DISEASES WITHOUT CURE

This is a few months old, but I can't always stay on top of the latest from monthly magazines in Australia. An Aussie doctor and writer offers a frank, sensitive, and comprehensive take on increasing rates of obesity and why we shouldn't expect doctors to fix it. It's long, but please read it before venting. By classifying obesity as a disease that implies that there are things doctors can do to cure or treat it. However, the doctors' tools are quite limited:

A recent New England Journal of Medicine article dealing with the rise of chronic lifestyle-driven diseases calls for a change in the way physicians think about their patients. The author suggests that medical students should be taught to be less reductionist, to learn how psychological, social and economic factors all act as determinants of disease. I do not know what medical school is like in the US, but even our surgeons – the most hard-arsed of doctors – sit reeling before the tragic combinations of circumstance and choice that lead our patients to weigh two or three (or four or five) times what they should. The doctors I work with have an excellent grasp of the bio-psycho-social factors that contribute to our patients' states, but we are only doctors. All we have are the tools of our trade: our ears, our voices, our hands, our pills and our scalpels. The waiting rooms are full, the waiting lists are long, the demand is swelling. Obesity is in many ways the logical endpoint of the way we live. Prevention beats palliation, but we'd need psychologists, motivational speakers, social workers, dieticians and physiotherapists to work with us in order to have any hope of tackling the problem. We’d need policy makers and activists. All we have are doctors like me.

In the absence of a holistic, comprehensive approach, we have doctors telling patients what they already know ("You should lose some weight!") and making them feel shittier than they already do. What we run up against, she suggests, is the reality that food has become a singular source of pleasure for a lot of people.

I ask a young 200-kilo patient what he snacks on. "Nothing," he says. I look him in the eye. Nothing? He nods. I ask him about his chronic skin infections, his diabetes. He tears up: "I eat hot chips and fried dim sims and drink three bottles of Coke every afternoon. The truth is I'm addicted to eating. I'm addicted." He punches his thigh….My patient is not addicted; he's a very lonely, unemployed young man who has gradually become socially isolated to the extent that the only thing available to him for comfort and entertainment is food. He has no friends, no money to buy other consumables, little education, no partner, no job. Some days he doesn't leave his bed. The choice for him is to eat this food or experience no pleasure.

And then, the kicker:

This is where the obesity-as-disease concept leads us – to a situation in which people demand that medicine shoulder the responsibility. What about the responsibility of the individual? And of society? My patient cries because the highlight of his day is returning from the supermarket with a plastic bag full of junk that he will eat and drink in his empty lounge room. What can I do for him? I can threaten him with his early demise, intensify his shame. I can offer him some evidence-based motivational lifestyle interventions – swap Coke for Diet Coke! Prescribe exercise? Walk for an hour at an average pace and you'll only burn off the equivalent of one slice of bread. I could take the old-fashioned approach and wire his jaw shut. I have no hope of resolving his loneliness, his hopelessness, his lack of a job. I could, and do, refer him to a psychologist – if he's lucky he may land one who is talented and sensitive and will try to get to the root of why this young man hates his own guts. More likely he'll be offered a few sessions of behavioural therapy that will make everyone except him feel better.

This hit me. I've been here.

I haven't been 200kg (440 lbs), but I've been through periods of my life in which eating was the sole thing I had to look forward to for days at a time. When you move to a new city, live alone, know no one, don't have many options for entertainment, and have some food/eating issues to begin with, it doesn't take very long at all for the pint of ice cream or the bag of Doritos or the candy bar to become the highlight of your day. It's the only thing that offers any pleasure. There's no one offering you a back rub before bed, no post-work happy hour with friends, no parties on the weekend, no frolicking outside on a sunny beach. There's food. There's work, dreary gray skies, frigid winters, and food. And that food is cheap – especially shitty food. If I want to do something I will get actual pleasure from, I can pay $75 for an hour massage or $2.99 for a bag of chips that will take me 45 minutes to eat. I can spend $400 on plane tickets and travel to visit friends somewhere, or I can spend $15 on pig-out food for Friday through Sunday.

That's the problem. That's why doctors can't help patients beyond giving them advice they've already heard, pills/surgery that won't work unless they change their eating habits. As the writer states, every "diet" that works amounts to the exact same thing: eat less, and stop eating so much garbage. We get it. The problem is actually doing it. We expect the doctors to "treat" the problem within an entire system set up to encourage it – a depressed and depressing economy, a trillion dollar fast food/snack/beverage industry and its refined marketing techniques, an agribusiness lobby that dominates the institutions of government, and a decreasing number of ways to connect meaningfully with the people around us.

Shockingly, doctors have yet to discover a pill that fixes all of that.

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61 Responses to “DISEASES WITHOUT CURE”

  1. Lecturer Says:

    There's also the fact that even starting to exercise can be deeply shaming if you're overweight. If you go to a gym, it's going to have a lot of pretty people with no body fat to speak of. So after putting in an hour at the gym, you can come away feeling even more worthless–which means that you actually have a disincentive to get fitter.

  2. John Says:

    I actually HAVE been that far along the road to self-destruction, almost exactly. In February of this year, I checked in at 430 pounds, almost exactly the 200 kilos that this guy did. And I was in a similar place, albeit better off — I have a good job, but very few friends, no social prospects, and the like. For me, it was a combination of food and video games, eating way too much and eating garbage, and playing games instead of getting exercise.

    Ultimately, you have to want it. You personally. A doctor can't help you with that. A psychologist might be able to, but they can only guide you along the path. In the end, YOU have to come to the personal decision that you want things to change. That you want to be different. That it matters to you, personally. And you can't just say it as a nice little platitude, you have to ACTUALLY want it.

    It took me a long time. Well over a decade. But I finally decided that I was tired of robbing myself of all of the good things in life. That there were things I wanted to do that I could not do as long as I was ultra-fat, and the only person holding me back was ME. I had to look in the mirror, look that son-of-a-bitch right in the eye, and tell him that he's not taking one more day from my life.

    I needed help. I enrolled in a weight loss center. They don't give you boxes of specially-formulated food, they don't give you miracle pills that make you crap out all the grease you're eating (they DO sell you some basic protein supplements, but then it's a protein-oriented diet, so that makes sense). They simply give it to you straight: You need to eat less, you need to eat actual good and not a bunch of processed garbage, and you need to get off your ass and exercise.

