Opening Plenary

 

Dr. Anna Peeters accepted her award with a talk on her winding path, imbued with a love of ideas, an ongoing desire to make a positive contribution, and shared enthusiasm with her colleagues. She gained from her early work at Monash University the value of non-traditional backgrounds and approaches. This took her to the Erasmus Medical Center in the Netherlands, where she did a post-doc learning more about cardiovascular disease treatment, prevention, and mortality, eventually leading her to obesity. She learned here the value of a creative, supportive environment that encourages critical thinking. She there thought to apply the techniques of measuring life expectancy with cardiovascular disease to obesity. To do this she used the well-known Framingham Heart Study, translating relative risk predicated on BMI to life expectancy differences. She realized at this point that the enjoyed working on tools that can inform public health, integrating health risks associated with obesity, population distribution trends, equity implications, and health benefits associated with intervention. All of this led her to work on “obesity duration,” providing a rationale for early intervention approaches. She then spoke about the complexities of setting population targets for obesity prevention, noting that even optimistic projections fail to reach 2005 obesity prevalence by 2025. All of this is to say, Dr. Peeters argues, that we need to think about how we define success. With a nod to the future, she sees obesity epidemiology moving in the direction of bringing inequalities to the fore, developing a greater understanding of the combined effect of interventions, and building a more sophisticated view of evidence.

 

Afternoon Plenary

 

Professor Mark Hanson of the University of Southampton begin his talk asking and answering a question on the minds of many conference attendees: “Why are we losing the war against obesity? Because we intervene too late.” He proceeded to characterize the current vogue in obesity thinking: large agreement on the etiological roles of genetics and lifestyle, combined with the immovability of genetic traits, builds a preemptive consensus for lifestyle intervention. It is the lifestyle intervention, Professor Hanson argues, that leads to the unnecessary guilting of individuals, and later on, exasperated calls for drugs and surgery. He then provides an alternative paradigm, one that move beyond the genotype and lifestyle to consider the role of epigenetics. This paradigm, known as the “life course” approach recognizes that risk increases exponential through the progression of life. In some emerging cases, he demonstrated findings suggesting that more than 70% of the variably methylated regions (VMRs) in one gene associated with later adiposity could be attributable to genotype-perinatal environment interactions. What this means is that interventions can target the pre-conception period and display their efficacy within five years. Professor Hanson himself is collaborating on a project (Jom Mama) with the Malaysian Ministry of Healthy and other academic and industry partners to provide health promotion services to newly married couples soon to conceive their first child. Adding to the lifestyle, pharmacological, and surgical options for obesity intervention, the life course approach offers a compelling set of tools.

Opening Plenary

 

Dr. Rudolph Liebel accepted his Wertheimer Award with a lecture on the physiology of the weight-reduced state that spanned its historical development, all the way up to the cutting edge. Research he and others have worked on over the last several decades build a convincing narrative for the role of leptin thresholds in energy homeostasis. His findings rebut the point that weight regain is mostly a function of decreased energy expenditure, arguing instead that a weight-reduced state is a leptin deficient state that drives increased intake. Put another way, it is unlikely obese individuals eat like birds — adding that “if they do eat like birds, it’s more like a pterodactyl than a finch.” Research builds the theory that evolution has made the wager that it is better to protect against fat loss than prevent against weight gain. For this reason, it is easier to raise leptin thresholds in subjects (through chronic weight increase, neuronal loss of aging, or pregnancy) than it is to lower the threshold (which seems to require lesions, leptin replacement, or cachectic illness). That said, Dr. Liebel called for reframing our understanding of weight loss. To develop effective treatments, it may be useful to see weight loss as a process that induces a non-physiologic state of hypometabolism and hunger, where the goal of treatment becomes restoring normal physiology under weight loss. One example of the cutting edge of this approach is research into Bardet-Biedl syndrome and dysfunctional cilia, which may lay the groundwork for transplanting brain cells to restore normal physiology.

