Thursday, April 28, 2011

Food Reward: a Dominant Factor in Obesity, Part I

A Curious Finding

It all started with one little sentence buried in a paper about obese rats. I was reading about how rats become obese when they're given chocolate Ensure, the "meal replacement drink", when I came across this:
...neither [obesity-prone] nor [obesity-resistant] rats will overeat on either vanilla- or strawberry-flavored Ensure.
The only meaningful difference between chocolate, vanilla and strawberry Ensure is the flavor, yet rats eating the chocolate variety overate, rapidly gained fat and became metabolically ill, while rats eating the other flavors didn't (1). Furthermore, the study suggested that the food's flavor determined, in part, what amount of fatness the rats' bodies "defended."

As I explained in previous posts, the human (and rodent) brain regulates the amount of fat the body carries, in a manner similar to how the brain regulates blood pressure, body temperature, blood oxygenation and blood pH (2). That fact, in addition to several other lines of evidence, suggests that obesity probably results from a change in this regulatory system. I refer to the amount of body fat that the brain defends as the "body fat setpoint", however it's clear that the setpoint is dependent on diet and lifestyle factors. The implication of this paper that I could not escape is that a food's flavor influences body fatness and probably the body fat setpoint.

An Introduction to Food Reward

The brain contains a sophisticated system that assigns a value judgment to everything we experience, integrating a vast amount of information into a one-dimensional rating system that labels things from awesome to terrible. This is the system that decides whether we should seek out a particular experience, or avoid it. For example, if you burn yourself each time you touch the burner on your stove, your brain will label that action as bad and it will discourage you from touching it again. On the other hand, if you feel good every time you're cold and put on a sweater, your brain will encourage that behavior. In the psychology literature, this phenomenon is called "reward," and it's critical to survival.

The brain assigns reward to, and seeks out, experiences that it perceives as positive, and discourages behaviors that it views as threatening. Drugs of abuse plug directly into reward pathways, bypassing the external routes that would typically trigger reward. Although this system has been studied most in the context of drug addiction, it evolved to deal with natural environmental stimuli, not drugs.

As food is one of the most important elements of survival, the brain's reward system is highly attuned to food's rewarding properties. The brain uses input from smell, taste, touch, social cues, and numerous signals from the digestive tract* to assign a reward value to foods. Experiments in rats and humans have outlined some of the qualities of food that are inherently rewarding:
  • Fat
  • Starch
  • Sugar
  • Salt
  • Meatiness (glutamate)
  • The absence of bitterness
  • Certain textures (e.g., soft or liquid calories, crunchy foods)
  • Certain aromas (e.g., esters found in many fruits)
  • Calorie density ("heavy" food)
We are generally born liking the qualities listed above, and aromas and flavors that are associated with these qualities become rewarding over time. For example, beer tastes terrible the first time you drink it because it's bitter, but after you drink it a few times and your brain catches wind that there are calories and a drug in there, it often begins tasting good. The same applies to many vegetables. Children are generally not fond of vegetables, but if you serve them spinach smothered in butter enough times, they'll learn to like it by the time they're adults.

The human brain evolved to deal with a certain range of rewarding experiences. It didn't evolve to constructively manage strong drugs of abuse such as heroin and crack cocaine, which overstimulate reward pathways, leading to the pathological drug seeking behaviors that characterize addiction. These drugs are "superstimuli" that exceed our reward system's normal operating parameters. Over the next few posts, I'll try to convince you that in a similar manner, industrially processed food, which has been professionally crafted to maximize its rewarding properties, is a superstimulus that exceeds the brain's normal operating parameters, leading to an increase in body fatness and other negative consequences.

* Nerves measure stomach distension. A number of of gut-derived paracrine and endocrine signals, including CCK, PYY, ghrelin, GLP-1 and many others potentially participate in food reward sensing, some by acting directly on the brain via the circulation, and others by signaling indirectly via the vagus nerve. More on this later.

Monday, April 18, 2011

Upcoming Talks

I'll be giving at least two talks at conferences this year:

Ancestral Health Symposium; "The Human Ecological Niche and Modern Health"; August 5-6 in Los Angeles. This is going to be a great conference. Many of my favorite health/nutrition writers will be presenting. Organizer Brent Pottenger and I collaborated on designing the symposium's name so I hope you like it.

