The Treatment of Obesity: Overview

Obesity is the most pressing public health problem of the moment. The average weight of Americans, adults and children, has skyrocketed over the past few decades. The medical complications secondary to obesity have risen precipitously as well. With infectious disease and food-borne contamination largely in the past, the medical establishment has hoped that longstanding health followed age-related illness would predominate routine care. Instead, diabetes, high cholesterol and hypertension are the bread and butter of the primary doctor bent on helping an obese population survive. Meanwhile, the current efforts of government and industry, the parties primarily accountable for this crisis, may reluctantly raise awareness but accomplish little else to find a solution.
The reasons for the obesity epidemic are clear although their relative importance is hotly debated. The transformation of the food industry and available choices in the local market has changed the way we eat. Fast food, sugary drinks and junk food comprise a significant percentage of our diets and explain why literally twice as many calories are produced in our country than what we need to survive. On top of that, the average American leads a much more sedentary life than a few decades ago. And our attitude towards food and weight has changed drastically. The most salient theory of the cause of the obesity crisis combines all three social forces--food options, sedentary lifestyle and preoccupation with food and weight. However, without a fully accepted theory, industry can blame lack of exercise, food pundits can blame industry and government can avoid needed regulations. The overall effect is to dilute the message and splinter the drive for a solution.
The government has finally signed on at least to acknowledge this issue. Despite the lobbying power of the food industry, Michelle Obama has devoted much of her energy to food choice and exercise, especially in children. There is no doubt that placing her powerful spotlight on an issue the corporate food world can easily evade was necessary to have any impact. In addition, government-sponsored nutrition education has taken a big step forward. The new food plate replaced the confusing food pyramid to make much clearer the basics of meals and nutrition. None of this changes the reality that fast food and junk food remain a much tastier and affordable way to feed yourself and your family. Although new initiatives can spearhead debate and, subsequently, awareness, more regulation of the food industry along with incentives to provide healthful food at reasonable costs will be necessary to stem the tide of obesity.
Faced with the deterioration of the health of the population, the medical profession has to tackle the myriad consequences of an obese population and, more to the point, try to devise strategies to fix the problem. Preventive medicine has a history of success with vaccines and vitamin fortification, but those were public health initiatives to combat preventable diseases, the wheelhouse of medical success. The conflicting forces at play in the rise of obesity, both within and outside health care, largely overshadow the good will of the medical community. While many physicians toil away to ensure the health of obese patients, our profit-driven cohorts endorse new, exploitative measures that purport to offer a quick fix for an intractable problem, such as medical weight loss programs and surgical intervention. But these band aids only mask the problem.
As of now, no doctor or specialty has the answer. Primary care doctors, with almost no formal training in weight management or nutrition, advise patients with their own personal and often distorted views of food and weight. Nutritionists recommend modified versions of weight loss diets with short-term benefit but almost guaranteed long-term failure. Studies show that about 95% of people who lose weight dieting gain it back and more within 6-12 months. After years of futility, patients seek a consultation from a Bariatric surgeon. The FDA recently lowered the BMI needed to consider this option, and many more people, some not even considered obese, are now eligible. While surgery has faster and longer-lasting effectiveness, it's already clear this is no panacea. Complications, subsequent health risks and unclear long-term safety and effectiveness are apt to plague the post-surgical population. Plus, how can we as a society abide lives of overeating followed by surgical remediation? This is no real solution.
As in past decades, frustration within the medical community at large leads to the general consensus that the underlying pathology is psychological. Increasingly, the road to obesity treatment goes through the mental health community and, more specifically, eating disorder specialists. Clinicians who treat eating disorders have two things going for them: a non-judgmental stance on food and weight and a willingness to tackle a challenging public health concern. Initial attempts at treatment combine behavior changes around food with a mandate to not let the weight impede on daily living. Losing weight becomes an obstacle to overcome through gradual lifestyle change rather than an actual disease. The crux of the therapy is a collaboration to change one's relationship with food, an approach fundamentally no different from treating an eating disorder, while simultaneously reinforcing the need to be engaged with the world. It's unclear how successful that philosophy will be, but the increasing number of obese patients referred for therapy will test this treatment quickly. The next post will explain obesity therapy in more detail.


Meaning vs. Materialism: How to Make Food Just Food Again

In all earnestness, a friend of mine once said, "Isn't all technology intended to make our lives better?" After my initial shock at such undiluted naïveté, it was hard not to berate myself for being so cynical. I consider myself a technophile. I can lament the loss of personal time and space and still covet the latest streamlined, expertly-hyped, mesmerizing Apple product. What I can't abide is the loss of process and patience in our lives.

