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Obesity as a Disease

I read in the news today that the American Medical Association has classified obesity as a disease, which has several public health ramifications.  The first being that physicians are now required to treat obesity like any other illness a patient may walk in with.  Historically, many doctors have avoided the conversation about a person's weight for a variety of reasons, including stigma toward people who are obese.

I've seen a lot of people struggling with weight issues.  While on internship at Jesse Brown VA Medical Center in Chicago, I helped teach the VA system's weight loss classes.  I learned quite a bit about why many people have a problem with maintaining a healthy weight by hearing the stories and seeing the struggles of the veterans I worked with.  Now, in our practice, I have clients who are considering bariatric surgery or who have gone under the knife and are now struggling with weight gain usually a few years post-op.  The themes of their stories are similar and highlight the complex biopsychosocial relationships that fuel obesity.  Here are some of the most common ones:

Membership to the Clean Plate Club.  Did you mom, dad, grandma, or all of the above tell you you had to clean your plate before you could get up from the table?  No matter how full you were, you were going to eat every last lima bean on your plate.  Many people carry this core value into adulthood.

Emotional eating.  I tend to eat when I'm bored.  It doesn't matter what the emotion is - joy, sadness, frustration - if you're eating when you're not really hungry, then it's probably emotions driving the ship to the kitchen.

The Yo-Yos.  The number of fad diets in this country is astounding.  A-stound-ing.  All promising to be the missing link to your weight loss goals.  Usually getting you to those goals in record time, even though the recommended pace for weight loss is 1-2 lbs per week.  People try one of these diets, have rapid results, feel AWESOME about it, then hit that inevitable plateau or have those inevitable cravings for the foods they've had to cut from their diet (more on that in the next point).  The weight comes back and usually 5-10 lbs are added on top of the original weight for good measure.  Thanks, hypothalamus.

A Case of the "Oh Screw Its."  Many diets fail when there's a special event, the holidays come around, or it's just been too long since you've had a bacon double cheeseburger or a plate of fettucine alfredo.  People on strict diets do so well at sticking at it that when something like this happens, a setback if you will, they decide that they might as well keep eating how they want for a while.

These things support the argument that being obese is the result of "lifestyle choices."  But that's not the whole picture.

Underneath these things is biology.  Thanks to our fancy technology, we know that the reward circuit in our brains is affected by things that make us feel good, including yummy food.  Structural changes happen when our brains are repeatedly exposed to substances that kick this reward circuit into high gear.  We typically think of this with people who are addicted to drugs, alcohol, or even gambling.

Recently scientists have found that the same structural changes occur in people who are obese, and that people who overeat may have a weaker circuit than those who eat less.  Unfortunately these changes in the brain remain in place even after a person loses weight, making it a constant struggle against anatomy to fight off cravings and maintain healthy eating habits.  So someone can have the best intentions to change their "lifestyle choices" but experience something similar to a heroin addict trying to come off the skag.  And I tell my clients with obesity that their fight is harder than the heroin addict because you can't abstain from food.  Not only do we need it to live, but it's such an enormous part of our social experience.

Like everything in life, obesity isn't dichotomous in its underpinnings (i.e. you either eat too much or you don't).  Yes, lifestyle choices, behavior, knowledge, and our upbringing influence what and how we eat.  But our bodies and brains react to these in a way that makes it harder to change, even with the best intentions.  Fad diets and reality shows (don't even get me started on The Biggest Loser) throw an added wrench into what is needed to reverse the obesity epidemic by setting unrealistic expectations, even pressures, on people to be successful.

Dr. T

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