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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To Sleeve (or Not to Sleeve) Series - #7, The Social Cost of Being Overweight

(This is part of a series I posted on my other (formerly anonymous) blog, tobypass.wordpress.com)

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An aspect of obesity those who are normal weights might not automatically appreciate is how it affects ones social life. In addition to contributing to all kinds of health problems, obesit also has the tendency to isolate a person in depression, decrease the depth of intimacy he/she enjoys in many interpersonal relationships, and weaken dating opportunities.

A key underlying contributing factor in all of this for me is the way we have stigmatized excess weight in American culture. Fat people are pariahs. Objects of scorn. Disgusting. Worthy of disrespect, judgment, unsolicited criticism, or paternalistic control.

Overweight people are considered to be in the position they are in because they lack self-control, are lazy, or have poor character. Because food is something everyone has intimate experience with — many who are at normal weights feel justified by assuming these things. “I’m not that heavy! I control myself! Maybe you should slow down a little bit at the buffet! Or go for a jog once in a while!”

Our culture celebrates and idealizes a certain body size – lean and thin. Women feel this more acutely than men in part because of our collective objectification of the female body; I’d argue that men feel it as well however (and this is often overlooked). Hugh Jackman’s physique as the Wolverine is just as ridiculously unattainable as ‘the norm’ as Angelina Jolie’s cover shots in fashion magazines.

These standards are difficult to not internalize for anyone who is not lives and moves through American culture. We inherit them through advertising, television, movies, and consumerism. Even product sizes available in certain stores tell us of how big or small we should be. (Even though I’d like to shop for higher quality clothing at Nordstrom, designer lines are cut a full size to a size and a half smaller than more standard or ‘bargain’ lines).

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As a consequence of these dynamics, I (and many other obese people) have developed an inner narrative that runs like a tape in my head — whether I actually hear the messages from others or not. The tape that tells me I should push back from the table and get on those running shoes? Ever present. The tape that calls me ‘fatty’ when I look at myself in the mirror when I’m undressed? Ongoing. The one that says I look sloppy and unkempt in my poorly styled xxl clothes? Every day. The one that tells me those people probably think I’m gonna go home and binge after I only ordered a salad for lunch? Like clockwork. The tape that berates me for my weight gain, even before I get in the lobby of the doctor’s office? Mine.

These voices are painful. Some have been developed from actual conversations but not all. Many are my own design – invented by an astute understanding of America’s stigmatization of fat.

One of the biggest casualties from these tapes in my life has been my confidence. It burns through it like gasoline in a dumpster fire. It’s incredibly hard to stand with my head held high, shoulders back, eyes clear, chin up, speaking clearly — when at the same time I’m telling myself that I look like a fat slob who everyone probably hates. I overcome it quite often — but it takes it’s toll.

These tapes in my head lead me to put words of judgment in the mouths of others — to assume others aren’t interested in friendship or think lowly of me. Of course, I had no way to know if those people were holding negativity overly head — and in reality, I WAS THE ONE PREJUDGING THEM!! Regardless, this dynamic has hampered intimacy in my life in many many ways.

Flowing out of these messages — I think — in part is a sense of depression. I’ve been on a mild antidepressant for the past month or so and I feel as though it’s really given me a boost. But I do think that my weight — and my inner dialogue has played a role in creating it.

Depression for me tends to drive me into isolation. I want less and less to do active things I know I like to do — or at least I used to like. I eat alone. Sometimes I compulsively crash a fast food drive through and get an ice cream cone or a hamburger — even though I know I’ll be eating dinner with my family later. There have even been times when I’ve turned down invitations to people’s homes because I just didn’t want to be around anyone – I didn’t want to have to visit – I didn’t want to be subject to whatever food they happened to cook at the time.

I think I sometimes use food to medicate my depression. I eat to try to make myself feel better. But like any addictive cycle – those chicken wings or cheerios or soft pretzels with cream cheese – only make me feel worse in the end (and usually it’s immediately after consumption).

Now — before I go on — I should say that I doubt these tapes will just end as soon as I lose weight. There is some truth to the movement afoot ‘healthy at any size’ and especially the categorization of obesity as a disease — both (in their own ways) attempt to destigmatize weight gain and to try to rescue people from these kinds of negative cycles I’m describing for myself. I’m sure I have some work to do in this area above and beyond weight loss. Dumping pounds will not be a panacea – it’s not a cure all – and it will not fix everything in my life.

