by Linn Steward, RDN

Mark Schatzker’s most recent book proposes a theoretical answer to a question. Why over the last 40 years do we keep getting fatter? And the answer is, in the words of the author,  that “… the obesity epidemic is being fueled by advancements in food technology that have disrupted the brain’s ability to sense nutrients, altered eating behavior, and given food an unnatural energetic potential”.

In other words, we’ve changed our food and these changes have changed the way our brain and out gut respond to what we are eating.

Last week I reviewed the book The End of Craving by Mark Schatzker. While I saw some merit in the book, I was critical of it and skeptical of his theory. Lin Steward formed a more favorable impression of the book and has written an excellent review of it. In the interest of moving beyond a binary perspective of food, I present her perspective. Enjoy—RLS.

The book is divided into 5 parts. Each part contains a series of events or discoveries that have happened independently. Just like the pieces of a jigsaw puzzle, viewed independently, these events appear unconnected. However as we start putting the pieces together, an image begins to take shape. By the end of the book the puzzle remains incomplete and many pieces are missing, however, the message that emerges challenges what I as a dietitian was taught about weight loss.

My plan therefore is to review this book in terms of my training and experience as a dietitian during the 15 years I worked off and on in weight loss. My nutrition studies date from the 1990’s. I got my RD in 1997 and was certified in Adult Weight Loss Management in 2001. I’ve worked in corporate wellness, weight loss counseling, and bariatric wellness. I left the field in 2014 because the behavioral approaches I had been taught were not producing the desired outcomes. I felt what I had learned had value but there were still too many pieces missing from the obesity puzzle.

Part 1 identifies two different approaches to a single disease.

Pellagra is a nutrition based dietary disorder caused by niacin deficiency. The disease is prevalent wherever the available food supply does not include a source of niacin. Both the southern United States and Northern Italy have experienced periodic bouts of pellagra. In Italy, the government encouraged its inhabitants to raise rabbits and drink yeasty wine. In the US, the government mandated enrichment/fortification of grains. Both solutions worked but the metaphor of a fork in the road between the old way and the new way dominates the book.

When I went back to school to study nutrition, my nutrition knowledge was based on a series of books written by a French food scientist. I found the books in the attic during the two years I spent doing private cooking for my friend Isabelle at her home in a Paris suburb. I went back to school to learn more. I remember to this day my sense of wonder as I learned about the discovery of vitamins and the miracle of enrichment/ fortification in my introduction to nutrition classes. I was delighted to find nutrients could cure diseases, assumed our policy was best practice had been adopted globally, and started taking a multivitamin. I never realized until I read Schatzker’s book that most European countries never adopted our policy of enrichment/fortification.

Part 2 explores some the many functions of our amazing brain.

We start in Lyon France and the experiments of the psychologist Michel Cabanac with bathwater temperature and starvation. We move to Bethesda Maryland and a Kevin Hall presentation on the results of the analysis he ran on contestants in the American Reality TV show The Biggest Looser. We spend time with illiterate laborers in Karnataka and learn why these men demonstrate a taste preference the sour/butter taste of the fruit from a tamarind tree. We learn about the golden age of behavioralist psychology. And we end with the work of Kent Barringer who, after twenty years of experimentation, was finally able to provide evidence for the critical distinction between the brains “wanting” circuitry (dopamine driven) and the brains “liking” circuitry.

Despite my training as an RD, I struggled to follow the intricacies of brain science and neurotransmitter patterns that were referenced in the book. Schatzker is a brilliant writer and he is able to put complex concepts into understandable common language. That being said, the literature on brain science is overwhelmingly challenging and was not part of my initial nutrition training. I was one of the first dietitians to get my certification in weight management and obesity at that time was considered a behavior problem. I was taught behavioral counseling techniques to help clients manage their bad habits and promote a healthier lifestyle.

Part 3 drills down into the specifics of the “wanting” and “liking” pathways.

We visit a laboratory scientist at Yale who stumbled on an unexpected finding in the glucose metabolism pathway, explore the seemingly irrational behavior of compulsive gamblers, learn how Swedish gerbils behave when fed a mixture of seeds and grains of sand, and take a whirlwind tour of food technology innovations over the last 40 years.

Schatzker coined the term “nutritive mismatch” to describe a situation where our taste perception confuses our brains signaling system. As he puts it “The system is designed for accuracy. But the system evolved in an environment in which food provided the senses with accurate information”.

