Obesity: Causes, Mechanisms, Prevention, and Treatment

Edited by Elliott M. Blass

2008
450 pages, 80 illustrations

About the Book

This new book is concerned with overeating and its consequent obesity. It provides, for the first time in a single accessible volume, an integrated approach to both causes and mechanisms underlying obesity and offers principled steps toward prevention and fitness. Expert chapters are written by leaders in their respective fields (see Table of Contents).

Multiple factors have contributed to the obesity epidemic. Social, sensory, cultural, medical, perceptual, conditioning, and developmental influences have combined to disrupt well established feeding controls. All are discussed individually and collectively from the perspectives of causation and potential mitigation, on individual and at group levels.

Another major cause of obesity that has not received its due attention is the unhealthy marriage of addictive overeating of sweet and fatty foods with federal policies of subsidizing agricultural industries through the USDA. These subsidies specifically target agricultural production that makes tasty, high-calorie foods widely available at very modest costs. This comes by eliminating subsidies for fruits and vegetables, resulting in higher, often unaffordable prices. The Food Stamp Program is discussed as one vehicle through which produce can be made more widely available to people who could not otherwise afford their purchase. The complexities, limitations, and potentials of such a program are evaluated.

Vulnerability to overeating, which develops in infancy and in early childhood, has been exploited by producers of children's foods (such as sweetened cereals) and by advertising campaigns to make them extremely enticing. The contribution to early obesity by extended inactivity through TV and computer engagement is discussed, as is increased dependence on the automobile (especially in unsafe public areas where there is no viable alternative) as the sole means of transportation.

Obesity identifies feeding strategies and unknown entrapments that cause severe overeating and ways that they can be combated. They range from exchanging large dishes and short, stout glasses for small dishes and thin, tall glasses to strategies of better monitoring portion sizes and the caloric content of foods served at home.

Reviews and Commentary

“For those individuals who seek a more complex exploration of some [of] the major factors that contribute to obesity than what our mainstream culture provides, Elliott Blass's Obesity: Causes, Mechanisms, Prevention, and Treatment is an excellent start.”
—Christy Barongan, PsycCRITIQUES

Preface
Elliott M. Blass

The editor introduces this text with a brief report of the remarkable over-the-counter success of a drug that had been a failure when obtainable by prescription only. The drug had not changed; the owners and publicity did, however. This sets the stage for the text, which identifies the very diverse causes of obesity—ranging from addiction to USDA policies—and what can be done to reverse the tide.

1. Critical Introduction to Obesity
Gerard P. Smith

This chapter is a critical introduction to the biology of obesity, its clinical phases, prevention, treatment, and politics.

2. The Epidemiology of Obesity: Causal Roots—Routes of Cause
Viktor E. Bovbjerg

Chapter 2 presents an overview of the current state of the obesity epidemic, its penetration into every corner of the globe, and its influence on human health and well-being.

3. Metabolic Influences on the Controls of Meal Size
Timothy H. Moran

This chapter provides an overview of the physiological systems involved in the controls of food intake and energy balance. This information is presented from the perspective of factors that contribute to the controls of meal size. Meals are the primary ingestive unit and variations in meal size are the major way in which changes in food intake are expressed. A variety of feedback factors arise from the presence of food in the gastrointestinal tract providing information to the brain on the nature and amount of ingested nutrients. The neural representation of this information is modulated by the overall energy state of the organism through signaling factors from body energy stores acting on hypothalamic sites with neurons expressing orexigenic and anorexigneic signaling peptides. These signals converge on hindbrain sites that modulate eating.