 

Afternoon Plenary

 

Introduced by World Obesity President Philip James, University of North Carolina Professor Barry Popkins led the audience through a tour-de-force of data and insights on global obesity dynamics and policies. Notably, he demonstrated that there is a movement from undernutrition in low-to-middle-income countries (LMICs) to overweight across all regions, with a larger share of the increase in rural areas. Moreover, the BMI distribution is shifting rightward at all levels, rendering obesity all the more extreme. Remarking that “we’re not going to reduce obesity by forcing everyone to run a mile every time they drink a sugary beverage,” he called for action on the food supply. To this end he extolled the efforts of Mexico for enacting a comprehensive plan to tax sugary beverages. Dr. Popkin reviewed the fight in great detail, citing the need for coalition building, evidence-based policy, a rigorous public campaign and media strategy, and international support. The media strategy in particular was particularly intrepid for keeping the controversy in the news through regular press conferences, advertisements, and public actions. Concluding with brief examples taken from Ecuador, Thailand, Singapore and the Western Pacific Islands, Dr. Popkin criticized the rarity of action among high income nations.

 

Debate

 

The debate at the conclusion of Day 2 opened to a packed house of observers. Taking stock of the audience predisposition prior to the debate, the moderator recorded 64 votes for and 81 votes against the motion: “This conference believes that preventing obesity is the responsibility of the individual not of the government.” Professor J. Prins brought the audience to laughter multiple times as he made jabs at the moderator, his opponent, governments, himself, and even his own position. Ending on some serious considerations, he argued for protecting individual responsibility as the “mainstay of civilized society.” Professor Prins pointed to Singapore as a model for encouraging personal responsibility while maintaining that the government can play a role in supporting individuals.

 

Jane Martin of the Obesity Policy Coalition began her case as the opposition by invoking some lessons learned from Australia’s tobacco control efforts. Notably governments were slow to act (she showed a progressive tobacco policy in the 1960s that took decades to realize) and when they did, price changes were most effective. She sees an analogy if food policy, especially with respect to marketing. Questioning the freedom of individual responsibility, she declared: “The food industry does not provide us with choice, it provides us with the illusion of choice.” Demonstrating a collection of ridiculous real-life examples of food industry tactics, she sees child food marketing regulations as a no-brainer. The industry, she showed through another spate of absurd examples, cannot be trusted to regulate itself. In a nod forced dichotomy of the debate topic, she showed that individuals are in favor of such government intervention.

 

Then the audience got involved, with one observer asking whether Professor Prins thought the freedom of choice means obese individuals choose to obese. Another sarcastically asked him to come and talk sense into the UK government who has imposed all sorts of controls on food safety, traffic laws, and financial activity. One audience member invoked his belly fat, saying he “doesn’t know anymore who to blame.” The debate concluded with a clear landslide of support for Ms. Martin and the opposition, with only 45 in the post-debate audience poll favoring individual responsibility.

I’m in Kuala Lumpur, Malaysia this week attending the 12th International Congress on Obesity. For a person that studies and reads and writes about obesity policy ad infinitum, events like this are a week in Disneyland. Except better. In that vein, I’m so fortunate to have the support of Magdalen College, Oxford, the Institute of Social and Cultural Anthropology at Oxford, the Malaysian Association for the Study of Obesity, and World Obesity. I took pages of notes from the conference, and there are many sessions to write up, but in the brief space between Day 1 and Day 2 I collected my summaries of the Willendorf Award Lecture given by the University of Copenhagen’s Dr. Arne Astrup and the Opening Ceremony.

Willendorf Award Presentation

The 2014 International Congress on Obesity began with the Willendorf Award, given to recognize outstanding clinical research into obesity. This year’s recipient, Dr. Arne Astrup (University of Copenhagen) was recognized for his work on appetite regulation via gastrointenstinal peptides. Setting the tone for his talk, Dr. Astrup said simply: “I do not think all calories are equal for their effect on appetite regulation.” While he certainly believes in the power of calorie restriction, he maintained that such an intervention is not helpful in the long run. He made his case by reviewing what we now know about the hormone glucagon-like peptide-1, or GLP-1. Beginning with studies that demonstrate increased satiety after infusing GLP-1 (while lamenting the still primitive visual-analog scale for measuring satiety) he then moved to link another gut hormone peptide YY (PYY) to the effect of GLP-1 on post-prandial satiety. After briefly reviewing research tying increased satiety following roux-en-y gastric bypass to GLP-1, Dr. Astrup moved on to the next major topic of his talk: diet composition. GLP-1, he noted, might account for at least part of dietary protein’s satiating effect relative to carbohydrates and fat.

