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Obesity as a psychiatric Disease

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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.]

Clearly, obesity is also associated with higher incidence of more defined psychiatric diagnoses including depression, chronic anxiety, social panic disorder, etc. But it is the “obese mind set” that leads to self-perpetuating behaviors – sedentary lifestyle, overeating, social isolation, fatigue and feelings of being “out of control.”

So, if we are going to establish a psychiatric diagnosis category for achieving an abnormally low weight, I think it would only make sense that the DSM include the psychiatric diagnosis of obesity (an abnormally high weight). It is high time that the medical as a whole and the psychiatric profession, in particular, join in the battle against this devastating disease process.

Editorially, perhaps if obesity were given a psychiatric diagnosis, the patient afflicted by this ailment could get medical insurance coverage. It is a never ending source of bewilderment to me, as a physician, to see insurance companies refuse coverage for the treatment of obesity. I am reimbursed by insurance carriers for treatment of an obese patient’s hypertension, degenerative arthritis, high cholesterol and triglycerides, depression, fatigue, chronic back pain, and diabetes. But, if I code “obesity” on the insurance form, it universally gets returned as an “uncovered diagnosis,” even though obesity is the underlying cause of the other “covered” diseases. The hypocrisy of the insurance industry is another source of discrimination that must be overcome before the obesity epidemic can ever be effectively addressed.

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  • http://selfaudit.blogspot.com 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.

  • http://dietdoc.blogspot.com 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

  • http://www.angel-and-soulmate-selfhelp.com/blog.html 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…

  • http://paperfrigate.blogspot.com 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).

  • 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.

  • http://dietdoc.blogspot.com 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

  • 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?

  • http://paperfrigate.blogspot.com 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?

  • Eric Olsen

    are many psychiatric disorders physically treatable?

  • 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

  • http://www.bigfatblog.com/ 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?

  • 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

  • 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

  • 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…

  • Eric Olsen

    unchecked appetite of any kind is an ugly, destructive thing

  • 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

  • Eric Olsen

    thanks Ron!

  • 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).

  • 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

  • dietdoc

    Correction: Actually “M” wrote the reply I was addressing.

    I thought she was James Bond’s boss?

    Never mind.

  • http://oakhaus.blogspot.com 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.

  • http://mercurior.blogspot.com 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.

  • 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

  • Akani

    Is someone’s weight really THAT important in the grand scheme of things? Jesus christ, get your priorities straight.

  • 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.

  • Eric Olsen

    super job on #23 Ron, and I support all of your statements there. As with other societal “anomalies” (this one is fast becoming the norm), we have to walk a line between fighting discrimination and, due to the health implications, not give the societal stamp of approval either

  • dietdoc

    Eric:

    Except for my “a hypothesis that hypothesizes that” (shudder), I accept your kind comment.

    As for your “we have to walk a line between fighting discrimination and, due to the health implications, not give the societal stamp of approval either” I completely agree. We cannot just say – from either side of the argument – that there is no problem. There clearly is. Do we, as a society, need to “accept” obesity and not socially stigmatize or discriminate against these people? Certainly! Do we, in the health profession, need to do a better job identifying and treating (better still, preventing) obesity? Absolutely.

    With smoking, we discriminated against it aggressively (in the name of protecting non-smokers) and made a dent, at least, in its prevalence. I think the answer to the health problem of obesity is more of understanding and education.

    I could go into the psychology of the “feeder” mentality (where members of a person’s social/professional circle actively torpedo the obese person’s attempts at losing weight), but it would take up too much space.

    Cheers,
    Ron

  • Eric Olsen

    in addition to society in general having to steer a difficult middle course, individuals do as well: not discriminating or mistreating but not enabling either

  • j9

    I believe this doc has his heart in the right place. I would ask the good doctor, what is your definition of obesity, and at what point does it become linked to a phsychological disorder? The BMI is very flawed – many people who are simply athletic yet not”fat” quality for “obese” under that measurement.

    I have many friend who are “obese” under that BMI standard, yet do not show the psychological symptoms that this doctor describes. However, I know a couple who are very obese and I have to admit they do exhibit some of these traits.
    Perhaps there is an “obesity point” at which folks above are likely to have these traits, and below which folks are relatively free from them.