4. Obesity and Addiction
Roy A. Wise

Obesity results from compulsive eating of food that is not needed by the body; addiction results from compulsive use of drugs that are not needed by the body. Food and drugs are habit-forming because they activate a common brain mechanism, a reward mechanism that served our biological needs well over millennia of foraging for nuts and berries but that no longer serves so well over decades of abundance of high-fat, calorie-rich processed foods. Much is now known about the reward circuitry activated by both palatable foods and addictive drugs. The best characterized elements of this circuitry are the mesocorticolimbic dopamine system and opioid systems that provide input to the dopamine system and opioid systems that receive input from the dopamine system. While there are genetic factors that predispose individuals to obesity and to drug addiction, the changes in the genome are insufficient to explain the obesity epidemic or the increased incidence of cocaine addiction of the last few decades. More closely linked to the development of the epidemics are the increased exposure to seductive foods and affordable quantities of crack cocaine. While attempts are ongoing to develop pharmacotherapies for obesity and addiction, and while the same drugs are hoped to be effective in both cases, prevention treatment is of limited success in either case. In the case of obesity, limiting the accessibility of our children to high-fat, high calorie processed foods, like the limiting of cigarettes and alcohol, particularly in schools and public facilities, would appear to be an advisable first step.

5. The Logic of Sensory and Hedonic Comparisons: Are the Obese Different?
Derek. J. Snyder and Linda M. Bartoshuk

To understand obesity, we need to understand why obese people consume more food than their bodies actually need. Do they experience food differently; do they like it more? The easiest way to answer these questions is to ask obese and nonobese individuals to rate the intensity of their sensory and hedonic experiences with food. However, for this comparison to be valid, we have to be sure that everyone uses the same rating to convey the same level of intensity. Inappropriate scaling has become dangerously common in sensory and hedonic research, resulting in confusion and conflict; it has also promoted widespread beliefs about the experiences of obese individuals that simply may not be true. Revisiting these views with measures that permit valid comparisons, this chapter shows that obese individuals perceive reduced sweet taste compared to the nonobese—but they like it more, particularly when it is paired with fat. Consequently, the obese generally like foods (and sweet–fat foods especially) more than do the nonobese. Individual differences in oral sensation certainly contribute to this effect, but childhood damage to the taste system produces surprisingly similar effects, suggesting a link between childhood disease and long-term obesity risk. These results appear only with scales that permit valid comparisons, underscoring their importance in sensory and hedonic research.

6. Development of Eating Behavior: Immediate and Long-Term Consequences
Julie Lumeng

The author addresses factors contributing to obesity risk into adulthood from a developmental perspective beginning in utero and continuing throughout childhood. Factors that are considered include: maternal weight status; weight status and patterns of weight gain in early childhood; parental feeding practices; children's eating behaviors, including food neophobia; the effect of repeated exposure and impact of modeling on food preferences; the ontogeny of flavor preferences; the development of hunger and satiety controls; and the impact of life stressors.

7. Learning and Hedonic Contributions to Human Obesity
Martin R. Yeomans

In the chapter, Dr Yeomans examines how our hedonic experience of food flavor leads to overeating. The initial discussion focuses on the nature of palatability and its relationship with the sensory quality of food, before discussing how the effects of palatability can act as a driver of short-term overconsumption. The focus then turns to a discussion of why certain foods are liked, starting with a brief overview of innate (unlearned) flavor preferences, and then an evaluation of how different types of flavor-based associations can lead to acquired flavor liking and consequent overeating. Attention then turns to the interaction between hedonic components and homeostatic controls of eating—in particular satiety—with an emphasis on how hedonic cues override satiety and so lead to overconsumption both in an active way (by stimulating eating) and passively (through acquired preferences for energy-dense food). The chapter closes with more detailed evaluation of the importance of hedonicity in obesity, and what implications this has both for treatment and future prevention.

8. Exercise for Obesity Treatment and Prevention: Current Perspectives and Controversies
Shaun M. Filiault

While exercise is often regarded as a primary method of combating obesity, the research record on exercise as an obesity treatment suggests a more subtle role for exercise in generating weight loss. Instead, exercise may hold a more promising role in preventing weight gain, rather than reversing it. However, in spite of the seeming inability of exercise to promote long-term weight loss, exercise can promote cardiovascular, metabolic, and mental health, and may be a better predictor of morbidity and mortality than weight status as such. Therefore, exercise can be profitably undertaken by everyone. After a brief overview of major concepts in exercise science, this chapter provides a review of the literature regarding exercise as an obesity treatment/prevention method, exercise and health, and major concepts regarding exercise program initiation and community health promotion.