Continuing on with the theme of ‘social cost’ — another way I’ve seen my weight impact my relationships is the rate at which I get invited to do active things with other people. I think I wrote about my love of sports in another post — but I’ll elaborate here a tiny bit. I LOVE SPORTS. Pretty much any one. I love playing, watching, following, talking about….etc.. There’s almost no sport that I find uninteresting…even those I’m scared of (skydiving, bungee jumping, etc) I’m absolutely fascinated by.

One of the things that happens when to people who are overweight — and i have certainly observed in my life — is that they get invited to do active things less and less. I often have large groups of friends who run races, go biking, play basketball, go camping, etc, etc, together (I know because they talk about it later, post pictures on social media, etc.) — but they very rarely invite me. These same friends regularly go to the gym together to work out, play raquetball or tennis, or do other physically intense activities with one another… These take scheduling, coordination, planning. Again – I very rarely have been included.

Now — I think there are several reasons for this. The first is the most insidious. As a heavy person, I’m not as fit as some of my leaner friends — I can’t run as fast or for as long — I can’t hike as hard — and i can’t bike as far. If they invite me to join them, I hold them back. This is aside from any determination I might have or willingness to really push myself. My 110% is the equivalent of some of my athletic friends’ 65%. It’s not fun for them to invite a lame duck to join them in their exercise. They don’t want to be held back. They don’t want to be slowed down. And I don’t think this is an entirely unreasonable concern. They have every right to want to pair themselves with workout partners that match their skill so as to maximize workout time.

The problem emerges for an overweight person in that it’s a nasty cycle… I walk alone. I bike alone. I jog alone. I go mess around on the basketball court alone. I hike alone. Accountability and a team spirit is super helpful in exercise programs. I do mine by myself. I rely fully on my own motivation and umph to get it done. The less I engage in athletics with others, the poorer fitness I have, and so the less likely they are to invite me to participate. It’s a nasty cycle.

All of this leads to a lower overall quality of relationships.

For men — we often bond by doing things with one another. Sports. Work. Adventures. Activities. We build friendships and trust by being active. My weight keeps me from a whole world of fun and by consequence — impacts my intimacy with many people. I feel sad as I write this.

This isn’t about being a victim — I certainly know I have personal responsibility and initiative in all of this — and certainly there are other factors that contribute to my situation specifically. But my weight DEFINITELY has an impact on how active I am simply by virtue of not being included in many of the active sporting things my friends and acquaintances take part in.

To state it in a positive way, one of the reasons I want to lose a large chunk of my excess weight (125lbs at this point) is so that I can be more active — work out with friends and do active things without such limitations. Activity breeds activity which breeds healthy weight — and the opposite breeds the opposite.

Finally — a word about dating.

This piece hasn’t affected me a great deal per se. I’m married to a wonderful woman who I love and adore – and have been for 10 years now. We have a pair of amazing sons – and she is a fantastic mom. She has helped me grow SO SO much over the years – emotionally, spiritually, personally. I can’t imagine life without her.

And in our case, my weight didn’t play into her attraction to me (of course when we started dating, I was about 50lbs lighter — so there’s that too). And I felt confident enough to return her affection, commitment, and kindness.

With that being said – I do think that in my dating life before I came to date my (now) wife, my weight did affect my confidence level and therefore willingness to ask girls out. I was scared. I was afraid of rejection — and I think arguably to a larger degree than other normal-sized men — because of my weight.

My sense is that the dating scene is particularly fraught for women — who, as I’ve noted, are subject to a far more strenuous and irrational standard of feminine beauty than men. An overweight woman is seen as unattractive by many many people — including women themselves. How do obese girls fare on dating websites and in bars? My only knowledge on this is anecdotal but my sense is that it’s fairly rough. (and certainly stressful).

While singleness isn’t a death knell for anyone — the prospects of not being able to create a long-term relationship or a family (or even delaying that process for many years), the prospects of having a limited sex-life even outside of a long term commitment, and the prospects of even being able to go through the fun of dating and relating are all negatively hindered by obesity. The cost is simply too real to ignore.

Yes, fat people get dates and marry.

And yes – it’s also arguably more difficult than those who are more normal sized.

Others might have dozens of other social realities that come from their excess weight. I like this little article that samples people from interviews and tries to coalesce a picture of the day-to-day experience of morbidly obese people. Check it out!