    There is a huge lifestyle and societal change that happens at some point along the obesity scale. The individual goes from being “just a fat person” to someone to be ridiculed, stared at, and looked upon with disdain. By everyone – children, adults, physicians. Wife-beaters and rapists are not as despised. Even the fat acceptance movement that was mentioned here does not advocate for these folks. They have nobody. It is no wonder that people living within this obesity range exhibit psychological problems.

    I would like to add, by the way, that obesity is not the “cause” for hypertension, degenerative arthritis, high cholesterol and triglycerides, depression, fatigue, chronic back pain, and diabetes. If it were, there could be no thin people with these same problems. Obesity may be a contributing factor, but it’s not the cause. Therefore, I have to support the insurance companies for denying a generic “obesity” code.

  • Eric Olsen

    it should also be mentioned that a certain amount of our tendency to be overweight stems from genetic predispositions lingering from the not-so-distant past when daily sustenance was the number 1 concern of the species and it was much more dangerous to be underweight than to be overweight, which was an unusual luxury

  • dietdoc

    j9 writes:

    “I would ask the good doctor, what is your definition of obesity, and at what point does it become linked to a phsychological disorder? The BMI is very flawed – many people who are simply athletic yet not”fat” quality for “obese” under that measurement.”

    Reply: Thank you for the very well-informed and thoughtful comments. Body Mass Index (BMI) is certainly not perfect. Underwater weighing or, minimally, impedence plethesmography, are more universally needed to quantify “body fat” – the truer defining characteristic of obesity.

    The “average” body fat for the American adult female is, statistically, 16-25%, men, 10-15%. Of course, the only way to measure actual body fat is not from calculations based on weight and height. It requires additional but, unfortunately, more expensive testing.

    We should, I think, concentrate medical efforts toward those with abdominal obesity as opposed to lower body obesity. At the risk of people acusing me of insensitivity, it is commonly referred to as the “apple” or the “pear” distribution of body fat. Apples are at much more server risk for comorbidities you mentioned.

    You also wrote:

    “I would like to add, by the way, that obesity is not the “cause” for hypertension, degenerative arthritis, high cholesterol and triglycerides, depression, fatigue, chronic back pain, and diabetes. If it were, there could be no thin people with these same problems”

    I should like to say that obesity is not the only cause for these conditions. In some people, obesity, indeed, is the cause. If the obesity is ameliorated, the comorbid condition (be it hypertension, hyperlipidemia, etc.) can “be cured.” So, I disagree with you here.

    Thanks, again, for the well thought out remarks

    Cheers,

    Ron

  • dietdoc

    Eric writes:

    “it should also be mentioned that a certain amount of our tendency to be overweight stems from genetic predispositions lingering from the not-so-distant past when daily sustenance was the number 1 concern of the species..”

    Reply: Eric, you are absolutely correct and the importance of a genetic propensity for obesity is so very important. If both your parents are overweight, you have an 80% chance of being overweight as an adult. We will avoid the argument of nature vs. nurture.

    Clearly, genetic selection leans toward the most metabolic efficient genes to store energy in times of famine. Unfortunately, we don’t have much famine in this country anymore. Thus, the problem, from a genetic point of view.

    Thanks for the important point.

  • http://oakhaus.blogspot.com Bill Sherman

    “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.'”

    The basic gist of Campos’ book is that the focus on size and weight – as opposed to healthy eating habits and exercise – has led to dubious research and bad practice. He does challenge many of the “very clear health statistics” you mention, which as a layman I’m not really capable of responding to either way. I do suspect that a good many studies are tainted by presumptive biases, however, and also wonder how many health problems have been created by the act of yoyo dieting than by maintaining a stable weight. . .

  • Eric Olsen

    I agree with all that Bill: good habits are more important than anything else because they will inevitably yield positive results over time, which is what really counts. I’d rather eat well, get plenty of exercise and be a few pounds overweight than starve myself, be sedentary and the “ideal” weight.

  • dietdoc

    Bill writes:

    “…and also wonder how many health problems have been created by the act of yoyo dieting than by maintaining a stable weight.”

