Perry: There is a key word there. You mentioned the word “stress”.  The reality is that we are a stress-oriented society and we all cope with it in different ways. Some cope with it by doing drugs, alcohol,  and whatever.  Some by becoming workaholics in our whole body and our social sphere. Others play it out by eating. And that is how we manage our stress. We, as a society, could do a better job  of managing our stress. If we did so, a lot of the other functions would get a lot better.

Bill G: I was just thinking. It is multi-factorial obviously.  But we can’t lose sight of the fact that we still have to figure out the best ways in which to have agency. We have to find a way to provide people with good information. We are talking about some way to provide them with motivational techniques. However, underlying it they still have (like any chronic illness) to find some sort of sense of agency and involvement in the care. When you listen to the Olympic athletes talking about getting up at 5am every day in order to hit the pool for a couple of hours. Then they study. They hit the pool again and the weight room. And then run several miles and then back in the pool.  And then they have their training table dinner. And then they are going to hit the hay and do it again at least five days a week.  In some ways, we are talking about dealing with any chronic illness by accepting a certain amount of agency.  So, you give people good information about the spectrum of healthy food stuff that is out there. They need to have some sense about caloric intake.  The 1,600 calory Starbuck drink obviously shouldn’t be on the menu. You should gain a sense that it is not a good idea to drink 1,600 calories of sugar at one sitting. And it is important to get an adequate amount of exercise—as we have talked about. So, the formula is there but you still have to encourage people (without shaming them). We must accept obesity as a disease. You would never not tell a patient that they have hyper-tension when they do. You would not tell a patient that they are obese. You would give them advice. But they still have to take the agency to deal with obesity.

Jeremy: I totally agree with that Bill.  I appreciate you bringing this up. I think that part of it is thinking of ourselves as clinicians. The data that we get helps to determine the decisions that we might make.  I would argue that the typical American going to the store is not getting meaningful information about what to eat—particularly because there is a blinding amount of advertising. And it is mostly regarding taste and cost. This is the basis on which we are making our decisions. For example, there is Fructose. Fructose came around because the corn industry was trying to figure out what to do with their byproducts. So, the invented fructose corn syrup—which got into the drinks that Scott was craving. His craving was for a large gulp of stuff that is actually cheaper than water.  Why are they giving that hugh amount of fructose. Well it is because that actually inhibits your satiety hormone, leptin, so that you don’t know that you are full. You are likely to eat more.  So, giving you a free drink of giant gallons of soft drink is going to make buy more hamburgers and eat more fries.  So, not to be conspiratorial about all this, the lack of understanding even among physicians regarding the impact of fructose on adult health is concerning.  Actually, liver disease resulting from poor nutrition and diet is leading to more liver transplants than is caused by alcohol. That is a mind-blowing fact.  To think that in my life span that alcohol-related liver disease has been surpassed by fatty liver disease.  And one of the positive agents of fatty liver disease is fructose.  Yet, there is no public discourse regarding the dangers of fructose. So, the public can’t possibly know that drinking that giant big gulp thing is poisoning their metabolic system.  So, I think that the way we speak about this has got to change. I think that fructose is one example of the change that is needed. We really have to step back and ask: are the agents who are making these choices have the right information  to make the choices? And I would say right now that they probably don’t.

There are other countries such as Brazil that label their food completely differently then we do. They label it by processing level.  If it is ultra-processed then the food gets a very low score. If the food is natural or receives very little processing, then it gets a high score.  They are making their decisions based on processing level –which actually is linked to chronic conditions like obesity and heart disease—as opposed to the multitude of diets that our people face. So, in our society there are thousands of diets from which to choose. None of them work more than 2 months.  We haven’t really had a fructose related discussion in our health care industry.