Premise: Obesity is, primarily, a psychiatric disorder.
As a physician who has dedicated 90% of his Internal Medicine practice for the past 15 years to the treatment of obesity, I have come to the conclusion that this disease is, primarily, a psychiatric disease. Certainly there are metabolic and endocrine conditions that can lead to obesity. However, for the vast majority of patients afflicted with this disease, it is clearly a well-defined psychological mind set that leads to the self-perpetuating set of behaviors manifests themselves in the physical state of obesity.
For the sake of argument, let us contrast obesity with the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria for the diagnosis of the polar opposite of obesity, anorexia nervosa. Anorexia Nervosa is diagnosed by the following criteria:
A. Refusal to maintain body weight at or above a minimally normal weight for age and height
B. Intense fear of gaining weight or becoming fat, even though underweight
C. Disturbance in the way in which one's body weight or shape is experienced, under influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
D. In postmenarchal females, amenorrhea (the absences of at least three consecutive menstrual cycles.
Allow me to revise these criteria to fit the typical obese patient in order to make a point:
A. Refusal to maintain body weight at or below a maximally normal weight for age and height (easily defined by the measurement of the Body Mass Index - BMI - which statistically defines a "normal" body weight as 18-25; obesity is defined as a BMI as >30)
B. Intense fear of losing weight or becoming thin, even though overweight. [While this may initially seem paradoxical there really is a significant fear in many obese patients of actually achieving a "normal" weight. It may be due to underlying anxiety of dealing with social acceptance in circles they do not have to deal with when obese.. Specially, it may be due to fear of intimacy from which they feel protected if they remain obese. It may be fear of having to "become someone else" if they go from one physical appearance to another. Also, obese people are clearly discriminated against not just socially but also in the work place. Remaining obese protects the patient from a “fear of success.” There are other examples.]
C. Disturbance in the way in which one's body weight or shape is experienced, under influence of body weight or shape on self-evaluation, or denial of the seriousness of the current high body weight. [Obese people are often in self-denial that they actually have a weight problem. Further, they are in denial that their obesity is actually affecting their health or sense of well-being. You must remember: obese people often function and feel most comfortable within a circle of overweight friends. They develop, as a result, a distorted body image. Also, denial is a strong protective mechanism for the conscious mind. Obese patients learn to shop at clothing stores that carry "plus" sizes. Likewise, they learn to shop alone or with obese friends so that they are not exposed to the anxiety of buying in the larger sizes while friends shop in the "normal" section.]
D. In postmenarchal females, dysmenorrhea (the abnormal frequency or duration of at least three consecutive menstrual cycles. [Obese women often have dysmenorrhea and do not ovulate regularly. This is due to a disturbance in the estrogen-progesterone cycle and the storage of estrogen byproducts in body fat. I cannot begin to count the number of obese patients who have started in my clinic saying that they have been told by their gynecologist that they "can't get pregnant." After even minimal weight loss (10-20% or their excess weight), obese patients begin to ovulate and, in my experience, many become pregnant.]
Article comments
— go to most recent comments1 - Aaman
Excellent post - even if obesity itself is not considered a psychiatric disease, the psychological effects of obesity should be accounted for in treating the same. Pills and diets alone cannot help.
2 - Diet Doc
Aaman writes:
"Pills and diets alone cannot help."
Reply: Yes, they can "help" (just like Prozac "helps" depression; it does not cure it). But I do take your meaning. They are certainly not the solution. If that is all we continue to offer those that are obese, the epidemic will continue. Experience, if nothing else, teaches us that.
Cheers,
Ron
3 - Angela Chen Shui
Thanks, excellent post. Louise Hay's Heal Your Body was all about using the body's map to track the emotional and psychological issues underlying all physical problems. Are you familiar with her work?
Most of the companies whose core business come from addressing obesity are trying to find creative ways to deal with the emotional and psychological aspects to complement the pills and shakes. Hence online support groups etc...
4 - DrPat
Here are a few Amazon ASINs for free: 1592400663 (The Obesity Myth: Why America's Obsession with Weight is Hazardous to Your Health); 1558494294 (Revolting Bodies?: The Struggle to Redefine Fat Identity); 0520225856 (Bodies out of Bounds: Fatness and Transgression).
5 - HW Saxton
Angela, I'm very familiar with Louise &
her books. I often consult the appendix
in "Heal Your Body" when I'm not feeling
right. 99% of the time I can directly
link whatever my physical symptoms are
with whatever is going on in my life in
the present or has happened in the past.
Her books are an excellent guide to help
track down & eliminate illnesses before
they become worse.I never used to put a
lot of stock into Self Help type books.
I would recommend this even to the most
died in the wool skeptics though.
6 - Diet Doc
Angela writes:
"Louise Hay's Heal Your Body was all about using the body's map to track the emotional and psychological issues underlying all physical problems. Are you familiar with her work?"