    Reply: Don’t bail out now, Bill! You made some wonderful arguments previously which were very meaningful and congent. Now, you start arguing about effects of “yo-yo dieting!” A completely different problem and a significant one, certainly.

    Just pulling your chain, Bill.

    I understand what you are saying. It reminds me of the recent BC blog about “Don’t think of an elephant.” And, you can’t not think of one. We put such a social emphasis on weight and appearance that it can be overwhelming to individuals faced with this lifelong (and it is that!) battle.

    A lifelong emphasis on healthy eating and vigorous, regular exercise – not worrying about what you “look like” in the eyes of others – will trump genetics everytime. I stand by that remark. It is clear, though, that some have to battle harder than others. But the battle – found sensibly and rigorously – will always lead to better health.

    Cheers,

    Ron

  • Duddits Cavell, M.D.

    “The BMI is very flawed – many people who are simply athletic yet not”fat” quality for “obese” under that measurement.”

    Many athletic people have high BMI’s, but ask yourself how many people with high BMI’s actually got that way on account of being athletic or genetically prone to muscle weight gain. Similarly, many basketball players are over 6′ 6″, but how many 6′ 6″ men in America are in the NBA?

    It’s easy to attack an anthropomorphic tool such as the BMI by looking only at outliers, but given the strong correlation between BMI and body fat on a population level this is underhanded and frivolous. If my son studies two hours a week and gets straight A’s at school, does this mean that studying is overrated or that my son happens to be intellectually gifted?

    “I would like to add, by the way, that obesity is not the “cause” for hypertension, degenerative arthritis, high cholesterol and triglycerides, depression, fatigue, chronic back pain, and diabetes. If it were, there could be no thin people with these same problems. Obesity may be a contributing factor, but it’s not the cause.”

    If obese people shed the symptoms of these disorders when they shed pounds, what difference does it make — except, perhaps, at the semantic level?

    “…it should also be mentioned that a certain amount of our tendency to be overweight stems from genetic predispositions lingering from the not-so-distant past when daily sustenance was the number 1 concern of the species…”

    If people can permanently lose weight by exercising more and cutting back on calories (and they can; the “yo-yo dieting” and “set-point” factors relate not to biology but to behavior, as people who have lost weight by altering their habits slip back into old, familiar ones) this is irrelevant — nothing more than an excuse. Fat people love to think they’re fighting their bodies by trying to lose weight because it absolves them of the responsibility for endeavoring to do something they find difficult.

    Paul Campos has a history of writing books intended solely to inflame (viz. “Jurismania”) and “The Obesity Myth” involves a massive, though cleverly couched, misrepresentation of the same statistics and data he claims were erroneously produced in the first place. He conflates real issues of discrimination and media attitudes toward weight with errancy and scheming on the part of doctors and the government. He is an apologist and a charlatan and is not taken any more seriously than he should be by anyone in the public-health sphere.
    As much as I agree that it would be great to see drug companies tabling the production of medications that are inevitably dangerous, they have a large market and always will until America’s fat people wake up and realize that fat is dangerous and that they in fact can do something about it without pharmacologic intervention if they care to.

  • dietdoc

    Duddits writes:

    “and they can; the ‘yo-yo dieting’ and ‘set-point’ factors relate not to biology but to behavior…”

    Reply: “Yo-Yo” dieting is, I agree, behavioral. It is also extremely detrimental to both short- and long-term health. Associated loss of muscle mass when yo-yo dieting is self-perpetuating cycle, as you well know, Doc.

    As for the “set point” I am not so convinced about it being purely behavioral. I have seen patients come in and lose 50-60 lbs and, then, fall off the wagon and gain everything back again. They will return, sometimes 5 years later. Guess what they weigh now? Exactly what they started at 5 years earlier, before they lost weight. It recurs too often to be chance. It’s weirdly frequent to be simply behavioral. IMHO.

    Thanks for the commentary on the author previously mentioned in this thread. It gives me newer insights.

