Tick Tock, Docs are building bomb shelters

Australia’s largest and most prestigious medical professional associations found the FAT BOMB report so startling, they actually issued media releases.

The Royal Australian College of General Practitioners’ media statement said that these “startling new figures on the obesity epidemic,” show that this crisis is “the ticking bomb for Australia’s health.”

"We support the call of the Baker Heart Research Institute, in their report Australia's Future Fat Bomb,” said Dr Kelly Seach, GP and RACGP Registrar Representative. "We have to act now to address this critical health issue. The link between obesity and cardiovascular disease, and other health conditions, makes this one of Australia's number one health priorities," said Dr Seach. "This is not only an issue for the health of our patients; it is also about the health of our medical system, which is nearing breaking point. Unless the obesity epidemic is halted, it may tip the scales.”

The Australia Medical Association’s press statement said the report “shows that Australia has become the fattest nation on earth, and we need to take immediate action to change that.” The AMA is behind the government in doing the right thing to help Australia lose weight. According to AMA President, Dr. Rosanna Capolingua, “We must now aggressively tackle this problem on a number of fronts, with tangible, concrete strategies that strike at the causes of obesity and help reverse the growing trend.”

The proposal she highlighted?

Front-of-pack “traffic light” food labeling should be mandated, she said, to help Australians to make informed, ‘healthy’ food choices. “Compulsory simple colour-coded labels that clearly state the sugar, fat, and salt content of food would take the confusion out of choosing food, and help Australians change their diet for the better,” she said.

Did these professional organizations of medical doctors read the FAT BOMB report, do you think?

Which answer scares you the most?

Traffic light diet

What is the evidence that traffic lights lead to healthier diets and reduce obesity?

Traffic lights label foods green that are “healthy,” which is defined as low-fat, low-sugar and low-salt. Bad foods are given a red light and supposed to “stop” you from eating them. The traffic light diet was developed in the late 1990s by professor Leonard H. Epstein, Ph.D., and colleagues at the Behavioral Medicine Laboratory at State University of New York at Buffalo, for their childhood obesity treatment program. Most of the published papers advocating this behavioral change technique have come from these authors.

JFS will remember professor Epstein from the recent study of TV allowance — those devices installed on televisions and computers that monitor usage and turn off when the time allotted fat children was up. The studies for traffic lights have followed the design used in that study with amazing similarity and include calorie controlled diets and keeping food and weight records, reducing sedentary behavior, exercise programs, and positive reinforcement and rewards for compliance. The small studies have been done primarily on white, upper income families who applied to participate or were referred to a clinical weight program, and none have been randomized trials. No long-term studies are in the literature, although previous studies of other behavioral change weight loss programs by Epstein and colleagues have shown that weight returns to baseline by 5 years and increases at 10.

As with any intensive weight loss program, with traffic lights, there’s initial weight loss or, in the case of children, slowed growth, with weight regain over time. The published traffic light studies, however, have all ended before weights had returned to baseline but while they were still on an upward regain trajectory. These research studies have also thrown in all of the other diet and exercise interventions used in diet programs, including restricting calories for children to 800-1,200/day, so one cannot make any conclusions as to any particular benefit for traffic light labels in the real world setting. More importantly, not one of the studies has examined the short-term or long-term health effects of their programs or shown any benefits let alone that they outweigh potential harmful effects.

Last year, researchers at the Department of Pediatrics and Nutrition at Baylor College of Medicine and Clinical Child Psychology at the University of Kansas published the results of their study evaluating the feasibility and effectiveness of the traffic light diet (TLD) in a clinical setting.

As they had noted: “Despite the abundance of support for [Epstein’s traffic light diet], an outside research team has yet to replicate these results.” The restrictive inclusion and exclusion criteria, the fact that participants were self-referred or doctor-referred for treatment, decrease the generalizability of research interventions to applied settings.

Their study was on 41 children — 90% white, 18 boys/23 girls, average age 12.3 years, all >85^th percentile on growth charts, and average family income $85,000 — all of whom had been referred to their for-profit weight loss clinic. The children were all taught to eat consistent with the traffic light diet, per Epstein. Families were also instructed to change their food environment to limit the number of red foods and increase the green foods in the home. The weight loss interventions included reducing sedentary activities and increasing exercise. A physical trainer assisted the families in implementing exercise and sports into their lifestyles, as well as provided an exercise plan and 45-minute training sessions each week. This study went on for 10 weeks.

