male has to run 8 miles at a 12 mph rate to equal the calories in 3 slices of pepperoni pizza.”

    Actually, it doesn’t matter how fast you run.
    (And it doesn’t matter what sex you are either ;))



    Hey, now that you are in Australia, you must learn to say ‘mum’ 😉

  35. Mlemaon 25 Jul 2011 at 5:49 pm

    National problem? National diet! Yeah, it’s high-calorie fast food. Yeah, it’s super-sized portions. Yeah, it’s lack of inexpensive fresh produce for poorer neighborhoods and lack of time to prepare by stressed working parents. But, in my personal, non-scientific opinion, it’s all about the refined carbs. Sugar is like a drug. People who eat white rice and pasta, soda pop, processed food of every kind where sugar is a ubiquitous ingredient, become addicted to it. The more you get, the more you want. It’s the up and down of blood sugar, and encourages higher calorie intake. If you’re raised on such a diet, whole grain “doesn’t taste as good”. And if you have to go a day without sweets, you have withdrawal! We also have a diabetes II epidemic, which of course is related to obesity, but also shows up in more people nowadays who aren’t necessarily overweight. Exercise helps not just because it burns calories, but because it quells appetite and helps stabilize blood sugar. Also, with overeating at least partly due to stress and lack of sleep, exercise can help combat causes of “comfort” eating. So, yeah, it’s about calories in vs calories out, but I think when it comes to the cause of too many calories in, the national problem is the presence of refined carbs in just about everything we eat. It goes by many names, but if you start checking labels you’ll see it everywhere. Used to be hard to find it in frozen vegetables, but now frozen veggies come all pre-dressed with a salty, sugary, fatty sauce that coats them when you zap them in the microwave. People think, “hey, I’m getting my veggies”. But they’re still craving a cookie a couple hours after dinner when their blood sugar dips. Also, more people used to smoke. That keeps you skinny as the nicotine depresses your appetite and increases your metabolism. And isn’t it true that storing calories as fat is a response stimulated by high blood sugar? So that perhaps you might eat as many calories of a lower-glycemic food and your body would not act as quickly to store calories from that food? Like i said, not scientific. But the national diet contains an abundance of refined carbohydrates, and I personally believe that contributes to overeating and obesity. Sugar is one of the cheapest foodstuffs. It adds calories and substance weight to packaged foods more cheaply than more of the main product would do. And it keeps ’em comin’ back for more! Mmmmm!

  36. steve12on 25 Jul 2011 at 5:53 pm

    I do realize that I came off a little strong earlier about people simply needing to eat less w/o being sensitive to how difficult that can be.

    But I really believe that a big part of any behavioral intervention that’s going to work is the notion that no one can ultimately stop someone from eating but themselves. Put aside high minded ideas of free will, etc. or what responsibility actually means for a second, and I think this is clear.

    I’ll keep t he reasoning-by-anecdote going here: I’ve never seen anyone who struggled with their weight succeed by externalizing the problem – even if they’re right. I’d even go so far to say that it’s pre-requisite that one place responsibility on themselves (even is that is ultimately an illusion).

    A question I cannot answer, however, is how do you get someone to do that?

  37. SloFoxon 25 Jul 2011 at 6:50 pm

    Despite the plethora of anecdotes and the evidence provided by Novella and others I think we’re still quite a long way off from understanding the ultimate cause of the obesity epidemic (proximate cause is, of course, caloric intake > output).

    Based on the above evidence I think it’s more likely that there are multiple causes for the increase in BMI over time in the US (and elsewhere). There are clearly environmental/cultural influences given the geographic distribution of obesity both within the US and abroad. There is also little doubt that genetics contributes to one’s susceptibility to be overweight or obese although genetics is extremely unlikely to be behind the recent weight explosion in the US (see KeithJM above).

    There may be public policy options worth considering when it comes to fighting the obesity epidemic but given the current degree of uncertainty I think it’s premature to be arguing which measures are the best to adopt. There is pretty good evidence (as Steve points out) that printing the number of calories on menus can help individuals control caloric intake.

    I think there are plenty of economic reasons why corn subsidies should be stopped. I don’t think there is enough evidence regarding how this would impact obesity (although the argument is interesting). I am curious what effect halting the subsidies would have.

    Although I’m not familiar enough with the literature to either support or refute daedalus2u’s argument regarding NO specifically, I do think research regarding the mechanisms of satiety vs. hunger, is both interesting and important.

    I also agree with Steve regarding rez’s claims. There is a big difference between the appropriate diet for training vs. the appropriate diet for general health and weight loss. I will go so far as to say that dietary extrapolations from the fitness/training community should not be made.

    mufi points out that Brian Wansink et al. have done some interesting work regarding how psychosocial factors contribute to the perception of satiety. I think these may have some potential in fighting overeating. These have the added advantage in causing consumers to think they’re eating more than they really are. This would mean increased margins for restaurants adoption of these sorts of interventions could occur without formal government regulation. Maybe a bit idealistic, but you can’t fault me for dreaming.

    Lastly, I think it’s almost irrelevant whether increases in a sedentary lifestyle are a major cause of obesity. The benefits of exercise on health are independent of its effects on weight. There is enough data on the positive effects of exercise on BP, glucose metabolism, cardiac fitness, sleep, etc. etc. to justify exercise independent of any effect on weight. For those who advocate public policy changes, tt may actually be good news that lack of exercise is not likely to be the primary cause for the obesity epidemic. Legislating increases in activity will be harder, in my opinion, than introducing measures to decrease caloric intake (though this will also be hard).

    I’m a little frightened by the thought of the government telling me what to eat and what not to eat. I’d prefer they provide the appropriate information and education (once we figure it out) and then hold people more accountable for their choices after we’ve eliminated that appropriate excuses.

    Rambling incoherently, sorry.

  38. rezistnzisfutlon 25 Jul 2011 at 7:00 pm

    If a person consumed 1500 cals a day of cotton candy, he’ll look much different than if he consumed 1500 cals a day from a balanced proportion of macronutrients consisting of lean protein, healthy fats and low GI, fibrous carbs. Not only will this person be severely malnurished if the former diet persisted, he’d look terrible will little lean muscle and a relatively high bodyfat percentage So I do think the kinds of cals consumed is as important as the number of cals. I will concede that there is a difference between overall weight loss and just bodyfat loss.

    Insulin is the body’s primary storage hormone, so a diet that’s consistently high in high-GI carbs is going to have persistently high insulin levels, even when muscles are insulin resistent, meaning unused calories will be shunted to fat cells. Carbohydrates are the biggest protagonist to insulin spikes, especially high GI carbs. Fats, though easily converted to or stored as energy by the body, do not have the same insulin response as carbs. Proteins also have far less insulin response, and is also the hardest for the body to digest and convert into energy via gluconeogenesis.

    There are numerously different metabolic pathways to different food types. The metabolic response to simple sugars (ie, sucrose, fructose, glucose) will be significantly different than the reponse to lean proteins. Even among the different sugars there are different metabolic pathways. I think it’s rather simplistic to say it’s just cals in vs. cals out.

    Here’s a pubmed article on physiometric delta% fat loss per genetic predisposition in response to reduced fat vs. reduced carb diets:

    Here’s a study indicating exercise prior to either high carb or high protein meals affect fatty acid oxidation, where the high protein meal indicates a marked increase in fatty acid oxidation. It also showed that serum insulin levers were lower post protein meal:

    This is a study showing how consumption of MCTs (medium chain triglycerides) show marked improvement of fat loss over olive oil (normal dietery fat):

    Here is one that shows a direct relationship between low fructose and moderate natural fructose diets for weight loss and metabolic syndrome individuals:

    I could cite many more studies providing evidence for direct correlations between macronutrient types and body composition, lipolysis, fat gain, gluconeogenesis, glycogenolysis, and a direct relationship between the different dietery macronutrients, and even different foods within the macronutrients, and the effect they have on the endocrine system, and how much the endocrine system affects body composition.

  39. Steven Novellaon 25 Jul 2011 at 8:37 pm

    rez – Your point about cotton candy is essentially a straw man. No one doubts that – because you would be massively malnourished. Such an extremely narrow diet would also be a big metabolic stress.

    That does not mean that differences of macronutrient proportions within a reasonable diet that would not result in malnutrition, however, would have significant metabolic effects.

    I know there is a lot of evidence looking at the metabolic effects of different nutrients. But when you look at the net effect of different diets on weight loss, it turns out that total calories is the only measurable effect. Other effects appear to be clinically insignificant (again – on weight, not necessarily on all aspects of health).