The science of neurotransmitters and the brain / gut connection was in its infancy when I got my certification in Adult Weight Management. Swedish pharmacologist, Arvid Carlsson, had just been awarded the Nobel Prize in 2000 for his contributions on the neurotransmitter, dopamine. And the assumptions at that time I took the certification coursework were that folks got fat because they lost control of their eating behaviors. Behavioral counseling techniques were based on an assumption Schatzker refers to as “The Hungry Ape” theory of weight gain. The rationale for this theory is that as humans we have spent most of our existence surviving cycles of starvation and we’ve learned survival depends of gorging when food is available so we have fat stores to carry us through to the next starvation cycle. Our job as dietitians was to help our clients manage their behavioral responses to the ever more enticing calorie proliferation of the modern food environment which has eliminated starvation cycles.

Part 4 is the section that took my breath away.

We take a vacation in 19th century Italy with Geothe and delight in eating figs, pears, macaroni, and Sicilian lettuce. We study the stalking behaviors of snakes. We learn about the evolutionary benefits of our “liking” food brain circuitry. And we delve into the beginnings of concentrated feeding operations.

The move from pasture to concentrated feeding operations has been gradual. Breakthrough research work done in the late 1940s enabled hog farmers to maintain a nutritionally adequate diet as they moved the animals from pasture to feeding lot. Corn and soy meal are nutritionally inadequate to meet a hog’s nutrition requirement, but agricultural science discovered a solution. Fortification with B vitamins solved the problem and the hogs no longer got sick. Fortification came with an added benefit. The hogs gained weight faster. As Schatzker himself put it: “Did I just say what I think I said?”

As students of nutrition, we learn the intricacies of the Krebs cycle, a complex of metabolic pathways that turns biological components into energy and cellular structures. I remember feeling a sense of awe as I studied and learned to name the steps. At no point in my nutrition studies had anyone questioned the value of enrichment. Or fortification for that matter.

The first edition of the RDA, Recommended Dietary Allowances, was published in 1943. Since then, the federal government has reviewed and updated nutrient recommendations. The policy of enrichment and fortification were presented to dietetics students as unqualified nutrition success stories because the body is well equipped to eliminate unneeded excess. As a colleague used to say, the only outcome of taking supplements you don’t need is expensive urine.

So what exactly did Schatzker say? If adding B vitamins to hog feed as was done back in middle of the last century promoted weight gain, could the same weight gain happen in humans? Is it possible that enrichment could actually be a contributing factor to human weight gain? Oh my goodness! That is exactly what Schatzker said. It took my breath away. I had to put the book down.

Part 5 positions the power of good food.

We start in Leipzig Germany and a doctor who works with clinically severe obese patients. We savor the taste of a perfectly crafted dark chocolate as it slowly melts on our tongue. We learn under certain circumstances that “liking” can extinguish “wanting”. And we end with the culinary equivalent of pastoral romanticism as the writer celebrates and indulges in the joy of eating really good northern Italian food.

The book ends with a metaphoric fork in the road. Italy represent the old fork. The United States represents the new fork. And we are left with a speculation. Maybe if we restore the relationship between flavor, nutrition, and enjoyment that food provides, we’ll have a chance to change eating habits and health status.

The book ends but the jigsaw puzzle remains incomplete.

These concepts are not completely outside the RDN tool box. Dr. Michelle May founded Am I Hungry?® Mindful Eating Programs and Training in 1999. Her program inspired the mindful eating movement, which in turn has inspired many of dietitian colleagues. I used her material when I set up the nutrition program at a bariatric wellness center. Some of my more unconventional colleagues have joined various activist movements which seek to stigmatize the role of modern industrial processing and to hold the food industry accountable for adverse health outcomes including the obesity epidemic.

For the vast majority of my dietitian colleagues, Schatzker’s book will be hard to read because it challenges certain aspects of our training and core principles. For example, the acceptance of enrichment / fortification as a net positive. Or the acceptance of artificial sweeteners / sugar substitutes as safe.

My first job in dietetics was nutrition counseling at a corporate wellness gym. When one of my social media savvy clients would bring a wild and crazy ideas to our sessions, I developed a novel approach. Rather than direct confrontation, I used a different approach.  I would explain to the client that there are two types of people out there in blogosphere: most of the folks out there are predatory charlatans who are only interested in their own self-enrichment but there are a couple of brilliant folks who are just slightly ahead of their time. Then I would add, sometimes it’s damnably difficult to tell which is which.

My reading of The End of Craving is that Schatzker is just slightly ahead of his time.

Next week: What is the difference between a food addiction and an eating addiction? Why does it matter?