    Cheers,

    Ron

  • http://oakhaus.blogspot.com Bill Sherman

    Whatever your thoughts of Campos as a writer (or “apologist”), the fact remains that some of his points are being discussed in some serious quarters – like here. I’d love to read a serious refutation of Campos’ work (as opposed to one that relies on merely calling him “inflamatory”), but though I’ve looked for one, to date, I haven’t read it. (Have read quite a few on-line essays that indulge in a lot of name-calling, though.) Doesn’t mean that one hasn’t or won’t be written, of course, just that an hour of serious Google-izing on my part hasn’t yielded anything. . .

  • Eric Olsen

    is our visitor Dr. Cavell an expert in the field?

  • http://oakhaus.blogspot.com Bill Sherman

    I thought he was a character in Dreamcatcher.

  • http://members.aol.com/pani113/myhomepage/rant.html S Sanders, MA

    What an absolutely uninformed opinion. Sad that some people still believe the anachronistic myth that fat people have psychological problems. In fact researchers have been trying for years to find a “fat personality” to no avail. There are few significant difference between fat vs. thin when it comes to psychological traits. Except that traditionally, fat people had a lower rate of suicide.(There was some truth to the old saying fat and happy!) Recent studies have contradicted this, probably because some antipsychotic drugs cause weight gain so this may bias any sample. And the pharmaceuticals are quick to pin any problem on obesity to increase their market for weight loss drugs.

    Of course fat people are stigmatized in this country, which may account for some perceived differences. Studies have shown fat people can develop the same survival traits as other opressed groups. Take the simplistic observation that fat people have fat friends. In his classic book The Nature of Prejudice, Allport found that “in-group” ties are often strengthened among groups who face hostility from the larger society. It is obvious why, no explanation required.

    And of course, fat people are not necessarily unhealthy, in societies where there is no stigma, they have far fewer health problems than western society. I am finding people up to 300lbs who lived long and healthy lives.

    Societies themselves get sick however, and lipophobia (fat)phobia is a serious illness in this country. We have taken a wonderful, beautiful, resilient, oh-so-necessary for survival body style and villianized it instead of addressing the real issues that plague us. The more insecure the individual personality, the more they are vulnerable to buying into societal prejudices and myths. Don’t look back in retrospect and ask howa culture could burn witches or persecute non existent communists. Those are the same people reacting to their social upheavals as you are reacting to yours!

  • http://paperfrigate.blogspot.com DrPat

    I think the fact that dietdoc was willing to include works on the other side of the argument in the ASIN list says more about the informed nature of this opinion than the fact that it diagrees with yours, Sanders MA.

    This is a very complex topic, and your contention that the stigma attached to fat is more of a problem to an obese person’s health than the fat itself really argues more, not less, to dietdoc’s contention.

    For all, please note: obesity and overweight are two different conditions. Obesity is a level of excess weight specifically coupled with health problems, from mild to moribund, not simply whatever current fashion says is too large. So Marilyn Monroe might have been characterized as plump by today’s standards, but she was not obese.

  • dietdoc

    S Sanders writes:

    “Take the simplistic observation that fat people have fat friends. In his classic book The Nature of Prejudice, Allport found that “in-group” ties are often strengthened among groups who face hostility from the larger society. It is obvious why, no explanation required.”

    Reply: I appreciate the passion and vigor of your comments, sir. Thank you.

    But, enlighten me, please. Are you refuting that obese people tend to socialize in circles which also include obese friends? I am not sure you are arguing against the “simplistic observation” that I made. Am I missing something in your comments?

    S Sanders writes:

    “And of course, fat people are not necessarily unhealthy, in societies where there is no stigma..”

    Here I am afraid I totally disagree with you. Certainly, some subgroups of obese people do very well, health wise. But I cannot explain it as being due to a lack of stigma. The majority of obese patients, regardless of the society they live in, have health problems related to being obese. I do not think our “lipophobic” (good word, BTW) society actually cause our country’s obese patient to be less healthy than those in societies where there is less lipophobia. I don’t accept that.

    Across all societies, obesity has added health risks. Certainly, some of the behaviors and social acceptance vary across cultures, but I cannot accept the argument that, when obesity is accepted in a society, those obese patients have no health risks.

    Thanks for the comments. They were very interesting.

    Ron

    Certainly, it is a defense mechanism! Absolutely.

