Reflections are only that, reflections, nothing more nothing less. Often these reflections are related to books I read, but occasionally also other things. These are often written very late, very fast,  using notes from my mobile phone, so the grammar and spelling is horrible.

Too much of a good thing, by Lee Goldman

This is a very interesting book. Below is first an overview of the book, then some longer quotes, and finally a discussion about obesity as I think it is an interesting area that shows some of the more problematic weaknesses with the book.

Before the overview of the book I think it is important to remember that the issues that Goldman writes about are not new. “And aren´t the most important aspects of self-discipline… establishing one’s own authority over the pleasures of drink, sex and food?”… “people are, thanks to inactivity and the diet we described, as full of fluids and gases as a marsh”. This quote is from Plato, Republic 389c, written 380 bc. So we’ve had, at least, a 2300 year long discussion about how we deal with a situation where we have too much. The big change is that for most of our written history this has been a problem of the very rich.

An overview of the book How to address the fact that we have too much, of things that we used to have to little of, is an extremely timely and important subject. For most of human history we have lived with potential and real scarcity (food, shelter, healthy environment, etc.) as the defining characteristic of life.

Now we see a change on a global scale where we in many areas have too much instead of too little. This is obviously cause for celebration and a triumph for human ingenuity. But a major challenge is that our bodies have evolved over 100 000’s of years to deal with scarcity. We have lived such a life so long that only those individuals that best could survive this scarcity where able to pass on their genes. The result is that people today are born with genes that lead to problems in our current society.

A little simplified we could say that our current bodies are reasonable well adapted to a hunter and gatherer society, but many of us live in an industrialised society. One example of the kind of results we now see was presented in a comprehensive report that was recently presented in Lancet. This report indicated that obesity now is bigger health crisis than hunger.

[Based on some initial reactions I want to clarify (what I thought was obvious) that the while our bodies are from a hunter and gatherer society, that society was not a better society from a broad health perspective as life expectancy and exposure to different illnesses made life very hard. Our bodies made the best of a very bad situation might be one way to describing it. Advocating for a hunter and gatherer society, food, etc. is therefore not a very clever idea.]

The challenge with a 1.0 body/brain in a 3.0 society is the key challenge that Goldman discusses. He start with a classic overview where he reminds us that we’ve been around for 2 million years as the Homo genus, 200 000 years as Homo Sapiens and that we have only lived 200 years in what he calls the ”modern civilized world ”.

How long we have been living in the industrial age obviously depend on where you live on the planet and how you define the modern civilized world. Goldman does not give a specific definition, he only writes that it is when we “no longer spend all our time hunting and gathering food or even tending to our farms or domesticated animals.” but rather ”creating science, technology, art, and other advances that define a modern civilized world. We have become a species of gradually aging, sedentary people who live indoors, ride in cars, take elevators, and may or may not engage in occasional exercise. ”

From an individual, or even country perspective, you can argue about exactly when this modern society begun (and some parts of the world are obviously not “modern”), but on the global scale it does not matter. Goldman is highlighting the difference in magnitude between timescales for how we evolve genetically and the speed of change in modern society. He makes two points. First, that most humans now live so long beyond our reproductive age that natural selection does not work (i.e. we die from things that do not affect our ability to reproduce) and second, even if this would be the case we are talking about time scales that often include 1000’s of years (depending on for example how important a new mutation would be for survival). So for all practical reasons evolution has ended.

If we look at the main causes of death today, as Goldman does, we see that much of it is related to areas where we get “too much”. The book divides these challenges, a little arbitrary, into four areas: 1. Hunger (Appetite and the imperative for calories), 2. Water (Our need for water and salt) 3. Danger (Knowing when to fight, when to flee, and when to be submissive) 4. Bleeding (The ability to form blood clots so we won’t bleed to death)

These four areas are quite different, but they work as a convincing overview that our body is not well adapted for the society we live in in a number of important ways. The one area that is most different is number three as it is more related to broader cultural and psychological aspects, while the other areas are more directly related to different ways our physical body works.

