Tuesday, June 12, 2012

North America's Health Crisis: Who's to Blame?

I'll apologize, up-front for this rather long editorial post, but this is an issue I've wanted to write about for a while...

Through my role as a fitness instructor, personal trainer, researcher, or speaker, I have been involved in health promotion in one way or another since I was 18 years old.  So naturally I am interested in understanding health behaviours.

I read everything I can get my hands on regarding chronic disease prevention, nutrition and fitness.  The factors responsible for North America's obesity epidemic and skyrocketting rates of associated chronic illnesses are hotly debated among academics, policy makers and health professionals.

Some feel it's entirely personal responsibility.  Others believe it is systemic, due to a toxic food environment that promotes the overconsumption of high fat and calorie, low nutrition foods, or fraudulent advertising that misleads the public about the health benefits of what they are eating.  Theories have cropped up about toxins or synthetic hormones in our environment that may encourage us to gain excess body fat and make it difficult to lose.  Still others believe the problem is our increasingly sedentary lifestyle.

Like everyone else, I have been looking for, and hoping for a simple answer to the question and a simple solution.  Unfortunately, after years and years of examining available information, my personal view - and many experts would agree with me - is that the cause is extremely complex and multifactoral, and therefore the solution likely is too.

First, there is the issue of poverty.  This is something which I feel a lot of what I will call, nutrition elitists/idealists, fail to acknowledge.  A recent study in Canada found that more children than ever in this country are living in poverty.  If people are facing food scarcity, there is not much chance that they can concern themselves with food quality.  In Toronto, the proportion of people using the food banks has increased dramatically.  Do you really think these users can afford to refuse a bag of pasta because it's made from white flour, or a can of tuna, because it's lined with BPA and isn't dolphin friendly?  Not a chance!!  Even most North Americans who can manage to put enough food on the table, can not necessarily afford frozen blueberries, let alone super-pricey superfoods like acai or goji berries, and really there is little evidence that they are any better.  Organic food?  Not an option for most people because of the cost.

There is also no doubt that we do indeed live within a toxic food environment.  Not only is high fat and sugar foods available everywhere, our culture encourages mindless rather than mindful eating, and consumption of on-the-go eating and convenience foods.

I recently began reading Outside the Box by Jeannie Marshall.  She describes how different the culture around food and eating is in Italy, where she lived with her family for several years before returning to Canada.  What has struck me the most so far, is that she explains how in Italy meal times and snack times are very structured.  There is no on-the-go eating.  Parents do not give their children food to eat in the stroller and THEY DO NOT TRY TO PLACATE THEIR CHILDREN WITH FOOD.  I am very, very guilty of this.  Instead, children are taught at a very early age to eat what their parents are eating (there is no 'kid' food nor convenience food) and eat with their parents as a family, sitting down and taking time to eat mindfully.  Of course this is beginning to change in Italy, as influence from North America increases and our products and advertising infiltrate their market.

Health experts have warned for years that eating out at restaurants should be limited because you have no control over the ingredients and their first priority is making the food palatable, no matter how much sugar, fat and salt they have to add.  Yet people eat meals out more and more.

Cooking has become cool - as evidenced by the growing number of celebrity chefs and the popularity of the Food Network and various cooking shows.  But this doesn't seem to translate into families eating more home-cooked meals, and food trends these days run in the opposite direction of healthy.  It seems most folks would rather sit on the couch and watch others cook than cook themselves.  The few who are interested in cooking seem to take one extreme or the other: full embrace of the traditional North American high fat, high sugar comfort foods (trendy foods right now are charcuterie, burgers, poutine, mac&cheese, cupcakes, ice cream, etc.), or on the other extreme (and there are far fewer of people at this end of the spectrum) complete rejection of virtually every component of the North American mainstream diet (no gluten, no meat, no dairy, no refined sugar, etc.). 

One food trend that bugs me is the locavore movement.  First, there is conflicting evidence that eating locally is any better for either the environment or the local economy (see this article for more), and local, and even organic, DOES NOT NECESSARILY MEAN HEALTHY.  There are restaurants popping up all over Toronto that are devoted to using locally sourced ingredients, yet their menus are often dominated by charcuterie, white flour breads and pastas, and butter- and cream-rich desserts.  Sorry folks, but cured meat, refined flour and saturated fat is not healthy even if it is organic and locally produced!  And, again, the cost of local food is too high for most people.  I am not arguing for or against eating locally here, merely pointing out that the two (eating locally and eating healthfully) should not be at odds and I don't see why they have to be.