  • Eric Olsen

    change “fat people” in S Sanders’s argument to “alcoholics” and see what it looks like

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    Wow!!! I should have gotten back to this thread sooner!!!

    HW, comment # 5: Hi, great to meet you. I use it all the time too… just yesterday I re-checked ‘ankles’ and it’s dead on, even if I didn’t get it immediately!

    Eric: The 4th edition that I’m currently using doesn’t have anything re compulsive oral behaviour. I have to get another copy of the book.. I’ve lost the section after p. 60, so I couldn’t look up smoking to help infer from that. HW, can you help?

    Ron’s: 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.”

    I completely agree… in my experience of helping people lose weight.. was involved in the leading network marketing weight loss company for a bit over a year and a half, the only persons who really lost weight and KEPT it off were the ones who were ready to deal with the ‘WHY did I need this weight ‘protection’ on me?’ question.

    and “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 anecdotal, but I am convinced of the mind over matter aspect of weight control.”

    Exactly and good job! But don’t leave out the power of the emotions and the need to release the emotional charge of the issues that sourced the mental attitude and subsequent physical shielding.

    and “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.”

    Yes, this societal ‘status’ attitude still applies to men… often thought to denote ‘prosperity’!! ;-) Thanks for that gender bias point, Paul and for your point about acceptance without discriminating or enabling, Eric.

    Sorry.. didn’t get to read much further… Great thread!

  • dietdoc

    Angela writes:

    “I completely agree… in my experience of helping people lose weight.. was involved in the leading network marketing weight loss company for a bit over a year and a half, the only persons who really lost weight and KEPT it off were the ones who were ready to deal with the ‘WHY did I need this weight ‘protection’ on me?’ question.”

    Reply: Great to see you back, Angela.

    Not directly responding to you but, as for this thread, it apparently tweaked quite a few noses over at BigFatBlog.com. This, at first blush, appears to be a “fat acceptance” BLOG and those people were made privy to my initial BLOG by an editorial on their website.

    WOW! While I understand where these nice people are coming from, I must say, they certainly did take exception to my premise. I only wish they had replied here directly (I do suspect some did) so I could have gotten into the discussion. After reading the thread there, I see that they have some very strong opinions on the validity of the hypothesis put forth here (and also questions about my manhood, parentage, etc.)(wink)

    Glad to have your comments again, Angela.

  • phila

    Just going to bat for Marilyn Monroe here (since she’s not around to check out blogs and all of the rumors about her weight). She was not plump, fat, overweight or obese. What we know about her is this:

    Height: 5 feet, 5½ inches
    Weight: 118-140 pounds
    Bust: 35-37 inches
    Waist: 22-23 inches
    Hips: 35-36 inches
    Bra size: 36D

    At her heaviest, her BMI would have been about 23 (give or take). This works out to about a size 12 depending on the designer. And contrary to popular American belief, a size 12 is NOT the end of the world.

  • S Sanders, MA

    Although one important if untended function of this book is to show how psychiatry serves to reinforce cultural dysfunctions. I can’t help but make a comparison with Freud and his “penis envy.” The good Dr. claimed that women felt inherently inferior to men. Of course women of his time might have been envious given they didn’t have the right to vote, educate themselves, work at many jobs and were totally lacking in power. It wasn’t anatomy they were envious of, but male’s privileged position in society. Ironic how so many of us who can look back at the ludicrousness of Freud’s logic are so myopic to the fact that most of the problems associated with fat are purely the result of social stigma. Once again, the psychiatric position is used as a tool of social control rather than true healing. I am glad I am a sociologist!

  • dietdoc

    S Sanders writes:

    “Although one important if untended function of this book is to show how psychiatry serves to reinforce…”

    Reply: My comments have nothing to do with this book. I noticed several comments on BigFatBlog.com implying this is a “book review.” Nothing of the sort. The comments I made were mine alone and the book reference was tacked on by the editors of this site after the fact.

    Just to clear that up.

    Ron

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    DietDoc’s “(and also questions about my manhood, parentage, etc.)(wink)” oh, dear! ;-)

    Well let’s throw it out.. is there anyone from the bigfatblog.com site who has visited and read this post and thread that would like to share comments here?

