Monday, December 23, 2013

Fat. And it Seems There is Nothing We can Do About It. A Summary of the Three Year Frustrations of a Future Registered Dietitian - Sara Kubetin

Currently in the United States, there are more people who are overweight than there are people who are of normal weight.  The words “obesity epidemic” are consistently plastered in the headlines of newspapers, websites, blogs, magazines, television news programs, talk shows, etc.  Obesity rates have been continuously climbing for the last few decades because the field of public health has been ineffective in even slowing the rate of increase in our waistlines.  As of 2010, 35.7% of American adults are considered obese.1  This is the highest the obesity rate has ever been in this country.  This high rate exists in spite of countless efforts, initiatives, national objectives and goals, and health professionals trying desperately to decrease the statistic.  More than one third of Americans remain obese because our country’s entire approach to treating the problem is severely flawed.  Our methods of treating this disease are ineffective because obesity is a complicated disease that requires a multi-level public health intervention involving public opinion, Registered Dietitians, and the food industry.
            To be classified as obese, a person’s Body Mass Index (a ratio of weight to height)  must exceed 30 kilograms per meter squared.1  The causes of obesity are numerous as are the comorbidities and complications associated with the disease.  From a clinical standpoint, obesity is caused by an imbalance in energy intake—energy consumption is higher than energy expenditure.2  This energy imbalance leads to weight gain.  Energy imbalance in the long-term causes obesity.2  In a broader view, obesity is an unfortunate product of our society.  Several risk factors for obesity are far beyond the control of the individual and include factors such as socioeconomic status, race, ethnicity, language, geographic location, family history, gender, and age.2  Current obesity interventions focus far too closely on the factors over which the individual has control.  In order to elicit large scale change, obesity interventions must focus on attacking external risk factors. 
This critique will focus on the three main problems with our current approach to addressing obesity.  First, many current obesity interventions are individual-level treatment interventions in spite of mounting research that indicates individual-level weight loss methods are ineffective.  Second, the gatekeepers to finding and executing a proper solution to the problem, Registered Dietitians, are highly undervalued.  Finally, the food industry has a tremendous amount of power over what people in our country are eating.  Most public health interventions fail to harness consumer power and use it to their advantage.
The Obese Stand Alone
            On the individual level, the only treatment for obesity is weight loss.  While this may sound simple, achieving significant, long-term weight loss is difficult, has a high attrition rate, and should not be the main focus of obesity intervention programs.  Weight loss is not going to decrease the obesity rates in the US for three main reasons.  First, the vast majority of individuals who are obese and manage to lose weight do not lose enough weight to be placed out of the obese BMI category.3  This means, even if a significant number of individuals who are obese manage to lose weight, the statistic will not change.  This does not mean that losing weight is not beneficial to the individual and to the population in general.  It has been shown that even a 10% weight loss in obese individuals is related to an increase in overall health and quality of life and a decrease in prevalence of comorbidities, regardless of post-weight loss BMI.4  That being said, if the true goal of our nation is to reduce obesity rates, the focus must be placed on prevention rather than treatment of the disease.  Moreover, current approaches to weight loss are flawed. 
Weight loss has the potential to help individuals who are already obese;  however, current approaches to weight loss are not very effective and follow traditional models of health that do not take enough external factors into account.   This is evidenced by the relatively low success rate of obese individuals.3  A review by Wing and Phelan assessed the success rate of long-term weight loss based on the results of several studies.  The definitions of successful, long-term weight loss varied across the different studies, but using an algorithm, Wing and Phelan estimated that approximately only 20% of individuals who purposely lose weight maintain their weight loss.3  Additionally, using data from the National Weight Control Registry, they estimated that the odds of weight regain decrease by 50% when individuals successfully maintain a weight loss for two years or longer.3  They also identified several factors that contribute to weight regain including loss of control while eating, decreases in physical activity, and other lapses in healthful behaviors.3  This study shows that achieving and maintaining weight loss is very challenging.  It is important to note that Wing and Phelan only addressed individual behaviors that contributed to weight regain.  This demonstrates that most weight loss interventions tend to focus on healthy changes only at the individual level. 
