Why Obesity IS a Disease and How This Helps, Not Harms

Forgive me for sitting on the sidelines for a week and watching the news from the bleachers. What I’m going to talk about is not the event, but the aftershocks.

Last week, the American Medical Association officially classified Obesity as a “disease state with multiple pathophysiological aspects requiring a range of interventions”, a hotly debated change that follows in the footsteps of the American Association of Clinical Endocrinologists (2012) and The Obesity Society (2008), and highly supported by the American College of Cardiology and the American Heart Association. It wasn’t a shoo-in: the AMA Committee appointed to the task recommended AGAINST the disease classification, but the AMA House of Delegates –  the providers – overruled that recommendation and passed the motion with a large  (no pun intended) majority (276-181: 60.4% to 39.6%).

The professionals arguing against the classification fell back on the same old sorry party line – there are no specific conditions associated with obesity, and that it is a risk factor for other diseases but nothing more.

The AMA made a kind and accurate comparison to other lifestyle-related diseases: “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.” Or diet and hypertension, or alcohol and cirrhosis, or sex and HIV, or drugs and Hepatitis C, or motorcycle accidents and brain injury among others. We are imperfect beings and we seek physical experience, sometimes to excess and to our detriment.

When they declared obesity a disease, you may have heard me doing my happy dance in my office where I practice Functional Medicine and Integrative Psychiatry, and treat obesity daily. Finally, I thought, recognition that obesity is NOT simple thermodynamics of calories in = calories burned. If it was that simple, everyone who ever lost weight would still be thin.

Not Everyone is Happy with the New Classification

I was stunned at the subsequent backlash that occurred, especially since all of the scientific evidence over the last decade points toward obesity as a progressive metabolic, endocrine, toxic, nutritional, psychiatric and inflammatory disease that sabotages weight loss efforts, no matter what the diet. Why would you NOT want obesity classified as a disease?

On Twitter, hashtag “#IAMNOTADISEASE took over with a vengeance.  People worried about the new obesity disease classification as (1) being more stigmatizing than being fat in a supposedly thin society, (2) overmedicalizing obesity because not everyone who is obese is unhealthy, (3) catering to the pharmaceutical and device industry, (4) being inaccurate because there is debate about Body Mass Index as an inaccurate and fallible measure of obesity and (5) promoting racial discrimination based on the epidemiology of obesity.

Let me try and answer their concerns:

Re: Stigmatization: People were offended and suspicious, especially the community of fat advocates. Apparently the word “disease” is worse than the word “fat”. I’m not sure how an already stigmatized condition can be further stigmatized, but I understand how an oppressed group may be overly sensitive to any slight or comment that seems derogatory.

Re: Overmedicalizing: Sigh. I understand that part of fat advocacy has been the Health At Every Size (HAES) campaign, which includes healthy eating and movement and a healthy balanced lifestyle, all of which I support and work with my patients daily to achieve. At any size. However the scientific physiological data just doesn’t support long-term “healthy obesity” on a micro or macroscopic level. Fat cells are metabolically active, and too many of them are eventually harmful. Years of morbid obesity will eventually erode joints, and take its toll on organ systems. Maybe the advocates need to change the term to “healthy obesity at this moment, but maybe not in 20 or 30 or 40 years”.

Re: Industry Profit: Yes. Assuming the pharmaceutical and device industries, and the supplement industry, and the medical and nutritional and even organic food industries will benefit is a given. They all always find a way. But the argument about the pharmaceutical industry making money off fat people is just simply a cost shift from the multi-billion dollar supplement and fitness industry that victimizes the gullible and the desperate among us.

Re: Disagreement within the medical and scientific community: There will always be disagreement within the medical community on disease and treatment – that is the definition of evolution. In a brilliant Aeon magazine essay The Obesity Era, science writer David Berreby said this, “One possible response, of course, is to decide that no obesity policy is possible, because ‘science is undecided’. But this is a moron’s answer: science is never completely decided; it is always in a state of change and self-questioning, and it offers no final answers.”

Re: Racial Discrimination: Absolutely, I give a nod that poverty is indeed associated with obesity in the United States, and a caution to not overinterpret or universalize epidemiologic data. In other countries, it is the middle and upper classes that are associated with obesity (such as India). I’m hoping that underserved populations will be able to see professionals about their weight, and have it covered, instead of not being able to afford a diet program or a gym. In my real dreams, there are urban community gardens, and decent produce and quality protein and fresh fruit in the food deserts, and safe areas to exercise or walk. The causal paradox of hunger and cheap food and obesity are not being ignored by classifying obesity as a disease. To the contrary, this reclassification calls attention to ALL causes of obesity – physiological, psychological, social, environmental, genetic, hormonal, economic.

What really struck me was that people who were upset about the obesity disease classification said “I AM NOT A DISEASE”, not “I don’t HAVE a disease”.  Yet they don’t say I AM ASTHMA. The AMA didn’t say “you are a disease”. Those of you who have read my blogs before know that I am a fervent proponent of turning the word “diabetic” back into an adjective where it belongs, not a noun. You are NOT a diabetic. You HAVE diabetes. You are NOT a disease.

So what is this about?

Maybe, just maybe, calling obesity a disease implies it is hopeless.

So let’s look at the actual AMA proclamation and how it is helpful, not hopeless.

Is Obesity Really a Disease?