    It was hard, the first month or so. Exercising was excruciating, and I felt humiliated with how little I could accomplish. I really missed the sodas and the candy bars.

    But you have to WANT it. And by god I WANTED it.

    About four and a half months later, I've lost a little under 100 pounds. I still have about 150 to go, but this is sustainable. It's a lifestyle change. I don't touch processed stuff anymore. Every other day I put down the controller and go on a brisk walk for about two hours on varied, hilly terrain. Every day I can feel myself getting stronger, doing things easier, not getting worn out so easily. Eventually, when I've reached my target of around 180 (still a tad high according to BMI, but we'll see if it looks like I need to go lower — I've got a fairly large bone structure going by the wrist method), I plan to start lifting weights. Not to get all pumped and bulged, but just to build some basic muscle density to help keep in shape and help keep the fat off. I intend to get SCUBA certified. I plan to form new habits and gain new hobbies that will help me meet more people and get incentivized to keep the weight off.

    I'm one of the lucky ones. I was born with a strong sense of self-motivation. I truly believe that we would be better off helping people with that, than trying to treat the weight itself as a disease. Obesity is not a disease of the body, it's a disease of the MIND. We don't need to figure out ways to cut the fat away or flush it out with pills, we don't need to figure out ways to TRICK people into losing weight.

    We need to come up with ways to make them WANT it.

  3. jon Says:

    I'm up to 230 pounds. Was a slim 172 a few years ago after being 190-200 most of my adult life. What changed? Depression. Lots of depression. Not diet problems. Depression.

    Was it situational or chemical? Yes. Is it still there? Yes. Am I happy with my life? Mostly. But I'm still depressed. Can't help it. And when I get into a depressed spell, I don't know I'm depressed until I'm out of it. Can therapy help me see that? Not really. I know what's wrong with my life and how I live it, thank you very much doctors and therapists.

    Learning to fake it isn't easy, but it's the best defense. Life is not easy, but it's a shared struggle.

  4. Lecturer Says:

    John, I'd actually recommend that you start lifting (and flat-out running) even when you're still trying to take off fat. After all, when you build muscle mass, you're naturally burning more calories all the time and lifting gives a boost to your metabolism. It's also a tremendous boost to the self-esteem to look into the mirror and say, "Wait… are those… PECS?"

  5. StoneFoxx Says:

    Being depressed sucks ass. You never really get rid of it, you just manage it and start to recognize when you're on a downslide a little better.

    Volunteering at an animal shelter is free, social, and benefits both the person and the critters. Animals are great therapy. One could even walk the dogs as an excuse to start getting some exercise in. Voila, something to do other than chow down!

  6. Sean Says:

    With few exceptions, being fat is a result of weakness. WEAKNESS. The answer is motivation. I've been there. I once weighed 350 pounds, and found at age 42 in 2006 that I was a type-2 diabetic. My doctor looked me in the eye and said "lose the weight or you might not live out the next decade". I listened, and I lost it all inside of two years and I've kept it off. If I can do it, anybody can.

  7. skyskier Says:

    As everyone says, losing weight is simple, watch what you eat. When you're shopping for groceries, if it's in your basket, you're going to eat it. Don't want to eat ice cream and chips? Don't put it in your basket. Once home if all you have is fruits and vegetables, meats and cereal, that's what you're going to eat. No way can you weight 300 pounds without junk food.

  8. Anubis Bard Says:

    An anthropological note as well. Our bodies have been exquisitely crafted by surviving a million years of surfeit and dearth. A human body is very, very efficient at packing on stored calories in good times, and then hanging on to that storage with every trick and stratagem it can muster. I firmly believe that one of the tickets to good health is listening to your body – but when it comes to weight loss – it unfortunately ain't your ally.

  9. Mo Says:

    Reading this, my mind connected it with The Persistence of Poverty by Charles Karelis.

    Karelis' math seems a bit sketchy, but the underlying premise – that small incremental "savings" have more psychic cost than, and deliver less pain relief, than spend-what-little-you-have-right-now ploys. Scrimp vs Binge.

    There's a threshold – once economic pain has been relieved, the motivation is to never go back to that place, to never be poor again, no matter what.
    Fear of Falling is intense. But reaching that threshold is for many people impossible, so their most rational response is spend-it-while-you-have-it, at least you get a few moments of happiness in an unending landscape of the hopeless grind of poverty.

    Also read Children of Poverty about a century ago, and one scene has a non-poor person wondering why migrant kids spent their money on candy bars instead of healthy food like oranges. Answer: sugar is cheap and delivers a much-needed energy boost. A friend of mine recounted having to scrape for a month until a paycheck arrived, and living on candy bars – "I figured if I could only spend a dollar a day, it might as well be on something I enjoyed."

    Also consider the increasing body of evidence that sugar is, in fact, addicting as nicotine or heroin.

    Then there's the fructose [now re-labeled as "corn sugar"] beloved of our agri industry – the stuff that isn't mediated by insulin, and is processed by our livers along a pathway that converts it directly to stored fat.

    OK, that may seem like a random pile of dots tossed out, but I think John's anecdote speaks directly to addiction and the never-gonna-go-back-there-again mental change that occurs once the threshold has been crossed. And how getting to that threshold can be one damned steep climb, with our economic oligarchs determined to make it as hard as possible.

    Poverty and obesity are social diseases.

    http://www.amazon.com/The-Persistence-Poverty-Economics-Well-Off/dp/0300151365

  10. Matthew Says:

    I look forward to the sensitive, subtle, and nuanced responses to this post.

  11. Hazy Davy Says:

    Well said.

    More to the point, social and psychological factors effect health in many ways other than this.

    And so much of psychology is crap, and most of sociology is, at best, observation, and at worst, anecdotal aspiration.

    The fact is, if you want to help a society with individuals with a variety of ailments, you need to find a way to make people feel differently.
    [And that's why, when I become supreme ruler, I will create a Department of Comedy,]

  12. Paul Says:

    This is actually a pretty straightforward example of the workings of the brain's need-reward system. I think it's very important that our society learn how it functions. This system is hazardous until properly understood.

