We vastly oversimplify the reason that people become obese

The AMA recently announced that they now considered obesity to be a disease.  This announcement set off the usual firestorm: swarms of posts and comments on the internet and elsewhere by highly opinionated people, each of whom was certain of his or her position.

There were those who were predictably outraged (“obesity is solely the result of gluttony and lack of will power!”) and those who welcomed the new label as a way to pressure insurance companies to pay for more treatment.  There were those who saw the disease categorization as stigmatizing to the overweight and those who raged that weight was not always related to poor health.  And then there were the conspiracy theorists who assured us that the only reason for the AMA’s move was to enable doctors to bill for more services and therefore get richer.

I am growing increasingly weary of the internet debates on obesity, mostly because so few of the commenters have any clinical experience with the problem and because their positions are so angrily and unassailably black and white.  Obesity is an emerging physiological state and we are only just beginning to learn about it.  There is no room for unyielding certainty.  Clinging to assumptions for way too long prevents us from advancing both understanding and treatment.  Thus, we can only say what our opinions and guesses may be as of today.  Everything else is up for grabs.

I personally don’t like this new disease classification much.  While it’s not competely off base, it seems linquistically and emotionally wrong.  We all sort of sense that it doesn’t quite fit.

If we look at definitions of the word “disease” they cluster around this description:

“a condition of the living animal… that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” (Miriam Webster)

If we parse this definition, obesity is (in my experience at any rate) definitely a disease.  Obese people often have a food balance disorder with “distinguishing signs and symptoms.”  Professionals don’t focus enough on the fact that people who have fallen into the weight gain cycle have a process that involves “impaired normal function.”  I strongly believe that obesity sets itself up and perpetuates itself because of changes in gut peptides, brain neurotransmitters, hunger and satiety hormones, and chemical changes in the fat mass itself.  For the most part, this is discounted in obesity treatment which tends to focus solely on self-control, self-deprivation and exercise.  If the re-classification of obesity as a disease means that we will start educating people about the fact that their weight is creating true changes that intensify the problem, I’m on that bandwagon.

On the other hand, the word “disease” has a common linquistic usage that suggests a process that comes upon us unbidden.   While we know that there are potential risk factors for cancer, gallbladder disease, emphysema and so on, they are not quite so direct or in our face as the known risk factor for developing obesity:  making the wrong choices in what we eat every day.  Here again, I believe that we vastly oversimplify the reason that people become obese.  Many of us can eat in a largely unrestricted way and not gain weight. ( I was one of these people until about 15 years ago, so I know).

But using the word disease to describe the problem of easy weight gain runs the risk of suggesting that the obese person must resign himself to having a condition,  a problem that has unluckily settled on him. There is a certain fatalism in this.   Diseases, at least in America, are usually treated with either drugs or surgery so it stands to reason that defining obesity as a disease will increase the tendency to look toward medicines and procedures.  While we need this, we also need a much stronger cultural imperative to clean up our eating environment.  Classifying obesity as a disease takes the heat off those who bear a large share of responsibility for our problem: the food industry.

The physiologic disorders that start as we gain weight are often linked to addictive eating habits.  I know so very many people who are battling obesity.   Yet I have been with these same people when they ate cookies, cake, pasta lunches, chips and other addictive foods, all the while decrying their inability to lose weight.  If those who are suffering from obesity and who truly want to change can’t stop eating modern foods, we must take very seriously the highly addictive nature of the substances that pass for food in our daily lives.  The results of such eating may lead to self-perpetuating disease, but the trigger is environmental.  And, of course, there may be many other environmental triggers.  I’ve alluded to these in previous posts.

When obesity gets a foothold in the body, it sets up a disease state—not always, but very often.  I cannot argue with the fact that these profound bodily changes need vastly more attention.  Telling people to eat less and go to the gym more does nothing for what is driving the problem.  (Eating foods that do not stimulate insulin, and so bypass the fat storage mechanism, does. And by the way, that’s what I believed yesterday and is still what I believe today—always subject to change).   Obesity is a problem with two heads.  The first involves addiction and behavior.  The second involves disease.

We cannot address one without the other and we need to classify obesity as a problem with both.

Barbara Berkeley is an internal medicine physician and board certified bariatrician who blogs at Refuse to Regain.

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  • Dorothygreen

    Nicely said. But the focus should not be limited to obesity.

    It is our “eating culture” that needs reform as well as our health care to reverse the prevalence of the chronic preventable diseases caused by a high caloric, nutrient poor diet. The cheap, 24/7 access to highly palatable products with layer after layer of sugar (include refined grains), unnatural fats, and high sodium is the root cause of obesity and obesity is the highest risk fact for these diseases. But folks also get diabetes II and heart disease without becoming obese by getting most of their calories from these products. Our brains are wired to desire sweet, fatty and salty and manufacturers have known that longer than the rest of us.