Reply:
No I am not. But I appreciate the tips and the reading. It should be clear to anyone - everyone - that what we are doing now isn't working. There has to be a better solution.
Cheers,
Ron
7 - Eric Olsen
very interesting and great advice from all on the books - I am suprised no mention of "personality types," ie, oral, etc. From what I have observed most chronically overweight people I know definitely have exhibit compulsive oral behavior: if it isn't food, it's smoking or chewing tobacco, or whatever, often just replacing one with another. Is there a way to mitigate compulsive oral behavior?
8 - DrPat
Your four points of a pututive psychiatric "obesity disorder" (failure to maintain body weight, fear of success, body dysmorphic disorder, dysmenorrhea) really should be reduced to three. I know the thrust was to match the definition of anorexia nervosa, but the last three are suggested as reasons for the first. (The same thing should apply to the anorexia definition.)
Also, if this is primarily a psychiatric disorder, why are all the real solutions so physical?
9 - Eric Olsen
are many psychiatric disorders physically treatable?
10 - dietdoc
DrPat writes:
"Also, if this is primarily a psychiatric disorder, why are all the real solutions so physical?"
Reply: Ah, Pat, there is the rub! Are the "real solutions" physical? Please don't think me trivializing here but, as the warden says in the movie, "You gotta get your mind right, Hud!"
I think we can exercise until we are blue in the face and follow the [insert your favorite here] for months and lose all the weight we want but 95% of the time, over the next few months and years, weight regain will occur. Until we change our psycholgical view and understand why we follow the lifestyle that causes our weight problems will we ever make progress toward long term maintenance.
When I was an intern, I was 69" tall and weighed 250 pounds. I over ate easily accessible foods and underexercised. I wore a really flattering (wink) XXL white coat. Then, about 5 years ago, I woke up one day and said, "This is nuts!"
Today I am still 69" and 200 lbs with a 32 inch waist (down from a high of 40"). I lift weights 5 days a week and eat a "sensible" diet (really whatever I want, just portion control).
It's that mentally I decided to change my life and my first step was to change my outlook on life.
I got my mind right.
Just anectdotal, but I am convinced of the mind over matter aspect of weight control.
Cheers,
Ron
11 - Paul
I am genuinely curious about the shopping angle of this. Men have had big and tall shops for years, and I don't think I have ever read anything in that time suggesting that men are in "denial" when they shop there.
Yet now that there are a handful - mind you, a handful! - more stores catering to fat women, it's promoted to something more. Does your comment on this include fat men, or is it just fat women?
12 - dietdoc
Paul writes:
"Does your comment on this include fat men, or is it just fat women?"
Reply: It's an interesting social situation for obese women vs. obese men. There is definitely a social and cultural divide between the two. It's probably media-driven, as are most things.
Unfortunately, at the least from a health perspective, obese women have a more negative social stigma attached to them than men do. Corpulent (how's that for a PC descriptor?) males do not draw the social negativity of women of equal body mass index (BMI).
I am sure it is some deeply rooted, culturally-drive group psychology but it exists, nevertheless.
As a side note, it's interesting to see just how schizophrenic societies are about weight and obesity. According to accounts I have read, by our current definitions of "overweight" (a BMI > 27) and "obese" (BMI > 30), Marilyn Monroe would be categorized as overweight today. Overweight people were once taken, by appearance alone, as being successful and of higher societal status that "skinny" people. It's a remarkably interesting history.
I am not sure I answered your question, but there it is.
Cheers,
Ron
13 - Eric Olsen
the entire nation should fast for a month and get up and move the hell around - I am appalled by the spread of the spread, and no less so for men than for women
14 - Shark
Small quibble/correction:
"You gotta get your mind right, Hud!"
It was "LUKE" -- from the greatest film ever made, "Cool Hand Luke"
Carry on.
PS: Are 50 hard-boiled eggs in one meal cosidered to be...
never mind...
15 - Eric Olsen
unchecked appetite of any kind is an ugly, destructive thing
16 - dietdoc
Shark writes:
"You gotta get your mind right, Hud!"
It was "LUKE" -- from the greatest film ever made, "Cool Hand Luke"
Reply: I definitely should have known that - "Hud" and "Cool Hand Luke" are two of the true classics. Thanks for reminding me of the difference.
Eric Olsen writes:
"unchecked appetite of any kind is an ugly, destructive thing"
Reply: Profundity at its best.
Cheers,
Ron
17 - Eric Olsen
thanks Ron!