9. Built Environments and Obesity
Jeffery Sobal and Brian Wansink

The built environment includes all things that are made, arranged, or modified by humans. Built environments shape much of peoples' lives, including their body weight. This chapter classifies built environments according to three levels of scale (macro, meso, and micro) and examines how factors at each of these scales influence two components of energy balance (intake, expenditure) that shape body weight. Food intake influences can be macro (food systems, commodity chains, food complexes), meso (food landscapes, foodsheds, food deserts), and micro (kitchenscapes, tablescapes, platescapes). Food expenditure influences can be macro (transportation, communications, mass media), meso (exercise landscapes, neighborhoods, facilities), and micro (rooms, furniture, clothing). Built environments can be changed through policies, planning, reengineering, and individual actions.

10. From Protocols to Populations: Establishing a Role for Energy Density of Food in the Obesity Epidemic
Marion M. Hetherington and Barbara J. Rolls

The current food-permissive environment promotes excess energy intake in many ways, including the widespread availability of a variety of energy-dense, highly palatable, inexpensive foods in large portions. In this chapter by Marion Hetherington and Barbara Rolls, the focus is on recent studies examining the role of the energy density of foods in the control of food intake, and how the mix of laboratory-, community- and population-based approaches has led to practical solutions that can be used to moderate energy intake.

11. Proposed Modifications to the Food Stamp Program: Likely Effects and Their Policy Implications
Conner C. Mullally, Julian M. Alston, Daniel A. Sumner, Marilyn S. Townsend, and Stephen A. Vosti

Some have suggested that the U.S. Food Stamp Program (FSP) should be revised with a view to combating obesity among the poor. In this chapter, we assess the likely impacts of allowing FSP participants to purchase only healthy foods when using food stamps. Our results indicate that FSP participants would probably increase their consumption of healthy food, but the implications for their purchases of unhealthy food are not clear. Immediate market-wide consequences are even less clear, because changing what may be purchased using food stamps would lead to higher prices for healthy foods and lower prices for unhealthy foods, and these price effects could feed back into consumer decisions. Reforming the FSP should lead to better diets among participants. After market adjustments, it will also increase fruit and vegetable intake in the general population and decrease intake of unhealthy foods.

12. Environmental Food Messages and Childhood Obesity
Shauna Harrison, Darcy A. Thompson, and Dina L. G. Borzekowski

On practically every ecological level, children encounter numerous and conflicting messages about diet and weight. The relationship between environmental messages and weight has been very well established. This chapter offers a discussion of this relationship and describes current and potential interventions to mitigate the impact of unhealthy messages and media.

13. A Framework for the Treatment of Obesity: Early Support
Cecilia Bergh, Matthew Sabin, Julian Shield, Göran Hellers, Modjtaba Zandian, Karolina Palmberg, Barbo Olofsson, Kerstin Lindeberg, Mikael Björnström, and Per Södersten

With the exception of surgery, the treatments which are used to treat obesity are largely ineffective. A possibility for this limited success is that the assumptions behind these treatments are only partially correct. A new framework based on the treatment of anorexia nervosa and other eating disorders is adapted to the treatment of obesity. The treatment is based on the assumption that humans need external support to maintain their body weight. Preliminary results indicate that the treatment is effective in morbidly obese adolescents and adults with binge eating disorder.

14. Epilogue
Elliott M. Blass

In the Epilogue, the editor integrates the preceding chapters to provide means and directions through which the readers can individually and collectively determine their food choices and the amounts of food that they eat. These suggestions are based on clinical and experimental findings provided in the text.

About the Editor

Elliott M. Blass received his PhD [Psychology] from the University of Virginia and his postdoctoral training [Zoology] from the University of Pennsylvania. He was on the faculty of Johns Hopkins University and Medical School [Psychology and Psychiatry] for twenty years, during which time he was trained as a Psychiatry Resident. He taught for six years at Cornell [Psychology and Nutrition] and is now a Professor of Psychology and Neuroscience and Behavior at the University of Massachusetts. Blass is a Research Professor in Pediatrics at The Boston University School of Medicine. His research interests have focused on feeding motivation, infant nutrition, mother–infant interactions, and obesity. He has served as a Johns Simon Guggenheim Research Fellow, a Fulbright Hayes Research Professor, and an NIMH Research Scientist.

