Wednesday, August 4, 2010

If Thine Eye Offend Thee...

"Has it ever struck you that there's a thin man inside every fat man, just as they say there's a statue inside every block of stone?"

George Orwell

As the national obesity rate continues to creep higher, Cheryl Fuller at Jung at Heart speculates about the deeper meanings, if any, of obesity. As she notes, there is a natural human craving for a smoking gun, a prime mover: a gene, an archetypal childhood experience, a cultural imprint, anything. It is a craving not to be satisfied, as it increasingly appears that weight is a complex result of human identity, no easier isolated and explained than, say, intelligence. It is the outcome of natural (and individually variable) gratification, energy expenditure and environmentally available calories.

Fuller notes that the inferred role of volition is central to obesity, and this combined with its unavoidably public aspect, makes it a virtually unique target of social judgment in our society. Most other objects of discrimination are either agreed to be unchosen (race, gender) or can be more or less concealed (sexual orientation, substance abuse). As a slender person who was fat through adolescence, I have always felt like a bit of an oddity in the great obesity debate. So I thought I would share how my attitudes toward food and lifestyle have developed over time. Crucially, I claim no personal merit or superiority for the experience--it could as easily be said that the weight was lost for me (by developmental genetic change, etc.) as that I lost it and kept it off. And indeed, as I think back on it now, I think that it was not so much an exertion of willpower as it was taking steps to minimize the need for willpower. Or I may have just "grown out of it." But aspects of the process suggest to me what might have to happen for a person to beat obesity.

My family history for obesity is I suppose moderate; some have had it (not morbidly), some haven't. I was basically born fat and remained that way to varying degrees until around age 17. I was not morbidly obese--certainly there were bigger kids--but it was significant enough to affect juvenile social relations, self-esteem, athletics, etc. Especially in my early teen years I went through many diets that were miserable and only transiently if at all successful. But I loved food dearly, a wide variety of foods, and it was painful to deprive myself of things I loved. I heartily disliked exercise, not least because I was out of shape.

When the change came, it came in stages and not as the result of some conscious plan. The first step was my first job at age 15, a newspaper route that, due to the inconvenience of stopping the car every 50 feet, I did on foot and, increasingly, at a run. Suddenly I had daily exercise that I did not have to force myself to do; willpower was removed from the picture. For while I loved food, I also loved having spending money, so I effectively had no choice but to exercise.

I had the paper route for only a couple of years, but I tried to adopt attitudes toward physical activity that would seem automatic, not requiring constant deliberation (the dreaded willpower). I take elevators only to ascend or descend five floors or more. Unless frankly fatigued, I try not to sit when I can stand, and not to be still when I can pace and fidget. I have never much cared for running, swimming, or biking, but found in walking a daily activity that suited my meditative disposition and that eventually came to seem indispensable. I am restless and uncomfortable when unable to take at least a short walk in a day.

But in terms of my psychological stance toward food, I think the more far-reaching change was that, somehow, food ceased to be for me the source of gratification that it once was. This is captured by the cliche "Eat to live, don't live to eat." In a process that seemed to be unconscious at the time, I "decided" that food would no longer be a major source of pleasure to me. I decided that certain foods (pancakes, doughnuts, elaborate desserts) would be largely off-limits to me--they became gratuitous, no longer worth the risk. It helped when, a few years later, I became vegetarian for ethical reasons, a change that in itself dropped the last ten to twenty pounds that I needed.

This has not been culinary asceticism per se. I still love chocolate, ice cream on a summer day, fresh bread, etc. But I no longer relish these things in the sense of arranging my life around them, that is, they are incidental. I will pick them up when convenient, but I don't go out of my way for them and do not relish them in the way that I might relish a piece of music or a book. Food beyond that needed for sustenance is just not a significant part of my life.

As I said, I do not claim any particular merit for this or any implications for any other persons; I merely describe how it seems with me. It is not something that I take smug pleasure in. The point is that it does not require prodigious or prideful effort; it flows naturally. It is well known that genes are not once and for all, that is, they wax and wane throughout the life cycle unpredictably. Perhaps as an adult I merely enjoy some genetic dispassion for high-calorie foods, whereas as a child I suffered the opposite. Certainly I have other vices--on any given day it would be easier for me to forgo food as opposed to caffeine or Internet access.

Alternatively, as Cheryl Fuller might speculate based on her blog post, perhaps it became psychologically intolerable for me to remain fat, such that the joy of eating, long gone from my life, was not too high a price to pay. I think that many people, and certainly not only the obese, delight in food as one of the basic pleasures of animal life and are not willing to give that up. So when a person desires thinness but does not achieve it, it reflects not weakness, but an unwillingness to pay the often steep price demanded. There is a major trade-off involved. And people should not be blamed for their choices (unless they expect others to pay the costs of those choices). The complication is that what appears as a choice may not always be so (does a nicotine addict "choose" to keep smoking? yes...and no). The unsuccessful dieter thinks that he can deprive and exert himself for a few months before reverting to the status quo, when the reality is that he must alter his basic worldview: he must fall out of love with food.

It is often pointed out that eating cannot be considered a true addiction because it is not possible to abstain from eating. That is true, but it is possible to abstain from a certain degree of gratification in eating. To my mind, this is the kind of lifestyle overhaul required to beat obesity, analogous to the alcoholic avoiding bars or hard-drinking friends. While this is a matter of choice, it is not a simplistic matter of weakness vs. strength or willpower. Willpower is the alcoholic sitting in a bar all evening long and not taking a sip--no one expects that to work. One cannot avoid food, but one can avoid food as pleasure. Just as an alcoholic must look at a bottle and see poison, someone wishing to lose weight must look at food and see not a sumptuous feast, but rather a necessary evil. And obviously it is crucial to construct compensatory gratifications, whether sensuous or intellectual.


