To Sleeve (or Not to Sleeve) Series - #9, Obesity as a Disease (or, Why I gained my weight, Part 2)

(This is part of a series I posted on my other (formerly anonymous) blog, tobypass.wordpress.com. An index of all posts in this series is located at the bottom of this article.)

As of the spring of 2013, obesity is a disease. So says the American Medical Association. This article from the NY Times looks at the medical and political ramifications brought about by the decision. The authors of the AMA report are quoted as saying:
“The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes,”
It apparently was a pretty hotly contested issue — at least among the sub-committee that prepared a preliminary report for the larger body that would vote the issue. That report recommended NOT changing consensus on obesity. But by the time it came to the floor for vote by the AMA at large, the concept passed with overwhelming support.

Now — one could discuss for a long time the finer points of this decision: its implications (articles published at the time by both the Atlantic and Forbes dig especially into the finances), whether or not it even makes philosophical sense, etc. But what most interests me about it has to do with what the AMA’s decision does to me personally — in terms of how I understand myself, how I feel about my weight, and my perspective on the future. To put it bluntly, I think the AMA’s decision has the capacity to change how we perceive personal responsibility when it comes to obesity.

What scientists appear to have discovered about obesity (particularly over the past few years) is that it is brought about through complex set of interactions among several bodily systems. Many years ago (and perhaps still amongst most individuals who either [a] aren’t overweight themselves or [b] haven’t read the relevant material) the dominant belief was that excess weight gain was nothing more than the result of ‘energy-in’ ‘energy-out’ and therefore obesity is caused by laziness, poor self control, gluttony, or stupidity. However, what we have come to know is that in reality, many different factors play off one another to impact that simple ‘energy-in, energy-out’ dynamic in our bodies.

Numerous studies have shown: Inherited genes from our parents impact the likelihood of us becoming overweight as children and adults — up to even a 25% increase. So not only did my family culture influence my patterns of eating as a child and young adult – it also gave me a body, DNA, that has a proclivity to push me to eat more and grow more.

Excess weight is heavily impacted by individual metabolism. That is, excess weight both influences our metabolism just as metabolism greatly impacts weight. It is a cyclical. As an overweight person loses weight, his/her body responds by slowing metabolism and becoming far more efficient in operation. Our bodies are designed to do this. Conserve in times of famine and store in times of excess. Unfortunately, we live in an environment of excess — and our bodies respond accordingly: store and prepare.  A person who is already overweight – but who is actively losing weight – will experience a slower metabolism as a response to his/her losses, making additional weight loss increasingly difficult. Some people (including my primary physician) talk about a “set-point” for weight that our bodies work incredibly hard at staying near.  Metabolism helps keep us at or near that point. Unfortunately (again), my set point appears to be around 300 pounds right now (and rising).

A key controller in this metabolism cycle are hormones. Medical scientists have just recently begun exploring how our brains and guts are connected (with many implications beyond weight) — but a well known hormone is called Ghrelin. This chemical is secreted by the stomach into the blood stream and it impacts our brains — telling it that we need to eat — it’s presence creates drive and it’s absence creates satiety. So in super general terms, the empty stomach releases the hormone to get it’s body eating — and it withholds the hormone when full. As a part of the metabolic cycle, when a person loses weight his/her ghrelin increases to ever higher levels — begging him/her to eat. Some studies have shown that an overweight person who is down a few pounds will have far higher Ghrelin levels than a person with normal weight. In short, it’s really really hard for an overweight person to lose weight and keep it off — our body does almost all it can to keep us from it.

As David Kessler wrote in his book, “The End of Overeating” –– refined sugar (especially) affects our brain much the same way as other addictive substances and activities (heroin, nicotine, alcohol, sex, etc.) Not only does an overweight person’s body work against him/her to achieve a healthy weight — his/her brain does as well! Like an junkie on a quest for the next hit, overweight people are compelled to find and eat that food that they have learned to use for a dopamine spike. Brains are plastic as we’ve been discovering — incredibly adept at changing and adapting. Overweight people (this one included) have changed their brain chemistry to reward ice cream, doritos, french fries, and snickers with pleasure. Just as a heroin addict is driven to use an ever increasing amount of his/her drug of choice — I’m driven to eat just the same. And just as any other addict, obese people get triggered by environmental, emotional, and situational cues — to go back to those substances (foods) that they subconsciously know will make them feel better. As is the case with many obese people, I very often cannot tell the difference between my physiological feelings of hunger (due to an empty stomach) and psychological feelings of hunger (due to my addiction).

I eat when I’m happy and sad and angry and ashamed and afraid — because I’ve taught myself that that’s a great way to cope with life. My brain wants that hit badly when it feels discomfort. This drive has had an enormous impact on my weight I’m absolutely convinced. And without a doubt, as I work through this process of weight loss and life change, other addictive cycles will crop up to replace the old system that has gone. (This is no doubt an influencer in the fact that bariatric surgery patients are over twice as likely to become alcoholics as the general population.) Trading addictions is easy — dealing with the underlying disturbances is much harder. And without a doubt, some addictions are more costly to one’s physical body, relationships, and life than others.

