28 Jun

Why We Can’t Cure Obesity

The latest desperate effort at combating obesity comes in the form of the American Medical Association officially declaring it a disease last week. No one has actually declared war on obesity yet, but I trust that at some point someone will. I feel equally confident that none of the grave warnings and reclassifications will change anything. Nor will the well-intentioned efforts by our government, our First Lady, and even the Coca-Cola cooperation. They are all working to educate the public about the caloric content of food and the need for consumption of fresh fruit and vegetables. These efforts are a response to the research showing that obese people who consume fast food on a daily basis are poorer, less educated and live in neighborhoods with more fast food restaurants and billboards than those who are not obese, as well as having fewer venues for purchasing fresh veggies and fruit. Hence the emphasis on nutrition education and the availability of healthy food.

However, a closer look at the obesity statistics reveals that the problem of obesity is widespread and not primarily an issue for the poor and uneducated. What these discussions ignore is that every demographic group in this country is gaining weight except for wealthy women, who apparently still take the old adage seriously, “you can never be too rich or too thin.” Every other group is getting fatter despite the efforts to combat it. Things are getting worse, not better. Four days ago a Gallup poll announced that obesity rates were ticking up yet again for 2013, the fifth year in a row.

Scrambling to find an answer to the country’s growing obesity-related health issues, primarily the epidemic of Type II diabetes, everyone is weighing in. The most recent issue of the Atlantic featured a picture of a Big Mac on its cover and touted “The cure for obesity.” Author David Freedman praised McDonald’s recent forays into providing lower calorie items (McWraps) and even slipping some whole wheat flour into their Egg McMuffins. He said that cutting a few hundred calories a day from someone’s diet translates into the difference between being obese or not being obese. Freedman’s “cure” lies in across-the-board engineering of healthier junk food. Ironically, he noted that the public is deemed better off not having these healthier choices touted as such. The author stated that McDonald’s deliberately did not announce these changes as “healthy” because experience has taught them that people will avoid foods with this label.

While that might not say it all, it says a lot. You may recall what happened when ice cream makers created reduced fat versions of their products. They failed to mention the increased amount of added sugar to enhance flavor, and subsequently discovered that people ate more of the reduced fat ice cream, thereby further negating any benefit from the slightly fewer calories per serving. What we are not addressing is that people eat frequently, and poorly, to comfort themselves. And if sufficient comfort is not forthcoming, either because the portion is smaller or the food less fatty, they are likely to simply eat more of it. (Studies showing people eating less when presented with a full, smaller plate are very short term in nature and prove nothing about what those individuals will do after participating in the experiment.)

The issue of comfort relates directly to the companion issues of stress, anxiety and depression. The American Psychological Association report on Stress in America says stress remains alarmingly high and constitutes a major mental health issue. Stress is also highly correlated with emotional eating and obesity.

Food is not a drug. Obesity is not a disease. But people need something when they are miserable, and the people with worse jobs, lower wages, and more stress often turn to increasing amounts of food to alleviate their emotional deprivation. Food is readily available almost everywhere. And, yes, this is a nod to the proven impact of environment on eating. You can also eat while working two jobs and desperately trying to stay awake because you are exhausted and sleep deprived (more proven contributors to obesity.) Or because you are a salaried manager expected to work sixty hours a week with no opportunity for overtime.

The combination of my experience with patients and reading the published reports of mounting stress, rapidly increasing fatalities due to road rage, as well as the recent Gallup report on unprecedented workplace misery, leave me asking myself why we ignore the obvious. Why are we not talking about the fact that our citizenry becomes more socially isolated, anxious, stressed, depressed and angry with each passing year? Why are we not talking about the effects of downward mobility and tyrannical workplaces that use profits to raise their stock price while American workers put in more hours than ever at lower wages? (And fear losing their jobs if they speak up about how they are being treated.) Why do we want to engineer junk food, but not the greater society? Why do we seemingly ignore the depressing impact of twelve years of war and the fears of terrorist retaliation that cuts across socioeconomic lines? Why do we want to spend hundreds of millions of dollars mapping the human brain instead of providing mental health coverage that would at least deal with some of the emotional carnage?

Instead of hearing constantly about the relationship between poverty, lack of education and obesity I would like to see some research about the disappearance of mental health coverage and the increase in obesity. We need substantial reality-based conversation about the underlying social causes of obesity, namely anxiety, depression, and lack of control over one’s own life, with no time to exercise or socialize. President Obama has called for a mental health initiative, but it relies chiefly on soliciting businesses, schools and civic organizations for increased awareness. But we need more than awareness. Given that roughly 8-10% of all emergency room visits are classified as mental health issues, it is clear that treatment is lacking even for those in the most severe circumstances. There simply is nowhere else for them to go for treatment. So they end up in the ER.

(UPDATE, JULY 5, 2013. Medscape reported today: “The number of pediatric patients admitted to US hospitals with chronic pain diagnoses increased by 831% from 2004 to 2010. The average patient was a white girl about 14 years old with headaches, abdominal and musculoskeletal pain, and depression and anxiety, according to a study published online July 1 in Pediatrics.”)

Our society is experiencing cascading stress-related social problems. Obesity is one of the most critical of these, given the health and longevity consequences that accompany it. But the underlying psychological causes need to be addressed as well as a concrete plan for providing adequate mental health coverage. But this is not happening. The White House can plant a vegetable garden on its grounds, but apparently it cannot sow the seeds for needed multi-pronged social change.

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