 

To showcase some ongoing insights on dietary protein satiety, he drew on the pan-European DiOGenes Project, a large trial with collaborators across 14 countries and a massive total study population of 140,000 people. The component of DiOGenes Dr. Astrup reviewed initially enrolled 1209 adults (mean age = 41 years, mean BMI = 34 kg/m2), of which 938 began the initial calorie-restriction phase of the diet (800 calories until 8% weight loss, mean = 11.0 kg weight loss). The 773 participants who successfully completed the restriction phase were divided into five ad-libidum groups where weight maintenance or regain was tracked for 26 weeks. The groups included a control arm, a high-protein/high-glycemic-index arm, a high-protein/low-glycemic-index arm, a low-protein/high-glycemic-index arm, and a low-protein/low-glycemic-index arm. Of the 548 participants who completed the intervention, the most compelling results were sighted in the high-protein/low-glycemic-index group. Not only did this group demonstrate the lowest drop-out (22%, compared the the highest drop-out rate of 37% from the low-protein/high-glycemic-index arm), but the significant weight regain only appeared in the low-protein/high-glycemic-index arm. Perhaps just as compelling was a brief tangent by Dr. Astrup into the spontaneous reduction in prevalence of overweight among children of the participating adults, who were not formally participating in the trial intervention.

 

Dr. Astrup ended his talk with a short cautionary note on blanket solutions to obesity. Drawing on recent research on the interaction between the gene TFAP2B rs987237 and dietary protein/carbohydrate, he showed that high-protein diets were associated with greater weight gain among certain allele carriers.  Ending his talk with the optimistic note that GLP-1 agonists (like liraglutide) may soon receive obesity indication, Dr. Astrup concluded a well-deserved award lecture with the refrain that diet composition matters.

 

Opening Ceremony:
Recognizing the international context of the conference, Malaysian Association for the Study of Obesity (MASO) President Ismail Noor began the opening ceremony with a moment of silence for the passengers aboard Malaysia Airlines Flight 370. In glowing remarks to the plenary, President Noor said it is a dream for any national or regional obesity organization to host the International Congress. He sees the conference tracks filling out every niche of obesity research, and told students in the crowd that this is their chance to “learn from the horse’s mouth, so to speak.” After thanking conference supports Novo Nordisk, the Cambridge Weight Plan, and the ICO Secretariat, he urged the audience to get to know Malaysia during their stay.

 

Following his address, the Deputy Health Minister of Malaysia Hilmi Yahaya spoke on behalf of Health Minister Subramaniam. Right at the outset Deputy Minister Yahaya recognized the peril of Malaysia’s non-communicable disease crisis, citing their 2011 National Health and Morbidity Survey to raise alarm at the country’s 2.6 million adults living with diabetes, 5.8 million with hypertension, 6.2 million with hypercholesterolaemia, and 2.5 million with obesity. In response, he highlighted the country’s National Strategic Plan for NCDs and the “whole-government approach” Malaysia is taking to integrate many public efforts for the promotion of health. These actions have led to food and beverage marketing guidelines for products targeting children, currently being implemented via industry self-regulation. A more recent initiative is KOSPEN, or Komuniti Sihat, Perkasa Negara (Empowering Communities, Strengthening the Nation) seeks to build  on grassroots efforts. Noting these policies, the Malaysian government recognizes there is still more to do.

