Practical Steps to Fight Obesity, Part I

Issues of public health, no matter how dire, can be a hard sell. Unless there's a dramatic angle to the story, few will get fired up by a nation's well being. It's not uncommon for an individual to find the altruistic impulse to help a person in need--there's a bit of a thrill, for example, in the guilty gesture of giving to the homeless--but the overall public health doesn't stir up the same generosity of spirit. With individuals focused on their own extra pounds, the people charged with drumming up support for the obesity epidemic, which shortens lifespans and is very costly to the government, have a tough time building any interest.

The successful public health campaigns in recent decades have gotten creative to generate enough buzz to try to make a difference. The dramatic attempts to shock kids out of drug use (this is your brain; this is your brain on drugs) or to horrify smokers with the medical effects of cigarettes (the public display of emphysematous lungs) elicit most often derision or outright mockery, certainly not the intended effect. Meanwhile, business advertising counterparts, trained in the coercive arts, something not taught in an MPH program, are much more effective in targeting their audience.

Appealing to the national zeitgeist of health at any moment is a challenge. The most effective strategy looks for a dramatic edge, most often the age-old battle of good vs. evil. With a natural enemy or corporate entity to blame, it's a lot easier to frame the solution and rally supporters. It's not hard to understand when the goal is to eliminate the root of the problem.

A systemic change in the way we as a society choose to live, willingly or not, poses a much harder dilemma for the public health rabble rouser. Changes to our food supply, the relentless pressure to be thin and the growing ranks of sedentary media consumers have created a tectonic shift in the public perception and reality of food and weight. A systemic change doesn't present a simple, black-and-white, good vs. evil message to hang the proverbial public health hat on, not when food and weight is on everyone's mind, from industry to the individual. There hasn't been a way to find consensus to galvanize the movement against obesity, not when the solution remains either elusive or incomplete.

Responsibility for the obesity epidemic ranges from business to government to medicine. But pinpointing causes does little more than instigate outrage and blame. Moreover, only information and action can disempower the entities that thrive on the aimless attempts to fight obesity. For future generations to be protected from the endless supply of food and concomitant weight gain, the public health outreach needs to inform the adults responsible to teach children and to connect to kids in novel, memorable ways.

For adults to listen, the campaign needs to present the stark contrast between the assumptions of the food and diet industry and the facts about food and weight. It's patently clear that diets don't work, yet, shockingly, dieting is still the only advice given by professionals and industry alike. That advice tends to come with either disdain for the obese person or with the faulty promise of a swift, magical cure. In other words, a public health advocate needs to debunk the myth of a quick solution to both the common and individual obesity epidemic and present the facts about food and obesity to adults. The caveat, and only reasonable fact the experts agree upon, is that moderation of food intake will lead to weight stabilization and moderate loss, with moderate health improvement. The public won't be eager to hear about lowered expectations, but accepting that reality can be a relief when presented as a true alternative to the diet and weight-obsessed lives that plague most people with obesity. Accepting slow change is worth the liberation from cyclic failure.

Winning over kids to the campaign is a much harder challenge but is essential to avoid passing the crisis down generation after generation. The power children wield in first world culture spurred the formidable advertising and marketing minds to win over the impulsive id of youth. Kids may not plunk down the money for said product but instead must generate enough of a fuss for parents to grudgingly buy the item--be it food, content, toy or electronic gadget--for a moment of peace. Clearly, business has spent significantly more creative energy to attract children than any anti-obesity program thus far. We can ply them with carrots galore, but it's the wont of childhood in this day and age to fight full bore until that candy bar is safely in hand. Add to this scenario the limitless supply of child-friendly content, including television, video games or apps, and a typical child's fate becomes clear: a calorie-dense diet and sedentary lifestyle has become the norm.

Parents may very well want to shape their children's lives into healthy ones, but the information available to do so is confusing and often contradictory. Parents pull blindly from the nutrition cache and try unsuccessfully to replace white bread with veggies and dessert with fruit. They sign their voracious reader up for every sport. The specter of obesity haunts them enough to embrace any half-baked idea about a child's health. The decades of knowledge about child development and the wide and normal variability of a child's body type through childhood and adolescence remain ignored.