The AMA says these are the “common criteria in defining a disease: 1) an impairment of the normal functioning of some aspect of the body; 2) characteristic signs or symptoms; and 3) harm or morbidity”.

Re Impaired physiologic functioning: “there is now an overabundance of clinical evidence to identify obesity as a multi-metabolic and hormonal disease state including impaired functioning of appetite dysregulation, abnormal energy balanced, endocrine dysfunction including elevated leptin levels and insulin resistance, infertility, dysregulated adipokine signaling, abnormal endothelial function and blood pressure elevation, nonalcoholic fatty liver disease, dyslipidemia, and systemic and adipose tissue inflammation”.

Re characteristic signs and symptoms: “including the increase in body fat and symptoms pertaining to the accumulation of body fat, such as joint pain, immobility, sleep apnea, and low self-esteem.”

Re Associated Harm or Morbidity: “The physical increase in fat mass associated with obesity is directly related to comorbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.”

In my opinion, the AMA made the case for obesity as a disease. It gets even worse scientifically. In a groundbreaking study published in PLOS ONE 6/26/2013, OVERWEIGHT may be a disease also. In a study of 200,000 people affected by a common genetic variant, even a ONE UNIT increase in BMI is associated with a 20 per cent increased risk of developing heart failure. Further, the study also confirms that obesity leads to higher insulin values, higher blood pressure, worse cholesterol values, increased inflammation markers, and increased risk of diabetes.”

How Does Classifying Obesity as a Disease Help Patients and Providers?

How does a disease classification help providers and patients give and receive treatment and help?

1) Insurance Coverage. In my world, a diagnosis of Morbid Obesity is not yet reimbursable. I find myself having to scratch out an explanation of an eating disorder or anxiety or irritable bowel syndrome to cover the time and appointments that are needed for someone to completely change their lifestyle. In addition, prescription medications that are sometimes helpful will be covered, as will surgeries for people who need drastic measures to prevent end-stage disease before they develop those diseases. Patients with obesity will be able to see the dietitian or nutritionist, unlike the present where those appointments are not covered unless you already have diabetes, and then, only once a year. Losing weight requires a great deal of support – people should be able to see their professionals as often as needed. And maybe, in an ideal world, physical therapy will be expanded to include physical fitness.

2) Reducing Weight Bias among Health Care Providers. One fact to consider is that currently many, if not most, physicians and medical students and nurses and other health care providers are biased against obese patients. Interestingly, health care professionals also freely admit they have no skill or training or knowledge in how to treat these patients’ obesity other than treating the associated late-stage diseases. We providers don’t like it when we have no idea what to do for someone. A formal disease classification opens the medical school curriculum floodgates with research, algorithms, evidence, and support.

3) Politics, Policy, and Funding The AMA decision does not have legal clout, but becomes a crucial guideline when setting medical policy and health regulations, and determining funding priorities. Honestly? I dislike the politicians legislating medical care as much as anyone, but at this point, I dislike lip service for obesity more. Fund us, and let us go to work.

How does Obesity as a Disease Benefit the Integrative Practitioner?

Functional Medicine combines the best of medical science with the newest of medical science, what some people consider “holistic”. I am just as likely to order labs, write a prescription for medication as I am to recommend a vitamin or herb, but the bulk of the healing occurs with lifestyle changes – one small change at a time – with lasting huge effects.  You can’t stop eating cheeseburgers and ice cream because you have an essential fatty acid deficiency and your brain is screaming for them. But once they are replenished in your body, using the correct ratio of fatty acids and a reputable brand which does not contain mostly junk fish oil, the cravings disappear. Not a thought, not a wish, not a command in your mind. Gone.

The more we learn, the more we have to offer. For some of the data, we’re currently working off of minimal research and findings, with a great deal of mainstream opposition. Remember the position of acupuncture 25 years ago? Now…acupuncture is totally mainstream, and covered by many insurers. We are in the early years with alternative obesity treatment. There is a dearth of substantial credible data, and we are relying mostly on observational or exploratory data or small studies lacking statistical power. And yet we know from those patients, one at a time, who have responded, that many alternative treatments have potential in the treatment of obesity.

Weight loss coach Steve Nicander, who lost 400 pounds through lifestyle changes, and promotes an holistic weight loss program, “Healthful Hope”, expresses this beautifully. Says Steve, “I may have lost a massive amount of weight, but in my mind I will always consider myself to be obese and have that potential to be again. What I think this will do is allow for better treatment methods starting with our chronic childhood obesity problem allowing them to feel more comfortable discussing it with their health care providers. I hope the best and biggest change coming from this new awareness is improved training in medical schools in dealing with this epidemic, where education is at a bare minimum. Holistic approaches and non-invasive measures, as you know, can still reverse the weight and cure the underlying diseases.”

Nothing works for everyone, most treatments work on someone.  Everyone needs to clean up their diet and increase their movement, but, as we now know, that may not be enough for people. Lately, I’m lying on my new pulsed electromagnetic stimulation device and running the obesity program to see if I lose weight with the same lifestyle (which is pretty organic but a little underexercised and overworked). So far down 7 pounds, is this for real? At the same time, I’m happy to share the latest animal data on green coffee beans which demonstrates absolutely no prevention of weight gain. I feel like I’m pitching blindfolded. It’s not enough. I need more, you need more, and just like the commercial with those adorable kids… I WANT MORE. The door just creaked open.