  40. WCAS41on 25 Jul 2011 at 8:42 pm

    For some interesting and amusing psychological reasons why we eat more, see the research of Brian Wansick. There are some videos on YouTube.

  41. rezistnzisfutlon 25 Jul 2011 at 9:25 pm

    Dr. Novella, didn’t mean to create a strawman, was just trying to illustrate, ableit using a drastic example, that there’s more going on than simple cals in vs. cals out. I thought the articles I posted would be enough evidence for that, so I’m not sure where the disconnect is. In fact, the preponderance of research data indicating positive correlations between varying macronutrient distribution related to fat loss is extremely high and I’d be happy to post more.

    Again, I disagree that macronutrient proportions do not play a role in body composition or weight loss, especially when considering genetic predisposition. I think the studies I posted are enough to demonstrate that. For instance, a person with a naturally slow metabolic rate (aka endomorph) will respond much better to a low-GI carb, moderate protein and moderate fat diet than they would with a high-GI carb, moderate protein and low fat diet. These individuals typically display high serum insulin and resultant ghrelin, low serum glucagon levels, relatively low t-4 and respondant GH levels, and higher levels of plasma IGF-1 as baseline. Feeding them a high-GI carb, moderate protein and low fat diet is contraindicated and will show a marked decrease in lipolysis over time as opposed to a direct reversal of this diet. Studies one and two I listed above illustrated this. These do add up over time.

    I don’t disagree that calorie levels do definitely play a role and higher caloric intake overall will generally produce heavier individuals, but inappropriate distribution of those calories will have different results for different people and, depending on how drastic the distributions are, will have a mean effect on the population.

  42. rezistnzisfutlon 25 Jul 2011 at 10:55 pm

    Honestly, it’s not my wish to belabor this particular issue as it’s really not important enough to me to continue, it’s not on topic and I see that the cal in vs. cal out subject was covered here three years ago anyway.

    A lot of where I stand is my background in personal training, where the goal is to shed bodyfat while retaining as much lean bodymass as possible. I’ll concede that, within the constraints of a reasonably healthy diet, the population as a whole will respond to positive weight loss with a simple cal in vs. cal out formula. However, from my perspective, weight loss does not equal fat loss and health, so that’s all I was really getting at. So, if I were to program a diet for a particular client, I’d definitely take into consideration their individual physiology and circumstance, then create an appropriate diet with specific macronutrient distribution.

    That being said, where I do feel strongly in the arena of adequate macronutrient consumption is protein intake; it’s the one macro that cannot be stored (unless one wants to call lean muscle protein storage). Again, this speaks more to body composition than pure weight, but it’s something no one should skip in their diet, or consume inadequate amounts. Not unless skinnyfat is their goal.

    Finally, I can see where the cotton candy analogy may seem like a strawman. Of course I realize that’s not anything you said or would recommend to anyone; it was intended only to serve as a pointmaker. So I apologize for the confusion there.

  43. bisteneson 25 Jul 2011 at 11:42 pm

    I am absolutely in favor of the increased availability of nutritional information of foods, especially in eateries. I am absolutely against the actual restriction of caloric content. Not everyone has the same caloric needs. I need to eat 2500 kcals per day to maintain healthy body weight. Currently I’m eating 3500-4000, which in tandem with my weight training program, is the minimum for gaining an appreciable amount of muscle. Homogeneous dietary restrictions would be disastrous.

  44. jt512on 26 Jul 2011 at 12:04 am

    Steven, you wrote: “That does not mean that differences of macronutrient proportions within a reasonable diet that would not result in malnutrition, however, would have significant metabolic effects.”

    Without regard to the slightly challenging use of negatives in your sentence above, the macronutrient composition of a diet indeed has a metabolic effect on energy expenditure. This has been known for decades and is uncontroversial biochemistry. The thermogenic (or simply “thermic”) effect of dietary protein is greater than that of either carbohydrate or (especially) fat. The thermic effect of a macronutrient is the energy expended to process that macronutrient. The thermic effect of protein has been shown to be 20–25% of energy compared with about 3% of energy for fat. Thus isocaloric substitution of protein for fat will increase energy expenditures by at least 17% (20% – 3%) (ie, substitution of 100 kcal dietary protein for 100 kcal fat would increase energy expenditures by 17 kcal).

    Whether this has any public health relevance is unclear, but (in addition to initial water loss) this difference in thermic effects is probably responsible for the greater weight loss observed in short-term trials of high-protein diets (which for some reason are usually low in carbohydrate instead of fat).


  45. john_chron 26 Jul 2011 at 12:29 am

    Steve – here’s an interesting study in the New England Journal of Medicine: Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men: http://www.nejm.org/doi/full/10.1056/NEJMoa1014296

    Unfortunately, I don’t have a subscription to view the detail of the study held over 20 years and 120,000 subjects. The summary appears to support that such factors as sleep, activity, and interestingly, the types of foods eaten are associated with long term weight loss/gain. Full dairy and cheese were neutral with respect to weight change, whereas nuts (a high fat food) were associated with weight loss. Potatoes and sugared drinks were positively associated with weight gain.
    It’s worth a read, especially if you can see the full article to gauge the quality of this study as it’s rare that such a long term study with so many subjects is carried out.
    The Australian public broadcaster (ABC Radio National) Health Report has an interview with one of the authors that is also interesting to listen to:

  46. eiskrystalon 26 Jul 2011 at 4:25 am

    The talk about different “calorie types” is a little pointless because at the end of the day if you’re going for a healthy diet, it would include a range of foods. A fad-diet with enough of one calorie “type” to make a statistical difference is probably going to be a really unbalanced diet anyway.

    I think internally learning good habits as a child is an important step that has been handed over to the food industry. I don’t calorie count, i just “know” how to eat well. It comes naturally because i learnt it from my parents without realising. As mentioned above, it can be derailed, and it is being derailed generally by your own food industry.

  47. Rikki-Tikki-Tavion 26 Jul 2011 at 6:21 am

    “Dr. Novella, didn’t mean to create a strawman, was just trying to illustrate, ableit using a drastic example, that there’s more going on than simple cals in vs. cals out.”

    He’s right. That was a valid reductio ad absurdum, not a strawman. At least if you add a couple of vitamin pills to the candy diet.

  48. Steven Novellaon 26 Jul 2011 at 7:37 am

    It’s not a valid reductio ad absurdum, it’s an invalid one because my position does not necessarily lead to that extreme.

    The point that commenters keep missing is that I am not saying there are no metabolic effects from different nutrients. I am saying that they are not clinically relevant enough to weight loss to be measured in clinical trials.

    The bottom line is – if you look at all the clinical trials of different diets, weight loss corresponds to caloric intake. Period. There is no measurable effect from macronutrient composition, except perhaps a temporary effect on hunger, but this does not appear to last more than 6 months and also does not have a significant net effect.

    Muscle composition is a different factor than weight. I agree, if you are building muscle you need to have adequate protein intake. I also think the evidence shows it’s important to exercise while losing weight to maintain muscle.

    Glycemic health is a different factor also. If you are insulin resistant, you need to consider the glycemic index of your diet.

    I do think it’s a major distraction for people trying to lose fat to concentrate of calorie type, rather than on estimating total calories. If you have a varied and generally healthy diet, for most people that’s all you need. Focusing on the wrong variable or adding unnecessary complexity can be counterproductive.

    Just get regular exercise, have a varied diet, and watch your total caloric intake. That’s it – but it doesn’t sell many books.

  49. uncle_steveon 26 Jul 2011 at 9:12 am

    I don’t think there is any mystery to why so many Americans are obese. Americans are less active than they used to be and they get too many calories from all sources.

    About 12 years ago when I was borderline-chubby kid, I switched to a near vegan diet and lost about 20 lbs. This weight has stayed off since. I found the transition of being a meat-eater to being a near-vegan easy since I never cared for meat to begin with. Dairy was a little more difficult to give up. I do eat eggs occasionally. I do have to take supplements to ensure I do not become deficient in zinc, iron, vitamin B12 and calcium, but I prefer this over eating meat to get those vital nutrients.

