This month, in its Finance bill, the Kerala government introduced a 14.5% “fat tax” – initially thought to be only on burgers, pizzas, tacos, doughnuts, sandwiches, pasta and bread fillings being sold at branded restaurants and food retail giants. But now it has been extended to all food items sold through all branded restaurants. The Kerala Hotel and Restaurant Associations had however been encouraging branding of domestic restaurants to compete with the multinational chains. So many local restaurants acquired trade mark registrations. Now they have also fallen into the tax net. The government hopes that people won’t get fat eating junk food.
Recently, Facebook had apologised after refusing to run an advert featuring a plus-sized model. The social network said it had made a mistake and had now approved the image. Feminist groups had expressed fury after Facebook rejected their advert for an event designed to promote body positivity. Originally the social network told them the advert "depicts a body... in an undesirable manner."
I know that it is not socially acceptable or politically correct to call someone fat or obese. May be we should diplomatically say they are “horizontally challenged”. But being plus-sized is not necessarily being beautiful. Being fat is not fashionable any more.
I can bet that all of you reading this article eat 3 meals a day, with an occasional snack in between. But eating 3 meals a day may also be excessive.
We eat because it is “mealtime”, not because we are hungry. And obese people eat too much, or eat the wrong type of foods.
According to the World Health Organization (WHO), obesity is one of the most common, yet among the most neglected, public health problems in both developed and developing countries. India, with 1.2 billion people is the second most populous country in the world and is currently experiencing rapid social and economic transition. According to the WHO World Health Statistics Report 2012, globally one in six adults is obese and nearly 2.8 million individuals die each year due to being overweight or obesity. Studies from different parts of India have provided evidence of the rising prevalence of obesity. In 1975, there were 8 lakh obese women and 4 lakh obese men in India. Today there are close to 2 crore women and 1 crore men who are obese in India – a 25-fold increase in 40 years.
Undernutrition due to poverty which dominated in the past, is being rapidly replaced by obesity associated with affluence. The hectic life style and resulting consumption of junk foods, snacks, easy-to-eat- packaged meals, (often high in sugar and salt) and high sugar-content juices are the result of this industrialization and urbanization. Add to this, more TV viewing, lack of sleep (we are unwilling to miss a serial, even if it means less sleep) and less physical exercise, and you have an oversized problem (pun intended). And in case you did not know, lack of sleep also leads to obesity. The more sleep-deprived you are, the higher your levels of the stress hormone cortisol, which increases your appetite.
The World Health Organization Asia Pacific Committee has suggested guidelines to be used to define overweight [body mass index (BMI) ≥23 kg/m2 but <25 kg/m2), generalized obesity (GO, is BMI≥25kg/m2), abdominal obesity (AO, is waist circumference ≥90 cm for men and ≥80cm for women) and combined obesity (CO, is GO plus AO).
Asian Indians have a greater predisposition to abdominal obesity and accumulation of visceral fat and this has been termed as “Asian Indian phenotype”. Actually in India, people who are thin (and who are usually thin because they eat healthy food and exercise regularly), are frowned upon. Being “plump” is synonymous with being prosperous.
Obesity is a disease. And it should be recognized and treated as such. Obesity is strongly associated with and often causes other metabolic disorders including diabetes, hypertension, dyslipidaemia, cardiovascular disease, strokes and (it may surprise you) even some cancers. And not surprisingly, higher rates of mortality and morbidity.
A projection of future health and economic burden of obesity estimates, that with current levels of obesity, we will end up having an additional 500,000 cases of cancer by 2030. Imagine the economic, social, and psychological implications of this. Doctors should make a radical change in their outlook on this. It should no longer be considered as a simple casual “that’s-just-the-way-I-am-made” issue or simplifying it as “just being oversized”. Or laughing it off saying obese people are “nutritional overachievers.” It is a matter of life and death.