Finally, the public strongly holds individuals responsible for the obesity epidemic.  A study by Lusk and Ellison sought to determine the public’s perception of who or what is to blame for the rise in obesity.5  They surveyed a diverse panel of 800 subjects using a questionnaire that asked “who of these seven entities is to blame for the rise in obesity”—government policies, food manufacturers, grocery stores, restaurants, farmers, parents, or individuals?5  Overwhelmingly, respondents blamed individuals for the rise in obesity with 80% blaming individuals.5  Combining this evidence with what was elucidated by Wing and Phelan, it is clear that there is a major disconnect in the treatment of obesity.  The public believes that obesity is caused at the individual level and is, therefore, an individual problem.  However, it has been proven that individuals are relatively unsuccessful at fixing the problem on their own.  Herein lies the problem.  The public’s perception of obesity needs to change in order for other changes to occur.  Additionally, current approaches to weight loss must shift from individual to group interventions.
RD:  Two letters after my name that mean seem to mean nothing
            When most people meet a Registered Dietitian, they do not quite grasp exactly what an RD does.  According to the Academy of Nutrition and Dietetics (AND, the professional organization of RDs), a Registered Dietitian is “a food and nutrition expert who has met the minimum academic and professional requirements to qualify for the credential ‘RD.’”6  These academic requirements include the attainment of a bachelor’s degree in nutritional sciences from an accredited program, the completion of a six month dietetic internship, and the passing of a national examination in order to obtain a license.  Once a license is obtained, RDs must continue their education for the remainder of their careers by earning continuing education credits.  Although it is currently not required by the AND, many RDs go on to earn advanced degrees or other certifications.  It is important to point out that there is currently no regulation on the word “nutritionist.6”  Anyone who has even the most basic knowledge of nutrition can legally refer to themselves as a nutritionist.  A nutritionist’s education level could range from earning a collegiate degree in nutrition to simply reading about nutrition on the internet.  Registered Dietitians are frequently referred to as or are confused with nutritionists.  This confusion greatly undervalues the profession.
            Because of RDs are trained to be nutrition experts, RDs play a critical role in addressing the obesity epidemic.  However, it is difficult for RDs to step into this role when the profession is so unrecognized.  This lack of recognition exists for a variety of reasons.  First, the AND does not require a Master’s degree in order to obtain an RD license.  Many other health professions already require the attainment of a higher degree beyond that of a bachelor’s degree.  Not requiring at least a Master’s degree for the practice of dietetics does a disservice to the profession as a whole.  If all members of this profession had a higher education, the average pay of RDs would increase.  Currently, the average starting salary of an RD is between $42,000 and $55,000 a year.6  This is significantly less than the starting salary of other health professionals.  Registered Nurses who also only need a bachelor’s degree make an average starting salary between $50,000 and $60,000.7  Physical Therapists and Occupational Therapists are required to achieve at least a Master’s degree and have an average starting salary between $56,000 and $80,000.7  This information shows that if RDs were required to hold a Master’s degree, their starting salaries would logically be higher. 
Second, the current population of RDs is very homogenous.  As of 2008, 89% of RDs identify themselves as Caucasian.8  Additionally, around 96% of RDs are female.9  This lack of diversity has several implications.  In the US, there is still a large gap in the salaries of men and women.9  This gap exists in the RD profession.  On average, the few males working in the dietetics profession earn around $5000 more a year than their female counterparts.9  Because the profession is mostly made up of females, the majority of RDs  are underpaid because of their sex.  Lack of diversity also affects how RDs are viewed by the public.  Research has shown that individuals are more likely to receive a message effectively and take action when the message is given to them by someone similar to themselves.  For example, a study by Halliday-Boykins et al. looked at therapist ethnic similarity on youth outcomes.10  The study found that “youths whose caregivers were ethnically matched with their therapists demonstrated greater decreases in symptoms, longer times in treatment, and increased likelihood of discharge for meeting treatment goals relative to youths whose caregivers and therapists were not ethnically matched.”10  This means therapists were more effective when their patient was of the same ethnicity.  RDs often see patients in the same type of counseling setting; therefore this theory likely also applies to the field of dietetics.  This implies a significant portion of the population will not connect effectively with the current RDs. It can be hypothesized that counseling by an RD will not be as successful for minorities or males because they are dissimilar from the average white, female population of dietitians. 
