The obesity epidemic is reaching an all-time high. It’s no surprise why – the fitness industry pushing expensive diets and intense workouts, combined with limited access to affordable health care options, makes it difficult for people to maintain health in our society today. And what’s even more concerning? More than 72 percent of Americans are now overweight or obese, impacting not just us but future generations too, affecting over 14 million children! On top of that, this chronic illness has caused over 200 other diseases, taking up a large chunk of global health care budgets each year. Recently, we’ve seen advances in lifestyle modification programs and medications linking back to managing weight loss, yet its effect remains elusive among those affected.
With relapse rates from diet and medication over 90 percent and post-bariatric surgery recurrence rate long-term above 70 percent, the prevalence of obesity is a major alarm for health care professionals. According to the World Health Organization, 2.8 million people die every year due to this preventable disease – despite best efforts like renaming it several years ago by the American College of Endocrinology or finally being identified as a disease. When will stakeholders take decisive action in light of these dire statistics?
Obesity is defined by the Obesity Medical Association as a “Chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.” For over a decade, I have specialized in treating obesity, and the number one conclusion I’ve drawn from my work is: Obesity is absolutely a brain disease. Tackled through neuroscience-based treatment algorithms, this chronic but treatable condition can be successfully managed and kept under control using a mindset in the form of curiosity and by rewiring brain pathways.
As a board-certified bariatric surgeon, I have extensive experience utilizing various treatment algorithms for obesity. After witnessing too many of my patients requiring additional surgeries due to weight recurrence, however, I knew something was missing from the equation. My patients helped me realize that what we weren’t accounting for was neurobehavioral science – an approach with the potential to make all the difference in tackling this critical health challenge.
From birth, neurobehavioral mechanisms shape our relationship with food and body weight. Caregiving events in early life particularly influence the development of BMI-related behaviors, as infants fed to soothe distress may be more likely to have a higher body mass index (BMI). This sensitive reward pathway is established at an incredibly young age; it’s no shock that these habits can become deeply ingrained later. Areas within the brain like the prefrontal cortex, reward pathways, and anti-reward pathways all play their part in modulating how we interact with food over time.
A reward pathway is a group of structures that gets activated whenever we experience something rewarding, like food or a drug. These stimuli release dopamine-activating neurons along this mesolimbic pathway often called the reward pathway. There has been research on unconditioned motivated behaviors stimulated by dopamine release as a separate pathway from learned conditioned behaviors. In western medicine, our practice is guiding patients on goal-directed learned behaviors. This is how we have been treating conditions such as obesity for years. We set goals and recommend changed behaviors, and the patient is off with their prescribed regimen.
Humans possess a powerful reward system that is activated when we experience something pleasurable, such as food and eating. Neurotransmitters such as dopamine are released along the mesolimbic pathway, often called the “reward pathway.” Research indicates this may be an unconditioned behavior separate from learned responses. In medicine today, goal-directed treatments focus on changing behaviors and prescribing regimens in conditions like obesity. Weeks, months, or even years later depending on the prescribed weight loss regimen, the patient is back with minimal success, only to state their old behaviors have gotten the best of them.
Neuroscience has revealed that habits rather than cravings typically drive food choices when faced with stress and pressure. This is proven to be true in many bariatric patients. Researchers have described a habit as an automatic behavior ingrained into the brain due to repetition of said action – which requires myelination for faster execution. Hence, habitual behaviors dominate cognitive processes during a weight loss journey. Consequently, lifestyle change relies on forming healthy behaviors through habitualization; pathways must become re-wired before any physical changes, such as stomach rerouting, if the behavior is to last.
Our prefrontal cortex is a fundamental brain area necessary for executive control and decision-making. Recent studies have demonstrated its role in allowing us to make decisions under free choice conditions. However, this part of the brain takes lots of focus and energy, which we may not always have available due to stress or fatigue, reducing our cognitive abilities. This portion only makes up a small percentage of our daily activities as most tasks are handled subconsciously to conserve mental energy – freeing it up for more important functions.
This explains why patients with a chronic condition have such a hard time not only learning a new behavior but also why it is hard to maintain some of these behaviors and why they often, even after surgery, slip back into old habits that may not be helpful to their weight loss journey. Another question I often ask is why people stop doing good behaviors. The answer lies in another area of the brain called the lateral habenula.
The brain possesses a specialized structure known as the lateral habenula (LHb), which acts as its own “kill switch” and suppresses certain behaviors. This remarkable feature has been around since immemorial, helping us learn how to respond appropriately when faced with adversity or disappointment. Its most profound impact comes through inhibiting dopamine signaling on acute levels in response to unpleasant stimuli like unexpected reward omissions, all of which contribute to our behaviors and habits.
Our brain is wired to learn from our mistakes – it remembers the moments of pain, like when you touch a hot stove, and quickly draws upon that experience so we can protect ourselves in similar situations by immediately pulling back our hands. Ultimately this helps us recognize dangerous events to stay safe moving forward.
Prescriptive behavior models often prescribe a certain action towards achieving a desired result, yet the patient may not enjoy the process or even attain their goal. The brain registers this as an unfavorable outcome and brings about resistance in similar circumstances – be it trying cardio exercise leading to knee strain or following keto being experienced as starvation. This results in what can feel like a lose/lose situation for patients attempting to reach health goals through prescribed methods.
The habenula is a guardian of our habits; the brain quickly knows which behavior to put the brakes on when triggered. Knowing how and why we start or stop particular behaviors is key to forming new healthy habits that will stick over time – an important part of sustainable weight loss.
What is the permanent solution to weight loss? Medication? Surgery?
Whether in weight loss or any other area of life, mindset is the key to unlocking our potential and achieving success. After working with thousands of obese patients, I realized curiosity was a better driver for lasting change than motivation alone. Curiosity keeps us actively seeking out new knowledge – like finding creative ways around roadblocks and exploring innovative solutions — which releases dopamine into the brain, making learning more efficient and effective over time! Research has revealed just how intimately linked this “curiosity state” can be to the brain and the ability to fuel new pathways.
Have you ever wondered what the secret to successful weight loss is? It might be simply being curious! Staying in a state of genuine curiosity and actively solving problems can trigger our reward pathway and boost neurons in the pre-frontal cortex. Plus, by being interested in trying something new – even if what came before didn’t work out – curiosity can help reroute the activation of our habenula for continued transformation and prevent us from giving up completely on a solution. Weight loss patients who are more curious can sustain their change because of this mental state. Those who embrace their innate curiosity can have better success at sustaining healthy lifestyle changes long term – so why not tap into your inner explorer today?
Weight gain and poor behaviors contribute significantly to the obesity epidemic. As a bariatric surgeon, I believe that to reverse this pervasive illness; we should first focus on establishing an effective neurobehavioral approach; involving curiosity as part of our foundational algorithm strategy. When coupled with other weight loss treatments such as medication and surgery, this could give us our greatest chance at successfully addressing weight regain, which you all now know is triggered by the brain.
Franchell Hamilton is a bariatric surgeon.