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

Viagra for Women: Why Your Doctor Might Prescribe 50 Shades of Grey

Could “mommy porn” have value in the doctor’s office? Unless you live in a cave (and we physicians sometimes do), you have heard of British author E.L. James’ modern erotic 50 Shades of Grey trilogy, 30-plus million copies sold, overwhelmingly to women. The trilogy is an erotic love story about a naïve college graduate who rescues an abused billionaire – a blend of the Story of O, Pretty Woman and a Danielle Steele novel. Not great literature, but clearly having some effect on the libido of millions of women. Do we finally have a safe and affordable clinical tool for women with blunted libidos and hypoactive sexual desire?

The prevalence of decreased female sexual desire and responsiveness has been estimated from 15 – 53%, higher in menopause and perimenopause. In one study, half of women with these symptoms spoke to their doctors about the problem, yet doctors have very few tools for women with hypoactive sexual desire. The phosphodiesterase inhibitors (nitric oxide agonists) such as Viagra increase genital circulation and can effectively treat erectile dysfunction in men, but have shown no benefit in women. Testosterone patches may increase sexual desire and satisfaction in both surgically and naturally menopausal women, but side effects can be uncomfortable, and long-term safety has not yet been established. The jury is still out on the effectiveness of adrenal hormone DHEA replacement, and herbal remedies such as gingko biloba.

So into the office walks a middle-aged female with a normal amount of stress, in a relationship that is comfortable but not passionate, and she wants her mojo back. Where does the doctor start and what is there to offer?

First, the differential diagnosis for diminished sexual desire and responsiveness in women: stress, relationship problems, depression, diabetes, endocrine (thyroid, prolactin, sex hormones), medication side effects (particularly antidepressants and blood pressure medication), vascular disease, nutritional deficiencies (and side effects of too much junk food), substance abuse, past history of trauma for starters. Eventually everything correctable has been corrected, you and your doctor have made a joint decision about the pros and cons of hormone replacement therapy … and still … no fire. Now what?

Think the missing hormone … oxytocin. That old induce-labor bag of pitocin IV hung on all those moms-to-be who weren’t progressing. Oxytocin, a major player in female sexual desire and responsiveness, released during any kind of cuddling – romantic, parental, puppies, and released during orgasm. And most importantly, released while reading romantic, erotic literature. But oxytocin blood tests are largely experimental and oxytocin replacement is not easily available at the pharmacy. How do you know if you have an oxytocin deficiency, and if it can be behaviorally corrected?

You take the oxytocin challenge test – read the entire Fifty Shades trilogy (all 3 books) in one week’s time, and see how you feel. (Don’t stop at the first book, it takes the next 2 books for the desired effect).

One middle-aged woman reported her animals sat next to her while she was reading, and she felt more connected and cuddly, but it didn’t save her relationship. She realized her lack of sexual desire was not physiological, but a result of relationship issues.

A younger woman reported more intense bonding with her young children and husband, and the “biggest orgasm” of her life.

A post-menopausal woman reported that she started to feel desire for her husband again, and had an increase in frequency of intercourse “like 20 years ago,” without hormone replacement, and with no change in their marriage. (He was delighted).

No meds, just books.

The key to the success of these books in women is not the abundant sex scenes, but the romance, and the massive release of oxytocin women experience as a result of immersing themselves in the “love” part of the book. Hearts and flowers increase desire in women; thus the success of the “chick flick” for dates.

Let’s face it. Pornography, written and visual, has existed forever, but remains a greater male stimulant than female. That difference is driven by physiology – women are not aroused by visual pornography to the degree that men are aroused. Male libido is stimulated more by visual and tactile erotic images and sensations – leading to a massive release of norepinephrine (energy/aggression) and dopamine (pleasure/reward). For men, increases in dopamine and norepinephrine appear to play a greater role in arousal than in women, whose arousal seems to be largely oxytocin driven.

What about men? Is there a diagnostic and treatment role for Fifty Shades and the like genre? As a sex manual, Fifty Shades has merit as a “touch here, kiss there, try this” benefit. As a male turn-on … maybe, but don’t count on it.  Cuddle? Pleasant, but not erection-inducing.

