Obesity: Character Flaw or Neurochemical Disease?

When is the last time someone challenged you to examine a cherished opinion or viewpoint? This comes close to describing my conversation with Dr. Jennifer Lovejoy, president of the Obesity Society, a clearheaded thinker whose insights are shifting attitudes and shaping future policies about obesity.

In a recent Society newsletter, Dr. Lovejoy challenged three prominent myths about obesity and weight loss. The article caught my attention because I generally subscribed to those three ideas. Clearly, our perspectives were at odds.

I contacted Dr. Lovejoy, and during our conversation, she explained why the myths were untrue and how damaging they were to individuals and to the larger society. As I listened to her, I realized that I needed to be open to the possibility of another point of view, and I invite you to join the discussion.

The first myth--that obesity is a lifestyle issue and not a medical condition--raises an important question about whether obesity should be medicalized.

Based on my own successful experience in losing weight (and, in the process, reversing potentially life-threatening medical problems), I've been reluctant to view obesity as anything more than a matter involving personal responsibility.

My own experience was straightforward: I ate too much and moved too little, so I got fat. When I ate healthfully and moved more, I trimmed down. Test scores that placed me in the 90th percentile of risk for heart disease, stroke and diabetes at the start of my makeover moved to the normal range once I adopted healthier habits. I assumed others were like me: we all have choices to make, and our choices have consequences.

In addition to my own experience, I've been (and continue to be) concerned that if obesity is fully medicalized, obese patients will shift all responsibility to their physicians for weight loss and for treatment of medical conditions, such as diabetes and cardiovascular disease, that are associated with obesity.

In discussing the issue with my personal physician, I found she shared these concerns. If, for example, patients felt they could indulge themselves at will and then have their physician prescribe a pill for weight loss and another pill to treat the medical problems arising from obesity, what incentives would there be for adopting a healthier lifestyle? And lest you think I am pointing a finger at others, I'm describing myself. Certainly had such an option been available to me, I would have considered using a medical solution rather than making the more difficult lifestyle changes.

Given my perspective, Dr. Lovejoy had an uphill battle to convince me that the following myths were untrue and damaging. But by virtue of her education (she holds a doctorate degree in biopsychology from Emory University and completed postdoctoral training in endocrinology and metabolism at Emory University School of Medicine, where she specialized in obesity and diabetes research) and her achievements (she has published over 50 scientific articles in peer-reviewed journals, written dozens of chapters and review articles and is a frequent speaker on obesity and nutrition at national and international conferences), her ideas deserved serious attention.

Here are her views on the three myths, why they are untrue and why they are damaging to perpetuate:

Myth #1: Obesity is just a lifestyle problem.

The reality is that obesity is a chronic, relapsing, neurochemical disease with a genetic basis. Simply telling an obese person to "eat less and exercise more" is overly simplistic and demonstrably ineffective. For many people, the extent of long-term calorie reduction and exercise enhancement necessary for adequate weight loss is not feasible for a multitude of biological and environmental reasons we are only beginning to appreciate.

Lifestyle changes such as diet and exercise are obviously key elements of any obesity treatment plan, but just like other chronic conditions that have a lifestyle component, e.g. hypertension and diabetes, there are strong bioregulatory networks working to defeat weight-loss efforts and sustain obesity. Thus, for many patients, obesity treatment requires lifelong interventions in addition to healthy lifestyle change. Ignoring this need ignores the human and financial costs of the condition. Obesity deserves serious treatment.

Myth #2: Obese people lack willpower and are overindulgent.

The reality is that pervasive weight bias is a major impediment to providing people who suffer from obesity with the treatment they need. Biased attitudes toward obese patients have been documented among the general public and health care providers. Such attitudes can obscure the need for serious intervention options for this condition.

The diet and beauty industry, whose sales are dependent on making people believe that "anyone can be thin if they just try hard enough" (and spend enough money on products), inadvertently perpetuate these myths.

Contrary to the notion of wishful thinking and the exercise of sufficient willpower, obesity is a chronic neurochemical disease, not a character flaw. As such, it requires an array of effective treatment tools.

Myth #3: Obese patients need to lose lots of weight to achieve health benefits.

The reality is that a 5 to 10 percent weight loss produces clinically significant reductions in blood pressure, lipids, blood glucose and other health parameters-illustrating that the goals laid out for those who have chosen to address their obesity should focus less on total weight loss and more on health improvement. And while there are measurable clinical benefits associated with significant weight loss that accompanies surgical intervention, weight-loss surgery can not be the only treatment tool that healthcare providers have in their arsenal. Just as one size does not fit all, one treatment will not work for every patient.

Dr. Lovejoy feels that these myths are accepted by obese and slim people in equal measure, along with doctors, policymakers and scientists. She also feels the myths are damaging because they support continued bias and stigma toward obese people and because they prevent the development of much-needed medication to treat a serious medical condition.

She points out that the bias against treatment is revealed in the absence of drugs to treat obesity. For example, over 200 drugs are on the market that can be used to treat hypertension (frequently a secondary consequence of obesity), but currently only one FDA-approved drug is available for long-term treatment of obesity.

Dr. Lovejoy adds, "As long as obesity is viewed as a matter of willpower rather than a medical condition, the Food and Drug Administration and the pharmaceutical houses will lack an incentive to develop and approve more medications--despite the reality that obesity is the most pervasive public health problem in our nation."

Dr. Lovejoy encourages us to stop equating body size with health and acknowledge that some people who are still very large have managed to lose 50, 60 or 70 pounds and keep it off successfully through diligent diet and exercise practice. She adds that this isn't true for every obese person; on the other hand, not every thin person has healthy behaviors.

Healthy debate, evidenced by Dr. Lovejoy's challenge of conventional thinking, of which I am guilty, is clearly needed if we are to successfully address the issues of obesity.

We have any number of reasons to act. Our impulse may be humanitarian; that is, obesity causes an incredible amount of physical and emotional suffering. Or perhaps we are concerned about the medical implications for our children and grandchildren. Dr. David Katz, director of Yale University's Prevention Research Program, recently reported on the migration of stroke down the age curve to children. He attributed this predictable migration to an epidemic of obesity in children.

Or perhaps we fear the frightening rise in the cost of medical care. According to predictions by UnitedHealth Group, one out of two Americans will be treated for diabetes or prediabetes at an annual cost of $3.35 trillion by the year 2020. And while this amount is staggering, we need to remember that diabetes is only one of several expensive chronic medical problems associated with obesity.

Obesity is the number one public health problem in the United States, and the urgent issue of whether we continue to address obesity as a character flaw or treat it as a medical condition is like the proverbial elephant in the room (or perhaps a herd of elephants.)

Although a few experts, like Dr. Lovejoy and Dr. Katz, openly share their insight and advice, too many of us (myself included) shy away from the hard discussions about how to address the matter.

I have no doubt that Dr. Lovejoy's candor, although unsettling to my opinions, is a force for positive change. Do your part: free this elephant by acknowledging its presence. At the very least, you'll create more space in the room.