    I’ve always been an avid exerciser as well, but even during periods when couldn’t exercise, I hardly gained any weight. Obviously, I am just getting fewer calories now than when I was a meat-eater. I often eat a lot of snacks(especially after a long run), but they are almost always raw, unprocessed nuts, seeds or occasionally fruit. Although nuts are high in fat(mostly heart-healthy, unsaturated fats), they can be very filling due to their high fiber content, which also blocks fat absorption. Nuts also increase metabolism, and are a good source of protein and trace minerals. I also avoid refined sugar and refined carbohydrates in general, but they can be okay in very small amounts. I drink almost nothing but water and never drink alcohol.

    Studies show that vegetarians tend to have lower BMIs than non-vegetarians – http://www.ncbi.nlm.nih.gov/pubmed/21616194 .They also have lower rates of heart disease and various other diseases. Studies also show that the Mediterranean diet is great for weight-loss and heart health, and it is almost vegetarian.

    People eating vegetarian/high carbohydrate diets compared those eating low carb – http://www.ncbi.nlm.nih.gov/pubmed/11320946 The vegetarians/high carb eaters tended to get fewer calories than the non-vegetarians/low carbs.

    The fiber content in a healthy vegetarian diet may be the main reason vegetarians are generally slimmer. Fiber not only fills you up so that you end up eating less, but may also block fat and carbohydrate absorption. Vegetarians like me eat a lot fat, but it’s mostly from nuts or olive oil.

    I realize that just because I have benefited from vegetarianism doesn’t mean it’s for everyone. I’m not trying to convince everyone here to go vegan or vegetarian. However, I think just about everyone can benefit by eating more vegetables, eating a lot less meat, dairy, and refined carbohydrates and exercising more.

    There is no mystery that needs to be solved here, or a magic pill, it’s all about lifestyle change, about calories in, calories out.

  50. uncle_steveon 26 Jul 2011 at 9:29 am

    A lot of people are afraid of eating nuts because they are high in fat, but little to no evidence exists showing they promote weight gain. In fact, people who eat the most nuts tend to be slimmer than people who eat the least nuts.

    For at least 3 reasons nuts generally do not lead to weight gain, even with their high fat content – http://www.dietriffic.com/2010/04/27/are-nuts-fattening/

  51. mufion 26 Jul 2011 at 9:31 am

    ccbowers said:

    I don’t think that the lesson here is that calorie counting is the specific solution for most people. Its not practical for most since most people don’t want to live in such a regimented way (me included).

    Then Steven Novella said:

    Just get regular exercise, have a varied diet, and watch your total caloric intake. That’s it – but it doesn’t sell many books.

    The suggestion of “watching your total caloric intake” implies to me a lesson that “calorie counting is the specific solution for most people” – albeit, in combination with regular exercise and a varied diet.

    Yet, is there any statistically significant evidence that thin people make calorie counting a regular practice in their lives? (Like I said earlier, I’ve always been thin and I’ve never tracked my calorie intake.) Or are fad-diet authors cashing in on the fact that (as ccbowers put it) “most people don’t want to live in such a regimented way”?

    In any case, whatever actually works in terms of preventing obesity seems as much a topic of psychology as it is nutrition science.

  52. rezistnzisfutlon 26 Jul 2011 at 10:09 am

    “I do think it’s a major distraction for people trying to lose fat to concentrate of calorie type, rather than on estimating total calories.”

    I don’t think this is true for most people who have at least some understanding of nutrition and dieting. No one is suggesting we should ignore calories only to focus entirely on macronutrient distribution. Of course overall calories make a difference when it comes to weight loss, but it’s my contention that calorie types do make a difference to weight on several levels, as much as counting calories does.

    For one, different macronutrients and different foods within macronutrients have different metabolic effects on predisposed genetic types and specific physiologies. For instance, fructose has an entirely different metabolic pathway than sucrose. Also, a diet too low in fats is going to reduce hormonal levels to a degree that will inhibit weight loss, much the way reducing calories too much slows the resting metabolic rate and makes overall weight loss harder. I have not seen one instance where removing high GI sugars, processed starches and grains from the diet only had positive effects on weight loss, esp. fat loss. The goal should be a healthy kind of weight loss that’s sustainable in the long run for a population. I don’t think simple calorie counting is a good enough solution for central obesity.

    Again, I don’t want to belabor this issue as it’s off topic and not something I feel will resolve itself anytime soon (it’s an ongoing debate in nearly all health and fitness forums), and for the most part, my emphasis in regards to clientelle diet is cleaning diet up; that in itself has a positive effect on fat loss and good, adequate nutrition. But there MUST be systematic and thoughtful distribution of macros for this to occur, as well as careful consideration of food types (fibrous and cruciferous veggies instead white bread and donuts, for example).

  53. ccbowerson 26 Jul 2011 at 10:15 am

    –The suggestion of “watching your total caloric intake” implies to me a lesson that “calorie counting is the specific solution for most people” – albeit, in combination with regular exercise and a varied diet. —

    Well, I thought my comment was clear, but I guess not. I was thinking in terms of people writing down everything that they ate that day and doing some math. Thats what calorie counting implies in my mind. Of course that may be helpful in the beginning, I don’t think it is a long term solution for most people. Being cognizant of caloric intake as part of an overall diet, and how it relates to a person’s weight makes perfect sense and seems like the right approach for most

  54. rezistnzisfutlon 26 Jul 2011 at 10:24 am

    “Being cognizant of caloric intake as part of an overall diet, and how it relates to a person’s weight makes perfect sense and seems like the right approach for most”

    Totally agree. It’s an unfortunate fact that most people have entirely no idea what they actually consume each day. I too agree it’s a very educational process for the uninitiated to keep a food journal for a week or two at least, then research what the foods they’re eating are. As a trainer, I’ve found that teaches them more about diet in less time than pretty much any other method, and often they are “scare straight” because they’re shocked at what and how much they were actually consuming when they thought they were eating healthier than they were.

    So unless a person is an athlete or competitive bodybuilder or fitness competitor, simply being aware of calories after they’ve learned what they’re actually consuming typically is sufficient, especially if they’re active.

  55. ccbowerson 26 Jul 2011 at 11:09 am

    Once a reasonable level of education is reached for the individual, the most widely applicable advice seems to be to eat less, with more fruits and vegetables.

  56. mufion 26 Jul 2011 at 11:29 am

    ccbowers said: Being cognizant of caloric intake as part of an overall diet, and how it relates to a person’s weight makes perfect sense and seems like the right approach for most.

    OK, but it’s an empirical question (one which seems to fall more into the domain of psychology or sociology than nutrition science) regarding which techniques (whether they are practiced consciously or unconsciously) actually help people (or Americans, let’s say) to avoid obesity. Lacking statistical evidence pointing one way or the other, the trait of “being cognizant of caloric intake as part of an overall diet” may or may not be an actual predictor of thinness (or, if so, either a strong or weak one) for most people.* Based only on personal experience, I have my doubts.

    In other words, to call it “the right approach” sounds more prescriptive than descriptive, and prescriptions sometimes fail – especially, it seems, when it comes to lifestyle choices like diet & exercise.

    * Note: I would expect this trait to be a strong predictor for certain demographic groups (e.g. professional athletes and those who suffer from certain eating disorders), so I’m using “most people” as a marker for everyone else.

  57. mufion 26 Jul 2011 at 11:38 am

    PS: That’s not to say that I doubt that weight is attributable to the balance of caloric input/output. I’m just saying that, in my experience, most thin people do not think in these terms, and those overweight & obese people who try to do so generally fail in the long run to lose weight.

  58. tmac57on 26 Jul 2011 at 11:57 am


    As a trainer, I’ve found that teaches them more about diet in less time than pretty much any other method, and often they are “scare straight” because they’re shocked at what and how much they were actually consuming when they thought they were eating healthier than they were.

    I would add to this,that translating exercise effort directly into caloric cost of specific foods,can be an eye opener.If a person who has just spent an hour doing strenuous aerobic exercise realized that they only burned off 1 soda’s worth of calories,or a handful of potato chips,that really puts things into perspective.It can make you think before you put that candy bar or donut in your mouth.

  59. Karl Withakayon 26 Jul 2011 at 12:05 pm


    “No one is suggesting we should ignore calories only to focus entirely on macronutrient distribution.”

    Always be wary of using absolute statements. 🙂

    Although nobody in this thread may have explicitly suggested that, many advocates of low-carb diets (or many other diets as well) do exactly that. Frequently you will hear recommendations to eat as much as you want of the allowed foods as long as you don’t eat whatever the diet forbids, as in eat all the fatty meat you want, just don’t eat carbs. You will even hear claims such as “That’s the beauty of this diet, you don’t have to count calories, just don’t eat carbs!” I’m not highlighting fringe, obscure practices, these are fairly common claims among many low carb dieters, for instance

    This is part of why the focus on types of calories is an unnecessary distraction. Even if the concept is valid, for the public at large, it’s a negative distraction for an audience that prefers simplicity over nuance.