My talk will be titled "Obesity; Old Solutions to a New Problem." I'll be presenting some of my emerging thoughts on obesity. I expect to ruffle some feathers!

Tickets are going fast so reserve one today! I doubt there will be any left two weeks from now.

TEDx Harvard Law; "Food Policy and Public Health"; Oct 21 at Harvard. My talk is tentatively titled "The American Diet: a Historical Perspective." This topic interests me because it helps us frame the discussion on why chronic disease is so prevalent today, and what are the appropriate public health measures to combat it. This should also be a great conference.

Saturday, April 16, 2011

Obesity and the Fluid-in, Fluid-out Therapy for Edema

I recently attended a lecture by Dr. Arya M. Sharma here at the University of Washington. Dr. Sharma is a Canadian clinician who specializes in the treatment of obesity. He gave the UW Science in Medicine lecture, which is a prestigious invited lecture.

He spent a little bit of time pointing out the fallacy behind conventional obesity treatment. He used the analogy of edema, which is an abnormal accumulation of fluid in the body.

Since we know that the amount of fluid contained in the body depends on the amount of fluid entering the body and the amount of fluid leaving the body, the treatment for edema is obvious: drink less, pee more.

Of course, this makes no sense. It doesn't address the underlying cause of edema and it will not help the patient. Yet we apply that exact same logic to fat loss. Since the amount of energy contained in the body (in the form of fat) depends on the amount entering and the amount leaving, the solution is easy: eat less, move more. Well, yes, if you can stick to that program it will cause fat loss. But that's equivalent to telling someone with edema to drink less water. It will cause a loss of fluid, but it won't correct the underlying problem that caused excessive fluid retention in the first place.

For example, if you have edema because your heart isn't pumping effectively (cardiac insufficiency), the heart is the problem that must be addressed. Any other treatment is purely symptomatic and is not a cure.

The same applies to obesity. If you don't correct the alteration in the system that causes an obese person to 'defend' his elevated fat mass against changes*, anything you do is symptomatic treatment and is unlikely to be very effective in the long term. My goal is to develop a method that goes beyond symptomatic treatment and allows the body to naturally return to a lower fat mass. I've been doing a lot of reading and I have a simple new idea that I feel confident in. It also neatly explains the results of a variety of weight loss diets. I've dropped a few hints here and there, but I'll be formally unveiling it in the next couple of months. Stay tuned.

* The body fat homeostasis system. The core element appears to be a negative feedback loop between body fat (via leptin, and insulin to a lesser degree) and the brain (primarily the hypothalamus, but other regions are involved). There are many other elements in the system, but that one seems to set the 'gain' on all the others and guides long-term fat mass homeostasis. The brain is the gatekeeper of both energy intake and energy expenditure, and unconscious processes strongly suggest appropriate levels for both factors according to the brain's perceived homeostatic needs. Those suggestions can be overridden consciously, but it requires a perpetual high degree of discipline, whereas someone who has been lean all her life doesn't require discipline to remain lean because her brain is suggesting behaviors that naturally defend leanness. I know what I'm saying here may seem controversial to some people reading this, because it's contrary to what they've read on the internet or in the popular press, but it's not particularly controversial in my field. In fact, you'll find most of this stuff in general neuroscience textbooks dating back more than 10 years (e.g., Eric Kandel and colleagues, Principles of Neuroscience).

Sunday, April 10, 2011

US Omega-6 and Omega-3 Fat Consumption over the Last Century

Omega-6 and omega-3 polyunsaturated fats (PUFA) are essential nutrients that play many important roles in the body. They are highly bioactive, and so any deviation from ancestral intake norms should probably be viewed with suspicion. I've expressed my opinion many times on this blog that omega-6 consumption is currently too high due to our high intake of refined seed oils (corn, soybean, sunflower, etc.) in industrial nations. Although it's clear that the quantity of omega-6 and omega-3 polyunsaturated fat have changed over the last century, no one had ever published a paper that attempted to systematically quantify it until last month (1).