    I never had a problem with overeating, but I smoked for 22 years. Cigarettes are a classic, maybe THE classic, "reward system drug." They barely deliver any high and they have very mild withdrawal symptoms, but many people find it impossible to quit. It's because their brain is telling them they NEED cigarettes. This is very hard to deal with when you don't know what's going on. What's interesting is that smokers, once they learn about this dynamic, tend to quit without much effort.

    With overeating, as with smoking, we prescribe a course of action that puts the patient in a face to face battle with his need-reward system—WITHOUT TELLING HIM ABOUT IT. He's focused on abstaining from something via willpower & whatnot, and suddenly he's stricken with a deep feeling of desperate panic, something like if his water supply were cut off, and intense deprivation and almost grief, as his major psycho-physical source of comfort and happiness is starved.

    People can't handle this unawares. It seems insurmountable. It also seems like it's going to last forever, which is very far from true. But until we educate people on how to navigate the need-reward system, they'll continue to support their addictions to things that stimulate it.

  13. grumpygradstudent Says:

    You forgot masturbation. Sweet, sweet masturbation.

  14. c u n d gulag Says:

    I once lose over 120 pounds over a 2 year period.
    How did I do that?
    I ate the right things – heavier on the leaner proteins, and fresh(or frozen) fruits and veggies, beans, and whole grains, and nuts. And I had 6 lighter "meals" a day – a decent-sized breakfast, lunch and dinner – and then snacks like whole nuts, and low-fat cheese, and high-protein crackers, or 1/2 slices of whole-grain breads, to keep from getting hungry, and gorging at dinner.

    I could afford to do that back then, because I was working, and making at least half-assed decent money.

    In the last 4 1/2 years, I've been either under, or unemployed, and living with my parents. My father passed away last year, so it's just my mom and me.

    And on her SS Survivor's Benefit's, and the little that I get in "Temporary Assistance (Don't you DARE call it Welfare," I've been told by the state workers), and the whopping $16 we get in SNAP for the two of us every month, we barely make it, from month to month.

    I try to "nutrition-up" the shit that we can afford to buy. I throw frozen spinach and peas, and other veggies, into soups and stews – as well as beans. And try to vary the meals as much as possible, and stay away from really fatty meats.
    Fish is expensive where we live – and even at that, it's all been frozen. Fresh fish being expensive, I can understand, but… Oh well.

    I wish we could both be eating the way I ate, but buying leaner proteins, and fresh produce, and whole grains, is very expensive.

    And so, instead of being daily dietary items, they are, instead, treats that can be "splurged" on, once or twice a month.
    Soon, corn and tomato's will be in season, and we can eat those fresh from our local farm.
    YUM!!!!!!!!!!!!!!!!

    Getting, and staying, thin is possible.
    But you have to afford to get, and stay, that way.

    And that's why most poor people in this country are fat.
    Fatty, grisly meats, are cheaper, and so are canned fruits and vegetables.
    And starches and sugars, are cheaper than anything.

    And our Reich Wingers scream, "Our poor people aren't poor, 't-all! Look at how FAT those MFers are!!! Cut their SNAP benefits!"
    Yes, and make us work to eat – even when there are no jobs.

    If there are still humans alive in 100 years, they'll look at what once was America, and think to themselves, "What kind of fucking idiots were those people, who voted cannibalistic vultures into political office, and helped fucked themselves up 9 ways to Sunday?"

  15. Sarah Says:

    Don't forget food deserts. There are a lot of people living in areas where they cannot get access to (nutritious) food (as in, it is not there for them to buy), and many more living in areas where the (nutritious) food is too costly. Thomas Sowell once wrote (rather smugly, too) that he had a friend from India who wanted to come to the US to see a country where the rich people were thin and the poor people were fat. In India the poor people are thin and unhealthy, and in the US the poor people are fat and unhealthy. In both cases, good health is the purview of the wealthy and the privileged.

  16. Alan C Says:

    It's hard enough to lose weight when you have a social support network and a partner who loves you. Just ask my wife, who's been in the mid-200s (pounds, not kilos!) most of our time together. It must be espeically hard without those things.

    And to John–Awesome! Keep it up! And I agree you should incorporate some weights before you get to your target weight.

  17. Ten Bears Says:

    There are other factors I haven't quite got all of my fingers on, but I see it in my GED, NCRE and adult basic education students as a big self esteem issue. There's more to it, though, as I see it in my better educated yet from that background students as a lack of understanding or perhaps defiance of the consequences of their lifestyle. A hefty young nurse of my aquaint is positively aghast that I (a semi-retired college instructor) would have the temerity to tell her (a highly educated medical professional) that it's not what she eats nor how she eats but both what and how she eats, an unhealthy lifestyle lain down as a child. That she's passing that lifestyle on to my grandchildren is certainly a bone of contention.

    There were no fat First Americans.

  18. Brian M Says:

    There may be other factors at play as well. Such as the soup, no the sea of organic chemicals and plastics that appear…tentatively…to have serious impacts on metabolism and hormonal imbalances. We are slowly poisoning ourselves, and OTHER animals are being observed as getting fatter as well (not just domestic pets, either).

    Throw in the inherent underlying logic of capitalism, and we are surrounded by cheap food and huge portions.

    I was heading to diabetes at one point, And I still have unhealthy food habits. But….one thing I did is transfer addictive behaviors to another thing: long distance cycling (and weight lifting). I've dropped 40-60 pounds, and am by no means lean, let alone "thin". It's a struggle, though, and I have certainly not solved other problems, but it can be done…with difficulty

  19. Brian Says:

    Thank you for that link.

    I will admit, I socialize with people who are primarily middle class white people. As a group, I would say that we are fortunate enough to have the means and access to a lot of outdoor physical activity. I would say that as a group, we are generally more physically fit than your average American.

    However, I have begun to notice this sort of underlying food obsession. I live in a fairly remote place with limited restaurant choices. The lamentations of a subsection of this crowd concerning the lack of quality dining experiences has always bothered me; it seems particularly decadent to expect to have Indian food one night and Mexican the next.

    Though not 'junk' food, this obsession with food and eating as an experience seems like another side to the coin of this western concept of food and requires extreme abundance.

    I doubt very much that the Sudanese people lament not having a good Indian restaurant.