  60. mufion 26 Jul 2011 at 12:11 pm

    rezistnzisfutl said: simply being aware of calories after they’ve learned what they’re actually consuming typically is sufficient

    How long does that awareness last? (My hunch: Not long or until soon after the reinforcement of having a personal trainer ends.)

  61. ccbowerson 26 Jul 2011 at 12:18 pm

    Mufi you are correct, I also have my doubts about the being congizant part alone as being sufficient (thats why I added the eat less comment later), but for those motivated to lose weight it seems reasonable to be educated on where calories come from (as at least as a baseline knowledge to be able to make reasonable decisions). The eat less advice (of whatever a person normally eats) is more widely applicable and is something that everyone who is trying to lose weight could apply to their lives.

    In practice, people have to look at their lives and make any changes that they think could help them eat less. I don’t know of any universal advice that works and thats why we are where we are. There are some studies showing that certain color and/or size plates help people eat less, but those always seemed a bit gimmicky. I can’t imagine anything like that having a long term effect.

    I don’t think we can simply look to what thin people do, and think that there is some insight for the rest of us (me included). For my personal anectdote, my wife has been <100 lbs her whole life, but on paper has lots of bad eating habits (snacks before bed, likes high calorie foods, etc), yet when I do them I gain weight like most others. She is just able to stop when I would eat more. It is clear to me that I have only 1 major eating problem and that is that I eat too much.

  62. jt512on 26 Jul 2011 at 12:36 pm

    The strategies used by successful long-term weight-loss maintainers have been studied. Almost all such individuals used a combination of diet and exercise to lose weight and to maintain their weight loss. Dietary methods employed included restricting intake of specific foods, restricting intake of fat, reducing portion sizes, and restricting intake of total calories by calorie counting. See the references below. Full-text versions are freely available.



  63. SteveAon 26 Jul 2011 at 12:55 pm

    I’ve never had too much trouble with weight, but unfortunate bone structure means that my chin disappears if I’m a bit overweight, ruining an otherwise gorgeous face. So I try to stay lean.

    I like the GI diet. The theory is that sugary/starchy food leads to a sudden spike in blood-sugar that prompts the body to produce insulin to mop it. Except then your blood-sugar dips too low and you feel like you’re starving to death. This seems to be my experience. On the rare occasions I ate bar of chocolate, or something similar, I’d often feel frantic with hunger an hour or so later. The temptation then being to stuff my mouth with a snack (usually something sugary again) to kill the pangs. And so the cycle continues.

    I found it very hard to control my appetite when the sugar crash hit, and I’m guessing the current abundance of sweet stuff might be helping erode people’s will power.

    I keep my weight down by not eating between meals, keeping an eye on portion size, and avoiding anything too sweet (chocolate, cola, biscuits etc). I’ll have an occasionally desert, but not many.

    I was surprised how quickly I stopped missing my favourite ‘bad’ foods when I made the decision to avoid them. For example, I used to love sugar in tea. I’d have around seven teaspoons and be drinking five or six mugs a day. Then I calculated the ridiculous amount of sugar I was consuming on a weekly basis and decided to try to do without. For the first two days the tea was horrible, then it got okay on the third, by the fourth I liked it. Now I can’t drink tea if someone puts sugar in it.

  64. ccbowerson 26 Jul 2011 at 1:10 pm

    “The strategies used by successful long-term weight-loss maintainers have been studied.”

    The problem with such an approach is that it is not prospective, and is likely a reflection of the patients’ attitudes about weight loss and not necessarily reflective of which component was the reason for the success. For example, perhaps only 1 or 2 changes were responsible for the weight loss and the other changes that were made were simply ‘window dressing.’

  65. kittensandrainbowson 26 Jul 2011 at 2:44 pm

    Steve, you made similar comments on SGU after the Twinkie Diet guy’s story came out. Until then I really believed the BS about just being genetically fat. I had tried so many fad diets and I was quite active. I hadn’t touched meat or dairy for a year and a half and I was still obese. I’ve dropped 65 lbs since then. People keep asking me how I did it. I tell them that I pay attention to my calories used vs calories consumed. Nothing is forbidden from my diet. It turns out you do not have to over eat or be inactive to an extreme to get extremely overweight. The scales just have to remain out of balance for a long enough stretch of time. So, adjustments for health don’t have to be extreme either. They just have to be consistent. I do think my insomnia and stress played a role in making me feel less active and more hungry than I would have had those things been under control. But ultimately the culprit was unused (and perhaps unloved…awww…poor things) calories.
    So, thanks. You really gave me something to think about.

  66. passionlessDroneon 26 Jul 2011 at 4:25 pm

    Hello friends –

    There is a very robust, well replicated set of data in the human and animal realms that tell us that obesity can be programmed by gestational and early postnatal influences.


    There appears to be a U shaped curve wherein being born too light, or too heavy, provides a propensity for metabolic syndrome. Similarly, early catch up of weight is a risk factor.

    – pD

  67. jt512on 26 Jul 2011 at 5:12 pm

    @ccbowers: In fact, the study has a prospective cohort design. The first citation in my last post briefly discusses some of the findings at follow-up. Numerous subsequent papers that used follow-up data from the cohort to investigate specific hypotheses have been published. These can be found in Medline by searching for the phrase “National Weight Control Registry.”

  68. rezistnzisfutlon 26 Jul 2011 at 6:44 pm

    What we’re talking about is a diet and activity regimen that’s realistic and maintainable in the long-term. Counting calories daily is not a practical long-term method. With clients I’ve dealt with, once they have a good idea what certain foods contain and can be included as part of a regular diet, the need for keeping a journal isn’t needed anymore. For instance, if a person knows exactly what a quarter cup of dried steel-cut oats contains nutritionally, and they have that on a regular basis, there’s no need to keep track of that.

    Ultimately, it’s up to the individual to maintain healthy habits. If it’s something they want bad enough, they’ll find the right ways and stick with it. The trick is to find diet and exercise methods that are permanent and sustainable, no just short-term fixes. That’s one reason why junk fad diets and diets that cut out entire macros aren’t realistic long-term, though they may work in the short-term.

  69. rezistnzisfutlon 26 Jul 2011 at 6:47 pm

    “Always be wary of using absolute statements.”

    I’m not sure how my statement was an absolute:

    “No one is suggesting we should ignore calories only to focus entirely on macronutrient distribution.”

    This was in response to Dr. Novella’s comment that it’s a distraction to focus on macronutrients and ignore calories. My response was that no one is suggesting that cals should be ignoreed, but a combination of focusing on macros AND calories should be employed when considering diet. So, it seems my statement is opposite of an absolute.

  70. rezistnzisfutlon 26 Jul 2011 at 6:54 pm


    Most clients who are successful after session with their PT are completed have to be able to use realistic methods for maintaining what they gained or lost when they were on a more regimented diet and exercise routine. Keeping a journal is very time-consuming and counting calories down to the last meal isn’t realistic or practical. As long as their diet is consistent, they know what they’re getting. However, they do have to be careful at times when, for instance, they eat out a lot or vary their diet significantly (hence the consistency part). IMO, that’s one of the problems with our culture is that so many people eat out, and when that’s done there’s no way of accurately knowing what the ingredients are or portion sizes.

    Unfortunately, too many people eat for taste, satisfaction or perhaps psychological reasons, not for health. Eating for health should be the primary focus. In our culture, eating for taste as if every day is thanksgiving has become commonplace. Nothing wrong with spicing up an otherwise bland meal, as long as it doesn’t reduce the health benefits.

  71. rezistnzisfutlon 26 Jul 2011 at 6:56 pm

    “No one is suggesting we should ignore calories only to focus entirely on macronutrient distribution.”

    Ok, I see what you’re saying about absolutes, with the “no one” part. What would be more accurate, then, is “no one here”… That’s really what I meant.

  72. uncle_steveon 26 Jul 2011 at 10:17 pm

    @ rezistnzisfutl

    “Counting calories daily is not a practical long-term method.”

    I agree. As someone who has kept a slight excess of weight off for over a decade, I seldom if ever count calories and I do not keep a food diary(everything else I explained before in a previous post). The way I see it, the more a person feels the need to count calories, the more likely they are eating foods they shouldn’t be eating. A lot of people don’t even count calories accurately, and many calories in high fiber foods just pass through the digestive tract without adding to your calorie count.