Is there anyone who should NOT read the Fifty Shades series? Yes – it may be too intense for younger women, even if sexually active, and it may be a trigger for women with sexual trauma or abuse histories, or it may simply be offensive. That said it’s certainly worth having a conversation with your doctor, and maybe getting a prescription for the bookstore or the library (if the waiting list isn’t too long!). You’ll love your doctor in the end.

This blog was originally posted on kevinmd.com

Dr. Sara Stein on the Medicinal Use for 50 Shades – Fox8 11-07-2012

STRESS EATING: RUNNING ON EMPTY

Stress is society’s greatest modern affliction. We have completely lost control of our workdays. A workday used to be dawn to dusk. It used to be from the time you arrived at your workplace until you went home. It used to be 5 days a week. Not anymore. We work constantly, 24 hours a day, 7 days a week. We work at our jobs, in our homes, at school, in traffic, at the grocery store. We work shopping on the Internet.

When we are resting, we are working: making lists, setting goals, reviewing today, and planning for tomorrow. We are not resting.

We continually increase our workload because work is addicting. We physically experience an increase in adrenalin, and energy and focus that expands our productivity. It’s a rewarding feeling to do a good job at something.

We add more work so we can feel even better. We start multi-tasking: the dishes, and the laundry, and the homework and the science project.

We add more forms of communication: television, radio, email, Internet, regular mail, newspapers, magazines, cell phones, voicemail, text messaging.More lives to keep track of, including people we don’t even know. Pretty soon, there is no time and we are multi-tasking every task, including some that should be enjoyable.

We read while we eat, we talk while we drive, we work on three things at once. Simple pleasures are eroded by a sense of urgency and the need for more adrenalin to keep us going. No time to say, “Hello”, “Goodbye”.

We work this hard because our society sets up overwork as a model of success. “Supermoms”, mandatory overtime, full-time students with full-time jobs.

One day I saw a 40-ish single mom who was working two jobs, going to school full-time and raising her children. She was exhausted, stressed, depressed, gaining weight and forgetting things.

“Why are you doing all of this”, I asked.

“For my kids, so I can get a better job.”

I looked at her without any humor, and replied, “If you live long enough”.

We are operating at a level of INTENSITY that causes DISEASE.

We have lost our ability to play, and live and love. We have lost our ability to experience emotion because we are so busy working. We have lost the ability to relax, and think and be alone with ourselves. We have lost the ability to feel content with our circumstances. We have forgotten how to look at the sky and wonder about the stars.

We have lost the ability to experience emotion when we are under severe chronic stress.

Hard at work and numbed out to everything and everybody.

When it’s time for me to relax and have fun, I often cannot. Unless I eat. Then I relax. The food pours out dopamine and GABA and serotonin and acetylcholine into my parched brain until I am positively serene. Am I relaxing because I’m healthy? Or am I relaxing because the food just drugged me into forgetting what I was doing.

For the five or ten minutes that you are stress-eating, your brain is transported to a lower-stress zone. You give your body, your brain, and everyone else in your life a break from the jagged energy you are projecting.

If you are eating all the time in response to stress, “all the time” is simply a reflection of HOW STRESSED YOU ARE!

Just in case you thought this was only about your own personal stress, there’s more. You can also absorb other people’s stress, particularly if they are close to you. Stressed people have a tendency to pour out their problems in rapid-fire succession, one after another, with great energy and emotion.

Relief from stress is about learning to say no: no to demands, no to internal goals, no to family expectations, no to overzealous work projects. Saying no does not mean quitting your job in a bad economy, nor does it mean walking away from a difficult supervisor and getting fired. Saying no means acknowledging your physical and emotional limits and respecting them.

Relief from stress is about recognizing your body’s signals. When you cannot sleep, and you cannot relax, and you cannot stop thinking about work, you are overworked.

The solution to stress and overwork lies in learning and practicing proper endings. To be able to say this is my workday and I am now off. This is my homework time and it is now over. The day’s work has ended and this is my sleep time. This is my stress, and this is yours and I cannot accept it. These are boundaries, yours, mine, and ours.

The solution for stress is to recognize that for your body, rest is as essential as exercise.

For your brain, quiet is as vital as thinking.

For your spirit, solitude is as healing as company.

The solution to stress is to accept your humanity and all its limitations.

excerpt from Obese From The Heart: A Fat Psychiatrist Discloses ©Sara L. Stein, M.D 2009 http://obesefromtheheart.com