About the Contributors

CHAPTER 1

Gerard Smith, MD is Professor Emeritus of Behavioral Neuroscience in Psychiatry at the Weill Medical College of Cornell University. His influential research and reviews on motivation, ingestive behavior, and neuroscience have made Professor Smith the recognized leader in his field.

CHAPTER 2

Viktor Bovbjerg is an Associate Professor in the Department of Public Health Sciences at the University of Virginia School of Medicine. His research focuses on translating evidence-based interventions into practice in chronic disease control. He teaches epidemiologic methods courses to clinical fellows, medical residents and students, and graduate students in public health.

CHAPTER 3

Timothy Moran is the Paul R. McHugh Professor of Motivated Behavior in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. He did his graduate work in Developmental Psychobiology with the Editor, Elliott Blass, at Johns Hopkins University. His research focuses on the physiological controls of food intake and body weight with an emphasis on gastrointestinal signals and neural integration. He has published over 250 refereed articles, editorials and book chapters. Dr. Moran is a Past-President of the Society for the Study of Ingestive Behavior.

CHAPTER 4

After three decades at Concordia University in Montreal, Roy Wise has been Chief of Behavioral Neuroscience at the National Institute on Drug Abuse [NIDA] since 1997, where he is also Deputy Director of the NIDA's Intramural Program. Dr. Wise's research has focused on brain reward mechanisms, especially the contribution of dopamine pathways in reward processes. Wise has studied the mediation of drugs such as morphine, amphetamine, and cocaine in the dopamine pathways. He has been able to segregate the rewarding aspects of dopamine, of sustaining behavior from the pleasure provided by food. Dr. Wise is continuing these and other programs involving addiction, expanding to alcohol addiction and its interactions with drugs of abuse.

CHAPTER 5

Derek J. Snyder is a doctoral candidate in neuroscience at Yale University, where he performs clinical and laboratory studies examining the neural basis of oral sensation in health and disease. He received his bachelor’s degree from Yale University and master’s degrees from Yale and Florida State University. He has been active in chemosensory research for nearly 15 years and has received multiple awards for his work, including the Rose Marie Pangborn Sensory Science Scholarship, the Lloyd M. Beidler Fellowship in Neuroscience, and a teaching fellowship from the U.S. National Science Foundation. In addition, he has held positions on the boards of the American Psychological Association and the Society for the Study of Ingestive Behavior.

Linda M. Bartoshuk, the William P. Bushnell Professor of Community Dentistry and Behavioral Science at the University of Florida, is an internationally recognized authority on the human sense of taste. Her research, described in over 100 scientific publications, examines how genetics and pathology contribute to individual differences in oral sensation that influence food choice and long-term health. Media coverage of this work includes articles in the New York Times and Washington Post, as well as segments on National Public Radio and the PBS series Nova. Dr. Bartoshuk has been elected to the U.S. National Academy of Sciences, the American Academy of Arts and Sciences, and the Society of Experimental Psychologists. She has served as president of the Eastern Psychological Association, Divisions 1 (General Psychology) and 6 (Comparative and Physiological Psychology) of the American Psychological Association, and the Association for Chemoreception Sciences. She received her bachelor’s degree from Carleton College and master’s and doctoral degrees from Brown University.

CHAPTER 6

Dr. Julie Lumeng is an Assistant Professor in the Division of Child Behavioral Health in the Department of Pediatrics at the University of Michigan Medical School. She is also an Assistant Research Scientist at the Center for Human Growth and Development at the University of Michigan. She is a developmental and behavioral pediatrician who sees patients and conducts research on the development of children's eating behavior and developmental and behavioral factors contributing to obesity risk.

CHAPTER 7

Dr. Martin Yeomans first trained in biology at Bath University, UK, and then completed a doctorate at the University of Edinburgh, UK, examining physiological controls of ingestion. He joined the University of Sussex in 1989, where he is currently Reader in Experimental Psychology. His research interests center on the nature of liking for food—originally focused at basic physiological controls, but more recently concentrating on mechanisms underlying preference acquisition. Current work is focused in particular on how motivational states modify food preferences and so impact on food choice and on the causes of overeating. He has published over 70 refereed articles and contributions to specialist books, and numerous conference presentations.