    If a person is eating a healthy diet of mostly unprocessed foods, unrefined carbs and minimizing or eliminating animal products, calorie counting is pretty much superfluous.

    I admit I may have an unfair advantage compared to people who struggle to lose weight. I can eat a lot of “bland” meals they probably wouldn’t find satisfying, and I eat them every day. I am almost never tempted to eat very high fat foods they often say they can’t live without. I never eat fast food. I never eat meat. Overall I am not a big eater, although on occasion I will eat junk food. I usually carry trail mix with me when I am extra busy, to avoid unhealthy, salty, fattening restaurant food(I do eat at restaurants sometimes). Maybe I am genetically predisposed to like raw unprocessed nuts and legumes. And no I am not an emaciated-looking vegetarian, I have a 6-pack and other well developed muscles.

    Many people come to me for advice and it’s obvious that very few people can eat like I do. Bread or rice with sunflower seeds and vegetables for lunch or breakfast, lentils with rice, and sometimes pasta, but with no meat or cheese, and I eat like this almost every day. I am generous with spices and sauces though.

    So basically, minimizing meat and dairy(fiberless high fat/high protein foods play a big role in obesity, along with too many low fiber or no fiber unhealthy carbs) and replacing them with fresh vegetables, raw nuts and legumes is probably the best way to go, along with daily aerobic exercise. If you also strength train at least 2 times a week, that’s even better since muscle can burn calories even as you sleep or do nothing, and the larger your muscles, the more calories you burn.

    Even just drinking a lot of water can prevent overeating in some people, since it can fill you up. Standing while watching TV or using a computer burns more calories than sitting while doing the same thing. Fidgeters tend to be slimmer than non-fidgeters. All these little things add up.

  73. mufion 27 Jul 2011 at 9:48 am

    rezistnzisfutl: With statements like “Eating for health should be the primary focus”, I think we’ve moved from nutrition science, through psychology, to moral philosophy (or normative theory). Let’s assume for the moment that we agree that well-being is primary goal of all moral systems.

    That said, I am told by my physicians (as well as a nutritionist from my company HMO, who recently subjected me to biometric screenings) that I am in excellent health. And yet health is not my primary focus in eating. It is one consideration, but then so are emotional (or sensual) and social (e.g. cultural) considerations, both of which are important dimensions in the concept of well-being.

    What I would grant, however, is that, when it comes to eating, it’s important not to forget about the physiological dimension, lest we eat to much or too little and thereby harm ourselves and others in the process.

  74. daedalus2uon 27 Jul 2011 at 1:52 pm

    mufi, you make a good point about not eating to attain good health. I think that is more true than you think. Organisms did not evolve their diet regulating behaviors to attain “good health”, they evolved the pathways that regulate food consumption to maximize survival and reproduction (the only thing that evolution can maximize).

    There are circumstances where short term adjustment to food intake is called for by physiology. During sepsis, appetite goes to zero and organisms survive by turning muscle into amino acids for gluconeogenesis. That isn’t “healthy” in the long term, but it does help to survive sepsis in the short term (which is more important).

    In a high stress environment, a quick shot of easily digested fat and sugar may facilitate surviving the high stress by reducing the metabolic overhead associated with digestion and carrying around fiber and inerts not readily absorbed, but at a cost of longer term health issues.

  75. rezistnzisfutlon 27 Jul 2011 at 7:47 pm


    You have to remember that we’re not living in a prehistoric world anymore where our simple survival depended on certain built-in mechanisms. For most, our survival mechanisms are actually working against us for good long-term health in the modern world. Additionally, considering our modern lifestyle compared to prehistoric, and especially pre-agricultural, they didn’t live in a world of overly processed food items with high concentrations of sugars and fats that were easily accessible. We are programmed evolutionarily to seek out such food items and, in essence, gorge on them as much as possible, because foods like that were a rarity and could make the difference in surviving a harsh winter or blistering dry season. In general, these days we aren’t faced with feast and famine on a regular basis, yet the mechanisms that help us survive those are still in place and going strong, but the problem is that that kind of food nowadays is too regularly available and most people aren’t active enough to counteract the extra calories.

    I wouldn’t go as far as saying it’s a moral appeal, though I can see where it may seem that way. It’s definitely an emotional appeal, because for most people, eating is emotional, whether it’s in attempts to offset depression, because it tastes and feels good, or perhaps for social reasons (going out to eat). Rarely is emotional eating a positive health contributor as typically the foods consumed either have little nutritional value or far exceed caloric requirements. I stand by my statement that, most of the time, diet should be more about health and less about emotional satisfaction; most people simply can’t get away with a high amount of emotional eating.

    It’s great that your health is good now. I am taking your word for it, and I cannot see what your diet actually is or why you’re in good health. Perhaps you make decent food choices or limit portions. Perhaps you’re an active person. Perhaps your subjective assessment of good health is different from my subjective assessment (no insult intended, just trying to be realistic). My medical screenings are pretty different from most people in that I include full blood panels, assessments from MDs specializing in sports medicine, and nutritionists specializing in sports physiology (when I can afford it). Most GPs know very little about nutrition and working with athletic patients, and dieticians in general are trained to program diets for sick patients, not healthy ones (which is why I seek out specialists).

    What’s been my experience as a (former) personal trainer is that when overweight clients come to me, almost universally they know next to nothing about nutrition, different food types, the physiological effect of macronutrients, what their diets consist of, and how much emotional eating they actually do. That’s why nearly all of them are shocked at how much they consume when they keep an honest food journal for a week or two.

  76. ccbowerson 27 Jul 2011 at 9:36 pm

    “For most, our survival mechanisms are actually working against us for good long-term health in the modern world.”

    Lets not lose perspective here, or romanticize the past too much. We are much “healthier” than in the past, by nearly any measure. We have traded a whole bunch of health risks which resulted in many early deaths, and got a few chronic ones that result in our later deaths (at least in most of the countries that the obesity issue is relevant)

  77. rezistnzisfutlon 27 Jul 2011 at 10:40 pm


    I agree with you. However, we’re now going down a path of regression with the obesity epidemic that’s threatening to reduce the average lifespan and overall health. Though medical science has done wonders for our natural health, we’re now promoting unhealthy lifestyle habits as a society that’s either reversing the positive health effects gained from medical science, or creating new unhealthy effects in spite of the health gains we made otherwise.

    I’m not trying to say that how we lived in the past was healthier, just that we have certain evolutionariy survival traits that serve to impede good health and fitness in modern society.

  78. Jonathan Rayon 28 Jul 2011 at 4:16 am

    It’s true that the effect of #3 vanishes when you control for #2, but Steve misses the point by not addressing the effect of #3 on #2 via satiety. I blogged about it.

  79. mufion 28 Jul 2011 at 10:59 am

    rezistnzisfutl: Like I said, I am told by others (viz. medical professionals) that I am in excellent health. You may have more stringent standards than they do. If so, then I have no comment on that.

    I raised the philosophical aspect only because that’s where questions of the “what should I do?” and “how should I lead my life?” sort are traditionally addressed. Medical information is often pertinent to these questions, but only on the reasonable assumption that people prefer to live longer and/or prefer a functional body to a dysfunctional one. (I might add that these may not be universal preferences, but that’s a topic for abnormal psychology.) Even then, these goals may only be means, rather than ends – say, if one aspires to goals that depend on remaining healthy (if only temporarily), but which are nonetheless deemed loftier. And some goals are lofty enough as to end up in self-sacrifice, which is as contrary to physical health as one can get.

    My own life goals are not so lofty, and I definitely would take seriously a negative report card from my doctors. But, lacking that, what else do I have to go on besides how I feel? Sure, I might be able to improve how I feel in the long run if I were to adopt a more rigid approach to food (including drink) and exercise. But, then, I went through more rigid phases in the past and came away with a negative impression.* Not that it’s easy to balance health concerns with the emotional and social benefits of food – but it’s the path that I choose.

    * What’s more, now that I have a teenage daughter with anorexia, “rigidity” is virtually a dirty word in my household – particularly as it pertains to food and exercise – which, of course, is not to suggest that anorexia is driven by health concerns.

  80. rezistnzisfutlon 28 Jul 2011 at 12:04 pm


    Sorry to hear about your daughter’s struggle with food. I’ve had a little experience myself with a loved one who struggled with anorexia so I have some appreciation on how it completely alters food considerations; my understanding is that once you have it, it’s similar to alcoholism, you always have to deal with it even if you’ve recovered. I just hope your daughter is able to deal with it now before permanent injury is incurred.