The education of Registered Dietitians has a strong focus on treatment of the individual.  The core courses that are included in accredited dietetics programs have very little focus on community nutrition.  Of the long list of coursework required to obtain an RD license, few courses teach a community-based or population level approach to improving health.11  This is why a large portion of RDs pursue clinical careers in the hospital setting or outpatient careers involving one-on-one counseling.6  As previously stated, this individual level approach has not been effective in reducing the obesity rates in the US.  If RDs are truly essential for an effective intervention in this epidemic, their education must change to place a greater emphasis on population-level health improvement.
Big Business in our Mouths
            The food industry is a very powerful driving force behind what types of foods are consumed in America.  Through advertising and pricing strategies, the food industry dictates who consumes what type of food in our country.  Currently, there is a perception that eating healthier food is a lot more expensive.  A meta-analysis was recently published by the Harvard School of Public Health demonstrating this exact phenomenon.  However, the media got hold of this article and press release and twisted the results of the study to create a sensationalized story that strongly implies eating healthier is not significantly more expensive.12,13,14 
            The meta-analysis done by Rao et al. looked at the results from several studies analyzing the prices of healthier versus less healthy foods and diet patterns.15  The studies included in the review were conducted in many different countries and all had developed some sort of model for quantifying the average difference in price of healthy foods versus less healthy foods.15  Rao et al. combined the results of the studies and came up with a mean difference in price between eating healthy foods and eating unhealthy foods.  Using random effects models, the researchers determined that healthier diets cost, on average, $1.50 more per person per day.15  The media is using this statistic to say that it really does not cost that much more to consume a healthier diet because $1.50 is not that much money.12,13,14  However, as the Rao analysis astutely points out, for individuals and families of low socioeconomic status, this $1.50 per person per day makes a big difference.15 
Using basic math, several conclusions can be drawn.  According to the United States Department of Labor, the yearly salary making Federal Minimum wage is $15,080.   In a household with two individuals earning minimum wage, there is a total household income of $30,160 a year.  For a family of four, if it costs $1.50 per day per person to eat healthier, the total cost will be  $2190 for a whole year.  Based on a household income of $30,160, eating healthier food will cost 7.3% of yearly income.  This percentage does not account for the total cost of food.  This 7.3% only accounts for eating healthier.  According to the USDA, as of October 2013 a family of four with young children on a “thrifty” or less expensive meal budget will spend an average of $556.30 on food per month.  For a whole year, cost of food would be $6,675.60.  Assuming this family is only making minimum wage, they are already spending 22% of their yearly income on food.  Add the 7.3% to make their food healthier, and they are spending almost 30% of their yearly income on food.  Most families cannot afford to be spending this high a percentage of their income on food. 
The media has taken the $1.50 extra a day statistic and is twisting into an individual problem.  Many news websites state that this extra amount of money is much less in the long run compared to medical bills associated with the outcomes of eating an unhealthy diet.12,13, 14  However, families making minimum wage cannot afford to pay extra to buy healthier food.  Therefore, they have to consume lower quality products, will likely develop obesity, and will suffer from associated health problems.  They cannot afford to avoid future medical bills because they have other expenses such as clothing, housing, and car payments that take priority over eating healthier.  This demonstrates yet another way that the media is blaming individuals for a public health problem even though individuals do not have control over the issue.  Low income families are not choosing to eat unhealthy food; they simply do not have a choice. 