The full name of the chapter for the third area “Danger Memory Fear and the Modern Epidemics of Anxiety and Depression” is also indicative of how many topics that it covers. The result is a lot of interesting ideas that I would like to know more about, e.g. DRD4 and the link to risk taking/innovation and attention deficits. Likewise the discussion about depression was very short and incoherent covering everything from the problems we have when it comes to worry about new threats to the fact that “suicide is now the tenth most common cause of death in the United States”. But the chapter was already fragmented enough and I think it was a good choice to give an honest and incomplete overview over a very complex area, rather than the more common approach of simplifying complex issues into sound bites.

After the chapters about the four areas the book becomes a bit problematic. First Goldman spends 40 pages reiterating what he already said in the preface about the possibility for our genes to evolve fast enough: “The bottom line is that we can’t expect new mutations or the rapid spread of any existing mutations to reduce the frequency of obesity, high blood pressure, depression, and excess clotting.” His discussion about how quick mutations can spread (see long quote at the end of this text) is basically everything you need to know about that the limits of natural evolution in a rapidly changing society.

Then comes the two normative chapters where Goldman discusses the opportunities he sees for addressing the challenge; either by changing our behaviour, or by changing our biology.

This is where I think the book fail to have an appropriate perspective on history and opportunities. We can change our behaviour and we can change our biology. Both are important, even if the later needs a lot of discussion before we start doing anything with irreversible consequences, as the implications could be extremely significant. But first of all we need to ask why people act in different ways, what kind of society we have and if there are measures we can take to make it easier to act healthy. Not only with incremental changes, as Goldman focus on, but structural changes.

Rather than a focus on only the individuals’ behaviour we should ask what structures, cultural values and incentives that influence how people live their lives.

Goldman makes a number of good points, and emphasises that he think it is a matter of both, not either or, when it comes to behaviour and biology. This is obviously true, but I think Goldman fundamentally fails to put the question in a broader context and only focus on a narrow, short-term and American, context.

There is almost no discussion about the differences in health/sickness between cultures/countries. There is no good overview of the different possibilities that different strategies have. It would have been good to see a structured discussion about options for lifestyle changes, government and business initiatives, medicine, physiology, as well as different combinations.

Two things where very good to see mentioned in the final chapters. First, tailor-made medicine and second, the need to think about the opportunities that an explosion in health related data provides.

As an endnote I want to add that the book has no footnotes in the text. There are notes in the back of the book. But these are of the worst kind with a heading and then a general reference (such as a full book). I think this kind of sloppiness can be accepted only if the underlying facts are not very important, or if the book is done with small resources that break new ground. This is a book where the underlying facts are very important as the book does not break new ground, it brings together existing knowledge. Also, Goldman was also supported by two people to help ”check and double-check references”. If this is the case there is no reason to have such a sloppy (should be page numbers) and unpractical (should have footnotes) system.

Longer quotes As there are a lot of interesting discussions, and some a bit controversial, I wanted to give three examples that I hope will encourage more people to read the book.

1. On personal health “One of the great excitements of modern biology and medicine is that we’re about to embark on an era of personalized health. With the ability to sequence our entire genomes, the ability to measure a variety of biomarkers, and modern imaging techniques at our disposal, we’ll increasingly know our future risks for a wide range of potential diseases. This information will facilitate the appropriate use of screening tests, help guide the selection of the best therapies, and permit an accurate estimate of our prognoses. There still will be a role for large randomized trials that determine, on average, what’s best for people like you in general, but these large trials will be supplemented by much more focused research to determine whether something is good or bad for people who share your particular genetic predisposition—or even just for you as an individual.”

2. How quick mutations spread “Imagine, for example, a mutation that carries a 25 percent survival advantage for you and your children if you get it from both parents and half that advantage if you get it from one parent. This mutation will spread to less than 5 percent of the population in about 50 generations (circa 1,000 years) but to more than 90 percent of the population in 100 generations (2,000 years) and to essentially the entire population by 150 generations (3,000 years). By comparison, if a single new mutation carries just a 1 percent advantage, it will spread more slowly—but it will still spread to nearly 100 percent of a population of a million people in about 3,000 generations, or around 60,000 years. Interestingly, these calculations don’t depend much on the size of the population. For example, it will only take about 1.5 times as long for a mutation to spread throughout an entire population of 100 million people as it would take for it to spread to a population of 10,000 people. Slowly but steadily and inexorably, natural selection has defined which genes—and, as a result, which people—inhabit the earth.”