Parents need useful information to read and clear guidelines to follow. The basic dietary advice about healthy eating that has little effect on adults is even less effective for children. Given a child's limited, or more likely non-existent, desire to follow any food rules, the endeavor quickly feels hopeless. Just hand over a supersize bag of chips, turn on the TV and give up already. The next post will outline some of the key points to make the public education of children effective and and the important facts for parents to hold onto in order to save their kids from the obesity epidemic.

A New Public Health Approach to the Obesity Epidemic

The original public health problems pitted man against nature. Bacteria in unsanitary water causes chronic diarrhea. Iodine-fortified salt fixes goiters. These days first world public health issues are manmade. Without a common, uniting cause, human instinct leads the search for a villain to blame for the crisis and subsequently purge from society. It's the superhero approach to public health.

Sometimes that's easy. The big, bad tobacco industry played the villain well. It took a while to break down the marketing juggernaut, and the powerful nicotine addiction, but the end result was secure. Sometimes finding the villain is much harder. Who's the bad guy in the obesity problem? If you're an activist looking to stir the pot, who exactly are you fighting?

The obvious first culprit is the food industry and agribusiness. Taken broadly, these companies create processed food that's extremely tasty, inexpensive and minimally nutritious. It's been easy to target industry as the cause of the crisis and embrace the newest David vs. Goliath battle. There's no doubt these companies haven't done society a service, but they're only a cog in the machine. Maybe the diet industry, which encourages a generation to await the newest miracle weight loss plan, is the evil villain. Playing on our deepest desire, its promises are patently false and only worsen the problem. Chronic dieting slows down individual and collective metabolism to a crawl and only leads to more weight gain in the end. Perhaps the fashion industry is most at fault by instilling the impossible goal of near-emaciation in generations of girls.

Even the academics themselves may just make things worse by peddling their solutions to the obesity crisis as if weight loss and maintenance couldn't be easier. The experts' insights into the causes of obesity are eye-opening, but every book ends with the same tired rhetoric. Let's all learn how to have "healthy" diets and exercise, and the obesity epidemic will miraculously disappear.

People who've turned to doctors for help know that the medical field can be implicated too. Internists blindly watch patient after patient fall into the same obesity cycle and scornfully shame each one saying, "Well, if you just eat less ... " Pediatricians hide behind BMI thresholds and ply meaningless suggestions to parents about cutting out extra ice cream or white pasta, as if simple food choice is the issue. And Bariatric surgeons reap financial rewards by mangling perfectly healthy gastrointestinal systems without any sense of the long term success or risk of these procedures.

And then government, regulators, journalists and chefs who do want to help don't know where to turn. The bland advice to eat more vegetables and less fast food, to move more and sit less, to cook more and have family meals is all sound but wholly ineffective. The growing number of desperate people fall into the hands of the powerful industries ready to capitalize with false hopes and dreams.

So whom do you fight? Who's the bad guy? What's the obvious target for a budding idealist? When all the facts are clear and the activists gather around the table to develop a plan, there is no real answer. The problem is systemic. The entire society lost its way with eating. There's no villain to be found. It's a new type of public health problem grounded in how we have chosen to live.

As of now, activists focus on the periphery, the tiny nibbles that won't really matter. Transparent food labeling in supermarkets and restaurant chains helps people know what they're eating even if it doesn't affect food choice. Banning large sodas might help some people decrease sugar intake. Increasing availability and affordability of Farmer's markets looks nice on paper. The slow shift to slightly larger fashion models certainly leads many to breathe a sigh of relief. But when a society expects availability of any food at any time, when the farming industry runs on the subsidized price of corn, when everything a population does is sedentary, when competitive dieting has become television fodder and replaced softball as the national office sport, the writing is on the wall. And a few political gimmicks won't do a thing.

The success of activism lies in its target. Effective public health campaigns have to focus on the future. All eyes on the obesity crisis have addressed the current obese. The paltry ideas of the experts are as ineffective as every diet on the market. The only choice with the current generation is to debunk the myths of a magic cure and encourage steady, sustainable diets with reasonable expectations of, at best, moderate weight loss and improved health.