This blog was first published on the American Holistic Medical Association blog

Functional Medicine and Integrative/Bariatric Psychiatrist Sara Stein MD can be reached on her blog at obesefromtheheart.com/the-blog or in her office at Stein Wellness in Woodmere Ohio.

What do Angelina Jolie and Bariatric Surgery Patients Have in Common?

Angelina Jolie discovers she has a breast cancer gene, the same one that caused her mother to die an early death, and she decides on a proactive, and possibly radical, prevention – double mastectomy. By doing so, she lowers her risk of genetic breast cancer from 70% to 5%. No guarantees, but definitely improved odds of survival. Assuming she continues her lifestyle changes to support her good health.

So while everyone is debating the wisdom of either her decision or her open conversation, I find myself thinking about bariatric surgery patients.

Moderate to extreme obesity increases the odds of dying from all diseases exponentially. Just like having a gene for cancer increases the odds of dying from that cancer.

Before you start eye rolling and pulling an Abercrombie on me, let me state firmly that we have enough scientific evidence that obesity is NOT gluttony, but IS a chronic and difficult-to-control disease of altered physiology. Genetically things are not always working in your skinny favor. Physiologically your body wants to regain the weight you lost. Psychologically that struggle is exhausting.

Some people will make a decision that their weight is beyond their own control. They recognize the downhill course of associated illness, the march toward an early death, and choose a radical procedure to change that course. Bariatric surgeries are not without risk, and don’t always work, but the odds of survival improve dramatically when the surgery is successful. Assuming the patient can continue the lifestyle changes necessary to support their good health.

See the pattern?

It takes an extraordinary amount of courage to say I have a disease risk and I don’t want to succumb to it.

It takes an extraordinary amount of courage to have a radical surgery to prevent an early death.

It takes an extraordinary amount of courage to face your mortality, discard the wishful thinking, realistically assess the ability of modern medicine to save you, and move forward with a life-altering (and life-affirming) option.

It takes an extraordinary amount of courage to change your lifestyle and not look back.

Here’s the thing…

There isn’t a right decision here. The right decision is the one that works best for the individual patient, one they can adjust to and live with, one that fits into their lifestyle, one that moves them farther away from deadly illness.

I support Angelina Jolie and her surgery decision to save her life. No hindsight, only moving forward.

I support those of you who have bariatric surgery to save your lives. No hindsight, only moving forward.

There are no guarantees. Angelina may still need medical treatment for cancer, and bariatric surgery patients may still need medical treatment for obesity. To the scientists of the world, keep up the great research. To the doctors of the world, stay educated and open to possibility. To the patients of the world (and that is all of us), be proud of your courage, regardless of your decision, and stay vigilant.

That’s the only guarantee I have for you.

This post was originally published on kevinmd.com

WebMD’s Health Care Social Media Disaster – Read the Fine Print!

Occasionally, my vocation of treating obesity and my avocation of health care social media intersect.

This is one of those moments. This is the story of a health care social media betrayal in which obese children and e-patients are the victims. Nobody died, except medical ethics, good judgment, and trust in doctors. This is WebMD’s Health Care Social Media Disaster.

Big Cereal Comes to DC 5

Recently, WebMD published an “advertorial” from Kellogg’s: "Mums, kids & breakfast: The truth about sugar“ with a brief disclaimer, “This content is from our sponsor. The sponsor has sole editorial control.” The kind of disclaimer a casual visitor might easily overlook. Here are excerpts from the article, meant to convince you that sugary breakfast cereals are nutritious, and that sugar consumption is a healthy option for your children.

Myth #1 :Sugar is always responsible for tooth decay

The truth: Breakfast cereals eaten with milk, even pre-sweetened varieties, do not increase the risk of tooth decay.

Myth #2 : Sugar is bad for you

The truth: A panel of world health experts recently reviewed the scientific evidence and concluded that a high sugar intake is not related to the development of heart disease, diabetes, high blood pressure or cancer.

Myth #3: Some sugars are more nutritious than others

The truth: All sugars provide approximately 4 calories per gram. And despite popular belief, no type of sugar is more nutritious than any other.

Myth #4: Children should eat a lot less sugar than adults

The truth: Children do have different needs to adults, so they have different Guideline Daily Amounts (GDAs) for sugar. But not as different as you might think.

Because they are active and growing, children are not vastly different to the “average person” used on the front of the pack. In fact, for sugar, it is very similar indeed.

Guideline Daily Amounts (GDAs) for sugar: Average person – 90g; Children – 85g

Advertisers can claim pretty much anything as long as they can manipulate data. No surprise Big Food is fighting back on the attack on the nutrient value of processed food. The problem is not the advertisers. The problem is WebMD and the trust we want e-patients to have on the internet.

The main tenet of health care social media is to advise e-patients, also known as empowered patients, to seek out reliable and credible medical information, most often on major medical websites, including WebMD. We “soc med” docs are working hard to direct the 88% of patients getting healthcare information off the internet* to these sites. Our good faith and theirs. When a major medical site allows this level of misinformation in advertising, the average person is at serious risk.

Here are the tweets ….

@Appetite4Profit What happens when a medical site sells out to Big Food? Kellogg & WebMD report sugar’s good for you!

@AplusPaz Cigarettes are good for kids too, the nicotine kills bacteria within their stomach.