  20. Grendel Says:

    I agree that it's largely psychological, and I've been there (several times, in fact) and I'm on the losing weight side right now… But there's also a physical component that's pretty complex.

    http://dish.andrewsullivan.com/2013/06/24/bound-to-obesity/

  21. Anubis Bard Says:

    I, for one, welcome our new obese overlords.

  22. maurinsky Says:

    This blog has provided me with much food for thought this week!

    I have lost 32 lbs since February – slowly, to be sure, but that's how I gained the weight, too. I have changed my eating habits drastically. No processed foods. No sweets, no snacks, no seconds, Monday-Friday – I give myself the option to have a sweet or a snack on the weekend days. I have severe osteoarthritis and ankylosing spondylitis, so exercise is hard for me, but I walk a minimum of 30 minutes a day now, usually much more on the weekend. I have found physical activities I enjoy – like hiking, which allows me to get out into nature and see beautiful things. Now that summer's here, I will be getting a lot of swimming in, too (best part: I can walk to the town pool from my house).

    I think eating processed food effects your ability to taste things, because they amp up the flavor, and then when you eat real food, you can't taste it in the same vivid way so you don't want to eat it.

    I gained the weight for many reasons, certainly being raised with poor habits was one of them, but also because even when I was married, I was lonely, if I was stressed out about money, I could still enjoy some cheap junk food, and I was in pain because of my osteoarthritis.

    I got divorced, found myself again, and that has made this much easier.

  23. Brian M Says:

    (other) Brian.

    I am certainly 110% guilty of "FOODIEISM"

    So mea culpa, there. I'm also a wine snob. Part of it is this kind of stuff becomes a "hobby" like too many things. I can't really afford this hobby, but I am having serious difficulty cutting myself off.

  24. middle seaman Says:

    Modern life, especially in cities, isolates many. Even a workplace ends for most at 5 pm leaving many a full evening of loneliness. Marriage doesn't always help. Communities are a thing of the past. Lucky people have places of worship that typically form communities. Other communities exist too.

    Our society cannot force the elimination of junk food. The food industry is ruling us. Encouragement to exercise fails. Work for everyone, FOR proposed, cannot happen. Durable decent unemployment benefits cannot happen either.

    As the doc said, obesity is here to stay. Don't despair, global warming will take of all of us.

  25. Elle Says:

    Telling people who are self-medicating unhappiness and/or poor mental health with food to buck up and eat less and exercise more, is as worthwhile as telling people with anorexia to buck up and eat more and exercise less.

  26. Karl Says:

    And here's where we get the pseudo-science about being fat not necessarily being healthy. I don't think it comes from a sincere belief, it's more a desire to not be shit on by the rest of society.

    Fat people (myself included) have to deal with this shit constantly. Complain publicly about the lack of comfortable seating on an airplane and the entire internet drops the hate in the comments section. And James Gandolfini died, so you should lose weight now! (Note there isn't a similar reaction when 90-pound Michael Jackson died.)

    The most frustrating thing is the policing and shaming can all be couched in "Well, we're concerned for your health!" So up springs a (marginalized) advocacy group or two that says "No it doesn't!" What they don't realize is that even if that was the truth, the rest of the world would still judge and shame fat people. And I keep wanting to believe these things too, because it's the only plausible path to a "Fuck you" for all the policing and shaming that goes on in our lives.

  27. Fizziks Says:

    This is only as 'simple' a matter as asking people to rewire their habits. There are a host of behaviors where people behave in a seemingly irrational way, and they are shouted at with a rational framework, and those behaviors do not change overmuch.

    It is almost never the case that people in the grip of that are actually stupid.

    You can't address these issues without engaging people on habits and reward systems, without developing the language and self knowledge of how to observe your thoughts. So, it's lovely to hear from all of you that have lost weight on the mechanics of how it was done. But even those that are sharing their 'tricks' are missing how to connect with those people still so much in the grip.

    You don't have to believe everything that you think. An urge will pass. having the urge is real. What you want to assuage that can often be substituted with something else.

    Treat the urge as something to pay attention to, not willpower through. Your willpower can and will fail you. If you're lucky, it will fail you rarely enough to not change your aggregate behavior, but if you are not lucky willpower is not your answer.

    Practice for a while capturing the thought/urge at it's beginnings, and try to pay attention all the way through surrendering to it and the aftermath. Develop a habit of seeing how the behavior you think you want does not give you what you thought it might beforehand.

    Now that you have that pattern you can recognize it. You may even have a list of predictable triggers. You are now empowered to make some choices. You can try to pare down your exposure to triggers. Depending on what they are an your life, that may not be possible, but try not to reflexively dismiss some life changes, even large ones. You can also try responding to that trigger with a different reward for the same old urge. Some will work, and some won't.

    But you know have two things to try that are independent of each other. You have a way to talk back to yourself in the moment without simply wrestling between two thoughts and letting the stronger one win.

    Your old habit has had lots of time to establish itself. Like a worn riverbed or a well trod calf path. It will take you more than one attempt to redirect it. But it can be done.

    I hope that's helpful to anyone. I feel kinda gross adding this next part, but I feel that this will be seen as a resentful overweight person talking. Not so; but I am someone that's had to implement hard changes, and some of them were dietary and among the hardest changes I ever made.

  28. Figs Says:

    I was most successful at losing weight when I was busiest. Full time job, 7-4:30, part time job 5-9, get home, eat a quick healthy meal I prepared on the weekend, exercise for an hour, go to sleep, do it again. There was just no room for error because it was all scheduled out. When I have a lot of time to play with, it's very easy for a little bit of leisure time to become hours and hours of leisure time. That is, I'll sit down at my computer meaning to spend a half hour doing something, and then three hours later I've blown through the time I was going to use for exercise, and I'm getting to sleep later than I'd intended, etc.

    When I really was able to pack my time and be healthy, I lost 50 pounds over the course of about 5-6 months (from a baseline of about 275). I've since gained it almost all back, and my circumstances have changed enormously to the point where I've got a whole new set of hurdles I've got to deal with. I don't think they're insurmountable, but I think I've got to adapt my strategy, rather than saying "Last time I did this!" and then not doing that.

