The Dangers of Thinness and Dieting

It isn't hard to find article after article expounding upon the scourge of obesity in our society today.  The most popular magazines know a little teaser on the front page about weight loss will always sell more.  Slower moving academic medicine has cottoned on to the trend with scholarly writing on various, unsuccessful weight loss measures.  Bands of young women cannot help but jealously ogle the newest pop star or actress singled out for her recent weight loss or demonize one who has recently ballooned.  Not to ignore the supposed even-handed media like the New York Times, any number of weight loss tips (written by an exercise-fanatic who herself does not look well) can be found regularly in the Science Times section.

The fetish of "fatism" and the concomitant obsession with thinness is so pervasive as to have surpassed the current mode and become an accepted fact of life today.  Everyone wants to be thin: it is considered healthy, attractive and necessary for survival and success.  No one wants to be fat, which equals lack of willpower, sloth and undesirability.  It has become much too easy to forget of course that this is a cultural preference.  There are many, usually poorer, countries for which the opposite is true.  In fact, the flip-flop of thin-fat preference is all but new, a few decades old.  How has it not only become the norm but unassailable?  Now even the most sober, rational parts of society cling fiercely to this notion, as if it were handed down from on high.
The most insidious means that leads skinny to prevail over fat is the medical establishment.  Although it is clear that the mass media preference follows the current mode, that is to be expected.  Fashion and trends are meant to be fickle. As much as the general population blindly follows the movements of the famous, what is fresh and new is meant to be upended regularly, and the masses will follow.  However, the medical establishment, and often confusing medical journalism, moves much more slowly.  The growing medical treatment for obesity now dominates many of the brightest minds of medicine and comprises a vast array of new preventative, medical and surgical treatments.  It has become impossible to ignore how mainstream the public health problem of obesity has become and how no one can question its veracity.
What goes unnoticed is that acceptance of a general issue by the establishment reinforces a prejudice by the masses.  When government and law supported slavery, the general public felt vindicated in the belief in such an abhorrent practice. When psychiatry included homosexuality as a mental illness, the hatred of gays was accepted.  That doesn't mean that being overweight can be compared with bias against innate parts of who we are.  However, it does highlight the power of the establishment to sanction accepted bias.  The rational justification of the dangers of obesity shouldn't condone blatant prejudice.
The way people sneer at an overweight person walking down the street, avoid him on the subway or scoff at him on a TV show now feels accepted, a part of daily life.  The irony is that although a fuller figure could become a la mode in a moment, the medical prejudice against obesity will take much longer to overcome.  Although the rationale of the medical risks of obesity are clear-cut, the overarching risks of promoting thin over fat are great.  Where are the articles on the scourge of thinness?  The underfed, underweight population risks osteoporosis, various vitamin deficiencies and anemia. The chronically underweight also are always at a cognitive loss, struggling to think clearly and to maintain a normal memory.  Moreover, it isn't just the underweight who suffer.  The number of overweight and even normal weight people who diet comprises a larger and larger percentage of our population.  One effect of "fatism" is a general sense that everyone could stand to lose some weight.  The pervasive and unchallenged diet industry has the freedom to tout one crash diet after another and guilt people, fat and thin, into severely restricting their food intake.  These normal weight people starving on the newest diet are not able to function at a normal level.  Even more troubling is the assumption based on the set point theory of weight explained in a recent post.  The long-term effect of chronic diet restriction is overeating to compensate for recurrent starvation.  The overeating and body's instinctive fear of famine triggers the body to slow metabolism, store fat and paradoxically gain weight.  In fact, the drive for thinness in the general population may actually be worsening the obesity problem.  We all need food to survive, yet this basic fact is summarily ignored for the supposed common good of facing obesity or perhaps facing our own misguided prejudice.
Medicine itself needs to own up to the risks of chronic starvation and an underweight population.  This goes beyond those with eating disorders and instead highlights the general population risking their health by following the unsubstantiated advice of the powerful diet industry.  Education is not just about a new government-sponsored food plate but a goal of weight normalcy.  The population needs to be aware of the risks of chronic food restriction, and the diet industry needs clear guidelines as to what is medically acceptable.  A strong voice against thinness and dieting might at least open the door to a backlash against this dangerous fashion and simultaneously ease the bias against the overweight.
The next post will apply these thoughts about diet and the drive to thinness to children and the risk not just of developing an eating disorder but of a culture of youth that prizes thinness over everything else.