Of course the lack of sufficient physical activity in our lives is a serious problem too.  Our culture thrives on speed and convenience, which often means less physical exertion.  But while we may now live in a highly automated culture with an abundance of food energy available, our bodies were designed for a more prehistoric lifestyle.

The reason humans are so efficient at getting fat and struggle so much with losing weight is that this was a necessary mechanism for survival back when we had to hunt or gather for our food, and often faced food shortages.  It also required quite a bit of exertion just to secure some sustenance.  Wooly mammoth meat may be fatty, but it probably required a fair bit of energy to hunt that beast down!  Even 150 years ago, if a person felt like ice cream, he or she may have had to milk a cow and churn it by hand, whereas now, you just have to open your freezer door and pull out the Haagen Daz.  And very few people worked sedentary jobs where they sat at a desk for 6 or more hours straight.

We also face a different kind of stress than our ancestors.  They dealt with intense but discrete stressful events - like running into a saber-toothed tiger - rather than the chronic low-grade stress that most of us in North America face (job stress, commuting, parenting, finances, etc.), that stimulates subcutaneous fat storage around the mid-section - the kind that poses the greatest risk to our health.

And there is the whole sleep thing.  We don't get enough.  Sleep deprivation is linked with obesity and chronic disease.

The influence of food producers, manufacturers and advertisers cannot be dismissed either.  They go to great lengths to convince us of the benefits of their products, or to minimize their risks.  Skirting the regulations set out by our governments as much as they can, the grocery store can be an intimidating place and even fairly nutrition savvy individuals can feel overwhelmed and confused about how to make healthy choices.

Even people who can afford the most nutritious food possible and follow the health information presented in the media, are not always well-informed in this area.  This is because it practically takes a PhD to decipher what sometimes seems like conflicting messages and recommendations.  The media also simply does a very poor job of reporting research findings, and because most people do not understand how to evaluate the credibility of the information or the source.

My parents who are ridiculously smart and well-educated, upper middle class Canadians, cannot always keep their nutrition facts straight. My mother eschews rice because, for some reason, she thinks its very fattening, yet she seems to barely consider the calories in pasta, crackers and cheese or wine. 

But I suspect that the real reason my parents have both struggled to maintain healthy weights their whole adult lives has more to do with their lifestyle choices.  No, they don't eat potato chips, fast food or 32oz slurpees.  They are foodies.  They eat at restaurants and travel a whole lot.  Very social people, they either throw a dinner party, attend one, or go out for dinner several times a week.  They exercise, but they do not stick to their routines whenever they travel...and they seriously travel A LOT!  Not even my mother's breast cancer diagnosis was enough to get them to make any drastic changes to their lifestyle. 

This has frustrated and worried me for years, but the reality is they are simply unwilling to give up their lifestyle.  And I suspect that this is the problem for many North Americans who have the resources to improve their health.

I don't think this can be put down to merely laziness or lack of willpower.  We are by nature hedonistic beings that seek pleasure and avoid pain, and our entire culture is based on the notion that consumption = pleasure.  To resist all the temptations around us that derail our health, is to practically reject our entire culture.  That's difficult for most people to do when you are steeped in it.  Similarly, it is challenging for anyone to give up a bad habit and adopt a new one.  Most people fear change, and people often like what they are used to.  If you grew up eating fried chicken and white bread, it may be far more difficult to convince you that you can like grilled tofu and sprouted grain bread.  But the reality is, you could most likely adapt to such a dietary change, and eventually even enjoy it.

But our cultural practices are not healthy ones and they are well-entrenched.  What is typical "American" cuisine, for example?  Fried chicken, hotdogs, hamburgers, grilled cheese, donuts, mac&cheese, pie, etc.  Canadian cuisine?  Poutine.  Nanaimo bars.  Maple syrup.   Not much else really.   And then all that American stuff we've appropriated.

There is a strong pull for many of us through social practices and traditions towards these traditional, less than healthy foods.  Asking many people to give up unhealthy foods is not just asking them to give up pleasures, it is oftten, also, asking them to reject an aspect of their cultural or family heritage.