    # 48 commentator.. sorry, can’t make out yr nick… thanks for defending Marilyn… I’m Piscean and she was on hell of a sexy Pisces girl, ;-)

    S. Sanders: thank you, thank you for your comments re the real power issues that women faced … ‘penis envy’ my foot! The still current lack of female orgasm for many women is linked, I feel, to power issues which we women still haven’t dealt with across the board…

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    sorry.. just thought of this…

    would be interesting to do a poll of heterosexual women who feel they are fat to see how many of them do not climax during sex…

    many women feel climaxing with a man in bed who they have power issues with in other areas of their relationship is just giving away more of their power to the man… so they don’t climax, although to ‘get it over with’ they may pretend to…

    sounds like a poll to add to my site…!!! ;-)

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    this doesn’t negate the reality that enough may not be going on in bed to entice her over the edge… :-)

    i know, i know… we’re all responsible for our own pleasure… but why the hell be in bed w/ someone if u have to deal w/ business b4, during or after, yourself, w/out much input from whomever?

    anyway, i don’t think any other comments on all of this will come again after i press ‘post’!

  • ZENA

    THIS IS ALL VERY INTERESTING

  • something

    i really think this is all very interesting

  • dietdoc

    Zena and “something” write:

    “THIS IS ALL VERY INTERESTING”

    Reply: Then, by all means, let us know what you find interesting! Specific would help continue the discussion and bring up points that others might not have thought of. BLOGs are very multi-authored….every throws a little something in the fire and it can burn very brightly at time.

    Thanks for dropping by!

  • http://dementeddelusions.blogspot.com/ Michelle

    I get so frustrated reading things like ‘change your attitude’ and ‘change your behavior’ etc… Plus I find the terminology “refusal to lose weight” and all this poppycock that I surround myself with fat people and only shop with fat people incredibly offensive, not to mention, untrue. (Just this past Xmas I went shopping with my size 6, model pretty friend at Lane Bryant–I bought fat clothes in public! Gasp!)

    The fact is science still does not have a good handle on how to treat obesity. If they did, this discussion wouldn’t even be occuring. It’s easy to point the finger at fat people, implying it’s their own damn fault. But that is not always the case.

    Case in point: Me.

    History of adrenal insufficiency, leading to development of PCOS (with NO family history of either PCOS or diabetes)and subsequent diagnosis of Metabolic syndrome (again NO family history). Two endocrinologists independently agree that the root cause of my weight and hormonal issues are due to the adrenal insufficiency (caused by medication).

    I know I am fat. There is no denial, none.

    I take steps, sometimes extreme steps, to try and lost weight.

    I have yet to be successful.

    I did more than 16miles of exercise last week. I have gotten to where I can lift 20lb free weights in my weight routine.

    I do all this yet I do not lose weight.

    I’m allergic to the medical regimen normally prescribed for people like me (as in an allergic reaction that could be fatal).

    Stomach stapling would be a short term fix. I already have good habits so once the stomach stretched out again, my body would pack on the pounds with even a restricted caloric intake.

    I am likely going to die 20 years before I should.

    It’s nice to know that, while I struggle with a very real physiological problem that society will whisper about my lack of self control behind my back (or say it to my face) and assume the worst about who I am.

    Thanks for perpetuating all that crap, because it’s not like I have enough to deal with already.

    Michelle

  • Eric Olsen

    Michelle, very sorry to hear about your situation and congrats on doing so much and trying so hard. This story speaks in generalities about most people, not the relatively few with actual physical conditions such as yours. No offense meant and only the best wishes for your health and happiness

  • http://www.docofdiets.com dietdoc

    Michelle writes:

    “The fact is science still does not have a good handle on how to treat obesity.”

    Reply: You are absolutely right. But to say that, for the majority of obese people, psychological issues are important is an understatement.

    For a more detailed reply, I would certainly need more information because wnat you describe sounds very odd. As an internist and not a gynecologist, I know of PCOS but am also aware there are a multidue of treatments for it. AS for the adrenal insufficiency you describe, what medications caused that? And it is my understanding that adrenal insufficiency causes weight loss and asthenia more commonly than obesity. The whole medical picture your describe is a bit nebulous.

