I read Will’s recent post about trying to cut down on soda with no small amount of dismay. He writes:
It is commonly said that soft drinks are “empty calories.” Not just devoid of nutritious content, but is also comprised calories that don’t even fill you up. Therefore you can get rid of the soft drinks without feeling more hungry, shedding yourself of tons of sugar content along the way. Would that it were so simple. Often, getting rid of soft drinks ends up ramping up your sweet cravings. And so the end result can be that instead of drinking sugary drinks, you’re eating sugary candy bars that are loaded with saturated fats.
My experience with dieting is that it’s like whack-a-mole. There’s never any one thing, because when you bash it, something else will typically take its place. I know that for my part, when I do miss my soft drinks, I do start to feel hungry. And it’s not just in my (conscious) mind, because I will sit in the evening wondering why in the world I am so hungry and then realize that I haven’t had a soft drink since breakfast. And nearly every conscious diet I ever embarked on involved giving up soft drinks first. And all of them failed. My weight loss actually came by accident, and with copious amounts of soft drink consumption. And when I tried to cut down from 3-5 soft drinks a day? I ended up drinking 2-4 soft drinks a day… plus a caramel mocha. Hit this mole, there comes another.
It’s no longer anything close to news that America has an obesity epidemic. Being obese is a risk factor for numerous other health problems, and not just in adulthood. For example, type II diabetes was once fleetingly rare in children, and it has become
a sadly an increasingly common diagnosis for pediatricians to make. When patients are overweight, it’s not a problem I can ignore. [edited for better accuracy]
So, what do I do when I have an obese patient? The first thing I ask is how much of a problem the patient/parent thinks it is, and how motivated they are to make a change. If the answer is that they’re not particularly concerned, then I don’t waste much more of anyone’s time on the issue. (I also thank them for their honesty.) Asking people to make changes in the foods they enjoy or the activities they don’t is hard enough if they’re willing to try. If they don’t think the problem is a big deal in the first place, then there’s no real point in harping about a solution. A common paradigm for healthy lifestyle choices is the “5210” set of guidelines — 5 servings of fruits and vegetables every day, 2 hours of screen time (television, computer and video games, excluding schoolwork), 1 hour of daily physical activity, and 0 sugar-sweetened beverages most days. For some kids, 5 may as well be the number of leprechauns they’re supposed to catch every day. I’m a big believer in the “stages of change” model of behavior modification, and if the patient is clearly “precontemplative” (meaning they don’t really think about the problem, and aren’t interested in making any changes) then my only goal is to get them to “contemplative” (meaning they’re at least aware that there’s a problem, and thinking about whether they’re willing to make changes). Anything more ambitious is likely to fail. Now, let’s say the patient is ready to make a change. A problem has been acknowledged, and there is some motivation to do something to correct it. I only ever ask patients to make one change at a time, and to pick the change they think is least likely to disrupt their lives. The more unpalatable a change is, the less likely it is to be sustainable. And what change do I often suggest? Drink less soda.
I have patients whose soda intake is (to paraphrase Waylon Smithers) truly heroic. Mountain Dew is an amazingly popular choice, despite my suspicion that it is scraped from the inside surface of nuclear reactors. I have plenty of patients who consume hundreds of calories of fizzy, caffeinated sugar water every day. (Many of them also have horrible sleep problems, and never consider that their steady stream of liquid stimulant may have something to do with it.) I never ask patients to cut soda out completely, because I try to avoid giving advice that I know patients will ignore. But for willing patients, I recommend a reduction in soda intake. And, at least in Will’s case, that only seems to create problems in other areas.
The truth is that obesity is a depressingly difficult problem to fix. It can be quite intractable, even for highly motivated patients. At a conference I once attended, the darkly cynical presenter reported that the only truly successful solutions to obesity are bariatric surgery and appearing on “The Biggest Loser.” And he wasn’t half wrong. No medical intervention that I am aware of has proven itself to be both safe and effective in the long term.
The truth is that we (doctors, nutritionists, the First Lady, etc.) don’t really know how to dent this problem. Unlike many doctors, I know what I want to say when I discuss obesity and weight loss with at-risk patients. I just don’t have much confidence that it makes much difference. It obviously does no good to ignore the problem, but at this time it’s not clear what will do any good.