    I don’t expect everyone to want to be a pro bodybuilder, fitness competitor or athlete. But, there is also a serious problem in this country and increasingly in the world and something needs to be done about it, without having to resort to what your daughter is going through. I think that would mean first seriously identifying the root causes of the problems rather than simply addressing the symptoms, and I have yet to see any study or panel address even this initial phase. Yet the supplement, diet, exercise and personal training industries are multi-billion dollar businesses and we have more access to information than ever before (though this can also be a detriment since there’s as much misinformation out there as well).

    However, I do think there are certain universal actions that apply pretty much to everyone: more activity, fewer calories, and better food choices. Beyond that, it’s a matter of personal preference.

    When I work with a client, I strive to find the most efficient way for them to achieve their goals that they will be able to sustain realistically and permanently after our sessions have concluded; slightly bad for business perhaps, and one reason why I don’t train full-time anymore, but a personal philosophy. That means they should become better educated on fitness and nutrition, and apply actual permanent lifestyle changes. Some people accept it better than others, usually the ones who really want it rather than those that know they should but only give it lip service because they don’t really want to give up their bad habits.

    Ultimately, though I consider myself somewhat of a “health and fitness evangelist” as I see there’s a serious problem with society today, I realize I cannot force anyone to do anything they don’t want to do. However, I’m of the opinion that, since unhealthy lifestyles that lead to obesity is a conscious choice that in reality affects everybody by increasing healthcare costs and using up resources in the care of them, any health problem that can show a causal relationship with lifestyle choices should have the financial burden shouldered by the patient. That would include health problems resulting from smoking and excessive drinking. Just a slight rant there.

  81. mufion 28 Jul 2011 at 12:46 pm

    PS: Having just reviewed my last comment, a few afterthoughts came to mind.

    Given my note about personal experience w/anorexia at home, it seems my parenthetical comment about “abnormal psychology” was more than speculative. After all, my daughter is actually more afraid of getting fat than she is of starvation and death. Her rigidity relates to the self-destructive rules that follow from listening to her eating disorder, and a rigidity towards a set of health-oriented rules would be a definite improvement in her case.

    What’s less obvious, however, is that a highly rigid approach to diet & exercise – even when health-oriented – is necessarily preferable to a more flexible one.

    For example, consider orthorexia (which is only a candidate for DSM at this point), whose “severe restrictive nature…could easily morph into anorexia.” While such a risk may only apply to a minority of the population, it applies to those who are already at risk of anorexia (e.g. those who possess a particular genetic and psychological profile), for whom an environmental trigger awaits. Given research on such triggers, a little extra weight may actually provide a hedge against a life-threatening mental disorder (or at least that’s what I recall reading in the eating disorders literature).

  82. rezistnzisfutlon 28 Jul 2011 at 1:08 pm

    Eating disorders definitely are psychological in nature. I can only imagine what it’s like for you to have to deal with that with your daughter.

    “What’s less obvious, however, is that a highly rigid approach to diet & exercise – even when health-oriented – is necessarily preferable to a more flexible one. ”

    Though I’ll agree that such rigid regimens sometimes invites a certain mindset who does it for unhealthy reasons, for most to achieve their goals, some rigidity is required. Most people simply don’t have the genetics to meet their goals without having dietery and exercise restrictions. Plus, there are those who maintain such lifestyles not out of some neurosis, but because they choose to do so as they simply prefer it, being lean, strong, athletic and as capable as their body allows them to be. Having the attitude of “everything in moderation” and “I want to fully enjoy life by eating what I want and socializing” won’t get them there, by a longshot. Any trainer who’s been around the block knows this simply from experience.

    I realize not everyone strives for this, but not everyone who does has a psychological problem. The simple fact is, they cannot achieve those goals without having a structured and regimented diet and exercise routine.

    It’s been my experience that those who have suffered from eating disorders need structure, especially in regards to diet. I would think that a structure geared toward optimum health would be preferable if they were to do anything.

    Finally, I would think that a health-oriented lifestyle would always be preferable to anything else. Don’t get me wrong, I don’t see any problem with the occasional indulgence, especially if fat loss is no longer the primary goal, as long as it’s occasional. As a trainer, I simply cannot support anything more than that.

  83. mufion 28 Jul 2011 at 1:31 pm

    rezistnzisfutl: Thanks for the kind words. Two comments:

    …since unhealthy lifestyles that lead to obesity is a conscious choice that in reality affects everybody by increasing healthcare costs and using up resources in the care of them…

    On the healthcare policy question, I agree that it’s important to control costs. However, I would first look for a less punitive way to do that before supporting a policy that denies coverage for medical treatment of “vice” (e.g. obesity, smoking, or substance) related illnesses. Given that we are all fallible (and not nearly as consciously in control of our actions as many of our prescientific forbears believed), a good healthcare system (according to my moral judgment) would account for that fact in an empathetic way.

    Don’t get me wrong, I don’t see any problem with the occasional indulgence, especially if fat loss is no longer the primary goal, as long as it’s occasional.

    Well, “occasional” permits of some interpretation.

    In my case, fat loss has never been a health concern, and I rely heavily upon feedback (both positive and negative) to keep me in that position, as I enjoy all aspects of diet & exercise (i.e. physiological, emotional, and social).*

    * See what I did there? I suggested that I not only eat for non-physiological reasons – I also restrict and exercise for non-physiological reasons (as my daughter did, before we noticed her anorexia, only she did so in an obviously self-destructive way). In other words, it’s possible to use these motivations to achieve healthy ends, as well.

  84. Steven Novellaon 28 Jul 2011 at 1:50 pm

    rez – I think it’s even more complex than you suggest.

    First – our eating is largely due not to conscious choice but many daily unconscious choices. We can override our unconscious choices, but that takes a lot of cortical resources and the evidence overwhelmingly shows that this strategy only works for a small minority of people (on the order of 5%). It does not seem reasonable to hold people responsible for not being able to do something 95% of people can’t do.

    This suggests the goal should be to make healthy choices easier and more often the default choice – not to tell people to work harder at it.

    Also – I think it’s fair to say that people generally want to be healthy and want to live a healthful lifestyle. It’s often not a black or white choice, but a matter of relative priority. Most people have many priorities in their life, and spending time maintaining their health is just one. Even for those who wish to make it a high priority, there may be other priorities in their life that make this difficult.

  85. rezistnzisfutlon 28 Jul 2011 at 2:01 pm

    Of course I agree with you. The benefits of exercise and healthy lifestyle are too many to list. From my perspective as a trainer, however, aside from a few obvious anecdotes, most clients simply do not respond to reasons beyond their goals. Typically, they have to find out for themselves what the benefits truly mean and feel like; they have no frame of reference to base it on because most of them have never felt what it feels like to be healthy and fit.

    As harsh as it may sound, I think something needs to be done for those who choose unhealthy lifestyles like smoking or morbid obesity and bog down the healthcare system as a result, forcing the rest of us to pay higher and higher premiums every year because of their choices. Most people who are like that won’t do anything about it until their life is threatened or it impacts them in some way that they can’t ignore. I certainly don’t think they should be refused health care, but people like this are persistently in the healthcare system and are responsible for a great deal of the cost, which is already completely out of control.

    “Well, “occasional” permits of some interpretation.”

    Not really, when the occasional isn’t enough to impact goals or add to what’s there. It’s a judgement call, true, but when it starts impeding progress is the meter to gauge it by.

  86. rezistnzisfutlon 28 Jul 2011 at 2:15 pm

    Dr. Novella,

    “This suggests the goal should be to make healthy choices easier and more often the default choice – not to tell people to work harder at it. ”

    How do you propose this be done? Any thoughts or examples? I suppose I’m not completely clear on what you mean by this.

    “Even for those who wish to make it a high priority, there may be other priorities in their life that make this difficult.”

    What’s more of a priority than health? It’s been my experience that most people have a lot more spare time in their life than they realize or let on. If they know what’s happening on Gray’s Anatomy or Survivor, then they have time to exercise. There’s always a way and I’ve yet to come across anyone who truly had no time to devote to exercise and healthy eating, with a little planning and creativity.

    I have a friend who’s a single mother of two, who works nearly full time and takes a full load as a mechanical engineering student, and still finds time to exercise regularly. It’s really not hard.

