Anything Is Possible Fitness

Fat City: What Can Stop Obesity?

This is a rather long article but definitely worth the read. It is written by a physician in an obesity clinic. I think it hits the nail on the head in summing up the obesity epidemic we face in our present society. We’ve gotten so accustomed to a reliance on western medicine to cure all our ills – “I’m fat, make me skinny”, “I’m depressed, make me happy”, “My blood pressure is high, make it lower” – that we no longer take responsibility for our own actions.

This year I started work as the physician in an obesity clinic with a group of bariatric surgeons. No one else really wanted to do it. The attempt to help people lose weight is generally seen as one of the most futile acts we as doctors of internal medicine can perform: pretty much all we can do is make you feel crappier about yourself than you already do. But the surgeons can do something: they can clamp a band at the top of your stomach, cut half your stomach out or bypass part of your small intestine so food is not absorbed. The waiting list for our clinic is long. One of my patients gained 60 kilos between referral and consultation. Some of our patients have become so fat they can walk only five steps without needing a rest. Many are only in their 30s. My role at the clinic is to tighten up their diabetes control, make sure they don’t have a catastrophic hormonal condition that has made them fat (no one ever does), treat their high blood pressure and discuss eating and exercise habits. To each patient we show a cartoon of a bolus of food traveling down the surprisingly long oesophagus and squeezing through the junction that leads to the stomach. I watch the food moving down slowly, over and over, one viewing per patient. This is how your food goes down, so if the surgeons lock a band here, it will take four times as long. You’ll have to slow right down when you eat or you will vomit it all back out.

Now, every time I eat I imagine the food going down my throat, being squeezed by the muscles in my oesophagus before landing with a splat in my smaller-than-I’d-thought stomach. I find myself chewing more and waiting between mouthfuls. Sometimes I even put my fork down on the side of my plate between bites. I’d never done that before; I’d been an eat-and-run kind of girl. I was not at all overweight, but by the third clinic I’d lost 5 kilos.

When my brother was 30, he developed high blood pressure. A general physician checked him out for secondary causes. My brother drank a lot of whisky, smoked, and ate a ridiculous amount of food. It turned out these were the causes. The doctor advised that if my brother religiously took the handful of pills he was about to prescribe, he could get him another 20 years or so. The doctor picked up his pen, opened the script pad. My brother turned white. “Hang on,” he said, “I’d like a couple more years than that.”

Drugs can help you stay healthy when you are fat, but drugs and doctors cost money. If you are overweight, you cost 25% more per year to keep healthy than a slim person. If you are obese, you cost 45% more. And no drug can fix the functional impairment of being obese. Strap two fully loaded suitcases to the back of someone of normal weight and make them walk up stairs. That only gets them to around 120 kg, which isn’t even close to the weight of many patients I see breaking into a sweat on the walk from the waiting room to my office, their knee joints slowly disintegrating. But so what? Motorized scooters are not so expensive. They too could be covered by Medicare.

There are other costs: the fatter you are the greater your ecological footprint. Globally, we are carrying 18.5 million tones of excess fat under the skin of the overweight and obese, which – if it were still food rather than adipose tissue  – would feed 300 million people for life. Fat people have been compared to petrol-guzzling cars. I feel terrible typing these sentences. I apologize; they are ugly.

I had a friend who had been anorexic and spent her teenage years in and out of hospital, being fed through a nasogastric tube. She recovered in her 20s and managed to channel all of her intrusive obsessional thinking about food into athletics. One day she said to me that she didn’t understand why she could be hospitalized against her will for not eating enough, and yet there was no limitation on how fat you could get. It was completely unfair, she said, that you could be refused alcohol if intoxicated but roll into your local fish-and-chip shop 100 kg overweight and be served the equivalent of a week’s worth of calories for lunch.

In some ways, scientific research has taken obesity outside the realm where it is a consequence of choices made by a more or less free-willed individual in a more or less free society, which nonetheless disapproves of excess. In current medical research obesity is often conceptualized as an unavoidable disease. It’s your genes, your metabolism, the chemicals in your environment, what your mother ate when she was pregnant, whether she fed you at her breast. It is everything but what you choose to put in your mouth.

From a biological point of view, once the stomach has reached capacity, further consumption of food should cause more pain than pleasure. There are well-documented peripheral and central mechanisms – hormones, receptors – that should trigger an aversion to eating any more. But that depends on how strong the pleasure attached to the consumption is. Your stomach is full, but will you say no if I hold my finger dipped in melted dark chocolate to your lips? What if your house is empty and your stomach is full, but you have a bowl full of crunchy somethings sitting in your lap that will make the nothing on television seem bearable? What if inside and out of the house is a constant barrage of powerful images convincing you that the crunchy crap tastes fabulous, and it costs only four dollars for two jumbo packs?