  29. Figs Says:

    Fizziks, was any of that stuff from the Charles Duhigg book, The Power of Habit? I've got it on audiobook, and I haven't listened to it yet, but I've heard a bit about it, and what you said dovetailed quite a bit with my understanding of what's in it.

  30. Fizziks Says:

    @Figs – not as such, but I'm familiar with that book, mostly because this is a semi hobby of mine.

    I'm much more familiar with Thinking, Fast and Slow. I'd recommend that book to *anyone* that wants to think about thinking.

  31. sinned34 Says:

    Fat people? Who cares? The Hawks won the Stanley Cup!!!

    Bread and circuses!

  32. ladiesbane Says:

    If you are eating your feelings, don't go to a pill doctor; go to a feelings doctor. If you don't, the reason why you're doing it won't change.

    I think it helps to view America's overeating from a substance abuse disorder (SUD) perspective. There are different reasons for overindulgence, different patterns, at different times of your life. Was it the way you were raised? Were you fine until you hit a bad patch (divorce, bereavement, unemployment)? Are you self-medicating, and if so, what caused the pain? Is it the custom of a new work group / peer group / lover to overindulge? Did you just start getting carried away and can't seem to get it back under control? Is it a combination of things?

    (I dislike the disease model in SUD as with obesity, but if you argue that it's a self-inhabiting problem that impairs function, it makes sense. And if it destigmatizes the process, so much the better. Shame doesn't help people change.)

    As in all disorders, proper diagnosis is essential to effective treatment. Some people might get lucky on their own, but more are better off not self-diagnosing out of popular magazines, celebrity websites, or any marketing outlet. Pricey cleanses won't do everything you need them to do.

    And kudos to Elle, as usual.

  33. Sarah Says:

    Thanks for posting. The article is one of the best things I've read recently about obesity AND address a lot of my conflicting thoughts about the broad topics surrounding food, fat, genetics, health, etc.

  34. Brian Says:

    @Brian M:

    I don't think any mea culpa is warranted. I don't mean to say that enjoying good food or cosmopolitan food is in any way something to be sorry about.

    The article just triggered me to think about those things as the other side of the food obsession coin.

    We are all part of this society and are all contributors and products of it.

  35. baxie Says:

    the # of awesome steel willed uber-menchen *completely missing the goddamn point* of this post is breathtaking.

  36. Jestbill Says:

    My own pet theories:
    It becomes much easier to stop an addiction if/when you become convinced it will kill you. Not "someday" but soon. The fact that this is (probably) true does no one any good.

    Back in the "good 'ol days" when people lived in/near caves, we ate the same thing day after day after day. We lacked some nutrients, not by choice but by necessity.
    If some new plant or animal became available, the healthy thing to do was to eat a lot of it. Logically then, a diet that varies day to day and hour by hour will "cause" weight gain.
    The fact that this is (probably) true does no one any good if they have already reached the point where food variety is the one pleasure left.

    We seem to have a lot of problems now in our society whose solutions are "right brain." We can't just say "eat less" or "work harder" or "pay closer attention." The solutions involve somehow understanding the entire picture and working through logic that is not linear and direct.
    Growing up is really hard work.

  37. Green Eagle Says:

    This was a really nice treatment of a subject that (as you can see from the comments) triggers a lot of emotions in people. Thanks.

  38. Weird Old Tip Says:

    Except for Brian M. (obliquely), nobody has mentioned alcohol.
    Remember that beer = bread = food. Wine also = food. Hard
    spirits, maybe not so much. For me, at least, losing weight always
    means cutting down on the drinking. Alas.

  39. just me Says:

    Elle is correct, as per usual, but I wonder which came first? Are people who are unhappy food-medicating themselves into obesity, or are overweight people locked into a self-perpetuating spiral due to the unhappiness caused by their weight? I suspect both are probably true, but in the latter case, it becomes a question not just of dealing with the current epidemic, but also how to break the cycle. Because the children of overweight people are prisoners of their parents unhealthy eating habits and are frequently overweight and very unhappy about it before they even have the ability to understand the causes and the cures. Of course it's true that parents lifestyle choices about countless things have enormous effect on their offspring, but IMO food is probably the major one.

  40. acer Says:

    I've had similar experiences with very heavy alcohol consumption.

    When life is a "downward spiral" anyway, why not crack another one?

  41. Khaled Says:

    My parents took a Mayo Clinic course on weight loss, a free "class" because the results were part of a study. The first thing they learned was that "eating" has nothing to do with hunger. If we just ate because we were hungry, we wouldn't eat the variety of foods or for taste. We eat because of all kinds of issues, hunger being way down on the list of reasons we consume food. They lost a whole bunch of weight, and were able to keep it off, mainly because they track their calories, weight *everything* and are generally no fun to go out to eat with, eat dinner with, or pretty much eat anything with ever.
    I heard on NPR today that according to a new study (no, I don't know who or how or whatever) that something around 25 % of children are in living in poverty- poverty as defined by the federal government, which means that it is mind-numbing, bone-crushing poverty. I wonder how many of them are "obese". I work in a low-income neighborhood, at a drug store. We sell an obnoxious amount of junk food, soda, etc. Why? Because it's cheap. There are no real grocery stores with fresh food nearby, but plenty of fast food (Rally's, McDonalds, Burger King, Church's Chicken, and a local fish and chicken place all on the same corner). There are no Whole Foods or other places for the people of the neighborhood to get a decent, healthy meal, and even if there were decent places, the healthy stuff would rot while the junk food sold. I once had an employee tell me that when he lived in a rough neighborhood, that he always thought that junk food consumption, smoking, etc, was all about instant gratification- that is, if you're unsure about your future, all you care about is the here and now, and so you eat whatever and smoke whatever, because the hard work to stay healthy is just that- hard.
    As someone who has struggled with weight loss for years, I would suppose that everyone who does struggle *knows* that we should eat less, but the ability to put down the soda or sweet tea or whatever is just too hard- the payoff from drinking the soda is instant, and the hard work and sweat is just a pain in the ass. Ironically enough, once I got help for depression, I actually gained weight- fat and happy I guess.

  42. haggis Says:

    I'm 6-3" and have weighed in at about 185 lbs from the age of 18 to 52. I grew up in Canada but have lived the past 20 years in Hong Kong. Hong Kong is a food obsessed place, and I travel a lot to the "foodie mecca's" of France and Italy. I rarely travel to the US but this winter my wife and I did visit and were kind of taken aback by the US restaurant scene.