    Most people pay lip service to wanting to improve their health and fitness, because they know they should, but simply don’t want to give up their habits enough to do so.

    I may sound unsympathetic, but I’m not really. The truth of the matter is, there’s no good reason why we’re in the state we’re in now, other than (for most) personal choice, a lifetime of bad habits, and little to no education in health and fitness. As I’m sure you’re aware, getting people to change habits, even the ones they know they need to, is very hard for people to do. For many, they have to reverse a lifetime of those habits, and that’s the trick isn’t it?

  87. mufion 28 Jul 2011 at 3:15 pm

    Most people pay lip service to wanting to improve their health and fitness, because they know they should, but simply don’t want to give up their habits enough to do so.

    Sounds to me like they value those habits as much or more so than their health. If the latter, then that would seem to answer your question: “What’s more of a priority than health?” For you: perhaps nothing. For them: whatever benefits they derive from their unhealthy habits.

    That’s not to suggest that it’s a wise prioritization on their part. But then wisdom was never our species’ strong suit (so much as an ability to adapt and reproduce in greater numbers). So, while I agree with Dr. Novella that “the goal should be to make healthy choices easier and more often the default choice”, it still seems a rather lofty one, given where we are today (at least here in the US).

    In the meantime, I’d say that the natural, long-term effects of unhealthy habits are punishment enough. I would certainly agree that we should try to head those off – e.g. with demonstrably effective prevention programs, but those cost money, too (albeit, less in the long run). And, if we agree that health is of the highest priority, then we should size our budgets (at all levels of society) accordingly, so as to manage the risks of being human in a land of plenty.

  88. ccbowerson 28 Jul 2011 at 4:04 pm

    “This suggests the goal should be to make healthy choices easier and more often the default choice – not to tell people to work harder at it. ”

    This could imply a restriction of choice, which Americans anyways are usually not OK with (that is until it has been done and they forget about it). I agree with the statement though, and I can think of many ways of doing this, but they usually require some increase in cost or other inconvenience.

  89. ccbowerson 28 Jul 2011 at 4:19 pm

    “As harsh as it may sound, I think something needs to be done for those who choose unhealthy lifestyles like smoking or morbid obesity and bog down the healthcare system as a result”

    Thats some slippery slope you are standing on there, and not in a logical fallacy sense. Perhaps something needs to be done for those who choose risky lifestyles and get into accidents. How about those who drive frequently, and by definition put others at risk? How about those thin people who never exercise? (these people are likely worse off than fit overweight people) How about anyone with any disease that is not 100% genetic? The truth is that this type of moralistic approach to health is not a good idea, if we claim to be a compassionate society. We all have some nonoptimal behaviors in our lives, and we should not be looking to wag our fingers when a health problem arises.

    Not to mention that such an emphasis is dependent on measurement bias. Just because it is easier to measure weight relative to other things does not increase its value as a metric. My understanding is that cardiovascular fitness is a better metric than weight is for many aspects of health, but is not as easy to measure (and you certainly can’t “see” it)

  90. mufion 28 Jul 2011 at 4:46 pm

    ccbowers: This could imply a restriction of choice…

    Or it could imply that one has to look a little harder for the less healthy non-default choices, even if they’re still available.

    It’s also possible that healthier default choices would actually be cheaper for consumers at point-of-purchase, but the market has thus far done little to promote them – say, because they’re less profitable for corporations (e.g. not enough “value added”) and/or because lobbyists have drawn scarce government subsidies elsewhere.

  91. ccbowerson 28 Jul 2011 at 9:20 pm

    “Or it could imply that one has to look a little harder for the less healthy non-default choices, even if they’re still available.”

    That is much more difficult from a public policy perspective, particularly if being done in a top down manner (in terms of regulations, for example).

    I agree that it can be done (and is preferable), but what you describe seems to require cooperation from the suppliers of the unhealthy choices, which means it will likely need to be driven by consumer demand to some degree. The recent McDonalds change of happy meals to have apples as a defult with less fries and no caramel sauce is an example of what you are suggesting, I think.

  92. rezistnzisfutlon 28 Jul 2011 at 9:26 pm


    I indicated in a previous post that patients would need to be assessed whether their health problem was related to obvious lifestyle choices. You make some interesting points with the example about accidents, etc, however, that I honestly don’t have a good reply for. The only thing that comes to mind is when someone exhibits continuous risky driving patterns that results on frequent accidents, then they should be paying, too. However, some people have to drive say, to work, every day for many miles while some people work from home and hardly ever use their vehicle, so I see your point there.


    “And, if we agree that health is of the highest priority, then we should size our budgets (at all levels of society) accordingly, so as to manage the risks of being human in a land of plenty.”

    I’m actually a proponent of universal healthcare as our current healthcare system is broken. I do believe, admittedly without having done any analysis, that the cost of universal healthcare would not be more than what we already pay in premiums and deductables, likely less (at least for some).

    But like CC said, Americans don’t like being told what to do, even if what they’re doing is killing them. Just go to any comments section on an article about smoking to see how staunchly they defend their habit. My position is, let them, as long as what they’re doing isn’t affecting anyone else. Problem is, often what they do DOES affect others.

  93. ccbowerson 28 Jul 2011 at 10:08 pm

    “Problem is, often what they do DOES affect others.”

    Do you really think that making “them” pay for it will not affect others? All of us are theoretically “them.” If your child/wife/mother/father, etc develops lung cancer and they are told that they have a $100,000 bill don’t you think that it will affect your whole family? Even lung cancer is only ~80-90% caused by smoking (radon makes a distant 2nd)… how could we ever make such an assessment of cause. I personally think its a mistake to think in those terms at all.

    Sorry I think your approach wrong in principle, but in practice it is even more scary. Imagine you grandmother dying of cervical cancer and the insurance cancer making the case that it is because she had a promiscious youth so they refuse to pay for treatment (perhaps that was how she got HPV, perhaps it was due to an unfaithful husband). I hope you see that such an approach is untenable in practice. I would really like for people to see how it is untenable in principle (but I’ll take the former)

  94. rezistnzisfutlon 28 Jul 2011 at 10:51 pm

    Ok, here’s my take, using your traffic analogy. People are fined when they break traffic laws, and when they display consistent abuse of driving privileges, especially risky driving behaviors like excessive speeding or DUIs, they typically have the priveleges removed. If it’s a simple accident where no one is at fault, then no one pays (other than their own property damage that may be covered by insurance anyway). For the most part this is accepted in society.

    When a person displays a persistent lack of care for their health, especially in cases where their health is a direct result of persistent unhealthy choices they make that they know they’re making yet do it anyway, then yea, they should have to pay for it, especially if they’re constantly in the health system because they can’t get their habits under control, and others are having to shoulder the burden of cost. I also think it has to be demonstrated to a high degree of accuracy that the health issue at hand is a direct result of their unhealthy lifestyle choices, with chances for the person to appeal if they think there are other factors they can show evidence for. Of course I’m not suggesting health care should ever be refused.

    I think a physician would be hard pressed to conclude that a grandmother’s cervical cancer is due to a previous permiscuous lifestyle, that’s a little ridiculous and approaching an ad hominem (it should be up to the physicians, not the insurance company, to make that judgement). If a person turned their life around and past mistakes come back to haunt them for some reason, then no, they shouldn’t be penalized for that. You have to be realistic and again, demonstrate that the health issue is (currently) being caused by persistently bad habits that the patient refuses to reduce.

    Furthermore, I do think help and counselling should be provided in reversing these unhealthy trends and perhaps giving people incentives to do so, like suspending or removing the previous costs incurred if they can demonstrate forward progress.

  95. rezistnzisfutlon 28 Jul 2011 at 10:57 pm

    Obviously, I don’t every little detail worked out. Any and all healthcare solutions are highly complex with a huge number of variables (just look at Obamacare). I’m for universal health care like I said, but I also feel people should be held at least somewhat accountable for their choices, but also allowed the opportunity to improve their situation. If a person is in the emergency room every week because of drug overdose or alcohol poisoning, then first they need help and should get it, but something has to be done to stop the cycle.

  96. mufion 28 Jul 2011 at 11:19 pm

    I think ccbowers makes the point more strongly than I did re: the problems with thinking of health coverage and its denial in terms of individual deserts (i.e. reward & punishment). I’ll just add one observation:

    If we are willing to criticize American culture for being short-sighted when it comes to health-consciousness, then why not also criticize it for being short-sighted when it comes to plans aimed at improving the situation (e.g. measures towards Dr. Novella’s goal “to make healthy choices easier and more often the default choice”)?