The only real place for activism is for future generations. That means proactive programs to teach children a different way to eat. Kids may need to learn what balanced meals look like and feel like in their stomachs. They also need to know that food means sustenance, health and pleasure. Kids need the basic facts about how eating is critical to body function and to the success of our species. And then they need a crash course to understand the wholesale changes in how we eat and how we want to look in recent decades. They need to be aware of the endless ways our world can hijack their minds and bodies into food obsession and the obesity epidemic. The world of food might change in years to come, but children have to cope now with the delectable treats on every corner, the endless pressure to diet and lose weight and the confused adults around them unable to find their way. Activists can take a stance to create a smart public health program that offers an alternative to this current world of food and supplies real ammunition to fight the daily pressures to succumb to the starve/overeat cycle which inevitably leads to obesity.

The Unspoken Reality of the Obesity Epidemic: What the Experts Won't Say

From the fame of Michael Pollan to the outcry about agribusiness to the first lady's signature Move Your Body! program, it's impossible to ignore the American struggle with weight. The interest in the issue may be apparent, but the proposed fixes remain rudimentary. Anyone curious how and why the rate of obesity has skyrocketed in recent decades can find a growing library of well-researched, thought-provoking books. Looking for an expert speaker to summarize the country's dilemma? They abound.

However, if you're searching for an effective approach to the problem, you're in trouble. Some experts focus on regulation of agribusiness and the food industry, similar to the fight against tobacco, but that's a long-term project complicated by the fact that people can live without tobacco, but not without food. Others emphasize the truisms of the diet industry, eat less and move more, without divulging the fact that 99% of diets fail. So why would anyone believe the collective national diet will have any more success? And the physicians obsessed with "evidence-based" treatment are holding out for the miracle weight-loss drug while chastising their mostly overweight patients. That's no more than a pipe dream at this point.

Food and weight are not particularly complicated. The real issue is that no one wants to reveal the truths this country faces, much better to pretend that a magic solution is just around the corner.

The clear facts about food and weight are as follows. There is much more food available than ever before, and most of the increase is highly processed and inexpensive. The combination of successful marketing and the development of irresistible foods decreases any one person's ability to manage daily intake effectively. The regular person's life is much more sedentary than in years past. Chronic dieting leads to rebound weight gain  and a gradual weight increase over time. Due to these factors, rates of overweight and obesity have skyrocketed. 

Similarly, the facts about ways to fix the obesity problem are clear. None of the current suggestions work. If any one idea had merit, the word would spread like wildfire. As it is, every new crash diet or exercise program has its fifteen minutes of fame, while the well-meaning "healthy eating" programs are the neglected stepchild compared to the advertising and delectable offerings of the omnipotent food industry. Everyone is desperate for a new solution to cling onto, but no one wants to be clear about what really can be done.

The problem needs to be split up into two parts. First, what are the practical approaches for the currently overweight and obese? And the second part of that question no expert wants to address: what are reasonable goals for long-term weight loss? Second, what can the country do to ensure the obesity problem is limited to a few generations and does not become the new norm? Although the two pieces overlap, separating them clears up the difference between realistic expectations and activism.

Only one weight loss approach works. And it's completely obvious and intuitive. In order to change ingrained behavior, one needs a long-term, sustainable, consistent meal plan developed with a professional or a program since an individual who struggles with food inevitably reverts to old patterns without external intervention. That means working with a doctor, nutritionist or a reasonable program such as Weight Watcher's to implement and follow a clear daily approach to food. The plan needs to provide adequate calorie intake to sustain health and to stay within the person's energy needs. After years of excess food, it will take years for a body to adjust hunger cues and adapt its weight range to a lower food intake. All of the evidence makes it clear this is the only effective option.

There's a reason no expert will make this point. The diet industry preys on the collective desperation to lose weight now. Even the smartest, most experienced dieters know that no magic diet will ever work. Yet the masses suffer under the delusion that permanent, speedy weight loss is in their immediate future. No one will hear otherwise and no one is brave enough to face the wrath of saying it like it is.