This is where the food industry plays a major role in helping reduce obesity rates.  The food industry has the ability to make healthier, affordable food available to low income families.  If Walmart can make a 100% whole wheat loaf of bread the same price as a loaf of regular white bread and make inexpensive fruit and vegetables available the same price equality can be achieved for other foods.16
Proposed Intervention: If obesity is a national problem, it should be treated like one
            It is clear that the current public health interventions for the treatment of obesity and reduction of obesity rates in America are not working.  In order to fix this, a new approach to the problem must be taken.  A successful obesity intervention cannot target individuals because individuals are not to blame for the obesity epidemic.  Currently, it is the view of the public that individuals are responsible for the spread of this disease, but several external factors are at work and must be addressed.  The proposed intervention has three components that are different from previous plans.  First, individual approaches to weight loss must transition to group level approaches in order to produce long-term weight loss and change the public’s view about the root causes of obesity.  Second, the value of RDs must increase in order for them to participate fully in the new approaches and to be able to deliver effective messages to the public.  Finally, changes in the food industry must occur in order to elicit large-scale changes in the diet of the nation.  If all three of these changes were to take place, the obesity rates would steadily begin to decline and quality of life for all Americans would increase.
Changing the Obesity Perception
            As previously stated, individual level weight loss strategies have a relatively low success rate in terms of maintenance of long-term, significant weight loss.  Therefore, alternative weight loss methods must be employed in order to provoke a significant decrease in the number of individuals who are already obese.  Currently, Weight Watchers (WW) is viewed as one of the more successful methods for weight loss.17  In 2006, the state of Tennessee partnered with WW to offer the program at a discounted rate to Medicaid beneficiaries.17  A retrospective study was published in 2012 assessing the effectiveness of this partnering which lasted from January 2006 to January 2009.17  Mitchell et al. assessed the association between WW meeting attendance and weight loss.  The researchers found that individuals who attended two or less meetings only lost 0.5% of their original weight while individuals who attended 13 or more meetings lost 6.4% of their original weight.17  They also found that weight loss increased with increasing meeting attendance.  While this study has a few limitations including a homogenous sample (female, minority, low income) and a limited follow-up period, it still has important implications.17  This study demonstrates that when given the opportunity to join a structured, group weight loss program, low income individuals were able to lose more weight successfully.17  Based on this finding, if all other states offered a similar Weight Watchers/Medicaid program, a significant portion of the US population could potentially lose weight.  The Tennessee study demonstrates that being involved in a support group with other individuals aspiring to a similar goal (weight loss) can help people modify their behavior more effectively.  Individuals who are obese need support from others in similar situations, as well as support from the public.
In order for drastic changes to occur, the public’s opinion about individuals who are obese must change.  In a study performed by Puhl et al., more than 370 videos from news websites were analyzed to determine the portrayal of the obese to the public.18  The study concluded that, in the 370 videos, “65% of overweight/obese adults and 77% of overweight/obese youth were portrayed in a negative, stigmatizing manner across multiple obesity-related topics covered in online news videos.”18  As previously mentioned, the public generally blames individuals for the obesity epidemic so these results are not entirely surprising.  This public view of obesity needs to change and the stigma needs to fade away before obesity rates can drop.  In order for this to happen, individuals who are obese need to know that they are not alone and need to be portrayed in a more positive light in the media.  For example, Puhl et al. states that many camera angles of obese individuals are purposely unflattering and zoom in on specific body parts rather than showing the whole person.18  Instead, obese individuals could be portrayed as actual, full human beings rather than simply unflattering body parts.    Public health interventions need to have a stronger voice in that convinces the public that obesity is not an individual problem.  I believe that Registered Dietitians can provide this voice.