A recent article on Medscape actually attempts to outline obesity specifically as a ‘brain disease’. The authors write, “If it were only caloric intake vs caloric expenditure, then the tapering off and resistance to continue weight trimming by the metabolism would not happen and produce long term failure and hopelessness is so many people. Fighting to recalibrate a set point that is unhealthy but stubbornly resistant leads to other unhealthy behaviors. It is a more complex problem than was originally assumed.”

Another (reviewing a recent book by Tracy Mann) from the NPR sitereinforces some of these underlying judgments — calling ‘willpower’ when it comes to losing weight, a “myth”. The author of this book rather explicitly argues that far more powerful underlying forces are at work to imagine that simple willpower is enough to overcome a body that has had its weight reset at a high weight. She argues that in order to get through it successfully – we have to learn to trick our brains into cooperating with where we want to go.

The question for me is — is bariatric surgery the right kind of trick in my life?

So as far as I understand it — from a limited perspective of a non-medical professional, the AMA took a look at all these dynamics and new discoveries about obesity (and more), and decided that a ‘disease’ label was most appropriate. In a very real sense — the AMA stepped back and seemed to say — “while personal choice is always in play when it comes to weight; it certainly isn’t the only player — and it’s particularly not the only player as a person’s weight increases. Therefore we don’t see this as purely a disorder or personal dysfunction — but rather a disease process that isn’t entirely in the person’s control.”

And that’s the key point for me — and many like me.

I am where I’m at because I made bad choices. And I am where I’m at because I’ve been influenced and impacted by a myriad of influencers that are entirely outside my control. If this is the case (and I believe it is), then a great deal of the negative inertia is removed against me having compassion for myself. I don’t mean – compassion for myself as in, throwing up my hands as a victim and giving up on doing what I can do to better my situation. But rather, the kind of compassion that I have found life-transforming through my faith in Jesus for example. The generosity of spirit that gives one the grace to get up from a hard fall, from a bad outing, from a bad choice — and to try again.

Blogger, Paul Fallon from ‘The Culture Club’ on medium.com – makes the counter argument quite pointedly in his article when he says, “…it is easy to see how an obesity ‘diagnosis’ will simply provide overweight people an excuse for their condition rather than the motivation to control it…..”. For someone who has not struggled with addiction or done much personal work, it’s easy to jump to the judgment that more criticism, more judgment, more blame, more condemnation, more harsh honesty — is the key to recovery. But what those who have gone through the process know in practice is that forgiving themselves is a key to getting through the whole situation.

Will the AMA decision give people an excuse to claim victimhood? It might. Will it have a negative impact on the finances of medicine? Quite possibly. Will people abuse the system or remain obese because of it? It’s not an unreasonable prediction.

But it will also give people like me incredibly important tools to stay on the road to recovery. Grace.

I want to close this missive by referencing a rising movement in American culture known loosely as “Health at any Size” — based on the work by PhD Linda Bacon. Quarreling with the basic medical assumptions that obesity is associated with (and therefore the key cause of) dozens of life-altering or life ending issues [heart disease, diabetes, sleep apnea, high blood pressure, arthritis, etc., etc.] — Bacon argues that obese people actually live longer than thin people and that weight loss doesn’t actually prolong a person’s life. Instead of continuing the war on obesity – Bacon invites people to make peace with their bodies and live a more happy life…as they are.

Now — this is a long post so I don’t want to get into the veracity of her claims here… but it seems that with regards to longevity and weight – her thesis is only true for those who are just a little overweight. It seems that the research points to the fact that those who are morbidly obese (over 40 BMI – which includes me unfortunately) are at a much higher risk of death — actually comparatively like that of a smoker. I’m 130lbs above where I’d need to be to be considered a healthy/non-obese weight according to the (albeit flawed) BMI system. Perhaps for someone who is 30lbs over weight, Bacon’s claims are more reasonable — I can’t imagine they’re true for me or others like me.

All this is preface to say that I think an underlying argument Bacon is getting at — is actually quite wonderful and beautiful. This is that shame and negativity about our bodies isn’t helping anything — that we need to quit the obsessive dieting schemes and crazy attention given to looking better, being better, improving our attractiveness, and increasing our fashion. All of these things aren’t making us happy. We can be happy – no matter what weight we are at. We can and we should. Life would be better if we were (and we probably would achieve a more healthy weight too!!).

In a sense, this is the same conclusion I get from the AMA designation of obesity as a disease: I NEED TO GIVE MYSELF A BREAK!!! I NEED TO HAVE COMPASSION ON MY SITUATION. MY LIFE WILL BE BETTER IF I RELAX A LITTLE. This doesn’t mean that my risk for diabetes and poor circulation and maybe an amputation will magically decrease. It does mean that I can feel better about myself and my life in the mean time before I get down to a weight where I’m not on the door step of some terrible diseases.

My weight loss desires (as I’ve elaborated) aren’t primarily or even tertiarily about my image or assessment of myself; they aren’t about my shame for how I look; — They are driven by my hope to be more active, to feel better physically, to be able to play more and better with my boys.
This will actually make my life happier!