    Education is sorely needed, massive public health information. There are many grass roots efforts,on the internet, in magazines, newspapers, a few on TV, documentaries, in communities. But the push back from Big Food and Big Ag is much stronger as well as “addiction being a part of the human condition.

    In the 1950s about 6O% of the adult population smoked cigarettes. Many getting hooked when very young. It became well established that smoking tobacco was the highest risk for lung diseases and shown to be a risk in many others. Smoking tobacco wasn’t the disease (although it was clearly established as an addiction). Now our cigarette smoking rate is about 18%. Every part of the “tobacco model” helped – but studies show the tax was the greatest incentive to quit. Dr. Koop was key here.

    Why aren’t physicians pushing for a model akin to the tobacco model. Granted, it will be more complicated but it is doable. Dr David Kessler was key in getting the Nutrition facts. This would be the basic for determining the (RISK) tax. There would be money to pay for the massive public education that will be required. All RISK tax money must go to reform our eating culture – in essence making nutrient rich foods less expensive that high caloric, nutrient foods.

  • Lezlee

    I don’t think the networks would want to lose the revenue from companies that sell highly processed foods. Seen any ads on TV about just eating broccoli? Or just eating meat? Highly processed foods stimulate all the feel good receptors in our brain, raises insulin levels which drive fat into storage. Back before the 60′s everyone knew that cutting out breads and starchy vegetables was the way to lose weight. Notice back in the 80′s that the USDA food guide came out pushing grains and people have been getting fat ever since.

    • f. lusu

      ranchers feed their cattle corn to cause them to gain weight quickly before they are sold. we have corn and corn by-products in almost all our own manufactured foods. the food industry uses salt/sugar/fat and chemical mixtures of artificial food flavors to intentionally keep people addicted. robert sapolsky, a neuroendocrinologist at stanford university,did a study about how prolonged stress impacts our bodies. how it can “shrink our brains,add fat to our bellies and even unravel our chromosomes.” he showed how stress and social standing can be a cause of major weight gain. stress can also be a cause of a psysical or mental disease. stress can be a cause of obesity, obesity can become a disease of addiction

  • Elizabeth Corcoran

    I agree 100% with your assessment, Dr. Berkeley. I believe that obesity as a disease is akin to alcoholism as a disease. There is a certain level of accountability that is lacking in both instances when it comes to bringing on the disease in the first place, but that does not make it any easier in either instance to undo what’s been done. There is a lack of whole, nutritious, affordable foods available to many who live in the inner city, so until we can solve that issue, we’re going to see this problem get worse before it gets better.

    • leemd46

      please read my remark to Wiseword…goes for you as well.

      • Elizabeth Corcoran

        Teabags? Really? When you hide behind a moniker like that you must feel it’s all right to be rude and obnoxious. Grow up and look at other people’s sides to things. You might learn something.

  • wiseword

    Miss Fatso is humping her four buttocks down the street while stuffing her face with a mass of congealed goo. She has a mental problem — stupidity — which eventually will assert itself as a medical problem — diabetes, etc. If she limited her goo consumption to 3 times a day while sitting at a table, she might be taking the first baby steps toward some rational weight control.

    • leemd46

      Wiseword: is not so wise. you need to read natsera’s comment above. Your comment is not unlike all the teabags stating that all on assistance are lazy lumps more than willing to be given a handout, when the truth is that most are children and the elderly, and increasingly the out of work and unable to find work in their field (and are doing min wage jobs that aren’t covering all expenses or the “too old to hire or too long out of the world of the employed.” Your remark is simplistic and stupid. I wish there was a cure for that…but your own baby steps might be to educate yourself before sharing your not-so-wise opinions based on fantasy.

  • natsera

    Well, to be blunt, I think you’re oversimplifying the problem, too, Dr. Berkeley. You seem to be assuming that the physiological disorders are caused by the behavior of eating, rather than the other way around, and that is in no way proven. I have a friend, RN, CDE, PhD, and Type 2 diabetic, and she is very obese. But she eats better and healthier than almost anyone else I know. She is NOT closet bingeing — I stayed with her and spent all my time with her for 2 weeks and never once saw ANYTHING “unhealthy” cross her lips. But she once said to me that eating is like holding your breath — you can hold your breath for just so long, and then you have to breathe. Same thing with eating — you CAN’T deprive yourself of food, because you get hungry. She satisfies her hunger with fruit, vegetables and whole grains, and only cooks meat for her family. So please don’t imply that she brought on her own obesity and hormone disorders. Her obesity did NOT bring on the disease state; the disease state brought on her obesity. Get back to me in 20 years when you understand the brain/gut/adipose hormone connection better.

    • Sara Stein MD

      It’s the grains. She’s intolerant. Stuck in a high insulin cycle response.

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