    What we noticed immediately was that the size of portions ranged from absolutely huge (Las Vegas on the way to Grand Canyon) to very large (Laguna Beach / Mammoth). There seemed to be a real emphasis on quantity rather than quality, and a lot of 'healthy' options like salads contained a lot of rather unhealthy 'embellishments' like big chunks of processed cheese. We usually ended up sharing a salad and a main course and even after a pretty active day of hiking the GC or skiing in Mammoth, we found portions contained way too much for an individual.

    I wouldn't say the US is more or less food oriented than Asia or Europe, but the emphasis is very different in that it seems to celebrate excess to cartoonish proportions: – the biggest sundae, all-you-can-eat buffets, the Heart Attack Grille, etc. One of life's great pleasures around the world is sitting down to a great meal in a fine setting.

    Americans aren't the only people who take great pleasure and solace from their food – Italians & French are more passionate, and I've never met an Asian willing to skip lunch or dinner to pursue business. The difference is getting to understand that when it comes to food "less is more".

  43. Cromartie Says:

    You buck up and do it people crack me up. Do you realize the 36 month recidivism rate for people who lose 80 lbs or more is 85%?

    That's right. More than 8 in 10 of you will fail and gain all of your weight back and then some. You're one Achilles. Injury away from sliding back to where you were.

    Weight management is just that. Management. And most people don't have the first. Clue as to how to manage their food intake. And until they're taught, they'll continue to fail. And all the 'I did it through exercise and you can too' rah rah in the world just adds to the problem.

  44. Death Panel Truck Says:

    Dayum, you people are a real buzzkill, talking about obesity and all while I sit here at the computer drinking a 40 of Olde English HG 800 while munching on Provolone-flavored Cheez-Its. But at least I'm being a foodie. See, they're gourmet provolone, rather than the garden-variety cheddar Cheez-Its. :)

  45. wetcasements Says:

    Ta-Nahesi Coates wrote about this a while back and was (as usual) pretty good. If things aren't going great in your life, the McDonald's Value Menu starts to look pretty good. That concentrated burst of sugar/salt/fat is an easily accessible rush of good feelings in the brain. And as he also mentioned, losing weight is a life-time thing, a habit, not something you just do once and fuggedaboutit.

    For me, gyms are OK but buying a stationary bike and some small weights has done pretty well for me. I like being able to do my workout while blasting my own music, then taking a shower by my lonesome. I have kind of a non-conventional work schedule, so it's nice to be able to exercise on my own time-table.

    "I wouldn't say the US is more or less food oriented than Asia or Europe, but the emphasis is very different in that it seems to celebrate excess to cartoonish proportions"

    After moving to South Korea this was one of the first things I noticed — from a meal in a restaurant to buying a can of soda, everything is just a lot smaller here. A single-serving portion is generally 25 to 50 % smaller than what would be considered a "good" size in America.

    And Koreans do love their food (especially meat) and booze, but they tend to be a lot more physically active as well. If they don't exercise regularly, they definitely tend to walk a lot more and use public transportation.

  46. Death Panel Truck Says:

    Used to be in America the standard for a bottle of soda was seven ounces (six oz. for Coca-Cola.) This didn't change until the late 1950s, when single-serve bottles grew in size from seven to 12 and then to 16 oz. Today people stride out of 7-Eleven with Super Big Gulps the size of 55-gallon drums, and no one seems to notice or care. I blame the stores that sell their products in the sizes they do, as cheaply as they do. People didn't used to buy large sizes when they simply weren't available.

  47. Xynzee Says:

    My experience of depression I describe like this:
    I felt as though I was in an impenetrable bubble. I could see you. I could hear you. However, between you and I, and any reasonable course of action (ie Stonefoxx's suggestion) and I was this barrier. Everything was boxed and compartmentalised.

    I was stuck and could not move.

    Until those outside the "bubble" understand that it's all hollow words. There is a hole in the bubble, the key is finding it. An important thing is to help the person to understand they do have the power to make some kind of choice somewhere in their circumstance. Nelson Mandela would move the chair he was forced to sit in before his beatings would move the chair one inch. It was one inch he did as an act of defiance. That one inch was one expression of will. That one inch was something he did and even though his tormentors didn't realise it, was something they could not take from him.

    To those outside the bubble, the stones of the footpath through the swamp are obvious. Show them the stepping stones.

    My ex during a stint would go to weekly $1 concerts at the Sydney Con. Sometimes you just have to look a bit harder for stuff to do.

    Food unlike other addictions is different. You *have* to eat.

    Haggis is pretty much spot on in his assessment. The American concept of "value for money" is **MORE**!!! Traditionally other cultures concept of "value for money" has been quality. Americans would rather spend $25 on 56oz of something that had been fished out of a port-a-pit + baked potato + roll + slaw and some kind of sugar and fat rich sauce with promise that they get their meal free or a voucher for a free meal.

    Every where else would rather pay the same or more for 150g of the finest cut of meat that has been prepared and presented beautifully. Unfortunately, as with all things American, the worst parts of our culture seem to spread.

    As for this bloke unlike his American peers his situ is no where near as dire as an American peer. I know for a fact that even on unemployment there is professional help for him. Ie he can access a psychiatrist through Medicare (free). You're reading this so it works. Prescription A/Ds can be acquired for >A$30 if necessary. A change to legislation now means a psychologist can be seen.

    More importantly this bloke can take control of some of his situationals. He can go to TAFE (tech college) on a VTEC deal. Most two year TAFE courses will be under $10k in total. If he has to go longer — remedial courses, special assistance (I did my TAFE course w/ a profoundly deaf person who had note takers) — that can be worked out with the institution. TAFE is aimed at the less academically bright but can turn a screw kind of people. In fact what I learned through TAFE in some ways was far better than my Degree. As for VTEC consider it a user friendly form of loan. You don't start to pay it off until **after** you start to earn over a certain amount. Even then the repayment comes out of your tax returns, you still have the option of paying it off earlier if you wish.

    So unemployment in Aus is desperate, but not serious.

  48. Major Kong Says:

    haggis is pretty much spot on. Americans and especially here in the Midwest don't feel like they're getting their money's worth unless their portion will feed a family of 4 anywhere else in the world.