Increasing the Value of an Invaluable Profession
            As previously mentioned, Registered Dietitians make significantly less money than other health professionals of similar importance with regards to patient health.  Additionally, the current population of RDs is homogenous and made up mostly of white females.  In order for RDs to have a greater impact on eliminating the obesity epidemic, several aspects of the profession need to change.  First of all, the Academy for Nutrition and Dietetics needs to require the attainment of a Master’s degree in order to obtain a dietetic license.  The AND agrees with this statement.  According to their 2012 visioning report, “RD salaries were 40-45% less than salaries of other non-physician health professionals” and “Education beyond the bachelor’s degree continues to be associated with hourly wage gains.”19  Based on this information, the AND needs to enforce this new educational requirement in order to increase the value of the profession.  Moreover, requiring RDs to pursue a higher education will increase their knowledge of other aspects of nutrition beyond a clinical scope.  An RD with a Master’s degree will have more education and more experience working in community nutrition, non-profit organizations, and public health promotion.19  Increasing the value of the profession will attract more students to the profession and will, therefore, increase the diversity of RDs.  When the diversity of the RD population increases, a greater variety and proportion of obese individuals will be effectively reached and treated.   
            Furthermore, RDs need to become the voice of people who are obese.  RDs have the opportunity to talk to and counsel many people who are obese about their disease, their possible weight loss goals, and their struggles.  Therefore, RDs are likely much more sensitive to the issue than other healthcare professionals, the media, or even the government.  Part of the education of a Registered Dietitian includes practicing counseling techniques that can elicit motivation and change in an individual without creating blame for the individual’s current state of health.  RDs need to become more present in the media and deliver these positive counseling techniques to a larger audience.  This can be done on a large scale, such as on national television, or on a smaller scale through social media or blogging.  When RDs create a stronger public presence, more recognition will be gained for the field of dietetics as a whole both from the public and other healthcare professionals.  If RDs can steer the public towards attributing the obesity epidemic to policies and the food industry and place a greater emphasis on prevention, a true impact in the obesity rate will be seen.
Change the Market, Change the Waistlines
            The food industry is a consumer-driven business.  Major food companies will respond to public demands for a certain kind of food.  A perfect example of this phenomenon is the development and distribution of trans fats in our food supply.  Back in the 1960s, research indicated that the consumption of excess saturated fat increased the risk of heart disease.20  In response to this discovery, the public began to avoid saturated fats such as those found in butter, baked goods, and other processed foods.  This is what drove the food industry to produce trans fats—hydrogenated, unsaturated fats with similar properties to saturated fats.20  At this time, the health risks associated with excess consumption of trans fats were not yet known.  The food industry exploded with products boasting that they were free of saturated fats and began feeding Americans margarine, Crisco, and baked goods made with hydrogenated oils.  Finally, in 1993, the Nurses’ Health Study elucidated the relationship between trans fat intake and increased risk for heart disease.20  In 2006, food manufacturers were required to add trans fats to the Nutrition Facts label.20  Eventually, the risks of trans fat consumption became widely known by the public and people did not want to consume this type of fat.  In response, the food industry removed trans fats from their products and came up with alternatives.20 
Presently, in 2013, the FDA removed trans fats from their “Generally Recognized as Safe” list.21  This is a prime demonstration of the power of the consumer over the food industry.  When people did not want saturated fat, the food industry gave the public trans fats.  Now, people do not want trans fats so the food industry is giving the market un-hydrogenated alternatives.  Several other examples of the consumer driven nature of the food industry include the increased availability of Greek yogurt, products free of high fructose corn syrup, organic products, whole grain products, convenience foods, and frozen foods just to name a few.  These products are now at nearly every grocery store because the public wants them.  Public health campaigns need to harness consumer-power to their advantage.