"Pathological" Obesity

A New York Times blog post this week started a discussion about "fatism."  It is widely accepted that obese people endure professional and social bias in America.  The data point to slower advancement in the workplace, decreased appeal as a mate and social isolation.  The shame of being fat in this day and age feels like a scarlet "F" emblazoned on your forehead.  Obese people frequently describe feeling invisible in their daily life, any attention quickly turning into scorn.
Although this is a sad commentary on the current trend to emphasize thinness above all else, the blog post aligns the bias against obesity with the gay rights, civil rights and women's rights movements.  Being born a homosexual, African American or woman is an inescapable fact.  Prejudice against people based on basic elements of their personhood is a strike against human rights.  Not to minimize the impact of the bias against overweight people, obesity is a not a similar genetic trait.  Although people may be born with a genetic predisposition to being overweight, that is a very different story.  Unfortunately, jumping on the political process that has been highly effective recently in the gay rights movement oversimplifies the growing bias against the obese and obscures the real, underlying problem for this population.
It is critical to remember that obesity has been rising precipitously for the last 40 years.  The significant advances in the food industry has created a land of plenty with more than enough food to feed our entire population, a remarkable feat of production and engineering.  The drive behind providing the country with adequate nutrition is the profit-seeking, under-regulated food production business.  Accordingly, the food widely available is what will appeal most to our sensibility and thus sell best: highly processed food laden with fat, sugar and salt and, based on increasing amount of hard data, deleterious to human health.  There is no reason a profit-driven company should factor public health into its business plan unless a regulatory agency insists on it to protect the population's health.  Although the exact medical reasons behind the rise in obesity remain unclear, the increasing availability of highly caloric, unhealthy foods is one obvious cause.
The clash between government just starting to recognize its collusion in this vast public health problem and industry hellbent on profit above all else has just begun.  In the meanwhile, the social problem of millions of citizens lugging around dozens of extra pounds continues to grow.  The empty promises of the diet and weight loss industries just cement the overall frustration.  The medical establishment tries vainly to keep up with the increasing medical problems associated with a vastly overweight population.  But, as the Times blog post suggests, individuals need to learn how to live with the reality of being overweight.
The eating disorder community has coined the term pathological obesity to describe this phenomenon.  In addition to the practical component of both weight loss and weight maintenance meal plans, the most important psychological step in obesity therapy is to separate the physical and psychological effects of being overweight.  The physical symptoms range from metabolic illness to orthopedic problems to long-term cardiac effects.  Psychologically, the overwhelming shame of obesity combined with the prevalent social bias creates a mental state of absolute obsession with food restriction and weight loss.  Repeated severe dieting triggers an overwhelming sense of starvation, as explained in the last post, which only exacerbates the ruminative state of pathological obesity.  The result is that a functional, driven and psychologically healthy person puts life on hold until the weight comes off.  Years can elapse while someone spends more and more energy focusing on the latest diet or exercise plan, holding off all goals for the future, only to be devastated when one magic cure after another fails to deliver.  The wasted years and energy of this process is so demoralizing as to render life truly hopeless.
The treatment of pathological obesity is twofold.  First, establishing realistic goals of weight loss and, more importantly, weight maintenance creates an environment of success and a promising direction for the future.  The hopelessness is replaced by an advocate clearly able to put the obesity and powerlessness around food and weight into perspective.  Second, the weight maintenance phase focuses not on change but on stability, a state of mind and body never experienced by an obese person obsessed with weight loss.  The relative calm of just eating to maintain weight enables the therapy to re-establish life goals, separate from food and weight and remind obese people of their true passions and goals.  The therapy can reconnect the person with true self-worth and label the weight issue as a solely medical issue.  Although this process cannot eliminate the fatism rampant in today's society, treating pathological obesity gives an overweight person the personal freedom and power to overcome this bias day by day.  Freeing the patient's mind from food and weight obsession opens up the possibility of seeing options in life and goals for the present and future once again.
The perceived powerlessness of the obese reinforces society to continue to overvalue thinness, but the resurgent voice of the obese population can allow those struggling with weight to feel empowered again.  While obesity therapy helps an individual separate self-image from weight and then re-engage fully in life, the steps towards generalizing the experience are less clear. The next post will address how to broaden the message about pathological obesity and help society share the responsibility for the clash between thinness and obesity in our culture today.