3. Supporting medications and/or gene modifications “At a time when food and salt are overabundant, physical activity is required less and less, anxiety and depression are so common, and we clot too much, medications will become an increasingly important way to offset the adverse effects of the mismatch between our historic survival traits and the world in which we live. We have to develop better ways not only to improve our behavior, with healthier diets and increased exercise, but also to improve our biology, with medications and procedures that either compensate for our inability to change our genes fast enough or that actually alter how our genes work.”

Obesity Goldman highlights medical responses as a key solution to the challenges we have with “old bodies” in a modern society. While such responses should not be rules out on irrational ground, but before such a response it is important to ask what we can change and if there are certain groups who are part of the problem.

It is no secret that there are strong groups with short-term economic interests that are lobbying intensively to avoid almost all incentives that aim to reduce our intake of harmful substances.

When it comes to obesity we should start by asking ourselves who the main stakeholders are the provide and encourage unhealthy food habits, as well as lobby against initiatives that try to encourage healthy living (e.g. sugar taxes, no fast food in schools, ban on linking children’s toys to unhealthy food, etc). We could start by analyzing the consequences of companies like Yum! Brands (World’s largest fast food conglomerate with three of the world’s ten largest brands: KFC, Pizza Hut, Taco Bell, Long John Silvers, A&W, Pasta Bravo, Wing Street, and East Dawning), McDonalds, and Coca Cola.

First of all it is important, as Goldman also does, to understand that obesity is almost exclusively about too much (bad) food. Exercise is very important for other health reasons – and should be part of a healthy lifestyle – but play only a marginal role (except under some extreme circumstances) when it comes to weight loss. First, because exercise do not burn as many extra calories as most people think, but event more as people tend to eat more when they exercise. Many of the bad food companies have a PR strategy and branding however that is all about “a more active life” and want to put the focus on the exercise. This is very similar to the tobacco companies that wanted to focus on genetic dispositions, other health aspects, etc. Everything to move the focus from the big problem they are responsible for.

The scientific discussion about the role of nutrition for weight gain is similar to that about greenhouse gases for climate change, i.e. in media you can see a lot of strange things, but among those who actually know there is no real discussion where the focus should be on. In scientific papers you see facts like this: "The pooled model results […] suggests that calories in account for 93 percent of the change in obesity from 1990 to 2002." The quote is from the paper “Why is the developed world obese?

Once we realize that there are powerful (rich with good political and media relations) companies involved we can begin to look at how the world looks like and if there are countries that have less of a problem, and what countries that have the most significant problems.

If we look at the numbers we can see that there has been a recent explosion of obesity, linked to changes in food habits and the creativity in marketing. There is no clear correlation between income and weight gain, and there is not more expensive to eat healthier. The tendency to take existing systems for granted and then look for old-school technology solutions is a big problem as these often strengthen the underlying problems.

Transformative transparency is probably the most important tool as it would show how money flows and the kind of lobbying that today happens behind close doors. It would also make mainstream media (that struggle to move beyond simple polarizations and think any suggestion that is more than marginal as unrealistic).

Below are two graphs that might inspire. These days’ simple and funny graphs are used in a way that would make Mark Twain laugh (or maybe cry). I have to say that I’m surprised that so many people can use statistics and graphs and with a straight face tell that they are trying to “educate” people about the “truth”. Obviously the mass media loves this kind of simplification, especially if the underlying message is that we are pretty much on the right track. Obviously all graphs have their underlying methodologies and you can show anything you want with statistics, but I wanted to include a few graphs that I hope indicate that a “more medicine/gene therapy to solve obesity” might be less obvious than some authors indicate.