The Parent Trap of "Healthy" Eating

A generation of parents raised on an unhealthy dose of dieting, weight obsession and eating disorders are ill-equipped to figure out how to feed their kids.  The deluge of parenting tips is overwhelming, and the often contradictory food-related suggestions subtly undermine even the most attentive parent.  How does a parent choose when faced with organic everything from produce to cheesy snacks?  What does a parent do when one misstep feels like it can cause a lifelong eating disorder?  And how can any parent tackle the impossible balance of "healthy" eating?  Indeed, there is nowhere to turn.  This is the case for the kids from well-off families while the poorer ones have limited access to "healthy" food, let alone supermarkets, and are becoming increasingly obese.  The irony is that the only children who may get off scot-free are the ones left to their own devices.  It may come as a shock to many, especially from a doctor focused on eating-related disorders, but food and meals are not meant to be perfected and obsessed over but simply to be eaten.

One of the almost magical abilities of our brains is to absorb skills and make them automatic.  For instance, the acts of, say, walking or driving are relatively complex endeavors.  They each entail a series of coordinated movements adjusting constantly to changing sensory input to be completed successfully.  Yet, after a surprisingly short amount of practice, each becomes automatic.  Both walking and driving can be accomplished with limited attention while our conscious minds are free.  The same can be said of eating.  Even if we focus our attention on the food we're eating, a few minutes into the meal the conversation, and our minds, have shifted elsewhere.  Eating is an automatic behavior meant to be shared and social with the added benefit to enable us to survive.  With the growing concerns around parenting and food, automatic eating is not the norm for the current generation of parents.  Instead, when it comes to food, they have become obsessed with two things: starvation and fear.

Starvation is sadly the ideal state for many parents today.  The pressure to remain thin is paramount.  In a parental miasma of endless days filled with various organic snacks and the requisite birthday party pizza and cake, not eating looks like the only lifeline.  Inevitably, the cycle of under and overeating takes root and numbs the parent into a cycle of hope and despair.  The flip side of the typical starvation trap is the obvious need for secrecy: the children need to believe everything is fine.  The fear of raising children similarly stuck in the disordered eating loop consumes many of today's parents.  The current possible solutions, however well-intentioned, are unlikely to have the desired effect.  Parents model undereating and overexercising behaviors, spend way too much time discussing “healthy” food choice and are often oblivious to their kids' inculcation into the cultural obsession with thinness.  In other words, raising "healthy" eaters in today's environment inevitably means welcoming the newest group of disordered eaters to the world.

The easiest way to understand the difference between automatic and obsessive eaters is to compare the two in real life.  Children are clearly born automatic eaters. Given a plate of food, it is mesmerizing (as an innocent bystander rather than a worried parent) to watch them work by eating, playing, experimenting and socializing.  By the end of the meal, the child will have eaten his fair share and fully tested the texture of each food while also testing the limits of his parents' patience.  In case it seems like I am describing an infant, this behavior lasts, in age-appropriate form, for years.  What is truly educational is that these children don't starve.  They eat what they need and play with or discard the rest.  And this is automatic and intuitive.  We are born with the knowledge of how, unconsciously, to eat.

The most obsessive eaters struggle with anorexia.  Food, rather than embodying its social and nutritional value, becomes the source of endless psychological and emotional torture.  The person has to consider every morsel of food in light of the internal drive to starve and become emaciated.  No bite is ever automatic but instead induces fear and dread.  Even in the face of medical illnesses from longstanding starvation, eating any meal is so wrenching that conscious attention can never be distracted from the food at hand.  A person with anorexia has unlearned the ability to eat automatically.  The concept feels completely impossible and foreign.

Armed with this information, the job ahead is apparent.  A child is born with the innate ability to eat enough and not starve.  Before the advent of endless child advice books to balance the current of thinness and dieting, parents just fed their kids.  Until very recently, food choice was much more limited, and meals were just meals.  Children sat at the table in front of a plate of food and ate what they ate.  They all survived and grew into adults focused on life, not food.  Perhaps today's parent will consider the more healthful options in a supermarket influenced by the powerful food industry, but to the children, food is just food.  If the parents sit down and eat their plate of food, just as the children do, without obsessing about portions and calories and dieting and carbs, those kids may keep eating automatically and never learn there is another way to eat.  The goal of talking to your kids about food is not to talk too much.

The next post will focus on some of the pitfalls that can still happen when faced with children dealing with eating issues at young ages. I am often asked either socially or by people who find me online similar questions about children and eating.  I'll try to address some of them in the next post.

Chronic Dieting: the Third Pillar of the Obesity Crisis

The most striking result of a population obsessed with thinness and weight loss is how unsuccessful most people are at achieving the goal. The more energy used for exercise and dieting, the fatter the country becomes.  Miracle diets blanket airwaves, papers and websites.  Exercise routines and gym memberships move through one community after another.  And yet we just get fatter and fatter.  When 99% of people who diet end up gaining all the weight back and more, when exercise programs seem to have no impact on a sedentary population, it is time to go back to the drawing board.  The new food political writers vilify the food industry, itself incredibly lucrative and grossly under-regulated, but there is no proof that eliminating McDonald's and Coke will solve rampant obesity either.  In fact, the evidence shows that the health-conscious, disordered eating sub-population can still gain as much weight on Pirate's Booty as they can on Doritos because overeating and a sedentary lifestyle are only two of the three pillars the obesity crisis has been built on.  The last, paradoxical and ignored issue is dieting.

