Among the all-too-often cruel remarks about obese people is that they all eat too much and move too little. In the eyes of the "never fat," everyone wearing a size 22 dress or XXXL pants has identical reasons for being that size, and if they all would simply activate their dormant will power and get on a treadmill, they would be thin. Nutritional and weight-loss programs also reflect this assumption. The lifestyle of all obese individuals is behind their excess pounds: Change the lifestyle, and people will be thin for life.
The Thanksgiving week issue of JAMA (a coincidence right after national binge day?) disputes the wisdom of assuming that all obese individuals will respond similarly to programs that prevent or treat their excess weight. The authors point out the minimal impact on weight loss of many obesity treatment studies, despite often years-long and multi-faceted interventions. Despite nutritional counseling, pre-packaged meals, personal trainers, psychologists and group support sessions, most participants fail to reach their weight-loss goal and often gain back the weight that was lost. [1]
Perhaps, the authors suggest, a better approach would be realizing that obese people are not a homogenous group with the same behavioral, or even genetic, reasons for weight gain. If sub-groups of obese individuals were identified, each with its own weight-gain characteristics, programs could be tailored to meet the needs of each group. In their examples of different sub-categories, they mention people who are sensitive to external food cues, or those who simply do not respond to internal satiety signals and can't stop eating. Their insights make sense: Should binge eaters be lumped with couch potatoes, and they with those whose extra calories come from too many business meals, who are then categorized as broadly identical with the stay-at-home mom who nibbles when her kids are fighting? Cultural differences also tend to be overlooked; obesity may not be perceived as a health issue or even cosmetic problem. The grandmother who thinks that a fat child means a healthy child, or the man whose obesity allows him to "throw his weight around!" in a conference room, these mental models are resistant to slimming interventions. Someone whose professional or social culture puts a priority on fitness and correct body size, however, rarely allows that they let themselves go.
The bodies of the obese look more or less the same; fat deposits seem to follow relatively similar patterns although, of course, gender differences and degree of obesity affect where excess fat is found. But our mistake in the treatment of obesity is overlooking the vast difference in causation and refusing to tailor the treatment to the cause. For example, bariatric surgery that decreases the size of the stomach pouch may work wonders for someone who gains weight by going to all-you-can-eat for $9.99 buffets every day for lunch. But making the stomach smaller may ultimately fail to reduce weight permanently for someone who is dealing with years of child custody battles with an angry ex-spouse or working under a boss from hell.
Food, in these cases, is a tranquilizer, taking away the pain of a seemingly unsolvable and emotionally painful situation. Such individuals will find ways to put enough food in their stomach to numb their emotions, despite its reduced size. They will gain back their weight and count themselves among the bariatric surgical failures. But are they the failures, or is the method treating them to blame? If as much attention were provided to help them deal with their stress without overeating as is afforded the surgery, might they have succeeded in keeping off their weight?
The de-personalization of obese individuals also leads to misdirected government interventions as well. For example, efforts to increase produce intake and thereby decrease calorie intake from high-fat and/or high-sugar foods is worthwhile. No one can argue with the nutritional value of a carrot over an orange soda, or baked chicken over chicken nuggets. But assuming that education about good nutrition practices will translate into changed behavior is like assuming that teaching how to read the alphabet will translate into reading a novel. Taxing junk food is irrelevant and useless unless we use that tax money to understand why these foods are being purchased and develop personalized methods to change this behavior. A teen may live on junk food because she doesn't want to eat dinner with her parents; a minimum wage worker may have no choice.
Pop-up diets, like those stores that appear between Thanksgiving and Christmas, are often heralded as "The Breakthrough Way" to combating obesity. Who follows these diets and who really benefits? Well, the already thin who want to be thinner take on the fast, or the colonic, or the eat "only while leaning on your right side," diets. Doing so makes for great chitchat at a party. Others eagerly follow the new diet program, hoping that, unlike the 500 hundred other "breakthrough diets" that have failed, this one might actually work for more than two weeks. But as the JAMA article pointed out, 70 percent of adults and 33 percent of children and adolescents in our country are overweight or obese. This would suggest that as more and more of these fad diets appear, the country becomes more and more fat. Yet no one points out to the customer buying the box of cleansing liquids (for weight loss, not for washing the floor) or deciding to fast, or whichever is the new breakthrough solution, that the weight gain may be caused by the antidepressants she is taking, or her night shift work every three days. What good is a cleanse diet going to do someone who is eating to keep awake, or whose medication is taking away a sense of fullness after eating?
Perhaps one explanation for the almost total absence of personalized weight loss care is that it is unprofitable. Appetite-suppressant pills, packaged diet-meal plans, health and drug store diet shakes, supplements, and weekly weight-loss support groups of 50-100 participants are antithetical to personalized weightloss care -- but they do provide for profit to a parent company. What happened to seeing each client as essential, but in the case of the weight loss industry, seeing less of them for as a long a period as possible, equating with success for client and company? Is this not in the best health interest of both?
The JAMA article pointed out the impressive results from understanding cancer as a genetically complex disease, and developing personalized therapies in response. Isn't it time for us to understand obesity in all its complexity and mirror this process?
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