What is the benefit of blowing the secret? And at this point would anyone really listen? No one wants to believe that the current overweight generation will remain overweight. Yet, with a little perspective, that fact is evident. As I have written before, chronic overeating drives up an individual's set point weight range. Since the body protects itself against weight loss much more than weight gain, as the set range increases, the low point of the range increases as well. The body will move easily within the range but will resist weight loss at the bottom of the range, even if the bottom of the range is still significantly overweight. Moving within the weight range is easy. Shifting the entire set range down is a much harder long-term proposition that involves sustainable, consistent decrease in food intake over years. It's not a big leap to realize how improbable that result is for an entire country.

It's important to recognize that even if this generation as a whole remain overweight, many individuals will find the right meal plan, rely on considerable support and gradually bring down the set weight range. As more clinicians and programs provide effective solutions, more people will find an approach to weight loss and maintenance that works. But the likelihood a country will do so is very slim.

In the fight against long-term obesity, the current generation will have a very specific role. The fate of the overweight generation is to attempt to reject chronic dieting in favor of a sustainable change in eating and live with the modest weight loss and health benefit. Adults can teach children how to survive the world of plentiful food and how to avoid the cycle of overeating and dieting and thus not become obese themselves. That's the topic of activism in the fight against obesity, and I'll address it in the next post.

What do the Experts Say about the Obesity Crisis: A Summary of the Current Information

The clamor for practical, effective information about obesity and weight loss is growing rapidly. Although the latest fad diet, magic cleanse or false nutrition claim still attract the most attention, word has spread through the major news outlets that 99% of diets fail. A quick review of the available resources reveals that the recent global transformation of lifestyle and food supply created and now perpetuate the obesity epidemic. More scientists, researchers and clinicians recognize that the issue needs thought, concern and action to counter the disastrous effect of unregulated food and diet industries. So what's the verdict of these newly minted experts thus far?

Even a quick summary of the available data about dieting is unequivocal. It doesn't work. Diets pretty much always fail. Any combination of severe calorie restriction, magic nutrient compositions and newfound supplement concoctions are sheer quackery meant to capitalize on the desperate willing to try anything for success. The underlying motivation of every diet guru is monetary gain. The diet industry is huge business and is sure to quash the obvious conclusion that diets fail at every turn.

Another consensus opinion is that nutritionism is man made myth, not true science or medicine. Nutritionism, as explained in previous posts, is the process of creating meal plans based on food components, protein, carbohydrates, fat, vitamins, minerals, etc., rather than actual food. The concept implies that current knowledge of nutrition is complete and that the best, healthiest meal plan is easy to create based food components and is completely effective for weight loss. Experienced academic nutrition professors and scientists dismiss nutritionism and instead expound on the dangers of spreading such misleading information. Omnivores one and all, humans need to eat a wide range of foods, not food components. We adapted to survive on an extremely wide range of diets, a trait sure to extend our longevity. The sage advice of the experts is that the best meal plan is simple and general: not too much food with ample variety. These are simple words to live by.

Yet the simple advice has been woefully inadequate to make a dent in the problem. At this point, the conversation inevitably turns to metabolism and weight management, basic facts needed to tackle the problem of obesity, which are incompletely understood and surprisingly complex. Metabolism encompasses how the body uses food, our energy source, to function. Weight is generally stable within a range but varies according to overall food intake and energy expenditure. The body stores energy during excess and uses that stored energy during lean times. And that balance has been very effective to maintain weight, until the last few decades. Put simply, the recent introduction of significant excess food with high fat and sugar content apparently overrides the mechanism that maintains weight and has triggered the obesity crisis. Human evolution protects against weight loss effectively but much less so against weight gain, something that has never before been a problem in human history. The experts then conclude with this statement: years of human function and evolution show that moderate food intake and moderate physical activity lead to a stable weight range, and we need to return to that basic concept. Beyond that, the experts, one and all, throw up their hands. As of now, they all seem to agree: that's all we have to counter the issue of obesity. Since everyone is still hooked on a quick fix for the crisis, the experts' message is largely ignored. Although the experts' opinion is undoubtedly accurate, it's the presentation that needs a little work.

