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Heavy Words

The post that forever doomed the world to have my writing forced onto them was one called Shame, in which I describe my frustration with how society stigmatizes people who are obese.  It was picked up by the NY TImes Health Blog and got a good conversation about the subject going on the blog-o-sphere.

A recent article in EverythingHealth (via Better Health) got me thinking again about the subject of society’s response to the “obesity epidemic.”  The article discusses a recent study that showed…well, read it for yourself:

Talk about a cruel trick of nature!  A study funded by the National Institutes of Health (NIH) and published in JAMA shows that physical activity prevents weight gain in middle-aged and older women ONLY IF THEY ARE ALREADY AT IDEAL WEIGHT. Did you read that?  It means that the recommended guidelines advocating 150 minutes of exercise a week isn’t sufficient to prevent weight gain in most middle age women.

The author, Dr. Toni Brayer, ends the post by saying:

So what are we to think about this study?  First, caloric restriction is the only way to maintain or lose weight.  The health benefits of exercise have been proven over and over in thousands of studies and that is not in dispute.  But weight control demands caloric restriction, period.

I am sorry about these results. Truly I am.

Hearing the frustration from my patients (male and female), and struggling with weight myself, I have to say that this is not really that surprising.  Losing weight is not easy.  Let me say that again: losing weight is not easy.  There are lots of reasons it is difficult to lose weight, from the food-oriented culture to a person’s own metabolism.  There are emotional and addictive aspects to obesity as well.  This study puts scientific evidence behind the hardness of weight loss.

So how should we handle the major public health issue obesity has become (and I believe it has)?  Saying “well, they just can’t help it” denies the fact that some people do lose weight, and that studies do show that obese people who lose weight are usually healthier because they do so.  Are we being unjustly judgmental by criticizing people who are obese?  Is it prejudice?  Or is it society’s job to look at its own faults and bring them to the light?  It’s far easier to find lower-calorie food now than it was ten years ago – thanks mainly to the public awareness of this problem.

Here is my take on it: we need to address it as a problem, not as a moral shortcoming.  My post on shame talked about the worthless feeling and inferiority many obese people feel in our culture.  I had a pastor recently tell me that he was ashamed of his weight and felt like a hypocrite being an obese preacher.  My response to him was, “Yeah, it’s a horrible thing to have a preacher who is also a sinner!”  He smiled, understanding that one of the central doctrines in Christianity is the fact that everyone is a sinner.

But I didn’t deny that in his case, his problem of overeating was due to his own weakness.  I know this because of my own struggle with weight, which stems from an addictive cycle of eating:

  • I feel bad, sad, or depressed.
  • I eat to make myself feel better.
  • I eat more to make myself feel more better.
  • I don’t feel better; I feel worse.
  • I feel more bad, sad or depressed.
  • I am tempted to eat more.
  • etc.

This is a cycle repeated with drugs, alcohol, cigarettes, compulsive spending, compulsively viewing pornography, and probably even compulsive blogging.  I deny that completely.  Anyone who has dealt with an addiction, either with themself or through a family member can say that addictions are very tough things to beat.  The fix to the solution is simple: don’t drink or smoke, and don’t eat or spend so much.  Simple, but incredibly difficult.

But it is a problem, and it is possible to overcome any of these compulsions.

One of the major ironies of our day is that a culture that has largely rejected absolute truth has not stepped back from moral condemnation at all.  Obese people are worse than those who are not.  Smokers are not smart.  Alcoholics and drug addicts are “diseased” or “defective.”  Compulsive spenders are fools, pornography addicts are perverts, and compulsive bloggers are…the bottom of the barrel.  There seems to be a need in our society to morally stratify, calling various groups of people morally worse than others.

Where am I going with this?  I think that we are missing the point on obesity, and any other compulsive behavior.  The root of addiction is the need to escape, and the need to escape is caused by stress and anxiety.  If we fix the obesity “epidemic” by a mass surgical campaign or a wonder drug, other problems would take their place.  This doesn’t mean that we should give up trying to treat obesity as the medical problem it is, it means that treating it only as a medical problem will change things on the surface, not at the heart.

Anxiety is the real epidemic in our society.  We no longer have the community we once had.  We are becoming increasingly isolated, increasingly self-absorbed, and increasingly insecure.  When the individual is at the center of the universe, the faults of that individual are of huge importance – and everyone has tons of faults.  But when community is at the center, when the individual is a part of a whole, then their shortcomings are compensated for by other community members.  The other community members help the person with their problem instead of belittling them.

This is, by the way, one of the reasons 12-step groups are successful.

I am not sure how this problem can be fixed, but like all of the other societal problems, it needs to be talked about.  It needs to be seen for what it is.  We are insecure because we wonder if we really matter.  We wonder what our mark on the earth will be, and if anyone would notice if we weren’t there.  Even people (like me) who have jobs that “matter” are always struggling with this – just check out the alcoholism rate in doctors, if you wonder.