CHAPTER 8

Shaun M. Filiault is a doctoral candidate in the human movement program within the Division of Health Sciences at the University of South Australia in Adelaide, Australia. His research has focused on sporting participation in minority populations, body image, and eating disorders. His work has been published in such journals as Medical Journal Australia and the International Journal of Men's Health.

CHAPTER 9

Jeffery Sobal is a professor in the Division of Nutritional Sciences at Cornell University. His research examines influences upon and consequences of obesity, food choice processes, food and nutrition systems, and commensality.

Brian Wansink is the John S. Dyson Chair of Marketing in the Applied Economics and Management Department at Cornell University. His research examines how advertisements, packaging, and environmental cues influence the frequency and volume of food consumption.

CHAPTER 10

Barbara J. Rolls obtained a B.A. in biology from the University of Pennsylvania and a Ph.D. in physiology from the University of Cambridge, England. Her early research career was spent at the University of Oxford, England. In 1984, she joined The Johns Hopkins University School of Medicine faculty as a Professor of Psychiatry. In 1992, she became Professor of Nutritional Sciences and The Helen A. Guthrie Chair in Nutrition at The Pennsylvania State University. Dr. Rolls is Past-President of both the Society for the Study of Ingestive Behavior and the North American Association for the Study of Obesity. She has been a member of the Advisory Council of the National Institute of Diabetes and Digestive and Kidney Diseases (NIH). Dr. Rolls was elected a fellow of the American Association of the Advancement of Science in 2006. She is the author of five books, including Thirst, The Volumetrics Weight-Control Plan: Feel Full on Fewer Calories and The Volumetrics Eating Plan.

Marion Hetherington received her D.Phil. [Psychology] from the University of Oxford under the keen supervision of Barbara Rolls. She was awarded a Fulbright scholarship to join Dr. Rolls at The Johns Hopkins University School of Medicine for one year during her doctorate, and then returned to Hopkins as a postdoctoral fellow [Psychiatry]. This was followed by a Fogarty International Fellowship at the National Institutes of Health [NIMH]. She returned to Scotland to take up a lectureship at the University of Dundee where she conducted research and taught in the area of Biopsychology for 11 years. She was appointed to Chair of Psychology at the University of Liverpool and then the Caledonian Futures Professor of Biopsychology at Glasgow Caledonian University. Her research interests include understanding appetite regulation, identifying risk factors for overweight and obesity in children, and applying psychological theory to increase intake of fruits and vegetables in children.

CHAPTER 11

Conner C. Mullally is a PhD candidate in the Department of Agricultural and Resource Economics at the University of California, Davis. In addition to the economics of nutrition, his primary research interests include the economics of risk in agriculture and rural finance in developing countries. Currently, he is conducting dissertation field research in Peru, and expects to receive his PhD in 2009.

Julian M. Alston is a professor in the Department of Agricultural and Resource Economics of the University of California, Davis. He teaches graduate and undergraduate classes in microeconomic theory and the analysis of agricultural markets and policies, and conducts research on agricultural policy. Dr. Alston’s main current projects relate to the economic impacts of US Farm Bill policies, including farm commodity programs, agricultural research policies, and food and nutrition policies.

Daniel A. Sumner is the Director of the University of California Agricultural Issues Center and the Frank H. Buck, Jr. Chair Professor, Department of Agricultural and Resource Economics, University of California, Davis. Sumner engages in teaching, research, and outreach on topics in agricultural economics and policy.

Marilyn S. Townsend, PhD, RD , is a Nutrition Specialist in the Department of Nutrition at the University of California, Davis. She develops theory-driven health promotion interventions for Cooperative Extension and conducts research in the area of nutrition education. Her research interests include: poverty, hunger and food costs and their relationship to obesity; evaluation of USDA programs for low-income families and children; validation of evaluation tools for USDA programs; and development of behavior change strategies for health promotion. Dr. Townsend is the recipient of the prestigious Award for Excellence in Community Nutrition sponsored by the American Dietetic Association and the Dannon Instutute. She was awarded the BC Decker Award for the Outstanding Research Paper of 2003 for her scientific article in the Journal of Nutrition Education and Behavior.