The underlying premise of the obesity crisis is that we need a fix now. Our current knowledge about weight and metabolism relies on the largely unchangeable evolutionary adaptations of the human body. Maintaining stable weight and energy stores is essential for life. Human survival depends on a body that can adapt easily to change and is resilient in hard circumstances. In fact, we even have multiple backup systems for any possible failures to essential organs, much like a backup generator for a power failure, all to maintain the status quo, or in medical jargon, homeostasis. Homeostasis means that the body always will work to keep things stable. This can refer to blood levels of various electrolytes and blood cells, heart rate and blood pressure, hormonal balance and pretty much all body function. Of course, metabolism and weight are included. In recent decades, the average weight range has gone up but that hasn't done away with homeostasis. Instead, the body recognizes the new norm is a higher weight range, and the body uses the evolutionary system to protect this new range. So a quick fix tests an age-old system and repeatedly fails. But if we apply the experts' advice, any approach to the obesity problem has to respect that homeostasis is here to stay.

The next step is to combine expert opinion and change the time of the conversation. Moderate food intake with variety and moderate exercise will, slowly and steadily, chip away at the obesity problem. Weight loss can only come with a gradual decline in each person's normal weight range as the body slowly reacts to a more moderate daily calorie intake. The key to effective weight loss is sustainable, consistent and small calorie decrease over a long period of time. For this message to work, the focus needs to shift from a quick fix to a reasonable, sustainable solution, one that takes into account how our body functions, not the desire to just fix the problem.

The next post will address how to apply this information practically and how to spread the word.

How Doctors Harm People with Eating Disorders

The prejudice against people with eating disorders extends to clinicians, who are as misinformed as the public. The basic medical and psychiatric understanding of anorexia and bulimia are not part of medical training. Primary doctors have sporadic exposure to patients suffering with these illnesses but no guidance about how to manage them. Even psychiatrists in training can graduate with no more than a cursory knowledge of the diagnostic criteria for eating disorders. If anorexia is the most fatal of all psychiatric diseases, then medical education is missing the boat.

The life of a recovering patient remains isolated, lonely and gravely misunderstood. While family and friends struggle to comprehend how anyone could have trouble eating, something so basic to human existence, the sick are typically silent. But what happens when physicians approach anorexia and bulimia with similar ignorance? The risks are much more consequential.

Too many of my patients have had difficult experiences with doctors. For some, the scars are emotional and that makes seeking medical help in the future a scary proposition. Arrogant doctors typically think one of two things: that they will save the patient or that the patient needs to just buck up and eat. Either erodes a patient's trust in medicine and prompts the person to go it alone. Many others are physically harmed by doctors unaware of the precarious balance the human body reaches to survive an eating disorder. A person with bulimia can adapt to usually lethal blood potassium levels and frightened doctors may dangerously raise the level too fast. Doctors also don't know that overfeeding a very underweight person with anorexia is potentially lethal and will do so anyway. The bold medical interventions aren't just pointless, they can kill.

This leaves treatment in a difficult spot. On any typical day, a doctor relies on the nearest hospital emergency room. I suspect everyone has heard a doctor's voicemail message stating the obvious, "If this is an emergency, please hang up and call 911 or go to your local emergency room." In this message, a doctor is sure to impart a clear directive to a scared and confused patient. In addition, the doctor implies confidence that the ER will address the problem adequately and quickly.

I don't say that in my voicemail message for a reason. It's not because my patients don't often need an emergency room. They do. It's that emergency room doctors do not know how to treat people with severe eating disorders. The sight of a malnourished patient tends to elicit horror and hasty action. The shockingly abnormal lab values in a very sick patient with bulimia leads to the same reaction. An ER doc is supposed to have seen it all. They are supposed to be able to handle any form of crisis and use their knowledge to save a patient. The misinformed, judgmental response of many of these doctors makes an ER one of the least safe places for anybody with an eating disorder. When I do send my patient to a hospital, I am sure to be on standby to protect them as much as anything. These patients often need immediate medical care I can't provide, but when in an ER they practically need an escort to be sure they survive.