Drs. Chris Ramsden and Joseph Hibbeln worked on this paper (the first author was Dr. Tanya Blasbalg and the senior author was Dr. Robert Rawlings)-- they were the first and second authors of a different review article I reviewed recently (2). Their new paper is a great reference that I'm sure I'll cite many times. I'm going to briefly review it and highlight a few key points.

1. The intake of omega-6 linoleic acid has increased quite a bit since 1909. It would have been roughly 2.3% of calories in 1909, while in 1999 it was 7.2%. That represents an increase of 213%. Linoleic acid is the form of omega-6 that predominates in seed oils.

2. The intake of omega-3 alpha-linolenic acid has also increased, for reasons that I'll explain below. It changed from 0.35% of calories to 0.72%, an increase of 109%.

3. The intake of long-chain omega-6 and omega-3 fats have decreased. These are the highly bioactive fats for which linoleic acid and alpha-linolenic acid are precursors. Arachidonic acid, DHA, DPA and EPA intakes have declined. This mostly has to do with changing husbandry practices and the replacement of animal fats with seed oils in the diet.

4. The ratio of omega-6 to omega-3 fats has increased. There is still quite a bit of debate over whether the ratios matter, or simply the absolute amount of each. I maintain that there is enough evidence from highly controlled animal studies and the basic biochemistry of PUFAs to tentatively conclude that the ratio is important. At a minimum, we know that excess linoleic acid inhibits omega-3 metabolism (3, 4, 5, 6). The omega-6:3 ratio increased from 5.4:1 to 9.6:1 between 1909 and 2009, a 78% increase.

5. The biggest factor in both linoleic acid and alpha-linolenic acid intake changes was the astonishing rise in soybean oil consumption. Soybean oil consumption increased from virtually nothing to 7.4% of total calories, eclipsing all sources of calories besides sugar, dairy and grains! That's because processed food is stuffed with it. It's essentially a byproduct of defatted soybean meal-- the second most important animal feed after corn. Check out this graph from the paper:

I think this paper is an important piece of the puzzle as we try to figure out what happened to nutrition and health in the US over the last century.

Friday, April 8, 2011

Office for National Statistics Consultation on Well-Being...

On Thursday 7th April, I took part in a consultation event with the Office for National Statistics (ONS) at Bolton University called; Are the Best Things in Life Free? A Public Discussion and Debate. Alongside fellow panelists Dr John Howarth – (Expert on wellbeing), Gillian Halliwell – (Manager of £17m Big Lottery Wellbeing Projects), Reverend Canon Mike Williams – (Spirituality and Wellbeing) and Rachel Burke – (Bolton Lads and Girls Club), I took the position that creativity, culture and the arts have a significant part to play in the ‘well-being’ agenda. This event gave each of us the opportunity to make a ‘pitch’ for our area of interest and, we hope, influence the ONS.

The event was chaired by Carole Truman, Professor of Health and Community Studies at Bolton University, and an opening address on the ONS consultation process was given by Stephen Hicks, Assistant Deputy Director of the Measuring National Wellbeing programme, Office for National Statistics.

Whilst I’ll make brief reference to them, I can’t aim to cover all the speakers’ contributions here, but want to give a taste of what I crammed into my far-too-brief 5 minute overview; some of the questions raised and some thoughts that didn’t have time to be aired.
An exhausted Clive tries in vain to keep his fellow panellists riveted.
It was significant that Stephen opened the session by framing well-being as being more than the subjective ‘happiness’ that seems to be the flavor of the month, and he gave a definition of the ‘dynamic’ nature of wellbeing that would be typified in the new economics foundation definition;

‘Well-being is most usefully thought of as the dynamic process that gives people a sense of how their lives are going, through the interaction between their circumstances, activities and psychological resources or ‘mental capital.’1
He went on to outline the coalition governments commitment to better understand of well-being and how it can be ‘measured’, expressing a clear understanding that subjective measurements of well-being fall outside the traditional ‘market model’. John Howarth talked about the intensity of work and family commitments and its impact on work/life balance. Gillian talked eloquently about the importance of personal resources in dealing with the stresses of life and the importance of positive social relationships.