Stephen A. Vosti is Associate Adjunct Professor in the Department of Agricultural and Resource Economics at the University of California, Davis. He received his PhD in economics from the University of Pennsylvania, and was a Postdoctoral Fellow with the Rockefeller Foundation in Brazil, where he taught economic demography and did field research on the socioeconomic determinants and consequences of malaria. He was a Research Fellow at the International Food Policy Research Institute, where he managed international research projects aimed at identifying and measuring the effects on poverty, economic growth, and environmental sustainability of changes in land use and land cover, and identifying the role of public policy in managing these trade-offs/synergies. Vosti has substantial field-based research experience in Ethiopia, Pakistan, Brazil and Ecuador, and, via his chairmanship of the policy working group of the Alternatives to Slash-and-Burn Consortium, also in Indonesia and Cameroon. He is Associate Director of the Center for Natural Resources Policy Analysis at UC Davis, where he works closely with biophysical scientists to develop bioeconomic models to predict the effects of changes in policies, technologies, and institutional arrangements on the environment, poverty, and economic growth.

CHAPTER 12

Darcy A. Thompson MD, MPH is an Assistant Professor in the Department of Pediatrics at Johns Hopkins School of Medicine. She attended medical school at Yale and completed her pediatric training at the University of California, San Francisco. Dr. Thompson then moved to Seattle where she was a Robert Wood Johnson Clinical Scholar at the University of Washington. She also has a Master of Public Health degree from Harvard and a Bachelor's from Stanford. In addition to research, she teaches medical students and residents in a general pediatric clinic. Her research is focused on understanding television viewing in young children. She has published multiple studies looking at media use in the family environment and its associated outcomes.

Dina L.G. Borzekowski completed her doctoral training at Harvard University's Graduate School of Education, studying Developmental Psychology. At Stanford University, Borzekowski did post-doctoral work in Health Communication. Currently, Borzekowski is on the faculty at Johns Hopkins Bloomberg School of Public Health in the Department of Health, Behavior, and Society. Borzekowski's area of expertise is children, media, and health. In her research, she investigates how media affects children and how children come to use different media. Borzekowski has examined a range of issues (e.g., obesity, alcohol use, smoking, violence, eating disorders, etc.) among diverse samples including preschoolers, third and fourth graders, high school students, incarcerated teenagers, and parents. She has considered print, radio, television, and Internet messages. Not only does Borzekowski conduct research in the US, but also she works extensively in Africa and Asia.

CHAPTER 13

Cecilia Bergh, PhD is Clinical Director of the Mandometer Clinics in Stockholm, Melbourne, and San Diego and Clinical Consultant to the Mandometer Clinic in Amsterdam. She has developed the treatment for eating disorders that is used at these clinics and adapted it to the treatment of obesity.

Matthew Sabin, MD, PhD is Clinical Research Fellow in the Department of Endocrinology and Diabetes at the Royal Children's Hospital in Melbourne, Australia. He works on the endocrinology of childhood obesity and diabetes.

Julian Shield, MD, PhD is Reader in Child Health at the Royal Children´s Hospital of Bristol University, England, and works on the endocrinology of childhood obesity.

Göran Hellers, MD, PhD is a surgeon at the Karolinska Hospital and Karolinska Institutet is Stockholm and works on implementing surgical treatment for obesity.

Michel Zandian, MSc is a PhD student in the Section of Applied Neuroendocrinology, Karolinska Institutet, Stockholm and develops computer-supported devices for the treatment of eating disorders and obesity.

Karolina Palmberg, Barbro Olofsson, Kerstin Lindeberg and Mikael Björnström are case managers at the Mandometer Clinics in Stockholm.

Per Södersten, PhD is Professor of Behavioral Neuroendocrinology in the Section of Applied Neuroendocrinology, Karolinska Institutet, Stockholm, and Clinical Consultant to the Mandometer Clinics. He develops computer-supported devices for the treatment of eating disorders and obesity.

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