Recently the state of Philadelphia in the USA has considered starting a “soda tax” -- a tax on all sugary and artificially flavoured drinks -- in a bid to prevent obesity. Just like Kerala’s ‘fat tax” I mentioned earlier. As you can imagine, the soft drink industry is objecting vociferously. Their reason? The cost will have to be passed on to the consumer, and so soft drinks will cost more, and hence people may not buy them. Please note that as far as the soft drink industry is concerned, your health does not even come into the picture. They are interested only in their profits
Many countries have tried this tax on fast foods, with varying (and often diminishing) degrees of success. After an initial dip in sales and consumption, there has been a rebound. The middle class and the rich will continue to eat the “fat-taxed” junk food, in spite of the increase in prices, because they are willing and can afford to pay more. In the West, it is the poor who eat junk food, as it is cheaper. In our country too, poor people eat junk food in the form of parottas, samosas, pakodas, and vadas, - and Indian sweets - all heavily calorie charged. And the corner shop and bakeries selling these are exempt from any tax, even though they sell the same junk food. It requires education and information to make people understand the healthy alternatives to junk food.
And if there is a “fat tax”, there needs to be a “sugar tax” too. Sugars are worse than the fats in making people obese. The soft drink industry especially needs to be more heavily taxed. And it should be compulsory for all food sold in shops to have the sugar content -- both natural and added sugars -- displayed on the packet.
Just telling patients they need to lose weight is not enough. It is not only about will power. It requires a three-pronged therapeutic attack – eat fewer calories, (e.g., cut out 500 calories /day) actually calculating the amount of calories consumed every day, exercise more (at least 2-and-½ hours a week). Exercise or “being active” means at least 30-40 minutes of walking, cycling, swimming or dance, 3-4 times a week ), and change unhealthy behaviors (if necessary with behavioral counselling to help patients stick with the plan – monitoring weight, setting goals, measuring food and calorie intake, and creating an environment at home and work that discourages overeating or snacking – throwing the sugars and snacks into the bin).
Diets that emphasize fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts should be encouraged. It means eating more home-cooked food (who doesn’t agree that actually mom’s cooking is the best?) It means cutting out processed foods. It means cutting down on the sugars in your diet (both naturally occurring and added sugars). And salt. The overall diet should include less than 2.5 grams/day. Seventy-five percent of sodium in the American diet comes from eating outside.
Saturated fats should not exceed more than 5-6 percent of total calories. For a 2,000-calorie diet, that is 13 -15 grams of saturated fat (1 gram of fat contains 9 calories). The majority of saturated fats comes from meats such as fatty beef, lamb, pork, and poultry with skin. Veal is much better. (Indian beef is generally lean -- our cows and buffaloes are starved). Full fat dairy products like butter, cream, cheese and milk products are also high in saturated fat.
However, I would like to make one thing clear. Food is meant to be enjoyed. Eat in moderation. Having a piece of cake and ice-cream at a birthday party is not a sin. It doesn’t need to be confessed. Occasional indulgences need not be grieved over. There is no need to make a disclosure to the priest the following Sunday. There is no need to feel guilty over an extravagance.
There is a risk calculator available now to determine the 10-year risk for heart attacks and strokes – to assess if people should take medications for high cholesterols. It helps evaluate people between ages 40 and 79. It deploys equations developed from community based populations, and includes race, gender, age, total cholesterol, HDL cholesterol, blood pressure, use of blood pressure medications, diabetes status, and smoking status. Based on information from the Framingham study, it predicts a person’s chance of having a heart attack in the next 10 years. If the risk of dying is over 7.5 percent in 10 years, then statins musts be used if the cholesterol is high.
The goal is not to get more people on statins. It is to help people reduce their risk of cardiovascular disease and stroke. To get people to live longer, healthier lives. To treat those at highest risk.
So my advice?
If you are serious about losing weight, get rid of all the sugars and snacks and refined foods from your fridge and kitchen.
Eating less is the best strategy for increasing your physical and mental aptitude, boosting your immunity and metabolism, and for lengthening your life. Eat in moderation. And enjoy the occasional indulgences.
And fasting occasionally may just be the best thing that you can do.
And it is my firm belief, that in a few years, just like trans fats are being banned, refined sugars will also be banned from supermarket shelves.
Obesity should be treated as a disease, which is what it is.
(The author is a former head of the department of cardiothoracic surgery at Christian Medical College and Hospital, Vellore. He is currently the chief administrative officer, and head of the cardiothoracic surgery department at Pushpagiri Heart Institute, Tiruvalla.)