I ask a young 200-kilo patient what he snacks on. “Nothing,” he says. I look him in the eye. Nothing? He nods. I ask him about his chronic skin infections, his diabetes. He tears up: “I eat hot chips and fried dim sims and drink three bottles of Coke every afternoon. The truth is I’m addicted to eating. I’m addicted.” He punches his thigh.

Addicted. The word is useless in my clinic, a mere barrier to any hope of self-determined change. My patient is not addicted; he’s a very lonely, unemployed young man who has gradually become socially isolated to the extent that the only thing available to him for comfort and entertainment is food. He has no friends, no money to buy other consumables, little education, no partner, no job. Some days he doesn’t leave his bed. The choice for him is to eat this food or experience no pleasure. The surgeon and I discuss his situation, concerned that he may overeat after the band has been fitted. We tell him that surgery may not be appropriate for him, given his situation. The patient is perturbed. “Well, what are you going to do for me if you won’t do the operation? Don’t you have some kind of ethical responsibility to help me lose weight?”

This is where the obesity-as-disease concept leads us – to a situation in which people demand that medicine shoulder the responsibility. What about the responsibility of the individual? And of society? My patient cries because the highlight of his day is returning from the supermarket with a plastic bag full of junk that he will eat and drink in his empty lounge room. What can I do for him? I can threaten him with his early demise, intensify his shame. I can offer him some evidence-based motivational lifestyle interventions – swap Coke for Diet Coke! Prescribe exercise? Walk for an hour at an average pace and you’ll only burn off the equivalent of one slice of bread. I could take the old-fashioned approach and wire his jaw shut. I have no hope of resolving his loneliness, his hopelessness, his lack of a job. I could, and do, refer him to a psychologist – if he’s lucky he may land one who is talented and sensitive and will try to get to the root of why this young man hates his own guts. More likely he’ll be offered a few sessions of behavioral therapy that will make everyone except him feel better.

But he’s not like us, is he? He’s in the minority; most people are just 20 or so kilos overweight. He’s one of those people with an overeating disorder. Actually, I think he is just like most people, but he’s got his volume on full. Corporations make it easier for us to eat than to abstain. They loudly promote and supply cheap, taste-intense, non-sating food that is bad for our bodies. They know us better than medicine does. When a fast-food chain dropped its television ads for a weekend, its revenue that week fell by more than 25%. There are more shelves in some supermarkets selling highly processed, nutrient-free combinations of starch, fat, sugar and coloring than there are bearing fresh fruit, vegetables, meat and grains combined. Very few people get obese and none get morbidly obese through the consumption of home-cooked whole foods. To get that fat, for most people, takes piles of highly refined, ready-to-chow junk food and drink. Try googling “what I ate when I was fat”.

Obesity is in many ways the logical endpoint of the way we live. Prevention beats palliation, but we’d need psychologists, motivational speakers, social workers, dietitians and physiotherapists to work with us in order to have any hope of tackling the problem. We’d need policy makers and activists. All we have are doctors.

Forget obesity as a disease; it’s a ruse. For whatever reason, the majority of the population can no longer say I have had enough. For whatever reason, the majority of human beings respond to advertisements inviting them to enter a pleasure state by eating a day’s worth of calories in one sitting, again and again. In the face of this, we are stuffed. We could say, “You are free agents, totally free, so pay for your own consequences.” We could make people pay at the point of choice, via a food tax, or we could limit choice. The other option, always unspoken, is: let us have our cake. Let’s just eat and eat, get fatter and fatter, and work out how best to live with it. This is where we are heading now: fatness, outside of morality, as an accepted consequence of the world as we have made it.

If you come to me, your doctor, and you ask me to make you thin, for now I will have to cut you or drug you, as these are the only weapons I have to ward off the sirens. There will come a time when patients stop asking their doctors to make them thin. It will either be because fatness is rare again, or because it has become entirely accepted. The choice is in your hands.

So what will YOU do? There are plenty of doctors to prescribe medications and cut you up. Sometimes it’s medically necessary to take this route, but there are also personal trainers, wellness coaches, nutritionists and more who can – if you’re committed to making some positive changes – help for a fraction of the cost while empowering you to take control of your own destiny. As the author says, the choice is in your hands.

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About Rick Binder, CFT, CES

Rick Binder, CFT, CES is an ISSA Certified Fitness Trainer in San Diego, CA. In addition he is an NASM Corrective Exercise Specialist, a Certified TRX Instructor and he holds a 3rd Degree Black Belt in Hapkido Blend. He has trained groups and individuals to improve their level of fitness and self confidence. For information, rates or to schedule training sessions you can reach him directly at 818-324-0462 or at