    If those plans can be effected in a bottom-up direction, that’s great. But such changes usually start with a “dedicated minority” in any case, and are not always widely appreciated until well after they’ve been implemented into policy or law (as economist Paul Krugman has written on several occasions, as I seem to recall, regarding the history of social insurance programs).

  97. mufion 28 Jul 2011 at 11:30 pm

    PS: How does one hold someone born into wealth “accountable for their choices”? The whole suggestion sounds inherently biased against the people who need financial assistance with healthcare costs the most.

  98. ccbowerson 29 Jul 2011 at 8:21 am

    “I think a physician would be hard pressed to conclude that a grandmother’s cervical cancer is due to a previous permiscuous lifestyle, that’s a little ridiculous and approaching an ad hominem”

    Actually I thought I was being fairly “generous” from the examples I used during this discussion as cervical cancer and lung cancer are among the diseases that we have the most certainty as to their cause. Most lung cancers are caused by smoking (>80% anyways) and most cervical cancers (nearly all) are cause by HPV infection which is sexually transmitted. Nearly any other disease state, there is less of a correlation to behavior, which makes the case much harder to pinpoint and hairier to determine.

    “it should be up to the physicians, not the insurance company, to make that judgement”

    Well the problem is given our current setup, the insurance company gets its power from paying for a good/service or not. Unless there are regulations to the contrary this decision would likely fall with the insurance company.

    Listen I get where you are coming from , but I just think its a bad idea, and the wrong approach. I don’t think it will solve our problems, and will create many more. The trouble is that there is no simple answer as you implied, and many things that could help are not politically viable at this time due to competing interests.

  99. daedalus2uon 29 Jul 2011 at 9:07 am

    A Physician would be hard pressed to come up with a “cause” of a person’s cervical cancer sufficient to deny them care for it. Scientifically and ethically they simply can’t do it.

    An insurance company on the other hand could justify it in a heart beat if it made them even a little more profit. They don’t have to worry about science and ethics.

  100. ccbowerson 29 Jul 2011 at 9:36 am

    “A Physician would be hard pressed to come up with a “cause” of a person’s cervical cancer sufficient to deny them care for it. Scientifically and ethically they simply can’t do it.”

    Of course, and that is why such an approach is not possible even in principle for any disease. That is why I used cervical cancer and lung cancer as examples (to give the counter perspective a best case senario). To be fair, I don’t think that rezistnzisfutl is advocating the denying of care, but some sort of monetary penalty. (I guess getting the insurance company off the hook and burdening the healthcare system further)

    rezistnzisfutl, I think it best to view healthcare in a different way. That we all contribute to our health to some degree, but that much of it is out of our control. We should not be in the business of assigning blame for circumstances (we can leave that to the Pat Robertsons of the world), but we should take the burden of healthcare as a society. That is not to say we can not ask people to take care of themselves or to contribute in some way, but lets not pretend that we can meaningfully impact an individual’s behavior. If lung cancer is not enough deterrent for starting a smoking habit, how will a large hospital bill after obtaining lung cancer be? We would end up punishing those who are already in a difficult situation, and those friends and family who care for that person.

  101. mufion 29 Jul 2011 at 10:36 am

    If lung cancer is not enough deterrent for starting a smoking habit, how will a large hospital bill after obtaining lung cancer be? We would end up punishing those who are already in a difficult situation, and those friends and family who care for that person.

    At least for the large majority of people who cannot afford large hospital bills. Wealthier individuals might reject such a penalty in principle, but would hardly be bankrupted by it (unless perhaps it were means-tested, which opens up another big can of worms).

    I get the sentiment behind the “Why should I have to pay for their indiscretion?” question. But I think it’s a reasonable response to say: Because it’s been logically and empirically demonstrated that a successful healthcare system does just that – it effectively manages risk by pooling financial resources and negotiating costs. It does not penalize individuals or families for being unhealthy (which, from a mental-health parity standpoint, might include the psychological factors that contribute to unhealthy behavior, like substance abuse and overeating).

    But, politics aside, the wisdom of prevention has not been lost on either insurance payers, be they public or private. It’s why every Spring I observe some of my otherwise more sedentary work colleagues walking in teams around the industrial park and/or at a run/walk “corporate challenge” event. They’re participating in an exercise program that’s promoted annually by our HMO. They a log point for every ten minutes of exercise and each team with the highest total collects prizes at the end of each week. The HMO also provides free biometric screenings before and after the six-week period.

    It may not radically change anyone’s lifestyle, but it’s a step in the right direction.

  102. ccbowerson 29 Jul 2011 at 12:51 pm

    “…it effectively manages risk by pooling financial resources and negotiating costs.”

    Of course you are correct. I realize that I have framed my comments in a way that it outside of skepticism and science to some degree (something that I rarely do at this website), but I felt it could have been an effective method for the topic. Its a topic that I have thought about before, but never engaged in a “conversation” about it. rezistnzisfutl seems like a reasonable and logical person, and I thought throwing a different perspective would help.

    “It’s why every Spring I observe some of my otherwise more sedentary work colleagues walking in teams around the industrial park and/or at a run/walk “corporate challenge” event.”

    I have mixed feelings about some of these things. Bringing attention to the concept of healthy lifestyle choices is good, but the implimentation can be pretty questionable and not evidence based. For example, I know people who have entered “biggest loser” “competitions promoted by their work as if losing the most amount of weight the fastest is a good approach. If anything the evidence suggests that frequent “dieting” in that fashion is harmful.

    Also my mother came to me a 2 years ago saying that her insurance sponsored annual health evaluation said that she had high cholesterol. I looked at this print out that had various metrics and whether they were “high” or “low” and what she could do to improve. Her total cholesterol was slightly over 200 (labeled high), but the breakdown was HDL = 97 and LDL = 98. I saw that in previous years she had similar results. I told her I wished that I had her type of high cholesterol. Of course I explained the flaw in the report, but its just an example of good intention with bad implimentation.

  103. mufion 29 Jul 2011 at 1:30 pm

    cc: I was skeptical of some of the qualitative (as in: simple-minded, moralistic-sounding) feedback that I received from my latest biometric screening. But that was partly because recent personal circumstances have forced me to think more critically about such metrics (particularly weight and BMI) than I used to. I was still glad to receive some feedback (especially given that it was positive) from a medical professional – and on the HMO’s dime.

  104. elion 20 Mar 2012 at 10:29 am

    Hi Steven

    You write:
    “It could just be culture, it could be the “supersized” fast food industry or it could be changing trends in eating habits. One factor often raised is the fact that families with both parents working have less time to prepare traditional meals, and therefore there is more reliance on fast food”

    Assuming you believe that a theory needs to explain all occurrences of the same phenomenon if we are to consider it seriously, how based on you theory of obesity you would account for the obesity epidemic in the following very-low-income population in Brasil circa 2001 (I just picked the first result in google for “obesity and malnutrition in the same population”):

    Apparently they get by on 9.62US$ per capita per month.
    81.6% unemployed (neither legal or illegally), “both parents working – have less time to prepare meals” is not an issue.
    91% of houses have no flooring, 97% have no water supply etc…etc..

    They are dirt-poor, they do not eat out, no fast food, industry or supersizing, yet the study notes:

    “Among the children (aged #10 years), the prevalence of wasting, stunting and wasting plus stunting was 3:8, 8:3 and 8:7% respectively. Wasting (10:2%) was the most prevalent form of undernutrition among adolescents; nonetheless, a higher frequency of stunting (11%) and overweight–obesity (5:5%) was seen specifically in girls, in agreement with trends found in other studies. Adults exhibited a high prevalence of overweight–obesity (25%), but stunting was also present (22%). Of the stunted individuals, 30% were overweight–obese and 16:3% were underweight. There were eighty-six families with
    at least one parent who was underweight (27%) and 104 families with at least one parent who was
    overweight (33%)”

    Also they write:

    “Underweight and overweight–obesity were both present in ninety-six households (30%). ”

    I’ll stress, it happens in the same households.

    It is also not a unique occurrence, as they write: “in agreement with trends found in other studies”, it is also very easy to find more such reports.

    Gary Taubes wrote in GCBC (from memory), that a working theory have to explain all the cases of obesity in ALL the populations.

    It is very easy to find an explanation that that works only on few selected cases and disregard the rest with some or other special pleading.

  105. elion 21 Mar 2012 at 3:28 am

    The link was corrupted:

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