    I'd say the best example of that is The Cheesecake Factory. I will see people standing in line to get into one of these. I ate there exactly once, and my impression was very large quantities of very mediocre food. I didn't even think their cheesecake was all that impressive. I can easily make a better cheesecake than that.

    I'm hardly what you would call "svelte" but when we go to a restaurant I usually end up bringing home most of my food and getting one or sometimes even two extra meals out of it.

  49. Misterben Says:

    Thank you for this terrific post. I think you handled the subject really well and sparked a great conversation here in the comments.

    I have had tremendous difficulty, since adulthood, in keeping the weight off. A big part of my problem is that I have pretty weak will when it comes to self-denial, a strong gluttonous streak, and a powerful aversion to physical discomfort – i.e., "feeling the burn". I've tried lots of diet/exercise combos, and my weak will and laziness undermined me every time.

    I am 35 now, and in better shape than I've been in a decade. I attribute my progress to two ideas that I would recommend to anyone else having the trouble I've had:
    (1) Get some exercise every single day, even if it's nothing more than 10 minutes of stretching.
    (2) ALTERNATION. If I eat a big steak dinner on Monday, then I eat lean and healthy all day Tuesday. If I have dessert on Wednesday, then no dessert on Thursday for me.

    My minimal exercise requirement might seem ridiculous. But it had a powerful effect for me: it started to "detoxify" exercise. That is, after doing wee little bits of stuff every day for a couple weeks, the idea of MORE exercise started to seem more palatable. So I started to do a little more, and a little more, and now (on good days) I'm doing a bunch of calisthenics and going for long hikes in the evening. But because the REQUIREMENT is just "do that little bit", if I'm having a shitty day and feeling really lazy, I can sink right back to "10 minutes of stretching", and it's OK. I haven't failed. It's not an excuse to never work out again.

    But the idea of alternation in my diet has been just huge. In the past, whenever I've tried to diet, I would cut stuff out completely. "No more chips, damn it! No more pizza!" And then, in a week or two, I would crack and eat a bag of Doritos and a large with four toppings. Partly, that was thanks to the utter horror I felt at the idea of never eating pizza again!

    So, now, I know that I can eat meat, or dessert, or pizza, or whatever, if I really want to. It's fine. I just can't eat that kind of thing EVERY DAY. Would I lose more weight if I cut that sort of thing out completely? Yeah, probably. But I've proven to myself that I'm not capable of doing that. Not yet, anyway. And for now, I find it very easy to say "I know I'm going to the bar tomorrow, and I'll want greasy bar food, so today I'll just have a salad for dinner." It's not perfect, but it's a hell of a lot better than eating greasy junk EVERY day.

  50. Fizziks Says:

    @Xynzee – that is a great post, and exactly what I think is missing from most discussions of how to help people manage their weight: acknowledging the "bubble", helping people through the mind-map of changing.

    I also want to second baxie: "the # of awesome steel willed uber-menchen *completely missing the goddamn point* of this post is breathtaking." Truefax.

    There is a growing body of evidence that willpower can 'fatigue' like a muscle, but that it can get a temporary boost in endurance with (wait for it!) sugar. Sweet cheap diabetes powder. If that finding holds up, it goes a bit toward explaining the 'cycle' of trying a willpower-based diet then binging.

    It's somewhat true that thinking you're immediately going to die can prompt change, sure, but just as clearly there are some this *still* does not work for. After all, there are people that do indeed die from this. Why didn't it work on them? Hint: answer is still not that they are stupid, nor that they don't understand the logic of exercise and moderation.

    Instead, often they *do* think they are trying moderation, (i.e. "I went all day with just a salad") often because 1) they kind of are, largely by making changes that are too large/many to be sustainable, hence bringing on an inevitable point of failure and/or 2) it's really hard to visualize the sheer number of good choices you have to make to offset a bad choice and still steer the aggregate in the direction of change. Think of it like high level Tetris: you only have to make a few bad moves to end up losing, but you can compensate for a bad one if you make the next 50 or so right.

    Those two habits of mind are what give rise to the feeling that "I *am* doing it – it just doesn't work for *me* (personal genetics/science-is-wrong/cultural-norms-are-wrong thinking goes here)" or "I can't possibly do it: I've tried and failed too many times, so that is proof" when what was tried is the equivalent of getting off your couch for the first time in a year and running a full marathon. No kidding that didn't work.

    Build and encourage a language for talking about thinking. Start by just observing habits of mind.

  51. Big Sister Says:

    Well, Ed,
    People are obviously concerned with this issue, as the quantity of responses indicates. In reading through other people's posts, I was touched by the discomfort so many posters felt about their weight. I think John expresses this very poignantly. I salute his honesty and his courage. I am sending affirmations into the ether on his behalf.

    I think avoiding processed food really helps a lot, but I'm not about to lecture on this subject.

    I also think killing your television helps a lot, since Tv colonizes one's mind in unhealthy ways,, but I'm not going to lecture about this either.

    Here is something to think about: in the so-called "Golden Age" of America, rich people were fleshy ( think Gibson Girl; think Uncle Moneybags from the Monopoly game). Poor people were skeletal. Nowadays rich people are slim and poor people are fleshy to corpulent. Anthropologists have pointed out that this is no accident. The flashiness of the Gibson Girl symbolized a life of abundance and leisure. The thinness of the average American was evidence of toil and want. Now, when food is ridiculously abundant, the rich go about saying stupid things like " You can never be too thin or too rich," (which is manifestly untrue on both counts). Meanwhile the less well off bemoan their corpulence. The well-heeled can afford to hire personal trainers and practice yoga three hours a day; they can afford to sit down to a lunch of four poached white asparagus stalks and a glass of Dom Perignon champagne. The rest of us grab a bite on our lunch hours and the operant word here is "grab." What this all points to is that "the unattainable" belongs to the rich and powerful. THEIR definition of beautiful is what the rest of us have to accept, because, in general, THEY own the newspapers, the magazines, the television station, the movie studios, where the definition of beauty and success get promulgated.

    It helps to understand that obesity is not simply a question of individual willpower if the individual in question doesn't have the tools to think outside the box. If people understand how heavily the hand of culture weighs on them, they have a shot at making informed choices. In general, though, the choices people make are not under conditions of their own choosing.