    Like Eric, I wish you every bit of success. I do know that a rare subset of obesity is caused by medical disease, but it is a small segment of the overall group. I also feel there are some things, medically and surgically, that can be done for your condition. I would strongly recommend you continue your search for subspecialty assistance of your medical problems. Perhaps at a major medical center in your state?

    At least you, unlike many of the folks at bigfatblog.com (an unfortunate name, I agree), you realize that your obesity is life-threatening and deserving of treatment. I wish you every success in finding some assistance in this complex matter.

    Good luck and best wishes,

    Ron

  • http://dementeddelusions.blogspot.com Michelle

    “This story speaks in generalities about most people, ”

    Eric, for me that is the problem. You may know there are exceptions, but the public at large does not.

    These ‘generalities’ are what fuel discrimination (sometimes even from doctors) of people in my situation. The lack of disclaimers and exceptions effectively translates into a fat stereotype believed by society to be true. They also are primary drivers of any psycho-dysmorphic (can I make that word up?) that the overweight struggle with. This is why I find these general statements so offensive and even irresponsible.

    Secondly, I suspect there are more than a few people in my shoes, whether science can recognize them or not. We won’t be able to differentiate those who are overweight solely due to behavior vs. those who are due to underlying physiology problems until we see more people exercising and modifying their habits–we still have not reached critical mass on changing behavior on a large demographic specific scale. Once we do, the people who have problems beyond eating too much and exercising too little will be identifiable. At the moment, we are just assuming based on what looks like logic that all fat people can lose weight if they just exercise and change their diet. That hypothesis, in my opinion, has not been throughly proven or else we wouldn’t be having problems with obesity.

    We are still at the point where, if I were to come to you as a patient telling you I try to lose weight, but can’t, that you are more likely to not believe me or think I don’t have the right information to be successful than to suspect any underlying physiological cause. I don’t think it’s just the fat people who need to adjust their attitudes.

    In fact, I was so frustrated with my inability to lose weight, I did an experiment on myself. For three months I followed a strict diet and exercised like I had found my long lost religion. I did not screw up once, not once. I followed my program without deviation. I did not lose a pound. Yet when I went to the doctor and relayed what I had learned, I was ignored. I was treated as if I didn’t know what I was talking about, or worse, as if I was a liar. It was impossible for my doctor to intellectually accept that I could not lose weight. She had to believe, because of her own bias, that I must have done something wrong.

    I have even told doctors I exercise only to have them ‘forget’ that fact and lecture me on how I need to exercise a mere five minutes later. Once one of them said, “Why are so chubby then?” (yes I do remember the words exactly) The denial is absolute.

    Ron: My body, I think, is specializing in the unexpected. My adrenal glands weren’t supposed to shut down, but they did. The med that caused it was prednisone and it did it to me 2x in my 20s (which made for a terrible decade).

    The weight gain was primarily from an inability to maintain good habits between the huge appetitie prednisone sparks and the muscle cramping it caused (it took me 2 years to be able to walk w/o pain the last time.) I am a gainer, the only reason I do not weigh 500 pounds is through extreme effort on my part to not gain weight. So take away my exercise, give me an almost insatiable appetite and that is a recipe for disaster. And when it was all over, it seemed my ability to lose weight and ovulate had disappeared.

    It is so clear, in hindsight, that this is when the PCOS kicked in.

    At least with the PCOS diagnosis I understand why now, because I did (and still do) blame myself quite a lot for being overweight. It doesn’t help that society is more than willing to assist me with my internal guilt trips. Books like the one discussed here are just another flog with which I can be whipped.

    I have been looked at by 4 separate endocrinologists and have access to on- going specialist care. I have also tried accupuncture (which was sooo not fun and was the one time I was glad something didn’t work so I could stop).

    The problem is, thus far, the standard paradigms of care have not been terribly effective and the doctors haven’t been willing to accept that. They keep trying to cram me into a cookie cutter template of care (with the best of intentions) despite any feedback to the contrary. The endocrinologist I’m working with now is hearing me and I think once I prove to him that I can’t tolerate certain things, we’ll be able to move on to the next step.

    In my experience, it is never good to be the odd one out when it comes to illness because they don’t know what to do with you and you don’t always get the attention to detail you need. Generalities, social or medical, can be dangerous for people like me.