I used to think this was not fixable, but I wonder if the Internet can be a source of community.  My Internet friends have become my “real life” friends, to a great extent.  I don’t think it replaces getting to know your neighbors or finding a group you can hang out with, but it has helped me.

Please join hands with me now, and start singing:  ”Kum-by-yah my Lord….”

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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21 replies »

  1. I am not sure how this problem can be fixed…..
    Petrochemicals!! (Or Laser, Or surgery, or radiation, or a scope put somewhere). Anything, ANYTHING, except:
    Stop shoving food into you pie-hole!!!

  2. I believe we all eat for reasons other than to simply “survive”. There is no doubting the emotional and psychological stimuli associated with eating. My journey, like others, has caused me to go up and down on the weight scale. Granted my range is a lot smaller (only about 10 pounds, but the changes in self-confidence are just as real).
    As I’ve said before, life is kind of a numbers game, and eating is no different. If you take in 3500 calories and only burn off 200 through exercise, you’re going to gain weight. Now if you take in 1800 calories and burn off 200, then you’ve got something to work with.
    Once I started some portion control, that’s when I started to get back to my playing weight in high school, 158 pounds. I just started cutting my dinners in half and the weight poured off. Even when I stopped exercising for a 3 week period in June, I stay right at 158.
    So play the numbers game, keep a journal, do whatever. But ultimately, just like with smoking cessation, you have to decide to change. Once that is done, the rest seems to take care of itself.

  3. Anon – You are right in saying that there is a strong cultural component, but one of the things the US has is abundant cheap food. Russia has a very high alcoholism rate, and vodka is cheap and easy to get. Escapes are escapes. I am not saying that we should not try to work on the obesity problem, but that there are significant underlying issues that will just come out in another way.
    That’s the reality of it from the exam room.

  4. I don’t agree that the root cause of self-inflicted bad behavior in America is stress and anxiety, although it plays a role. America doesn’t have a monopoly on stressful lives, even when compared to comparable other Western-style societies. Yet Americans have higher prevalence of obesity than those nations. I agree that stress and anxiety play a role. Perhaps the root cause, rather, is that other comparable societies’ have the ability to manage that stress, and that there are other factors that offset the impact of stress.
    To illustrate further, assume every nation has the same inherent level of stress. Other nation’s have infrastructure or cultural factors that manage the stress and/or the obesity; could be people spend less time in cars, or their 3-story apartments don’t have elevators. In other places it might be the norm to see 3 generations to go dancing every Saturday night.
    You can’t just wish away stress. Foreign, healthier societies are not utopian, stress-free zones. Our culture and infrastructure just offer nothing to offset it. Compulsive over-eating (and the like) is a symptom of not managing that stress.

  5. Of course watching the scales and reacting when you’re up 2-3 pounds is the way to manage weight.
    But, if you are an anxiety driven eater with anxiety management skills then you can trade anxiety about the numbers on the scale for anxiety about your family, financial, work etc… problem that caused that mega-meals at Friendlies.
    If everybody were naturally skilled at managing their emotions we’d have a good start at managing all the other things in this world that go haywire on us as well. It’s something you learn at an early age and it’s hard to un-learn if you get set off on the munching path.

  6. “pcp: I have heard of no such study.”
    And neither have I. That’s why I wonder about comments such as Dr. Motew’s in the first response:
    “It is up to us, as providers, to prescribe the regimen for activity and diet, much of which is clearly supported by excellent data, and follow-up on it as part of our patient-centric care paradigms.”

  7. Well said, Dr. Lambert, and that argument can be applied to all sorts of behavior. The need to feel superior, the need not to miss out on something or let someone gain a perceived advantage over us – these are all part of living in a society bent on competition, not cooperation. America thinks it thrives on this. It doesn’t. Instead, wealth pools instead of moving around and creating prosperity, knowledge is withheld lest it lose its power, and social strata are bolstered lest we feel less superior and lose the will to climb toward a place where we don’t have to compete anymore.
    There is no top of the ladder. There is no over-the-wall. In the end, we all die. Life is a tie. Let’s stop finding out who is inferior and sneering.
    But not now, and probably not soon, and probably not this planet, or these people. We’re told in every nuance, every word from the top and the side and below that gentle and kind are known moral weaknesses; they only make us patsies and victims. We’re told that we can be perfected, that imperfection means we’re morally weak, or stupid.
    And meanwhile, my doctor tells me I can’t stop eating because it’s bad for me, but insists I have to lose weight. Perhaps it’s time to change some rules.
    I dare us.

  8. K: A commenter on my blog pointed out that the ill-effects of poor eating don’t show up immediately, and so it’s harder to make a negative connection than it is with alcohol and other substances. On the flip side, alcoholics don’t wear around a sign saying they are alcoholics, but obese folks cannot hide their problems, so the social pressure is much greater.
    pcp: I have heard of no such study. From my reading, the weight-watchers approach has the most evidence (especially keeping a eating diary), but as I tell my patients: if I had an easy answer, I’d be on Oprah.