@MagWrites I guess that now really makes them cereal killers

@YoniFreedhoff Kellogg’s states 360 calories of sugar daily = good 4 kids. That’s 20-30% daily cals!

Obesity expert Dr. Yoni Freedhoff pondered the judgment of advertising authority in his blog, Weighty Matters, “I wonder who the WebMD genius was who decided giving sponsors sole editorial control over content was a good idea?”

I’m figuring it was the person who ate the sugared breakfast cereal, and was cognitively impaired for the rest of the day.

 

(This blog was originally published under the title “Sponsored content on health sites can mislead patients” on KevinMD.com 8-22-2011)

(Photo courtesy of Ted Eytan MD, http://tedeytan.com)

My Street Creds – The Real Medical Evidence Of Obesity

cropped fat Sara I am on an Obesity Mission. I’m going to single handedly (with lots of great help) change the way we treat obesity. And the way we treat obese people.  The following is an open letter to all the skinny doctors, trainers, dieticians and therapists in the world …

WITH ALL DUE RESPECT DOCTORS AND COLLEAGUES…YOU ARE WRONG ABOUT THE MEDICAL EVIDENCE!

Listen up. (That’s me BEFORE circa 2003). A fat doctor. Imagine. (Scroll down to see the AFTER).

Obesity is NOT simple thermodynamic imbalance. It’s not  how many calories we eat and how little we exercise.  That may be true for people who are overweight and have 20 or 30 or 40 pounds to lose. Any diet and exercise program that is basically healthy nutrition and movement will work for them; it’s just a matter of matchmaking – the right program for the right person.

For the rest of us, the obese…Eat Less Move More fails 95% of the time. Worse yet, severe restrictive diet and exercise may worsen, not improve, the obese person’s health. Emotional Eating and Behavioral Control don’t fare any better, but at least they don’t ruin someone’s health!  cropped thin Sara

Here’s me with a recent 2010 AFTER (down 100 lbs). Winning an award because I figured out how to lose weight and how to apply that knowledge to every patient I see and how to teach to anyone who will listen. (Thanks Kaiser!)

Here’s what I know about Obesity. I’ll share it all with you in the hopes that you will go back to your exam rooms and order some labs for starters.

Obesity is a medical condition of serious inflammation, chronic pain, disordered endocrine function, changes in insulin metabolism, altered brain chemistry, food sensitivities, serious vitamin and mineral deficiencies.

Obesity is a psychosocial condition of depression and hopelessness and isolation and loneliness.

Obesity is a spiritual condition of broken hearts and broken souls and broken families. It’s not how we feel inside, but it’s how the outside sees and reacts to us. It hurts to be fat. Physically, psychologically, socially and spiritually.

Now…does that sound like gluttony to you?

Yet, if I go to any one of you, even the most esteemed physician or medical center, you will tell me Eat Less, Move More.  Or you’ll send me to your behavioral health department because clearly there’s something wrong with me. There I will receive medication for depression and six weeks of therapy about how I’m a good person and I should love myself and not eat chocolate. Or you’ll throw up your hands and say I can have surgery, but I’m not sick enough to qualify yet. Wait a few years.

You can treat obesity, it’s easy. You already know how. But it’s not Eat Less Move More. And it’s not emotional.

It’s replacing Vitamin D, detecting Vitamin B12, A, Zinc, Iodine deficiencies, finding food allergies even when the lab tests are not sufficiently sensitive, treating pain and weakness with gentle movement therapy, jumping on that sleep disorder, correcting inflammation and insulin resistance, helping that sluggish thyroid, changing obesigenic medications to those with a more neutral weight profile. And yes, sometimes it’s sending us to behavioral health, but not nearly as often as you think.

You can treat obesity by understanding the many pathways and reactions that have been altered in response to excess inflammatory adipose and its causes. And one by one, correcting them. Just like you learned in medical school. Imagine that.

And I’m here to tell you, if  you do that, your patients will lose weight. And feel better. And love you forever.

Announcing the opening of Stein Wellness Centers in May 2011, dedicated to comprehensive and integrative treatment of obesity. In person and distance.

Offering free consultation to any medical professional.

See one, do one, teach one.

Sara Stein, M.D.

Stein Wellness Centers (opening May 2011)

800 680-3451

http://SteinWellness.com (under construction)

info@SteinWellness.com

A Matter of Size: The Deserving of Obesity

(An obese psychiatrist analyzes an obese comedy, A Matter of Size, the heartwarming story of four obese Israeli men and one woman who decide to quit dieting and become Sumo wrestlers)

They had me from the opening scene. The obese little boy gingerly lifting his foot, hoping the scale will drop down a bit at the school weigh-in. Thirty years later, morbidly obese, single and living with his mother, taking off his watch at the diet club weigh-in wishing that an ounce will matter.

The loving, interfering, nagging, long-suffering, conflicted mother. Why are you eating that, she asks him as he unloads the refrigerator in the night. He argues until she begrudgingly gives in, if you want there’s rice to go with it.

The brand new pants in the used-to-be right size that fit like sausage casing.

The diet club. The misguided skinny diet director who thinks tough love and sarcasm will make fat people lose weight. That’s because we haven’t had enough bullying in our lives.

The looks, the nasty comments, the derisiveness, defensiveness, the loneliness, the rejection.

They had me back in my childhood, in my adulthood, in pain and embarrassment and agony. I felt so badly for the people in the movie. I felt so badly for me. Obesity is the heart of loneliness.