Sadly, much of the problem lies in the prejudice. Doctors absorb most of their information about eating disorders from the press and entertainment industry. Convinced of their suspect views about food and weight in general, doctors typically know even less about eating disorders but have no trouble expressing faulty opinions, even when on call. And that precipitates poor, dangerous treatment decisions. Most doctors consult textbooks and supervisors when faced with an unfamiliar situation, but who can help treat anorexia and bulimia? There is ever-growing public attention on food, weight and eating disorders; the problem is ubiquitous and garners significant attention. Just a little time engaging with the main stream media attests to the topic's popularity. It's about time the medical community pays attention and realizes our job isn't to form an opinion but to learn how to keep these patients stable and safe.

Who Among the Obese has an Eating Disorder?

The last post was a call for the community of eating disorder clinicians to recognize that all people with eating disorders, irrespective of weight, deserve adequate treatment. One specific point to help circumvent the bias was to create a clear interview process to distinguish between obesity and eating disorders. When the data says that up to 60% of Americans are overweight, obesity becomes a public health problem more than a disease. And so it's critical to know who among the overweight do and don't have eating disorders in order to provide the best treatment plan for each person.

Weight is an important marker in eating disorder treatment, but it also has clear limitations. For Anorexia Nervosa, following a patient's weight helps track progress during refeeding and helps prevent relapse. Similarly, someone who is overweight with Binge Eating Disorder needs weight followed to manage meal planning and possible medical consequences. However, there are just as many complicated cases in which weight is less useful. A patient with chronic food restriction over many years who attempts to eat may gain more weight than expected due to drastically slowed metabolism. Longstanding malnutrition or laxative abuse can impair the body's ability to manage fluid and result in 10-20 pounds of swelling just from retained water. Some people with Bulimia Nervosa always maintain normal weight yet remain severely ill for many years. Weight may be useful but only in conjunction with the person's full life story.

What lures young people into eating disorder symptoms and what captures the attention of the media are the dramatic cases. Photos of extremely emaciated girls and lurid stories of self-destructive eating episodes with rapid, large weight fluctuations draw a wide audience and simultaneously reinforce the notion that eating disorders are first and foremost based on weight. And society at large truly believes that if someone is at a normal weight, they must not have an eating disorder. The public has completely misunderstood what these illnesses are about.

Once the genetic predisposition, personality structure and life experiences have started an eating disorder, the outward manifestation of distorted eating behaviors and weight changes reveal only the surface of the illness beneath. What truly separates disordered eating from an eating disorder is the psychological torment. The obsession with food and meals combined with constant assessment of body shape and weight are relentless, yet even part of this reaction is a physiological response to chronic starvation that is cured by normalizing eating. For the person with an eating disorder, the failure to eat according to strict rules and to maintain the body shape demanded by the illness trumps all else. The thought process goes as follows: by failing to do exactly what the eating disorder laws dictate, you are a horrible person who deserves nothing and whose life is worthless. This personal philosophy feels immutable, like an unquestionable truth, and is not ameliorated by normal eating. By taking even a moment to imagine life under this edict, one can hardly compare the emotional pain of such internal punishment to the number on a scale.

Differentiating obesity from an eating disorder is conceptually clearer when weight is only a physical manifestation rather than the central component of the problem. Many people who are overweight or obese struggle psychologically with weight but don't have any semblance of the internal torture of an eating disorder. These people represent the majority of people who comprise the core of the growing public health problem of obesity, but they don't have eating disorders.

By understanding that the central experience of an eating disorder is psychological, a clinician can tailor the interview process accordingly. The goal isn't solely to assess food and weight because then the majority of the population would be sick. Instead, uncovering the punitive thought process will reveal the difference between obesity and an eating disorder and help ensure that those who need eating disorder treatment can get it.

Psychiatry, from a public health perspective, is likely to have a role in curbing the obesity epidemic. Without any direction, it's not clear how society will curtail the problem. Food is a powerful mediator of emotions, and with so much food at our fingertips, the pull to eat for emotional calming is often too strong to withstand. Sometimes it feels like society is even writing off the current generation of the overweight to fix the problem only in the future. The next post will address the role of psychiatry in the public health realm of obesity.