            If public health interventions can convince the public that they want healthier, more affordable products, the food industry will respond by producing them.  There are several ways to accomplish this.  As previously mentioned, a disproportionate amount of individuals of low socio-economic status are obese.  These low income individuals and families are often eligible for food assistance programs such as Women, Infants and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP).  WIC and SNAP differ in several ways including who is eligible for benefits and the type of food that can be purchased.  WIC only allows certain types of food to be purchased that tend to be healthier options—whole grains, fruits, vegetables, low fat dairy, etc.22  Additionally, only pregnant women, breastfeeding women, infants, and children under the age of 5 are eligible for WIC benefits.22  SNAP, which is afforded to a greater number of people, does not regulate the type of food for which the assistance can be used.23  SNAP benefits can be used to purchase an apple or a candy bar.  In fact, the USDA website states “Soft drinks, candy, cookies, snack crackers, and ice cream are food items and are therefore eligible items.”23  Low SES individuals are going to be more attracted to items like this because they are less expensive.  SNAP benefits need to change its list of eligible food items to encourage healthier eating habits.  Because WIC only allows the purchase of healthier foods, the country is holding pregnant women and young children at a higher standard than the rest of the low income population.  This is not just.  All low SES families should be held at this high standard.  Everyone deserves to eat healthy food, even low income individuals.  The USDA must change the SNAP policies and frame the change using the core value of justice.  This change in SNAP will lessen the purchase of cheap, unhealthy food.  The food industry will respond to this by making less expensive, healthier products available so that they do not lose money.  This change in the food market will then have positive benefits for the whole population, including those not eligible for SNAP.
            Public health campaigns can increase public demand for healthier products in other ways.  Television and internet advertising are powerful tools used by the food industry to sell less healthy products.  These tools can also be used by public health campaigns to sell healthier foods.  Using similar strategies to those used by the food industry will be more powerful in swaying the public towards favoring healthier products.  Rather than boasting the healthy benefits of fruits and vegetables, public health campaigns should highlight other benefits including increasing one’s freedom and independence, increasing one’s attractiveness, consumption by celebrities, or increasing one’s popularity.  If food companies can use these methods to get people to buy products, public health should use them too.
Concluding Remarks
This intervention will help reduce the impact of external risk factors for obesity including low SES, race, gender, ethnicity, language, and geographic location.  Increasing the value of Registered Dietitians will earn them greater respect in the healthcare field and from the public and they will therefore be able to have a stronger voice in the media.  The dietetics profession will become more diverse and be able to reach out to a larger portion of the population effectively regardless of race, ethnicity, sex, or language.  Once we convince the public that individuals are not to blame for the obesity epidemic, public call for a larger scale intervention will occur.  This will increase the demand for healthier food at affordable prices, which will dictate what the food industry is producing.  As healthier, affordable food becomes available, it will be easier for individuals who are obese to lose weight and will prevent future obesity. 
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10.       Halliday-Boykins CA, Schoenwald SK, Letourneau EJ. Caregiver-Therapist Ethnic Similarity Predicts Youth Outcomes From an Empirically Based Treatment. J Consult Clin Psychol. 2005;73(5):808–818.
11.       Boston University. Didactic Program in Dietetics. Boston, MA:
12.       CNN Health:  The Chart.  Healthy eating costs you $1.50 more a day.
13.       NPR: The Salt. Godoy M. What Separates A Healthy and Unhealthy Diet?  Just $1.50 Per Day.
14.       NY Daily News: Health.  Healthiest diets cost about $1.50 more per day than unhealthiest: study.
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16.       Walmart: The heart-healthy pantry.
17.       Mitchell NS, Ellison MC, Hill JO, Tsai AG. Evaluation of the Effectiveness of Making Weight Watchers Available to Tennessee Medicaid (TennCare) Recipients. J Gen Intern Med. 2013;28(1):12–17.
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19.       Academy of Nutrition and Dietetics. Visioning Report. Chicago, IL: AND, 2012.
20.      Remig V, Franklin B, Margolis S, Kostas G, Nece T, Street JC. Trans Fats in America: A Review of Their Use, Consumption, Health Implications, and Regulation. J Am Diet Assoc. 2010;110(4):585–592.
21.       Food and Drug Administration. FDA Targets Trans Fat in Processed Foods. Silver Spring, MD:  Food and Drug Administration.
22. United States Department of Agriculture. Women Infants and Children. WIC Food Packages - Regulatory Requirements for WIC-Eligible Foods.  USDA.
23. United States Department of Agriculture.  Supplemental Nutrition Assistance Program (SNAP) Eligible Food Items. USDA.

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