And then everything changed. These weren’t fat suffering people. These were resilient, strong, courageous people. People who took lemons and made lemonade. They fell down time and time again, and picked themselves up from the insults and the sneers and the disdain. Just in order to have a life and love and happiness. Out of obesity came sumo.

Obese people kissing on the screen. Fat people in love. In tears and fears. With hopes and dreams. Imagine that.

A film that depicts obese people the way we are… simply human beings, divine creations, with perfections and imperfections that allow us to stand out as individuals, and combine into relationship and community.

A film that depicts our struggles the way they actually exist.

In all of my pounds and all of my years, believing I deserve a good life has been my biggest struggle. Losing those pounds one at a time did not increase my feeling of worth.

What changed my life was accepting those pounds. One at a time. And allowing those same pounds to leave – one at a time – because they no longer represented who I was inside. The essence of me was not how my body looked or acted or felt. The essence of me was how I loved and cared and created. The essence of me was not fat. It was life.

And for that reason alone, obese people

Deserve love in our relationships

Deserve success in our endeavors

Deserve respect for our efforts at making a life.

“My heart is not a muscle.” My soul is not obesity.

The lesson of sumo, and of comedy, is acceptance and deserving…and seeing the divine romance of it all.

Dr. Stein will be facilitating a community discussion on obesity following the screening of A Matter of Size at the Cedar-Lee Theatre in Cleveland, OH on October 9, 2010 beginning at 9 pm. Please join us!

NOOOOO!!! An Open Letter to Oprah on Obesity

NOOOOOO!!! That eardrum shattering scream you just heard was mine after I listened to Oprah Winfrey (I adore her) talk about her very public weight gain with emotional eating maven Geneen Roth. (Oprah on a Time She Forgot Her Loveliness, 5-11-2010)

I hear the thundering herd of hoof beats running for a book THAT IS NOT MEANT FOR OBESITY. And I hear the collective thud a month or two from now, of millions of copies tossed into the failed diet books collection. (Yes, we have those).

Don’t get me wrong – Geneen’s elegantly worded conversation on emotional eating is entirely appropriate for someone with 30 pounds to lose, or binge eating, or anorexia-bulimia. She even says that. Yet the audience was stocked full of morbidly obese people. Like me. And Oprah, God love her.

Certainly obese people have emotional eating that needs to be worked through for successful weight loss. But it is NOT the predominant driving force behind sustained obesity.

“I shamed my fat self”, Oprah said, “when I put myself on the cover of O and said how did I let this happen again”.

OPRAH! YOU DIDN’T LET IT HAPPEN! Anymore than you LET your bladder fill or LET your body go to sleep. This is your brain and body we’re talking about, not your soul.

Yo-yo dieting and weight regain are NOT the result of weak wills. THEY ARE THE RESULT OF AILING BODIES. And frantic brains trying to heal them.

Obesity is NOT a state of feeling badly about oneself – it is a MEDICAL CONDITION…with:

1) Chronic Inflammation, Pain and Exhaustion –  Addicted to sugar and caffeine? Maybe you’re an ENERGY addict! It takes additional energy in the form of calories to move your extra-large aching, swollen, inflammed self down the hall. The worse your end-stage illnesses of obesity are (such as sleep apnea, diabetes, arthritis, fibromyalgia, hypothyroid), the longer that hallway becomes. Even if the end-stage illnesses have not yet manifested, the inflammation of obesity is simmering inside you, and exhausting you.

2) Altered Metabolic Pathways – abnormal insulin, leptin, cortisol metabolism (and others) cause the obese person to hold on to weight, be hungry all the time, have higher blood sugar and insane food cravings. Your continuously elevated stress hormones have convinced your trillions of cells to HANG ON TO EVERY BIT OF FAT BECAUSE WE”RE IN A FAMINE!! Don’t you wish you could explain grocery stores to them?

3) Altered Brain Chemistry – Depressed and anxious brains screaming for serotonin and GABA and dopamine driving you possessed toward the chocolate counter. Searching for oxytocin love in all that comfort ice cream and macaroni and cheese. Driven by sleep deprivation, changes in genetic expression and medication effects. Responding to toxic food injury from junk food as addicting as crack cocaine in your brain. This is not emotional eating; this is your brain directing your chemistry ingredients.

4) Severe Vitamin and Mineral Deficiencies – such as (but not limited to) D, B12, A, iodine, fatty acids:

Vitamin D from the sun – a prehormone – manufactured by the cholesterol in your skin when exposed to that beautiful yellow orb in the sky. Vitamin D that gives us energy and happiness and relaxation and protects us from diabetes and heart disease and cancer and obesity. You don’t get credit if you stay indoors and look out the window, or if you live in Cleveland like I do and there isn’t any sun half the year, or if you’re African American and your skin acts like sunscreen. And you’re never going to be able to lose weight with Vitamin D deficiency until it is corrected.

Vitamin B12 from animal proteins (not vegan diets). Blocked from absorbing by all those prescription reflux medications. Vitamin B12 that gives us energy, memory, concentration, happy moods, relaxation.

Vitamin A from fruits and vegetables for our skin and eyes – night blindness, psoriasis, eczema – the 5th leading cause of blindness in the world – not found in junk food, you can be sure, but a good carrot or sweet potato might help.