We were always forced to wait for answers. Life took its own sweet time to reach a conclusion. Things happened when they happened and our ability to speed them along was fairly limited. Now we can immediately satisfy our urgency with a text message, email or web search. I embrace the change. I know the unbridled pleasure of googling the answer to a heated personal dispute or the quick fix for a household emergency. But it is the process, the debate, the creative thinking, even the aftermath of doubt, that no longer exists. That internal world, such an essential part of being human, feels as if it's being phased out and, like the iPod classic, discarded into the dustbin of expired technology.
However, the loss feels much greater here. The new adage may say that we have gone from creators to aggregators, the transition utilizing the plasticity of our minds in a new reality. And content, the new term for the creative process, although necessary, is beside the point, relegated to the least adaptable minds stuck in the 20th century. But as our inner lives continue to erode from a steady stream of media and entertainment, packaged and repackaged into new products of sameness branded as content, so goes life's meaning. And as I have stated time and again in this blog, the loss of meaning is intricately connected with the rise of disordered eating.
Our collective minds more and more resemble a linked computer network than an amalgam of individuals. What passes for individual thought turns out to be a formulaic gimmick, advice just reworked from old-wives' tales or self-help mumbo-jumbo. The savvy self-promoter can transform into a modern guru able, perhaps, to unlock life's deepest mysteries, or at least powerful enough to leapfrog a new book to the top of the bestseller's list. Our minds gobble up the endless stream of content, and we each pledge our allegiance to the network by parroting back the information to our colleagues and friends, duly doing our part in the mass marketing machine. What used to pass as individual thought now just marks our acceptance of the vetted data, content, meant to fill our brains.
Each community, class and region has its own information niche, but the self-worth download to our own workstation in the collective server is fully nationalized. Everyone knows the drill: diet, exercise and thinness are the only road to inner peace. Yes, the sidekicks of yoga, self-help and meditation may reflect new paths to nirvana. But come on! Those people are skinny first before they ever set foot in a yoga studio, or at least so goes the completely misguided, but common knowledge. In the download, you see yourself first in the ideal body gliding comfortably and confidently through life. Only that iteration, body 2.0, will incorporate yoga into a daily routine or check off the list of self-help items in the hippest, new advice book. Body 1.15, the reality version, fails the newest diet, glumly re-ups the membership at the gym and impatiently waits for life to finally start.
The personal loss of mental space, process and patience has created a new universal dilemma. We all may be searching for meaning but have settled for materialism instead. Surprisingly, the transition from meaning to materialism, both in physical possessions and in physical appearance, runs the socioeconomic gamut. The occasional existential crisis may feel as antiquated as a record player, aerobics or Levi's jeans but is as prescient as ever, just in a new form. Some part of our society needs to care before the gluttony of materialism reduces us to a national eating disorder.
Yet there is one fundamental fact I have learned from working with people with eating disorders. Only in a world devoid of meaning can so many bright, driven women become focused on something as mundane as food. The fundamental misunderstanding starts with the self-worth download. Take a driven, talented but confused teenage girl and give her basic rules about food and weight to live by, and it's not hard to see how a few simple mantras become an eating disorder. It is one thing to follow the strict guidelines set by family, school and society, but the adolescent drive for autonomy needs an outlet too. What better alternative exists than to be skinny? Before long, skinny becomes the only way to view life's meaning.
A patient in recovery suffers from the reverse of the dilemma. Faced with the search for life's meaning outside of an eating disorder, a patient quickly grasps that few models exist in the modern world. Is a choice between the eating disorder and a new existential crisis placed in a cultural void really a choice? Obviously, I would say yes. The therapy for people with eating disorders is a tutorial in how to apply age-old philosophical questions to modern life. The time in therapy focused on process and patience brings a disoriented soul to a calmer place long enough to find the meaning food and weight will never really provide.
This is really the underlying lesson. The food business, diet industry and self-help marketing machine have become the parallel educational system of our time. Yes we all learn reading, writing and arithmetic, but we also know about junk food, dieting and how to look skinny for the summer. What we don't learn is how to create a life of meaning. When the matter and substance of our existence are topics of discussion, when a life is considered for its value to society, when a parent's priority is to teach a child how to love and live, food can go back to being plain old food. Social contagion can spread quickly. A people bent on tearing down the old foundation can do so in a moment of time. Harnessing the creativity and desire, deftly deleted from the current self-worth download, would steer the debate from the latest fad diet back to the value of a human life.
The next series of posts will shift to the problem of obesity. A growing health problem, obesity has tested various medical specialties from primary care to pediatrics to general surgery. Increasingly, patients are being referred to eating disorder clinicians for treatment. The next posts will summarize the current therapy and treatment for obesity.