Mike talked about faith communities as being ‘gold-mines’ of resources for community well-being; a point I’d agree with, but in my opinion he over-egged the point that well-being and spirituality are inseparable and can only be achieved through a belief in God. For me his comments about the ‘myth of the happy poor’ could warrant a full debate in itself, particularly when one considers the doctrine of some organised religion that places an emphasis on suffering in this life to gain eternal salvation. Rachel gave a full and rounded picture of the very real impact of the work of youth work and sporting activity on the well-being on children and young people as an investment in tomorrow’s citizens.

For my part, I used a number of stories in an attempt to paint a picture of how the arts/cultural engagement can impact on individuals and communities, by opening up new opportunities and offering a means of transformation. Here I’ll make reference to the points I made, and some I didn’t have opportunity to expand on.

Because this was a public event, I spelt out some clear messages: that this agenda went beyond murals on hospital corridors and that I was not a therapist, but grew as an artist within a tradition of community and participatory arts.

I shared the story of a man marginalised by learning disabilities in a long-stay hospital I worked at in the 1980’s, and how the arts enabled him not only to express his individualism, but impose some order on his chaotic life. For me, this was a significant stage in my understanding of the transformative impact of the arts.

Making sense of this individual story in relationship to wider community impact, I shared research findings from the Invest to Save: Arts in Health Project2 which illustrated not only the reduction in symptoms of ill-health, depression and anxiety in the participants of robust arts/health projects; but the increased well-being, evidenced through environmental mastery, autonomy and social connectedness. In fact, much of what are commonly referred to as the 5 Ways to Well-being3.

I discussed the range of questionnaires used, but emphasised the importance of story in making wider sense of this work and talked briefly about the importance of the arts/health community getting better at telling a richer story, of how we create value. I wanted to stress the importance of both longitudinal studies in the field, as well as embracing some of the ideas posited by John Knell and Matthew Taylor around Contingent Value and Social Return on Investment4; a point I later laboured with Stephen, and one that should be taken seriously by the ONS and the coalition government. These are areas that I would be keen to explore with partners in the field.

I spent some time equating the reported rise in anti-depressant prescribing in England over the last four years by over 40%, with consumerism and the pathologising of our day-to-day anxieties and worries, in our bid to be ‘happy’, and as Pascal Bruckner observes, “unhappiness is not only unhappiness, it is worse yet, a failure to be happy.'5

Whilst the World Health Organisation tell us that over the next 20 years, depression will become the single biggest burden on society6, I see some of the social and economic issues affecting society, married with our blind faith in well-marketed pharmacology, as contributing to high levels of social disconnectedness and isolation.

Previous editor of the BMJ, Richard Smith comments, ‘More and more of life’s inevitable processes and difficulties—birth, sexuality, ageing, unhappiness, tiredness, and loneliness —are being medicalised, and we are growing the budget of health care to tackle them. But medicine cannot solve these problems, and…I believe…that the humanities can help us with a problem as pressing as that of attitudes to death (and) climate change. Scientists have long identified the problem, but we have failed to act effectively– largely, I believe, through our evolutionary flaws of selfishness and lack of imagination.7

I did find time to describe yet another story of people whose lives had been turned around through organizations like START in Salford8, that not only give people a sense of community and pride, but through challenging art experiences give opportunity make informed choices and flourish.

If time had allowed, I would share some of the remarkable work that I’m engaged in with Derbyshire Community Health Services, where we have evidenced astounding changes in the lives of people affected by dementia; where again, engaged in challenging art activity and not soporific reminiscence, we have evidence sentience in a number of people, who’s prognosis is in itself, the biggest discriminator. On the basis of this early work, we are embarking on an action research process to better understand this remarkable affect of the arts. And this work is not about finding a magic-bullet cure, but is focused on the quality of our existence in our later years.

Darren Browett
It is here we must strive to develop more than statistical analysis of our findings and marry the numerical data with real stories to affect cultural change in the way we perceive aging and dying, and how we care for growing numbers of people affected by dementia.