Mineral and element deficiencies like Iodine – Iodine that keeps your thyroid running and your breast tissues healthy, essential for the production of every hormone. Added to salt in the early 1900’s so you wouldn’t get a thyroid goiter, but now you eat fancy non-iodized kosher salt and sea salt or no salt at all. Iodine that used to be in flour until the 1970’s when it was replaced by bromine (the stuff they gave soldiers in World War II to kill their sex drives!)  Makes you tired, in pain, obese, dull.

Essential fatty acid deficiency – I know you’re eating fish 3 times a day, right? Essential means brain function – attention deficit disorder, memory, mood. Essential means skin – eczema, rash, dryness. Essential means inflammation and immune function – cancer, heart disease, arthritis, dementia. My grandmother frying those smelts every week – she knew something!

5) Food sensitivities like 1) gluten from all that fake wheat processed stuff used to thicken, texturize and cheapen your food, 2) corn from the high fructose corn syrup that makes you gain MORE weight than the same caloric amount of sugar; 3) processed soy that slows your thyroid down because it’s no longer recognizable to your immune system. 60% of people with obesity have food sensitivities, aka allergies.

Now…does that sound like ‘”only eat when you’re hungry in a quiet room focused on food” is really going to make a difference?? Treating morbid obesity with emotional eating techniques is the same as treating cirrhosis of the liver with 12-step programs. The proverbial peeing in the ocean.

Here are some suggestions if you are obese.

Get your vitamin and mineral levels checked. Be careful of those who tell you what you should be eating. Pay attention to when you feel sick, what did you eat in the last 24 hours? The hell trinity of obesity is gluten, dairy and sugar. Purify your food and water sources. If you can’t pronounce it or picture it, don’t eat it. It’s making you fat, and that INCLUDES artificial sweeteners. Forget gourmet, aim for plain. Like grandma used to make. Whatever you’re doing now…do the opposite. Get out of the chair. Sleep more. Eat grapes. Watch less TV. Spend more quiet time. Work less. Work out less. Play more. Do nothing that causes physical or emotional pain. Take baths. Dance in a chair. And if you cannot do anything at all, at least get a little sun.

Try 70% dark chocolate EVERYDAY to fool your body about that famine delusion. The heavenly trinity that treats depression…exercise, Vitamin D and dark chocolate. Can you add one in?

There is hope and healing from obesity. One medical condition at a time. Give your emotional soul a rest.

Sara L. Stein, M.D., is a bariatric and integrative psychiatrist  who runs Obesity Clinic at Kaiser Permanente in Cleveland, and is the author of Obese From The Heart: A Fat Psychiatrist Discloses (2009). Learn more at http://obesefromtheheart.com

I Know I Am Obese; Where Do I Begin??

This is the question I am most often asked. My patients come dragging in reluctantly, sent to Obesity Clinic by the primary care doctor or their own frustration and failing health. They are certain they will be given a lecture and a diet or told to go have surgery. They are surprised when they leave my office with directions to eat chocolate, take these supplements, get some more rest, and stop working out so hard.

“WRONG” says the medical world and the diet industry and every magazine you read. Restrict your diet! Quit eating things you crave! Work out harder! No pain, no gain! YOU MUST SUFFER!!!

Puhleeze. As if obese people aren’t already suffering.  Apparently all those skinny trainers and nutritionists and doctors think we were having a great time during those lonely nights by the refrigerator or trying to run in gym class with our thighs chafing.

I have news for you if you are obese. You have suffered enough. You have struggled enough. It isn’t difficult to lose weight, it’s just different than what you have been told.

By the time a person has become obese, they have an ailing body, even if there are no visible end-stage diseases such as diabetes or hypertension. Pain, inflammation, changes in metabolism, nutritional deficiencies, altered brain chemistry. It’s not fun to be morbidly obese. It hurts physically and emotionally.

If you push a broken body (or a broken car) too hard, it breaks down further. To your body, exercising and nearly starving feels like incredible stress. So does divorce, bankruptcy, unemployment, problems with your kids, or working two jobs. Your brain doesn’t make a distinction between one bad stressor and another bad stressor. To your million-year old brain, bad stress means the famine is coming. (Remember that one? 7 lean years?) “OMG,” says your brain to each one of your body’s many trillion cells, ”We’re starving to death…HOLD ON TO OUR FAT!!! We need it!”

Ever see the program where the fat people stop losing weight as the workouts get harder, until they go home, relax and eat? It’s called stress relief.

Welcome to the No-Stress Zone. Here’s where you start, and this is the first of many blogs that will help.

You start by determining what very small change in your food you can make today that will not send your brain into a starvation frenzy. If you drink 5 sodas a day, can you drink 4 and one water? If you skip breakfast and binge every night, could you move a little food earlier in the day? My first change was drinking coffee instead of lattes. And if I really wanted a latte, I would have one.

Next, what movement can you do that WILL NOT HURT?? Can you stretch a little in your chair? Can you walk a little? I started out cycling my legs in the bathtub – it was the only place I didn’t have pain.

Finally, what joyful or relaxing moment can you treat yourself to today? When’s the last time you heard music you loved, or called someone you care about? Or took 10 minutes to read something beautiful?

And when you wake up tomorrow, do this again. A little further. A little longer. And again the next day, and the next.

That’s it.

That’s the secret to losing weight with obesity.