 

Rounding out the Opening Ceremony were talks by World Obesity President Philip James and ONEGOAL representative Mr. Liew Tong Ngan. President James meditated on the significance of ICO 2014 being held in Malaysia as obesity continues to rise there and more generally in Asia. Citing the need to go beyond studying obesity, he explained the rebranding of the International Association for the Study of Obesity to World Obesity, an apt identity for an organization that studies in addition to organizes, advises, advocates, trains, communicates, and more. Mr. Ngan spoke to the campaign ONEGOAL, which seeks to improve grassroots support for childhood physical activity and nutrition for all of Asia. Among the many driving factors of this campaign was a good-humored, candid ask: How will Asia win its first World Cup without proper nutrition and exercise? His presentation closed with a high-energy demonstration by ONEGOAL trainers showing their football skills. Following them was a multicultural dance drawing on the many cultures of Malaysia. Together, these performances ended the first day of the conference with a great deal of momentum for the meeting ahead.

Tim Hartford of the BBC hosts a show called “More or Less” that fact-checks ostensibly outlandish claims making headlines with “a sock full of statistics,” more or less. The perp (or victim) this week was a report released by the UK-based National Obesity Forum that contradicts other reports to find that the problem of obesity is worsening. Titled “The State of the Nation’s Waistline,” it warns:

The Foresight Report (2007) concluded that half the UK population could be obese by 2050 at a cost of £50 billion per year. However, upward trends in obesity levels suggest these conclusions could be optimistic and could be exceeded by 2050.

Hartford took to task this statement in an episode that interviewed both an author of the Foresight Report and one of the National Obesity Forum. The 2050 forecast was generated using data taken between 1993 and 2004, when obesity and overweight was without a doubt increasing. Since then, though, the 2012 Health Survey of England found obesity rates to be increasing at a slower rate. Not that this is terribly less alarming:

Between 1993 and 2012, there has been a marked increase in the proportion of adults that were obese. This increased from 13 per cent of men in 1993 to 24 per cent in 2012 and from 16 per cent of women in 1993 to 25 per cent in 2012. The rate of increase in obesity prevalence has been slower in the second half of the period than the first half, and there are indications that the trend may be flattening out, at least temporarily. However, obesity in both men and women peaked in 2010 and was at its highest level since 1993.

This finding leads one of the Foresight authors to the reflection that the 2050 forecast was most likely an overestimate. That the author of the report itself makes this note is what motivated Hartford to mug the National Obesity Forum (NOF) with his sock full of statistics. The polite confrontation with the NOF representative yields almost immediately that the basis for sensationalizing the 2050 prediction as an underestimate is predicated on observation and anecdotal evidence, on the order of increasing claims for obesity-related comorbidities like heart disease and hypertension (I would guess these are lagging indicators for the “peak” obesity mentioned by the survey) and the jab that health statistics for obesity project BMI, which he claims underreport obesity.

The issue Hartford takes with the NOF is not so much that they’re wrong, but that they misrepresent the data by not making clear that their projections are based on anecdotal observations. Sidenote: Seldom have I heard stats-savvy folk speak in terms of right or wrong. In a methodology that aims to say something about a population using a sample of data, the cardinal sin is not being incorrect, it is misrepresenting the data, to say anyways what cannot be said about a population based on the sampled data.

Pummeled with socks of stats, the NOF guest is…unperturbed. Maybe stats weigh less than rocks. He thinks the problem of obesity is a major one, a claim hardly in dispute by Tim, the Foresight Report, or the Health Survey. To him, despite its characterization, the NOF report is not a vehicle for reporting data. It is a tool for advocacy. He accepts the criticism, saying ”a little exaggeration forces the message home, and that’s what we wanted to do.”

I’m reading anthropologist Adriana Petryna’s ethnography of the Chernobyl meltdown Life Exposed. Tucked into one of her arguments about the way in which the Ukrainian state was founded on claims of biological citizenship is an insight into the instrumentalization of certainties and uncertainties of radiation science.

Ignorance does not represent a negative state of knowledge. Nor does it imply a simplistic lack of access to or unwillingness to recognize the truth. It refers to “a praxis, a method, a path to a certain sort of attitude” … the modern idea of scientific progress will be the sum total of something like ignorance, knowledge and imprecision as an important “intervening phase between simpler truths and more complex ones.”

