Day 2 of ICO: Energy Balance Physiology, Low-and-Middle-Income-Countries, and a Debate

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.




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.