Small, easy, sequential changes that add up over time. And give your body and your mind a chance to heal with each small adjustment.  From my husband who lost over 100 lbs: “Tell them this is the first of many small changes they’ll make, and they’ll be surprised how easily they rack up.”

Now that didn’t hurt, did it?

Trading Sex for Food – Tiger’s Search for Dopamine?

So Tiger Woods is a sex addict and goes to rehab…and gains 30 pounds.

Maybe the food there is great, but probably not; or maybe he’s sitting around doing nothing, but probably not. The food isn’t as good as fine dining, and certainly not good enough for fine golfing. Plus, he was photographed going for a run.

So why is he eating so much?

He can’t help it. His brain is screaming for “substances”. Not sex – dopamine and oxytocin and serotonin and norepinephrine and endorphins…he has the brain of an addict. Here’s the breaking news. So do we all – it is what enables us to experience blissful pleasure.

I understand Tiger Woods. Well, maybe not his choice in sex partners, but I understand the insane cravings. He craves sex. I craved food. You might crave alcohol or drugs or tobacco or gambling or shopping or working or exercising or rage…

Our brains have a built-in reactor system to determine “things-that-make-us-feel-really-great”. We respond to life’s greatest pleasures with a chemical explosion that rocks our world. Without this internal nuclear reactor, we would ho-hum through every moment of our lives. With the reactor, it only takes one orgasm to love sex. It only took me one chocolate chip cookie to love food.

The moments of an orgasm or a taste of chocolate are fast and fleeting – the natural timing of brain chemicals. Like fireworks. If you blink, you miss them. We quickly return to our baseline mundane and uninspired living. Boring is our neutral. (Some people call it calm, most addicts call it boring).

And here’s the really bad news, known to every addict of any substance. The bliss level is never the same as the first time. Your brain accommodates to stimulation – good, bad or ugly. You get used to sex or chocolate or CSI or winning. And it takes more and more of your substance of choice to get the same level of explosion. When I was four, it only took one cookie to reach nirvana. Nowadays I would need an entire factory. After awhile you can’t get there at all. Unless you keep changing it up a bit.

So why would anyone keep doing a substance that isn’t even bringing them joy anymore?

You only have to look at Tiger to understand. He looks depressed. It’s the day after the binge, and he’s crashing. And while it’s tempting to say ‘of course he’s depressed, look what he’s done to his life’, the reality is that much of what is happening in his depressed brain is a biochemical rebound of misery. It takes a nanosecond to explode feel-good chemicals in your brain; it can take weeks or months or years to replenish them. Forget the highs. He keeps using to stay at neutral. Anything to avoid the crash.

I feel for the guy.

There really isn’t any difference between us. Our brains all crave reward, stimulation, excitement, curiosity, feeling good. Even to point of overindulgence.

Life is filled with joys that can create the same explosion of feel-good chemicals, without destroying your life or health or emotional well-being. Exercise will release dopamine and keep the level high for more than a day, unless you do it for a living and have attached the stress of daily life to it. Music, art, love, petting your animal, aromas, company, movement, prayer, meditation, playing with your children or grandchildren, and many others. It may not be as dramatic or intense the first time around, but it sustains you with a deep and abiding joy.

And it stops the cravings.

Is Kevin Smith Too Fat To Fly? Thoughts on Obese Discrimination

What difference does it make if a fat producer is kicked off an airline? Isn’t that a private issue between the passenger and the company? If he didn’t fit in the seat, he should get off the plane, right?

Wrong.

This one had me from the first tweet. Even if I had to ask my husband who is Kevin Smith other than a guy with 1.6 MILLION followers on Twitter? (Answer: a producer of movies that teen & 20 & 30-somethings love).

A lifelong big guy, returning home after speaking at MACWorld, is seated as a standby on a Southwest Airlines Oakland-to-Burbank flight and then summarily ejected because he is a “safety” problem. One that involves the width of his body in his seat. (I still don’t get that one, what’s the safety problem?)

Of course, they saw his body habitus when they ticketed him at the gate for standby. They sized it up again when they seated him. They saw that his seatbelt fastened without an extender and his armrests went down. They polled the two ladies on either side who didn’t object to his presence.

Yet they made him get up from his seat in front of 150 watching people, retrieve his carry-on luggage from the overhead compartment and get off the plane. Like the bad kid being sent to the principal’s office.

And he was FURIOUS!!! And tweeted all night long.

I’m pretty confused about this. I like Southwest. I fly them, their seats are comfortable, their service is pleasant. They were extremely nice to my 88 year old father who needed some extra assistance last fall. But I am also a person with lifelong obesity. And there have been times in my life, 90 lbs ago, when I needed a seatbelt extender. I did my best to stay within the boundaries of my seat and be invisible and non-offensive.

So why can’t the airline just say they screwed up?

Instead Southwest has created a public relations disaster in which they blog their apology by making fun of his comedic character “Silent Bob” and his real-life angry persona. They titled their blog “Not So Silent Bob”, and defended their customer size policy while intimating that his badmouthing the airline publicly was oh-so-unfair. Unfortunately, they also explain the parameters of the customer size policy which, in this case, appear to have been applied arbitrarily if indeed he successfully buckled and put his armrests down. I’m guessing he was profiled more on his hoodie & pants-on-the-floor look than his actual size.