Weight Maintenance: the Crux of Obesity Therapy

Psychotherapy to treat obesity cannot be another weight loss program. The most popular medical treatments for obesity focus only on weight loss and are no better than the latest fad diet. The clearest message from any unbiased data assessing the weight loss industry is that diets just don't work.  Calorie restriction, in whatever proportion of nutrients deemed successful by the latest guru, inevitably leads to a powerful feeling of starvation. Surprisingly, the psychological effects of starvation--obsession with food, strong urges to overeat and slowed metabolism--are a universal reaction from the anorexic to the obese.  Although an anorexic patient may have the genetic predisposition to withstand starvation without eating, everyone else will be compelled to eat when ravenous, an evolutionary response clearly geared towards the survival of our species.  So the obese person starved for months on a diet can only resist eating for so long and inevitably will eat enough to compensate for the long-term starvation and gain back the lost weight.

A universal reaction to starvation, even in the obese, makes little sense.  Shouldn't the body be aware that extra weight has medical consequences?  The medical explanation for this conundrum is called the set point theory which postulates that everyone's body has a relatively fluid weight range of about 15% of body weight but will strongly resist moving outside that range. Any pressure to go above or below this range triggers a powerful metabolic response aimed at maintaining the set range.  At higher weight, the metabolism increases to burn off extra calories and hunger eases. The opposite occurs at lower weights.  The human body has a powerful, innate drive to maintain the status quo.
Based on this theory, the eating disorder treatment community has focused on weight maintenance rather than weight loss.  Most anyone who is overweight can lose weight but, once the protective mechanism of set point theory kicks in, no one can keep it off.  Built into obesity therapy from the start is a focus on slow, gradual weight loss for a period of a few months followed by a similar period of weight maintenance.  In fact, weight maintenance is not only meant to be a critical component of treatment but is necessary for consistent, long-term weight loss.  At the end of a weight loss phase, the person will be at or near the bottom of the current set point range. Weight maintenance will allow the set point range to slowly decrease and enable another weight loss phase in the future. It is usually a shock to an adult devoted to the study of dieting to realize that weight loss is only half the battle.  All diets promise short-term, rapid weight loss with long-term effects, but all the promises are false.  The lure of a diet is rooted in the hope for salvation, for the perfect fix to a lifelong problem.  The therapy for obesity immediately grounds the relationship in much slower but realistic prospects of success.
Practically, the treatment involves establishing the calorie and meal goals likely to maintain the patient's weight. For the first 6-12 weeks, the initial weight loss phase, eating 10-15% below the maintenance level should lead to gradual weight loss of 10-15% of body weight. As the patient's weight nears the low end of the range, weight loss slows and then stops, hunger escalates rapidly and metabolism begins to slow and conserve energy.  Further dieting invariably triggers excessive hunger, overeating and a profound sense of food deprivation quickly followed by overeating and weight gain. These physiological responses, in a society that idealizes restraint and thinness, become signs of psychological weakness, not the body's adaptation to extreme hunger.  Instead, the therapist can identify any sign of increased hunger or deprivation as a sign that the therapy needs to enter the maintenance phase.  The addition of the extra food will curtail the excessive hunger quickly and help the body adjust to a new phase of adequate nutrition.  After a period of months, the therapy will be ready for a new weight loss phase.  At the start of treatment, most patients, after a recent period of overeating, are usually at the top of the set point range, but after a period of weight maintenance, the weight is more towards the middle of the range.  Thus, subsequent weight loss phases lead to 5-7% weight loss.  Perhaps the hardest aspect of obesity therapy to accept is the length of treatment.  The behavior modifications are meant to be lifelong, but the weight loss associated with true weight maintenance takes years, something unheard of in a dieting culture.  It typically takes years of overeating to lead to excessive weight gain and it similarly takes time for the body to adjust to weight loss.
From a medical standpoint, this therapy often has long-term success.  Several practical issues can disrupt slow and steady progress such as a sedentary lifestyle, diabetes and a chronically slow metabolism from years of excessive dieting.  These issues can be addressed with education about the process of obesity treatment and the help of a knowledgeable primary care doctor.  However, psychological obstacles also impede the treatment and serve as the most powerful reasons an obese patient gives up.  The next few posts will address the pitfalls in obesity therapy and how to overcome them.