They compared the results of this treatment group to archival data from kids who had gone through standard, nonbehavioral treatments at their weight loss facility before the authors arrived, with similar time spent with the participants each week. In other words, they didn’t have a control group with each variable the same except for the use of the traffic lights to isolate the effects of the traffic lights. They concluded that after 10 weeks, the traffic light kids had reductions in projected BMI growth, losing 1.2 to 2 pounds/week. But a closer look finds that only 2 kids had moved from “overweight” to the “at-risk category” — exactly the same as in the traditional weight loss compare group. So, while the authors concluded that traffic lights could feasibly work for use in intensive, for-profit clinical weight loss programs, even they were not able to conclude any long-term effectiveness or recommend it. As they noted:

Long-term data for this sample are currently unavailable... A specific consideration is the cost of the program. In fact, the main reason for the length of the program was the cost restrictiveness. Whether similar results can be obtained in less-expensive settings (e.g., community, family service, and primary care centers) remains to be seen.

[S]everal limitations are worth noting. First, follow-up data are not yet available... a demonstration that these children either maintain this weight loss or have a continued decrease in BMI is needed before effectiveness can be completely assessed... Epstein’s research also suggests a fairly high number of children and families relapse into overweight... Similar to other studies, most of the children completing this intervention remained overweight and, for some, significantly overweight.

A specific limitation for this investigation is that participants were not randomly assigned.... further evaluation of the TLD using randomized clinical trials is needed before the TLD would be considered effective. A final limitation of the present investigation involves the income level of the participants. The cost of the intervention may explain the small number of participants from a lower socioeconomic status (SES) that received services in this study...

The most critical cautionary note before jumping ahead of the science for traffic lights was the need for “examination of the long-term impact of treatment on physical and mental health outcomes,” which they said “is especially important.”

Of course, as has been covered at JFS extensively, children need a variety of all foods for health and optimal growth and development, not just “green” foods. Teaching children to avoid fattening foods or that certain foods are bad and to be avoided or restricted has no evidence to support a benefit to young people’s health, or effectiveness in reducing obesity. Even “moderation” nutritional messages are beyond their cognitive abilities and they think in black-and-white when encountering information beyond their understanding. They react emotionally, with growing fears of foods they believe are bad for them. So, if something is bad enough to restrict and eat only in moderation, then it’s felt safer to avoid it completely. This has been shown even among college women, restricting dietary fat to 4% of their diets. Even seemingly harmless good-bad food messages have also been shown to backfire.

When a school traffic light nutrition tool — that encouraged school children to freely eat green food, eat amber food in moderation and stop and think before eating red food — was tested among 5-7 year olds in an elementary school in the UK, their negative behaviors and attitudes about green foods increased after ‘nutrition’ education, so did the numbers of kids refusing to eat red foods. In other words, the effect was an increase in nutritional misinformation and dysfunctional relationships with foods, not normal eating.

Traffic light labels have been promoted by groups such as the British Food Standards Agency and authors from Baker Heart Research Institute, Menzies Research Institute, Dairy Australia and Australian Division of World Action on Salt and Health who wrote a letter in support of traffic lights last year in the Medical Journal of Australia. In it and their supportive webpage, they made their case for red-yellow-green labels, saying they would make “healthy” foods more easily identifiable, especially for “the less educated, and the economically and socially disadvantaged... poor readers... the less motivated... sick and elderly who have little time and/or energy for shopping, and parents who can tell demanding children ‘no foods with red lights for fat.’”

[ Children, sick and elderly are those who often most benefit from calories, fats, sugars and salt in red light foods. These controversial ideas raise nutritional and medical concerns, and regrettably, the words illustrate the myths that fat and lower-income people must be eating badly and are too stupid to know how to eat right.]

“Red lights are a warning of the risk of preventable diseases due to nutrient excess,” they wrote. “Some red/amber boundaries might start fairly high, becoming progressively stricter over the years (like the Heart Foundation ‘Tick’).”

They added that it will be natural for people to see red lights as a warning, red is for danger... “Thus, for FAT green means low fat and good health... for SUGAR red warns of sugar-related health problems like obesity... for SALT green means low enough to prevent and/or treat over a dozen salt-related health problems...and red puts you at high risk.”

In their supplemental paper, they said Australia needs traffic light labels because Australian children are heavier than ever and “all children need to be protected from foods with red lights.” To meet the “Australian government’s national campaign to arrest the growing epidemic of childhood obesity,” they concluded:

“Food choices to control obesity involve a radical change in shopping behaviour, and traffic-light labels are expressly designed to promote radical change. They need to be mandatory, and they need to replace industry-sponsored schemes, which we believe are less likely to alter a customer’s buying patterns.”

To scare kids from eating, the government could just go ahead and put monsters labels on them. Artist, Andrew Bell’s Do Not Eat! monster illustrations might be just the ticket. It makes just as much sense.