Blaming the fat guy for discussing the anger-causing events never works well for the merchant. You’d think they would just say, “we made a mistake, you fit in the seat, we’re really sorry, we misapplied the policy, we’ll make sure it doesn’t happen again”. Doesn’t require they rescind the policy, just acknowledges they were overzealous in its application.

The story doesn’t end there – it gets worse.

Smith put up a long, rambling, profane “Smodcast” (his name for his podcasts) of the events. The ‘AHA!’ moment occurs more than 50 minutes into the rant.

On the next flight, he had two paid seats of his own. An obese young woman was seated in the third seat; his paid-for, empty middle seat between them. After she was seated and settled, the attendant took HER to the principal’s office. Where she was told that she had to ASK PERMISSION from our fat producer to spill over into his empty seat, or she would be ejected too. And next time, she should purchase two seats. Different flight, different crew, different passengers (except for our angry producer).

Bullseye! Kudos to the airline. You have now effectively destroyed the very shaky self-esteem of yet another fat person who will invisibly skulk away into the night in shame, never to fly your airline again without paying double.

Now I’m furious. Once is a misapplication of a policy. Twice is a pattern of pointless and opportunistic discrimination. No wonder they didn’t apologize. They feel righteous in their contempt for adiposity.

And so do hundreds, if not thousands, of commenting passengers on forums, blogs, tweets. Thousands are in support of the producer (and by proxy, the woman on the second flight); some vow to boycott the airlines forever. But thousands others have seized the opportunity to be venomous and verbose slayers of fat people. (often anonymously, gee I wonder why).

The language is at best intolerant and unforgiving. Those are the people who are talking about being uncomfortable on an airplane. They have a point, although it could be expanded to include passengers who drink, smell of cigarettes or perfume, have screaming babies, or crack chewing gum among other encroaching habits.

At its worst, however, the language in these comments is frightening and revolting, almost horrific. If you changed the word fat to black or Jewish or female or gay or Muslim….the rhetoric would sound illegal. These people aren’t commenting about their crowded seat. They are taking the opportunity to express mindless, revulsive hatred against a group they feel is inferior to them.

Southwest needs to take a step back from this sizeable group, and from their uneven and discriminatory enforcement of “customer size policy”, and return to the idea of helping ALL people navigate the often difficult world of airline travel. With dignity and respect. Just the way they treated my dad.

If you have been a victim of obese discrimination, you are not alone. It is the last unanswered prejudice. Do what Kevin Smith had the bravery to do. Tell your story, even if just to a friend or a family member. Be assured that you do not deserve to be hated or hurt because of your weight. Or your skin color, religion, sexual preference, gender, political beliefs…

So to answer the question about why we should care because a fat producer got kicked off a plane…

Maybe we should care because it is uncovering the worst in us, both individually and corporately.

Sara L. Stein, M.D.
Author, Obese From The Heart: A Fat Psychiatrist Discloses (2009)

On Childhood Obesity and Genetics – It’s All in The Family!

Today at noon First Lady Michelle Obama unveils a new Nationwide Initiative on Childhood Obesity. About 1/3 of our children are overweight, 1 in 5 are obese. In some states, the numbers are nearing 50%. These numbers go up as people age. Currently 60% of adults in our nation are overweight and 30% are obese.

Clearly this is a progressive condition. It’s getting worse. We’re getting worse. More people are getting fatter and sicker as they get older. The prevalence of obesity has risen 3000% in the last couple of generations. That is NOT an explosion of genetic illness.

It is convenient and absolving of responsibility to think that our DNA is causing obesity. While there are genetic obesity syndromes, they are rare – estimated at 1 in 7000 obese people. These syndromes present very early in childhood and are often accompanied by other developmental conditions. That means that 6999 out of every 7000 obese persons have to find another reason for their overweight besides their genes!

The genetics of obesity is how your body distributes fat, and what shape you are. Apple vs pear is genetic. Gaining weight as a result of eating too much is not.

Still, for those of you who insist on genetics as a cause of your obesity, you’re right. Sort of.

Most of the genetics of obesity involves on-off switches that regulate metabolism, inflammation, energy. Low quality foods, nutritional deficiencies, artificial additives and preservatives can flip the gain-weight or the do-not-lose or even the burn-calories-slower switch. If you are obese and dieting, it may not be your imagination that you are not eating much and still not losing weight.

Obesity IS generational and familial and cultural. We become overweight because we are served certain foods in an environment that encourages us to eat. It might be low quality food, or it might be the highest calorie home cooking of our dreams. We overeat because we attach meaning and emotion to our food, whether it’s the SuperBowl, Christmas or a funeral. Quickly we learn to use food to regulate our emotions, our energy, our happiness on a daily basis.

What about exercise? You need it! Your body is designed to move, and without movement, you become ill. It gets better though. When you combine healthier foods with movement, those on/off gene switches go back to where they are supposed to be, and your body weight begins to readjust. It doesn’t take starvation and boot camp and pain. It may just take a few less preservatives, a little more home cooking, and a walk after dinner. And a good nights sleep.

So what do you do for you and your children and your family? Here’s the good news.

If you come from a family that has always used food as a measure of the joy and sadness of life, try music instead. Use food for fuel, not emotional fullfillment. Use love as comfort, not ice cream. Use movement to blow off steam, not potato chips. Use prayer and meditation to find your bliss, not cookies. Use your family as your support, not your frustration. In the end, all we have is each other. With or without the meal.

Now you can live with that, can’t you?

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