    Since, to date, we have found no pill that my body will tolerate, I’ve been focusing on exercise and diet. I will spare you the details, just suffice it to say I’m doing the best I can with the circumstances dealt to me.

    Reading things like the summary of this book, remind me of when women were thought to be ‘hysterical’ just because they didn’t behave the way a male dominated society thought they should. There seems to be a kneejerk reaction in science and society that if something can’t be explained then it must be ‘all in our heads’ and, ergo, our fault due to a personal failing. That kind of belief system is just as damaging as being overweight and it would be nice if we could move past that kind of derogatory thought pattern.

    Secondly, I wish the medical community, when dealing with patients, would focus more on encouraging exercise and providing nutritional information than telling patients to lose weight. All patients, regardless of weight, should be exercising and avoiding trans fats, but for some reason the size 4 woman with so little stomach tone she’s got cellulite on her gut isn’t told she needs to exercise. Somehow she gets a free pass while the fat people get a lecture. Yet her lack of fitness is detrimental to her long term health as well. In my opinion this is a prime example of the hypocrisy fat people seeking medical care experience.

    This is too long already, so I shall stop here. I hope I have given you some food for thought.

    Michelle

  • Eric Olsen

    all makes sense to me Michelle, I would think that your intelligence and articulateness will help you find the medical assistance you need – don’t give up

  • http://www.docofdiets.com dietdoc

    Michelle writes:

    “It doesn’t help that society is more than willing to assist me with my internal guilt trips. Books like the one discussed here are just another flog with which I can be whipped.”

    Reply: Once again, I reitterate, my BLOG is totally unrelated to this book. The book was tacked on without my knowledge. It has nothing to do with my comments.

    Michelle writes:

    “just suffice it to say I’m doing the best I can with the circumstances dealt to me.”

    Reply: All that anyone and, in particular, physicians, could ask of anyone.

    Michelle writes:

    “Secondly, I wish the medical community, when dealing with patients, would focus more on encouraging exercise and providing nutritional information than telling patients to lose weight. ”

    Reply: I certainly agree with you. And I know that, while things are changing, some of the “old school” physicians (especially those who don’t actually deal with obesity daily) continue to harbor the belief that obesity equates with gluttony, sloth, etc. etc. It doesn’t.

    In my clinic, weight loss and a size 6 body are not goals I discuss with patients. It’s not realistic. In point of fact, among the things we do – together – at our initial encounter, is decide what a realistic health goal should be. Healthy habits are the focus – not weight loss. If you establish a healthy lifestyle, everything else, except for rare exceptional cases, usually takes care of itself.

    When I see people in follow-up, my first question is not: “Have you been following a diet?” It is, invariably and unrelentingly, “What have you done for exercise?” What people are eating is not, IMHO, the problem I need to work on. It’s what they are not doing – specifically, not being active.

    I do sympathize, truly, with your plight. You seem to be, unfortunately, an extremely complex physiological conundrum. You are doing what you can, it appears, and I commend you for it. Perhaps there are medical solutions in the near future. I do hope so. And, in the interim, I wish you continued resolve to do what you can with the cards dealt to you. No greater effort could anyone ask for.

    Warmest regards, Ron

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    ((((((((Michelle))))))))))

    Thanks so much for joining the discussion.

  • Dr. C

    Sorry but pure rubbish.

    The hormonal influences on obesity are well established. Combine these with dietary advice for the past 40 years that stands in the face of the methods in which our body has become accustomed to dealing with nutrients (and by nutrients I mean proteins, fats, and very little carbohydrates only in the form of frueits and vegetables – i.e. the diet we have been eating for millions of years). Feed people a diet heavy in substances that their bodies are poor at metabolizing (simple carbohydrates) and they get fat and feel terrible.

    People are not fat because they are lazy, eat too much, or have a psychiatric illness, but rather because they are eating the wrong nutrients and unnaturally stressing their body with large amounts of sugars and other “new” food items that are a burden on the body (thus causing release of abnormal amounts of insulin and irregular storage of fat).

    This has been beyond proven, yet we choose to ignore the elephant in the room and it is both harmful and a shame.