It's abundantly clear how overeating and lack of exercise can lead to weight gain, but the link between chronic undereating and weight gain is not obvious to the majority of the population.  The newest diet plan stationed alongside the tried and true, established programs constitute a bevy of healthful and hopeful alternatives to the frustrated masses longing to reach their goal weight.  The proponents for various diets rarely experience public questioning and are instead viewed as saviors for a population lacking willpower.  Our national obsession with thinness blinds us to the dangers of chronic dieting.  Just look at the parade of celebrities that the diet industry uses to lure us into their web.  As one television star loses weight, her success is charted by the company to prove the plan's effectiveness and induce people to follow its success.  But, inevitably, as the person begins to gain weight, she is succeeded by the next star as spokesperson.  Of course, the company quietly blames the person’s inability to follow the plan.  No one questions the plan itself.

To understand how dieting fuels the obesity crisis, it will help to return to the set point theory.  As a reminder, the body has a set range of weight, about 15% from top to bottom, within which it moves freely.  Homeostasis, the mechanism the body uses to maintain stability in a variety of functions necessary for life, applies to weight as well.  The central tool to maintain weight is metabolism, which represents a host of changes in the body to use energy, namely food, either more or less efficiently.  At first glance, the set point theory seems contradictory.  Overeating when a person is at the top of the weight range leads to a metabolism increase, decreased hunger and burning off energy.  In fact, a significant spike in eating over a period of weeks can increase metabolism sharply and curtail any further weight gain above the top of the range.  Why, then, if there is a built-in cap on weight gain do so many people become obese?  On the other hand, chronic undereating leads to a conservation of energy: metabolism slows down, hunger increases significantly and the body, when given any surplus, voraciously stores food as fat.  In addition, studies of evolutionary adaptation have shown that the tendency to survive lean times, such as the winter, is much stronger than the need to override times of plenty.  Practically, this means that periods of chronic starvation will trigger a strong, protective mechanism to expect coming famines and store food for the future even when the times of plenty follow.

It will come as no surprise that even the most overweight portion of the population spends a fair amount of time dieting.  The more overweight, the more drastic the diet.  In fact, many diets suggest intake of 50-75% of the food needed for a given day.  A few weeks with such low food intake will trigger a powerful homeostatic response from the body, which means initial swift weight loss, followed by a sharp metabolism slowing and voracious appetite.  After reviewing the set point theory, the overall effect of periods of chronic dieting are clear.  These periods of undereating bring about the adaptive response to famine and that undoubtedly means weight gain.  In fact, the most overweight who follow the most severe diets can then continue to gain weight past their set point because of their extreme dieting.

To understand this confusing link between undereating and weight gain better, it can be helpful to look at chronic anorexia.  One of the most confusing aspects of anorexia is the patient, ten or more years into her illness, who, despite continued food restriction, no longer is underweight.  The psychological toll on the patient is overwhelming: how can years of decreased food intake, which consistently produced a very low weight, suddenly stop working?  For the more rare patients who maintain very low weight, severe illness and death around age 30 is almost certain.  For those whose weight returns to the normal, or at least not emaciated, range, the answer lies again in the set point theory.  Built into their genetic make-up is the ability to severely curtail metabolism.  The drive to slow down energy use, increase hunger and store fat easily overpowers the drive of the eating disorder and causes enormous frustration and despair in the patient, even though it also enables them to survive.  The most confusing aspect for the general population to understand is that an anorexic patient of normal weight can still be as severely ill as the emaciated one.  The medical complications and psychological torment from years of restriction, even if the body maintains a more normal weight, are severe and lead to disability, illness and premature death.

The set point theory is old, established medical knowledge.  Why has this information been summarily ignored through the obesity crisis?  How has the medical community spent so much public capital on new, ineffective weight loss techniques?  Can't an obese population desperate for successful measures to stop the trend look at the basic scientific data for simple answers?  With effective measures like weight maintenance plans and with a critical examination of the diet industry, these changes seem well within our grasp.  Instead, there has been an explosion in weight loss television shows while the nation tolerates a large number of children attending fat camp.  The public forum ignores this third pillar in the obesity epidemic while searching for the enemy to explain away our problems.  Yes, the food and diet industries are largely responsible, but we refuse to acknowledge the truth.  We have to stop dieting and praying for a miracle cure and instead need to find our own maintenance meal plan.

In adults, this transition is complicated by years of chronic dieting.  Finding a maintenance plan also entails the process of normalizing metabolism, which can be challenging for someone searching for a quick fix. But nowhere is this more important than in children.  As promised in the last post, I will address how to apply the idea of a weight maintenance meal plan for kids and their parents.

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.

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.