Because of custom and social practices, we are constantly being offered or tempted with food, most of it unhealthy.  A lot of North Americans practice what I call, "The See-Food Diet".  We eat what is presented to us, mindlessly, without any thought of what our bodies need or whether we are even hungry.  The reality is staying healthy in our society generally requires a degree of social exclusion: saying no to food we are offered, turning down invitations to restaurants, etc.  This can be ackward and in some cases, can cause offence.  Not everyone feels comfortable doing this or is willing to risk social isolation.

Also, humans have a tendency to rebel against rules.  We are constantly being bombarded with the message that we are a fat, slothful culture and we need to eat less of the stuff we love and are used to eating and more of the stuff we don't like as much.  Personally, I think this is why the dominant food trends have swayed so far to the unhealthy extreme (i.e. gigantic hamburgers served on donuts instead of buns, bacon added to everything, etc.).  Many people are chafing against all the health warnings and lectures.  Sometimes I wonder if ignoring these warnings is as much a political statement for some folks as is veganism for others.

Another contributor to our health crisis, that I think is often overlooked, is substance use.  Yes we all know smoking is bad, but while smoking has declined among men recently, the same is not true for women.  And personally, I think the risks of alcohol consumption are often overlooked, even by health professionals.  In case you didn't hear, the research on the heart health benefits of red wine was largely recently discredited, and there is mounting evidence that even what many people consider to be moderate drinking significantly increases the risk of various cancers.  While health experts are all over the health costs of soda and other sugary drinks, most fail to mention all the empty calories North Americans get from alcohol.  Moreover, when people drink, their inhibitions decline, and they are more likely to over-indulge in food calories as well.  The social and health costs of alcohol consumption are massive, yet drinking continues to be socially sanctioned.  But drinking is not a health promoting behaviour, and should be treated as an occasional indulgence, not a regular part of everyday life.  But again, drinking is a deeply entrenched part of many cultural traditions and social practices.

Of course, there is also the more serious issue of substance ABUSE, which often involves addiction and mental health issues.  Substance use - like eating - can be an avoidant coping strategy used by people who lack more functional coping skills, or it can be a concurrent disorder, common among individuals we serious mental illnesses.

So What is the Solution?

Just like there are many, complex causes of our growing health crisis, the solution too is complex and multifaceted.  Here are some of the things that I've been thinking need to happen (whether or not these things are realistic, or even possible, I don't know, but I'm throwing this all out there anyways):
  • Address poverty and hunger in Canada and the U.S.;
  • Making healthy food more affordable;
  • Stricter regulations for food manufacturers and restaurants (trans fat use has finally been restricted, but what about added sugars, sodium, BPA, refined flours, caramel colour/artificial colours, etc.?);
  • Stricter regulations on the health claims food manufacturers can make about their products;
  • Stricter regulations on advertising (i.e. not targetting children);
  • Making education about physical activity and nutrition an integral part of school curriculums;
  • Making cooking an integral part of school curriculum (it's an important life skill!);
  • Designing cities, towns and urban spaces to promote active living;
  • Better access to mental health services (in Ontario, for example, only psychiatrists are covered by the provincial health care plan, and getting to see one can be difficult. In addition, many extended health insurance plans only provide $500/year to see a registered psychologist, or sometimes a social worker, and this usually covers no more than 3-4 sessions, max.);
  • Providing incentives to employers to give employees flex-time and other benefits that can assist with work/life balance and wellness (fitness facilities, on-site kitchens, ability to work from home, etc.);
  • Making the media more accountable for presenting accurate health information.
Even if you believe that individuals who are suffering from obesity and associated chronic illness are entirely to blame because of their poor lifestyle choices, I think the problem is that if we leave it up to individuals to change their lifestyle, this growing health crisis will be a losing battle.  Why? Because we have developed a society, culture and infrastructure that makes it too easy to do all the wrong things and too difficult to do all the right ones.  Healthy living requires constant effort and vigilence.

Regardless of what the reasons behind it are, I think most people cannot or will not make the necessary drastic changes.  That's why I think most of the focus has to be on the environment and addressed at a macro level.  Being as contentious an issue as this is, however, I don't even hold much hope there will ever be enough agreement or support of this position for this approach to ever come to fruition.

Inspite of all this, I don't plan to give up my micro-level health promotion efforts.  While I do think the majority of North Americans cannot be inspired or convinced to make drastic changes to their lifestyle in the current state of our society, some are, and I can help even a few through education, inspiration or motivation, than I feel my efforts are worth it.  Lately though, I have been mulling over how I can have a bigger impact through some community activism.  I'm still working on this one...