After many months of writing about diabetes and obesity conferences, scientific papers, and news stories, as well as promoting visual health content, I’ve finally made the move over the pond to the UK, where I’m starting graduate studies at Oxford. But first, some highlights from the summer:

Running a 5k with the Close Concerns team at the American Diabetes Association 73rd Scientific Sessions in Chicago, IL:

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Hanging out with part of the Upworthy Mafia after-hours in San Francisco:

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Climbing Half-Dome in Yosemite with good friends:

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But then I went hopped on a suspiciously short plane ride that took me here:

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On Addison’s Walk from the entrance of Magdalen College to my housing.

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My neighbors fawn over me.

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The Stables I share with some lovely folks:

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The New Building. Pro-tip: Even those things that are called “new” in this town aren’t.

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Moving on to the campus town, the famous Radcliffe Camera and “Bod” (Bodleian Library) 5 minutes from my college.

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The University Church.

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And All Soul’s College just off to the side.

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The Bridge of Sighs.

DSC02353One of the many college buildings.

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The front of All Soul’s College facing High Street.

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This is a tiny part of what I’m tremendously lucky to see every single day on the walk to class.

Written for PolicyMic.

The late David Rakoff left us with this insight: “There are some questions in life, the very speaking of which are their own undoing. Am I fired? Is this a date? Are you breaking up with me? Yes. No. Yes.” One of these questions could be seen headlining an article in New York Magazine early this week: Can an Asian woman be taken seriously in rap?

Beginning from this premise, one need not get past the third paragraph of the short profile before Awkwafina (a rapper alter ego for Nora Lum) is compared to the literary heavyweight Haruki Murakami. Don’t be alarmed — the comparison is not made from race, but rather finds that both speak with the same “awe.” The writer really dodged a bullet with that one. Or maybe a throwing star.

To ask whether Lum can be taken seriously builds a frame for considering the rapper already. It precludes serious consideration by asking if a serious consideration can take place. Compare this to asking whether Awkwafina will be taken seriously — that construction has a decidedly different connotation. It presupposes that the rapper is already worthy of serious consideration, and that it is the task of everyone else to catch up to this realization. Alternatively, you could ask should she be taken seriously. That question poses a still more neutral frame; it actually sounds like a real question.

Still more doubting is the use of “Asian” in the question’s frame. That women can be taken seriously as rappers is not asked much, if at all, anymore. The question has lost its novelty to the the likes of Lil Kim, Missy Elliot, MIA, Azaelia Banks, Queen Latifah, Lauryn Hill, and until fairly recently, Nicki Minaj. It’s telling that we have to ask whether an Asian woman rapper can be taken seriously. What it tells is that there are still some salient expectations and stereotypes governing what can pass as normal in the game. The question therefore becomes self-defeating in its redundancy —translated, it asks: Can a stereotyped archetype be judged free of the stereotyped archetype in the rap game?

Unpacking one’s knapsack aside, there’s another reason this question is its own undoing — it is currently unanswerable. A reasonable definition for “taking something seriously” might include the option of finding the subject bad. But Nora Lum may not yet exist on the plane of good-or-bad. At the risk of sounding uncompromising, this argument will be made by analogy from the following clip by Hari Kondabolu:

In other words, the path taken by many to Awkwafina’s emergence on the scene is to celebrate her ability to emerge on the scene. When enough Asian female rappers join her such that we stop primarily identifying them as Asian female rappers, then it might be appropriate to judge them.

That sounds contradictory, hypocritical even. Why is it okay to celebrate a female Asian rapper for her Asian-femaleness when it’s not okay to judge her based on her Asian-femaleness? Because race and ethnicity are complicated. But more so because positive and negative judgments hold differing consequences. To pose negatively the judgment by linking it to the randomized qualities of Asian-femaleness perpetuates the social context that makes it weird for Asian women to be rappers. To celebrate Awkwafina’s Asian-femaleness doesn’t judge her as a rapper either — but as a judgment, it’s difficult to argue this is as deflating.

If you have to ask whether Asian women can be taken seriously as rappers, they aren’t, and won’t be. If you celebrate them as Asian women who rap — or better, as just rappers — that builds an emerging social context for more to come onto the scene.

If the asking of some questions are their own undoing, perhaps it is better to just do. Here is Awkwafina, on her own terms: