Q&A with Dr. Yoni Freedhoff, Part 2: Challenging the orthodoxy in obesity medicine
As a health writer and weight-loss management specialist in Canada, Dr. Yoni Freedhoff engages every day in the ongoing conversation about how we get a handle on North America's obesity problem, which is quickly becoming the world's obesity problem. We spoke last week about how he started managing weight-loss cases and what prompted him to start writing about the topic. The first part of our conversation was posted on Wednesday. The second part of our conversation has been edited for space and clarity.
Q: You've taken on industry-sponsored branding efforts like Health Check that purport to tell consumers which foods are healthy. Have you seen efforts where industry has taken an active role in food guidelines or labeling requirements and it has produced good results for consumers?
A: The very definition (of) the industry's job is to sell their products. I'm unaware of any intervention anywhere that actually had people purchasing fewer products. All of those interventions – like Health Check – are geared toward selling products. Eating more of things, even healthy things, isn't going to help this problem very much. Blindly telling people to eat more of these supposedly good things may backfire. Brian Wansink has done tons of work on health halos. Things like low fat on the label lead people to eat more calories because they believe they are eating a lower calorie item and can get away with it. They are duped by this health halo into thinking they are doing the right thing for their health.
Q: What is a food guideline or labeling program that you have seen that you think works?
A: I love NuVal. Quite regularly, I blog about it. It's David Katz's baby. It's based on a rigorous algorithm that looks at various dietary considerations, and it was developed by some of the finest nutritional epidemiologists and without influence from the food industry. And they don't just apply it selectively. It is applied to every single product in a grocery store. Not just the products where companies have paid to have some label. It's a scale from 0 to 100, and it's a brain-dead simple system to use.
Most of the other systems are not rigorous enough. Health Check looks at three or four things, and that allows a company to take a product that is crappy and make sure those three or four things are included in the product. That's all it takes to get the stamp of approval. Baked potato chips are still potato chips. Hannaford Bros. has a Guiding Stars program that also scores everything in the supermarket. But I'm not sure there are studies about whether people who are consuming with NuVal and buying all these things that are values of 60 to 100 are actually any healthier or losing weight.
Q: For those who absolutely can't seem to lose weight, the only surgical option in Ontario, where you work, is gastric bypass surgery, is that right? Why is that?
A: It's a different surgical landscape here than in the United States. There was a time when we were doing gastric bypasses, duoduenal switches and vertical sleeve gastrectomies. Ontario actually led the country in terms of access to surgery. But now pretty much the only thing we cover is the gastric bypass. Lap-Bands have never been covered, with the exception of adolescents. Because they are removable, the thought is that are better for adolescents because there is some concern about whether they should undertake a nonreversible surgery.
Q: Should Lap-Bands be covered?
A: It's a tough question. I have no shares in Allergan. Nobody is paying me to say anything. We know that the surgical mortality of a Lap-Band is extremely low when done in a good clinic. Some of the things you have been writing about may have to do more with the Dr. Nicks of the world -- to use a Simpsons reference – than with the Lap-Band itself. When you look at the good centers, the surgical mortality of Lap-Banding is far less than gastric bypass, but the outcomes are not as impressive in terms of weight loss. They are impressive when it comes to resolution of things like type 2 diabetes. The question and problem in terms of Lap-Banding, based on my understanding of the literature, is that there is a very significant of percentage of patients who require re-operation. Something on the order of 1 in every 3 patients requires a reoperation. This is either a consequence of a complication from the surgery or a consequence of something going wrong with the band itself. That puts the Lap-Band into question a little bit. If we are talking about low mortality rates, that's wonderful, but if one surgery becomes two surgeries then the complication rates and risks change. From my perspective – being a medical doctor and not a surgeon – if I had to choose a surgery, I would choose a gastric bypass in terms of the outcome and the durability of the surgery.
Q: Do you think that these billboard marketing campaigns that say "Dieting Sucks" and "Diets Fail" are irresponsible?
A: Some of the things that have gone on and that you have reported on make me think that you could save a lot of heartache if you were able to insure that he billboard doctors were not going to be the ones who were operating on you. It's a scary situation to have these billboards shouting at you to surgery. Obesity surgery without proper follow-up and proper education and proper care can lead to horrible consequences. These cases you have been writing about probably would have been avoidable if patients were provided preoperative and post-operative education and follow-up. That is probably where things are going wrong when people are rushing into these fly-by-night, get-a-Lap-Band-put-in-tomorrow clinics.
But then I also don't know what happens when you call the number on the billboard. If you get an appointment with a dietician and the risks are explained and everything is spelled out in terms of what the surgery entails and what it will be like post-surgery, then maybe those are great billboards. I have my doubts. They seem to be preying on people's desire for the magic bullet of weight loss. Bariatric surgery is not something to be entered into lightly.
Q: You seem to think that exercise, like surgery, is another "magic bullet" that won't solve our obesity problem. Why is that?
A: Exercise is important, but encouraging more exercise won't solve the problem. Food is where we need to start. People would rather go out and exercise than cook whole meals from scratch in their kitchens. They say they don't have time, but the amount of time it takes to cook dinner from scratch is between 10 minutes to 20 minutes a day. People can tell you what their favorite television show is every night of the week, but they say they can't cook dinner. Instead of telling people that they should make time to make whole meals, people get told they need to go walk or they need to park further way from their office or they need to take the stairs when they go to the store. As far as weight management goes, if people in our country were cooking from scratch more nights than not, that would go a huge way in terms of dealing with chronic disease.
Q: How much of a role does food choice play? There tends to be a lot of finger pointing at big fast food chains and companies that make sugary cereals for kids. Are people given no other choice than to eat food that is bad for them?
A: It's not the fast food stuff. Fast food is vilifiable, but it gets overly vilified. I'm talking about all those aisles in the super market that have the canned tomato sauces and the boxed pasta and the mixes you add to your ground beef and the orange juice that says it's going to cure your heart disease and the yogurt that is going to make your kids smarter. Those are the things that fool us into thinking we're doing a good job. People think they are cooking meals, but they are just mixing meals. The food industry has really taken over our lives.
Both of our governments – yours worse than mine, but mine is on its way – have allowed far too liberal packaging claims. If you put a few nutrients in a food, you should not be allowed to claim that it has health benefits. This is why you have Froot Loops saying that it's good for you because it's a source of fiber. Some people will recognize that it's ridiculous, but others won't.
The pace of living has changed. We are electronically tethered to our jobs 24/7. We chauffeur our kids to and from events now where once upon a time there weren't organized sports. Because of that, it's easier to use those boxes and cans and to go to the restaurants than to cook from scratch. Dollars spent on food outside the home has gone up to 50% when it was closer to 30% in the 1970s. Those dollars, combined with the food inside of the home that is processed –boxed junk food dressed up to make it look good – mean we are spending most of our food budget on food that isn't good for us.
Q: Are you saying that organized sports are contributing to the obesity problem? I certainly haven't heard that one before.
A: I have three little kids. When I was a kid, I maybe did baseball for a year. There's this whole notion of "When I was a kid, I played outside. So kids should play more." That's a BS notion. When we were kids, yes we played outside, but I didn't bust my hump outside. Swinging on a swing or going on a leisurely bicycle ride is not going to do anything for my energy expenditure. The notion that we're going to get kids away from the X-boxes and internet and cell phones is insane. Kids are consumers of time, and they will spend their time wisely on the things they enjoy the most. When I was a kid I would spend time with my parents or go outside with my friends. There are a lot more options now for our kids. Spending huge amounts of resources trying to get kids moving more is misguided both in terms of how much it's going to do in terms of their energy expended and how realistic it is. Maybe if we installed X-boxes in parks we would get kids out there. Kids are not bad or lazy because they want to play video games. They are just enjoying their time.
Q: So if we don't encourage kids to go out and play, what do we do?
A: If we could have Michelle Obama saying, "I don't want a kid graduating from high school without knowing how to cook 10 healthy low-calorie meals," that would go a long way. It would go a lot further than half-assed guidelines for healthy school lunches. We need to bring back the family meal, the cooked meal made from whole ingredients. The second component includes caloric literacy and understanding the concept of energy balance. How many calories are you likely to need in a day and what food choices do you make based on that? It's just like money. I know how much I spend every month because I look at the price tags. The price tags for food consumption are calories. This doesn't mean you can never consume 1,000 calories of ice cream, but you need to understand the implications to your weight of 1,000 calories of ice cream and you might be less likely to know that two low-fat blueberry muffins from Starbucks have the same amount of calories. It's good that your country is putting calories on menus, but that should be combined with a program of teaching them the truth of how many calories they need. People are saying it doesn't work, but they have done studies that show that, if you provide people with an anchoring statement where they understand what they are aiming for when they eat, they actually make the right choices. David Katz, the most eloquent speaker I've ever heard, talks about the concept of a levee. We have to put a lot of sand bags out there to stop the flood of problems related to weight management. No one sand bag is going to do it.
Q: You wrote on your blog about the fact that the only medical organization in North America that offers any form of certification in obesity medicine is the American Board of Bariatric Medicine. Why do doctors need to be certified in obesity medicine?
A: For one we're not taught anything in school about weight management. At the same time, just because a person passes a course and becomes certified doesn't mean they are a going to be a good doctor. Before picking a doctor, you should meet face to face and go to places like RateMDs.com to see what other people have said about them.
Q: What about for bariatric surgery? When you recommend it for your patients, what are the minimum certification requirements for surgeons who receive your referrals?
A: In the states there is a certification program run by the American Society for Metabolic & Bariatric Surgery, and to gain that seal of approval, the morbidity and mortality states have to be low for your center. If you have a bad surgeon in that center, you would expect it would throw the statistics off. The main thing you want is a surgeon who has done a lot of them – more than 250 – and who has had good outcomes. A surgical mortality rate of .002% makes me feel very comfortable.
Q: One last question: when do you find time to write your blog every day?
A: I have no idea. It's definitely a labor of love, because I don't make any money from it. I get a lot of negative comments on the blog, too. Take a look at my piece on Gary Taubes' book. There are definitely haters out there. As far as how I actually do it, I use the Blogger platform, which allows me to time when the posts go out. So if I have an extra hour I can hammer out a bunch of posts in advance. Luckily, I write very quickly. Sometimes it's 4:30 in the morning and I haven't written a blog, and I have to quickly get something out. I don't think I have missed a weekday in years. I do take one week off at Christmas, but the traffic goes down so dramatically then I don't think people miss it.