It seems that the backlash to current NHS reforms has encouraged the coalition government to enter a ‘listening exercise’, and I hope that the arts are seen as a valuable way of exploring issues around health, education and well-being. We know that the arts contribute hugely to the UK economy and according to a DCMS report in 2008 the creative industries employ 2 million people in Britain and contribute £60 billion to the economy each year, 7.3 percent of UK GDP.9

Sceptics of the arts/health agenda still call for a cold measurement of impact, holding up the Randomised Controlled Trial as the ‘gold standard’. Stephen and the panel seemed to agree that measuring well-being is far more subtle than this, and I illustrated how the figures can be manipulated, citing an article in the BMJ that showed drugs manufacturer Pfizer, chose to hold back back 74% of patient data from the clinical trials of the antidepressant Reboxetine, that showed that it is, ‘overall an ineffective and potentially harming antidepressant’.10 As Jonah Lehrer in Proust was a Neuroscientist quips, ‘…measurement is always imperfect, and explanations are easy to invent.’11

I’m not going to suggest that it’s wrong to attempt to measure well-being, or indeed the way that the arts may, or may not, contribute to this agenda. I’d go so far to say that statistics, and what we can garner from mass observations, are incredibly useful to society and knowledge. What I’d like to do though, is raise the level of this debate and the profile of our work. We observe that the arts connect people; encourage activity, learning and imagination, and through active engagement with high quality arts experiences, there is the potential to impact on public good and civic society.

The participatory arts offer us potential to flourish as humans and I urge us all to think less about illness, and disease and more about salutogenesis; the focusing on the factors that create health and well-being. I suggest to you that the arts offer us all, a way of making sense of the world, communicating our aspirations and facilitating change.

Please feed your comments into the Office for National Statistics, Measurement of National Well-Being @

5. Perpertual Euphoria: On The Duty To Be Happy, By Pascal Bruckner

Thursday, April 7, 2011

News, Views and Opportunities...

Health Innovation Challenge Fund (UK)
The Department of Health and the Wellcome Trust are inviting proposals from organisations and research groups seeking to draw on funding from the Health Innovation Challenge Fund to further the development of innovative healthcare products, technologies and interventions, and to facilitate their development for the benefit of patients in the NHS and beyond. The theme for this funding round is Smart Surgery: Innovative technologies or interventions to reduce, replace or refine invasive surgical procedures. Up to £10 million is available to organisations such as NHS organisations (including NHS Trusts and NHS Foundation Trusts), and equivalent UK authorities; universities, and research institutes and not-for profit organisations; start-up companies founded to capture and develop intellectual property of relevance to healthcare; and biotechnology, pharmaceutical, bioinformatics, engineering or other companies; etc that will deliver ‘Smart Surgery’ solutions that will translate into safe and cost-effective practice into the NHS. The deadline for submitting preliminary applications is 5pm on the 28th April 2011. For more information visit: Fund/index.htm

Artist to work with Arts for Health group for Culture Shops
The Arts for Health service are looking to run two eight week creative courses. The courses run weekly for two hour sessions. The artists will need to have experience of working with adults suffering with mental health difficulties. The artist would work with the Arts for Health group to produce work which would then be exhibited as part of the Blackpool Culture shop programme, whereby work is displayed in an empty shop in Blackpool. The first course would be April- June 2011 and second course to be June-August 2011. Details at:
Arthur and Martha

An Interesting Project to Watch
Arthur and Martha engagement project with older people in St.Helens.
Over the course of this week the Arthur and Martha are working in diverse settings such as the local health centre, library and bingo group... These initial pilot taster sessions will shape how we move forward from this period and develop the activity. As well as delivering the project Arthur and Martha will be blogging about the work and I thought you would be interested in being kept up to date on how the project is progressing.
The link to the blog can be found here:

Knowledge Lives Everywhere
Arts and Health week 2 - 8 June 2011
Do you work with arts and health? Are you an individual or an organisation with something to contribute to the new FACT exhibition Knowledge Lives Everywhere? Throughout this exhibition there are themed weeks being held in Gallery 2, programmed by FACT collaborators and guests. We would like to hear from you if you work within arts and health and have a film you would like to screen (or suggest a topical film), give a talk, do a performance or wish to have a change of scene and hold a meeting in the space! Do you have any burning issues surrounding arts and health you wish to communicate to the world via a webcast? We will try and accommodate your content and ideas. Please use this opportunity to put the spotlight on arts and health during an exciting exhibition which celebrates all things creative and collaborative! We look forward to hearing from you. If you are interested in taking part please contact Angy or Kat on 0151 707 4416 or  