The Anti-Obesity Prejudice of the Eating Disorder World

The anti-obesity bias in the first world is undeniable and unchallenged. The obese have to weather ridicule and discrimination both in the workplace and in their personal life without any recourse to fight back. The causes of the obesity epidemic, when viewed objectively, are not personal: an excessive amount of available, processed food and a sedentary lifestyle combined with the genetic predisposition to facile energy storage. Still, the default world view of the overweight is that they are lazy and slothful.

Due to the overwhelming bias against the obese, people prefer to believe that being overweight is a choice. Much to the layperson's dismay, eating disorders are diseases of physiology as much as psychology. The emotional and psychological ways to use food to numb feelings and to cope with seemingly unmanageable problems in life are well-documented. But in order to become ill, these people also need to have certain physiological adaptations to hunger and fullness. Without the genetic ability to adapt to chronic starvation or chronic overeating, two sides of the same coin, all the exposure to food obsession and thin models won't trigger an eating disorder. The grand experiment combining the world of plenty with the desire for thinness created the epidemic in the first place. After forty years, we're now living with the results: a population that tries to starve while surrounded by limitless, delectable food will develop chronic food problems, and those at risk will develop eating disorders, including obesity.

To believe that we all have sound judgment about food and weight is no longer a given. The desperate longing to be thin led to an alternate sensibility which rewards any method used to successfully attain a desirable weight, and that includes eating disorders. It even includes ranking these illnesses in a hierarchy of preference. Anorexia Nervosa remains atop the heap. Despite the gruesome photos and sad stories of this lethal illness, the media and culture can't help but glorify Anorexia as the grand solution to our collective focus on weight. For a person to live on only a few hundred calories per day mystifies the masses bent on finding the magic diet. In fact, the primary medical intervention for the overweight is to create a similar state of starvation, either through a crash diet or Bariatric surgery, with no long term proven success. In reality, Anorexia is a mental and physical prison, but the world continues to believe otherwise. Bulimia Nervosa is a notch down in the ranking but remains more socially acceptable, especially if it is a successful means to lose weight. Any binging disorder, especially one that leads to significant weight gain, is regarded by society as a lack of willpower, not an illness. And the obese don't even make it on the list. The general consensus is that they just need to stop eating.

A bigger disappointment is that the eating disorder community has largely followed suit. Even though some clinicians are starting to treat overweight people with eating disorders more equitably, the prejudice remains strong. The mental prison in which a patient with Anorexia or Bulimia lives is no less evident in the obese person with Binge Eating Disorder, Compulsive Overeating or Bulimia Nervosa. However, the clinical community continues to focus on underweight people with eating disorders. A quick search for residential treatment programs or day treatment programs makes the bias obvious. Obese people will get into a treatment program but they're not truly wanted. Even the current diagnostic classification system leaves the catch-all diagnosis of Eating Disorder Not-Otherwise-Specified as the only option for the obese. As of now, there is no available treatment for the overweight.

It's time for the clinical community to recognize that societal prejudice has altered the direction of diagnosis and treatment. Just as with underweight patients, the overweight with eating disorders struggle with psychological and emotional symptoms and endure a wide range of medical effects from their disease. Moreover, these patients have the same genetic predisposition to an eating disorder, experience the same type of triggering external circumstances, benefit from the same kind of therapy and work through the same stages of recovery. The difference of weight is exclusively based on the person's innate physiology. This means the clinical community excludes a population of sick patients from treatment based solely on their body's response to an illness. Clearly, this is unacceptable. 

The eating disorder community can take a few simple steps to change this pattern. First, expand the available diagnoses to eliminate the weight bias. Second, create a clear clinical interview process to identify eating disorders in the overweight, one that enables clinicians to bypass their internal bias. Last, expose this discrimination to the community by emphasizing the behavioral and psychological symptoms of eating disorders over the focus on weight. A few small steps will open the door to treat all people with eating disorders.