18 - M
You're a little behind the curve on proposing a counterpart to anorexia. Binge-Eating Disorder is heading towards the DSM, I hear, and meanwhile, is diagnosed as ED-NOS (Eating Disorder-Not Otherwise Specified). I know this because I spent several months in intensive treatment for this disorder (treatment for all eating disorders is essentially the same"it's not much different, psychologically speaking, to binge than it is to binge and then purge, for example). But not every fat person's got an eating disorder. Just as many thin women have unhealthy relationships with food and their bodies, but couldn't really be classified as having eating disorders"their food symptoms don't tie directly to other identity factors, perhaps, or maybe it's just a matter of simple functionality"many fat people have similarly unhealthy relationships with food and body but couldn't be diagnosed as eating-disordered. The phrase the shrinks use for "not quite eating disordered" is "displaying disordered eating." But we, as a culture, display disordered eating"whether thin or fat. I'd argue that that's why there are so many fat people. Our eating habits are polarizing toward extremes.
By the way, speaking if things that won't help: large-scale (pun intended) generalizations about fat people, like the one about plus-size shopping. I've always been the only fat girl in my social circle, and when my smaller friends discovered Torrid, they got me there in a hurry"and definitely not alone. We'd love to all shop together, but there just aren't that many stores in which that's possible (the cool kids don't do department stores).
19 - dietdoc
E writes:
"You're a little behind the curve on proposing a counterpart to anorexia"
Reply: That is where I usually fall! Sadly, that appears to be where I am most comfortable. I also appreciate the insights into some of the psychology of female "group-shop." I absolutely was speaking from a observational perspective on that. Your comments were most appreciated.
Cheers,
Ron
20 - dietdoc
Correction: Actually "M" wrote the reply I was addressing.
I thought she was James Bond's boss?
Never mind.
21 - Bill Sherman
Sorry, I don’t accept it.
dietdoc’s description of the “typical obese patient” is so totally weighted to support a stereotypical image of the self-deluding fat person that it flies in the face of observable reality. Perhaps the “fat patients” he sees present some serious psychiatric dysfunction (for something to be diagnosable in the DSM, the patient needs to be experiencing serious distress, after all), but I’d wager that this isn’t the case for many fat adults. The “obesity as a shield” or “fear of success” line is one that’s been used for decades, and it’s been regularly challenged by advocates for size acceptance. Too, this vast population of fat adults that you describe in denial about their size is surpassed by an even larger fat population that knows " and is reminded daily " that it is fat. To assume that all fat adults (or kids, for that matter) are all suffering from the same disconnect between their self-perception and the actual body size is like assuming every skinny girl has an anorexic mind set.
For an alternate look at this topic, check out Paul Campos’ current The Obesity Myth: Why America’s Obsession with Weight Is Hazardous to Your Health, which critically deconstructs many of the recent studies on our so-called Obesity Crisis.
22 - mercurior
dont you realise that so called fat people, all have to shop at the same place, not because they want to but because they have too, its like saying all people who shop at a sports shop have to be sick in the mind because they shop there. or have an unhealthy thought that they have to be muscular . if other shops had clothes to fit dont you think we would go there to buy stuff.
23 - dietdoc
Bill Sherman writes:
"To assume that all fat adults (or kids, for that matter) are all suffering from the same disconnect between their self-perception and the actual body size is like assuming every skinny girl has an anorexic mind set."
Reply: Bill, I see your points which you make very clearly. Thank you for your remarks and the reference. I do not assume "all fat adults" are anything. I am presenting a hypothesis that hypothesizes that obesity, as a disease (and to dismiss it as not is clearly flying in the face of clear health statistics) may have certain psychological characteristics in common among some of the patients.
I certainly see enough obese patients, medically, that I am able to present at least a working hypothesis. Now, the point I am making is not that all obese patients are "nuts" - they aren't. But, a large proportion of obese patients do share some of the characteristics of the anorectic patient in their approach to food, body image, and societal perception/alienation.
I am very clear on the position of "fat acceptance" and support many of the tenets. But, while discrimination against obese patient is very real, so are the medical consequences. The book you mentioned, while I have not read it, I hope is not one of the increasingly popular "it's OK to be fat and you shouldn't worry about doing anything about it."
From a societal point of view, yes, it is incumbant on society to avoid discrimination against obese people. I totally agree and it is a serious problem. It is shown that obese patients make less money and are promoted less frequently than normal weight counterparts.
But I am concerned about putting across the idea that obesity is OK from a health perspective. It is, clearly, not OK to be obese from a health perspective. Should society be concerned about the health of the obese patient? Absolutely! Should we make efforts, as health care professionals, to treat obesity, yes! Does obesity, like smoking, predict a higher morbidity and mortality? Yes again.
Those are the only points I am trying to make.
Thanks again for your well though commentary. I appreciate it.
Cheers,
Ron
24 - Akani
Is someone's weight really THAT important in the grand scheme of things? Jesus christ, get your priorities straight.
25 - dietdoc
Akani writes:
"Is someone's weight really THAT important in the grand scheme of things? Jesus christ, get your priorities straight"
Reply: I am not at all sure what your "grand scheme of things" is, so I cannot comment.