  52. Anonymouse Says:

    @gulag: "Getting, and staying, thin is possible. But you have to afford to get, and stay, that way."

    That's very much the truth. I have found the only way to keep "bad" foods out of the house is to buy my meat/eggs/milk/cheese from a farmer and get my produce from a CSA (this year I found one that delivers to my house, which is worth the extra money for me). This keeps the trips to the grocery store for non-meat and non-produce to just once a month. However, this is not a cheap way to go and it's only through some very good fortune that I'm able to do that this year. In previous years this was simply out of my ability to pay for. But when the only food is your house is unprocessed anything you eat must be prepared first so you really have to want to eat it.

    Food is complicated; it makes you feel good, and as others have pointed out, if you can't afford a $15 movie ticket, well, a $2 Big Gulp and a $2 bag of chips can entertain a whole family for an evening in front of the tv. Also, if your job sucks bigtime and you haven't had a raise in 3 years and your idiot co-workers are driving you nuts, if the boss brings in a box of donuts, the momentary pleasure of a big hunk o' sweetness is really, really hard to say no to.

  53. Desargues Says:

    I take it this post was really about the pathologies of everyday life in late-modern capitalism. So why are most comments about how to lose weight quick? If that's what I want, I can turn on night-time TV.

    Ed's real point was that institutions designed to make our lives better have malfunctioned and, when contingently allied with geography, now turn them into nightmares that only compulsive eating can relieve.

    So, the real question was, What has gone so wrong and can we fix it? Not, should I eat less or work out more?

    Jesus.

  54. haggis Says:

    How we approach food is a cultural thing. Just like smoking, drinking, consumer 'ism', etc.

    There is a societal benefit to figuring out how we need to address our less healthy tendencies: Do we outright ban it? Or, regulate it? Or, educate.

    I think in essence, the methods used reduce smoking are a good point of departure in terms of figuring out how to wean people from their current idea of what food represents. I remember ad campaigns in the 70's which reframed the whole image of smoking as a negative. Followed by medical exposes of the detrimental health aspects of smoking and pretty hefty taxes (in Canada anyway). And, I suppose, the final coup was the outright banning of smoking in public places.

    So how do I perceive smoking now? Well, I actually enjoy the odd fag but at the same time I would be absolutely disgusted to live with smoking as it was when I grew up. Back then, it was almost rude to question why you were breathing someones second-hand smoke. The end result is that people who do smoke probably smoke less and they are certainly far more courteous towards non-smokers. I'd call that a win.

    Obviously smoking, as an indulgence, doesn't correlate to food, as a necessity, other than in offering an example of how entrenched habits can be modified.

    Is there a benefit to re-framing peoples perceptions of food with an idea to making them healthier and happier as a society? I think so, but then I'm a raging 'socialist' Canadian. Societies are constantly redefining themselves. Sometimes that redefinition is generated purely from a commercial perspective (iPhones et al) and sometimes it's from a long term 'uncommercial' perspective (government anti-smoking campaigns).

    And quite often, that redefinition works out OK.

  55. Jane Says:

    extraordinary post, Ed.

    I've been there too.

    I can't diet every day, I'm trying the Fast Diet — you eat very little two days a week and whatever you want the other days. It gives health benefits in terms of better blood chemistry as well as weight loss.

    I hope this works long term, because I have twice taken off a lot of weight and twice gained it all back and more.

    Why would anyone gain the weight back? Feeling like a permanent failure for eating a pizza. Not much else fun going on. I'm soo tired I need some energy. Mistaking thirst for hunger. Not understanding how to change habits. Once the weight piles on, self loathing and it can't get any worse, so…

    Lecturer nailed the shame of going to the gym or swimming when fat.

  56. Fizziks Says:

    @Desargues – yesssssssssssssssssssssss! Exactly. I feel anything I've said to talk back to "eat less and excerise more" had only contributed to this being the defact topic, which wasn't what I meant to do. You said it so much better.

  57. Nancy the math teacher Says:

    I don't see the weight as the issue, it's the loneliness and isolation. Recently I read about a community based approach to helping people with disabilities when their parents pass away. Perhaps it isn't only those with disabilities who need this kind of help.

  58. mayya Says:

    To adhere to the belief that all obesity is simply an energy balance equation, i.e., calories in calories out, is to be willfully ignorant and deliberately obtuse. There are no – repeat, NO, exercise/diet weight-loss programs that have a better success rate than a few percent. With any other condition, this would lead researchers to SCRAMBLE to discover what was really going on. Until we lose this ridiculous stigma attached to fatness, we're not going to find out what really causes it, what really "cures" it. I bring your attention to this article:
    http://www.aeonmagazine.com/being-human/david-berreby-obesity-era/

  59. Keith Says:

    Very interesting article, mayya. I note, however, that the low success rate of exercise/diet weight loss programs says nothing about the fact that thermodynamic principles apply to weight gain and weight loss, just as these same principles apply to all other physical and biological systems. At some level, obesity can indeed be reduced to an energy balance equation. The article you linked to discusses some of the complex environmental factors that covary with human metabolism, but changes in gut microflora or how our bodies interact with BPA and other environmental contaminants still cannot negate thermodynamics.

    Food quality (new fats, more sugars, etc) and food quantity have clearly changed over the past four decades (the USDA has many good reports on these trends), and these changes have gone hand in hand with other social changes that promote more sedentary lives. So yes, we should ask what is really going on. And yes, we need to stop the fat shaming. But I don't think denying thermodynamics will get us any closer to understanding the obesity phenomenon.

    As to why diet and exercise so often fail? Well, one obvious reason is that these are radical lifestyle changes that most of us find very difficult to undertake or sustain.

  60. Ahab Says:

    The comments discussion on obesity and poverty has been fascinating. When I've spent time among rural, working-class people, I saw that many of them were either obese or emaciated, with few falling in-between. Weight tended to fall along labor and gender lines. Men who worked at physically demanding jobs tended to be rail thin, while women and men with sedentary jobs tended to be obese. I suspect that many factors created this situation, such as upbringing, rural food deserts, the cheapness of processed food for families with tight budgets, and the live-for-the-moment tendencies of those who have had hard lives.

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