Reading for Wellbeing: The Reader Organisation’s Second National Conference
Tuesday 17th May 2011
Floral Pavilion, New Brighton, Wirral
“Get Into Reading helps patients suffering from depression in terms of: their social well-being, by increasing personal confidence and reducing social isolation; their mental well-being, by improving powers of concentration and fostering an interest in new learning or new ways of understanding; their emotional and psychological well-being, by increasing self-awareness and enhancing the ability to articulate profound issues of self and being.”
‘Therapeutic Benefits of Reading in Relation to Depression’, Billington et al., 2011
Further details at

Music & wellbeing: Making Music Conference
10 – 11 September 2011, Glasgow
The impact and application of music to improve mental, physical and social wellbeing has many advocates and well-established initiatives demonstrating positive impact. Making Music will be looking at programmes taking place across the UK and the opportunities these create for voluntary music.

Arts in Health – a new prognosis
In this article, our friend and colleague Mike White looks at how the arts community can adapt and respond to changes in healthcare provision and organisation. In recent years the arts in health field has acquired the expertise to address a wide spectrum of medical, health and social care issues. It has the resilience and resourcefulness to weather the impending health service reforms in an era of austerity. But it will need to adapt conceptually and in delivery to healthcare environments in which patient choice, GP commissioning power and a new public health workforce are the drivers of change.  

Tuesday, April 5, 2011


I recently bought the book Food in the United States, 1820s-1890. I came across an ad for an interesting product that was sold in the late 1800s called Fat-ten-u. Check your calendars, it's not April fools day anymore; this is for real. Fat-ten-u was a dietary supplement guaranteed to "make the thin plump and rosy with honest fleshiness of form." I found several more ads for it online, and they feature drawings of despondent, lean women and drawings of happy overweight women accompanied by enthusiastic testimonials such as this:
"FAT-TEN-U FOODS increased my weight 39 pounds, gave me new womanly vigor and developed me finely. My two sisters also use FAT-TEN-U and because of our newly found vigor we have taken up Grecian dancing and have roles in all local productions."
I'm dying to know what was in this stuff, but I can't find the ingredients anywhere.

I find this rather extraordinary, for two reasons:
  • Social norms have clearly changed since the late 1800s. Today, leanness is typically considered more attractive than plumpness.
  • Women had to make an effort to become overweight in the late 1800s. In 2011, roughly two-thirds of US women are considered overweight or obese, despite the fact that most of them would rather be lean.
A rhetorical question: did everyone count calories in the 1800s, or did their diet and lifestyle naturally promote leanness? The existence of Fat-ten-u is consistent with the idea that our bodies naturally "defended" a lean body composition more effectively in the late 1800s, when our diets were less industrialized. This is supported by the only reliable data on obesity prevalence in the 1890s I'm aware of: body height and weight measurements from over 35,000 Union civil war veterans aged 40-69 years old (1). In that group of Caucasian men, obesity was about 10% of what it is today in the same age group. Whether or not you believe that this sample was representative of the population at large, I can't imagine any demographic in the modern US with an obesity prevalence of 3 percent (certainly not 60 year old war veterans).

Here are two more ads for Fat-ten-u and "Corpula foods" for your viewing pleasure:

Friday, April 1, 2011

Great New Product

Do you feel sad sometimes? Are you tired when you get up in the morning? Do you get winded running sprint intervals? I've just found a great new product that I think can help. It's called bozolol.

Bozolol is an amazing nutritional supplement extracted from the bozolol berry, harvested wild in the heart of the Amazon rainforest. To the native Ilotaca tribe, the bozolol berry is sacred because it alters the molecules in your brain to make you smarter AND sexier.

Here's how it works: bozolol actually
increases the uptake of fat-soluble vitamins from your food, while reducing inflammation in the arteries and helping you shed fat faster than a pork roast! Guaranteed! Learn more about it here

April fools!