  9. Is there any evidence that aggressive non-surgical, non-pharmaceutical intervention by physicians leads to significant long-term (five years or greater) weight loss?

  10. I believe the difference between eating addiction and any other addiction is the fact that one must eat to survive. When an alcoholic successfully goes through AA, they vow to never drink again; but that is not an option for those who over-eat. The truth of the matter is that most people are bullies: While almost everyone I know has struggled with some sort of weight issue at one point in their lives, it is easier to criticize someone who is worse off than themselves than it is to deal with their own issues (I too am guilty of this). Therefore, I wholeheartedly agree that the issue of community is paramount to changing the American obesity culture. If everyone takes responsibility for not only themselves, but those around them, we would all be better off.

  11. Oh please, please, please, please let there be a valid hope in the potential of leptin, amylin, GLP-1 analogs, and dpp4 inhibitors to readjust the metabolic and satiety parameters of those of us blessed with “thrifty energy” genetics.

  12. And yes, I supposed I missed the point of the post also, but I don’t know how to fix that underlying problem. I will observe that, like Rob, many of my internet friends have become my real friends – an unexpected development and, I believe, an under reported benefit of the Internet in this un-community world.

  13. I have become convinced over a lifetime of observation that the key is not to become overweight in the first place. This sounds obvious, but I weigh myself every day (recognizing there are daily fluctuations) and it’s much easier to attack those 2-3 lbs I see accumulating, than wait till it’s 10-20 lbs. Weight loss programs,like smoking cesssation programs, have a huge rate of recidivism, as we all know.
    Perhaps some PCP counseling BEFORE the patient gains those 20 lbs about careful weight maintenance might be helpful. Of course, these days that requires starting with the pediatricians….

  14. It must be so hard to break the circle of events that lead to over eating. I definitely rhink more research and help need to be provided on the subject.

  15. This post was insightful in so many ways. I want to add to the discussion that I’ve seen books lately that focus on weight loss based on some of the things you mentioned. For example, Victoria Moran has a book called the “Love-Powered Diet” which focuses on improved self-love as a means of addressing eating addiction. Also Janeen Roth was recently featured in Oprah’s magazine because of her book “Breaking Free from Emotional Eating.” Janeen points out, as you do, that you never make progress from a position of shame. Thanks so much for your post – one of the best ones I’ve seen in awhile!

  16. I find it interesting that many of the so-called healthy foods, are not so healthy. Jenny Craig and other weight management companies offering food, the food is well portioned, but still loaded with sodium and partially hydrogenated oil – the true killer.
    It may be a bit archaic, but I still read every label of everything I buy at the store.

  17. Simple_once you are at a certain fatness, the fat cells’ output of hormones and toxins prevents the fat one from stopping the grazing. To stop, requires a state of ketosis. Getting there is tough.

  18. I think you missed the point of this article. I do understand that the conditions of society need to change so that eating better food is easier, and I do think that this should be one of our priorities. But my point in this post was to underline a more basic reason for problems. Most people who don’t exercise, avoid it simply because they don’t want to. Many people who overeat (myself included) do so despite the fact that good food is availabe. You can put good food in front of people, and many will still choose the junk.
    I believe that this is because of anxiety and a need to escape. The word “addiction” makes some people think that the person is making excuses for their bad behavior. I disagree. I see it as the persistence of destructive behavior despite the fact that they see the harm it causes and despite the opportunities to avoid the bad behavior. If it isn’t overeating, it will be compulsive spending, sex, or gambling.
    I just get frustrated that people who are obese are the way they are because they are stupid or lesser. The reasons for the things we observe in our society are far more complex, and I think are related to the shattering of the idea of community.

  19. No doubt obesity is a disease. While there are certainly ’emotional’ and ‘addictive’ and even hormonal issues, the basic tenet remains the societal and cultural prevalence of poor dietary habits and lack of physical activity.
    Unfortunately the accessibility and affordability of nutrient-poor foods (ie processed grains, sugars etc) requires a committed restructuring of the cultural norms we are all used to.
    It is nearly impossible for a low-income family to adhere to a ‘paleo’-type regimen which is not only costly, but takes effort and many times falls outside of the traditional norms. Its a lot ‘easier’ (and cheaper and tastier!) to buy a loaf of white bread and cover it with highly processed ‘cheese food’ than to eat a lean piece of meat, some nuts and an apple.
    Read “Good Calories, Bad Calories” by Taubes, who, although controversial at times, gives a nice history of how we have rapidly transitioned into being the most obese country in the world.
    It is up to us, as providers, to prescribe the regimen for activity and diet, much of which is clearly supported by excellent data, and follow-up on it as part of our patient-centric care paradigms.