Cheryl Fuller, Ph.D. said...

At the end of your post, you say, One cannot avoid food, but one can avoid food as pleasure. Just as an alcoholic must look at a bottle and see poison, someone wishing to lose weight must look at food and see not a sumptuous feast, but rather a necessary evil. And obviously it is crucial to construct compensatory gratifications, whether sensuous or intellectual.

If it were actually that easy, then wouldn't dieting likely have a far higher rate of success? As it is, only about 5% of dieters manage to maintain a significant weight loss for more than 2 years; in fact most regain all of the weight lost and then some. If you look at the studies tracking participants following any of a number of diets over a year or more, the average weight loss in that year seems to be around 12 pounds. That is not a lot of payoff for the kind of vigilance that is required to adhere to any diet.

Everyone has a theory about what fat people need to do to become not fat. But so far none of those theories has panned out. This suggests to me that maybe what we have here is something far more complex than pleasure in food or deranged appetite or any of the other explanations offered. What if fat people are really not to blame for their fat, anymore than the myopic are to blame for their poor vision?

Novalis said...

Good points, but isn't it oversimplifying in the other direction to liken obesity to myopia? Is alcoholism as inexorable as cancer?

Behavior is complex, but grant for a moment that obesity, broadly considered, is a behavioral matter. That is, if you were to force overweight people to consume 800 calories per day for months they would lose weight. Their myopia and cancer, if they had them, wouldn't improve.

However, if people theoretically can lose weight but do not, it raises the more audacious possibility that obesity is not really a disorder at all. That is, it does cause distress as well as medical morbidity, but it is offset by other gratifications. That gets back to the point in your blog post about obesity as "symptom;" that is, maybe obesity is a defense, and we know that defenses needn't be disorders. Society seeks to make it a disorder because of culture-wide anxiety about the mysterious x that is being defended against.

And as you say, if it is a symptom, we don't know what it is a symptom of. These behaviors may be so complex that a single case report such as the one related here implies nothing at all for anyone beyond its subject. In which case, never mind...

Novalis said...

I would add that nowhere in the post do I argue that people *should* be losing weight. In mild to moderate cases it is probably just a matter of cultural aesthetics, i.e. prejudice.

And even in more severe cases with significant health implications, it could be argued that people are (implicitly at least) choosing not to make the massive lifestyle trade-offs that major sustained weight loss would entail.

Similarly, we know that if the Interstate speed limit dropped to 20 mph, fatal crashes would plummet, but no one wants to make the sacrifice of convenience this would require. It isn't the case that we "can't" drive 20 mph; we won't. Or perhaps at a certain point the two become the same.

Anonymous said...

There's a distinction between physiologically based obesity such as hormonal dysregulation, and obesity induced by maladaptive behaviour consequent to some psychological ill. Two entirely different 'disorders'.

People do definitely over-eat as a form of compensation for some existential lack. Food is accessible, legal, socially acceptable and cheap (well, most). It's not difficult to see how it's a 'drug' of choice for many. And as for exercise...well, inactivity is the path of least resistence and humans generally don't like resistence.

I tried overweightness for a short didn't take too well from a subjective point of view. But I did notice how the behaviour of everyone around me changed (schadenfreude related pleasure or something or other...)Health concerns for the other trail well behind selfish social aesthetics, it seems.

I love good food in pleasureable quantities - which is to say in moderate contrasting amounts. And I love the endogenous high from exercise. It's the pain/pleasure illusive dichotomy which really is a unity. What really hurts is the resentment because I choose a lifestyle certain others can't be half-arsed to embrace...yet they somehow still feel worthy of its entitlements.

Everyone should have a hobby, I think.

Novalis said...

Yes, I guess the mistake is seeing the self, or the will, as monolithic. Each of us is a bundled democracy of "selves."

If an obese person accepts his body in defiance of cultural norms, I think that's wonderful--more power to him (and let's do what we can to attenuate prejudice).

But if he insists that he really wants to lose weight but *can't*, that is the wrong way to think about it. Part of him may want this, but other parts--presumably more decisive--do not in fact want this. Whether we approach these dissenting "selves" existentially, psychologically, or biologically may be a matter of preference.

Retriever said...

Very good post. What I like is the compare and contrast with alcohol. The similarity is that in both cases, regardless of the cause (genetics, psychology, abuse,other stress or environmental factors), the only solution to both obesity and alcoholism is discipline and self-denial one day at a time. Tho I might not go so far as to call food poison! That smacks of the anorectic, tho I know you aren't that.

I think one has to change one's tastes, learn to reach for a peach instead of chocolate. Personally, I know many people who have managed weight by simply cutting out alcohol, soda (including diet), white flour, sugar, and other simple carbs. Things like brown rice don't tempt one to gorge as white basmati does.

I,m working on a book chapter on anorexia with Brain Posts right now, so my head is on opposite problems.

In youth I was scrawny, as a teen a semi-anorexic dancer who improved once I escaped my family by going to boarding school. Now a typical middle aged mommy watching her weight.

Dr X said...

@ anonymous,

"People do definitely over-eat as a form of compensation for some existential lack."

Anon, I have serious doubts altogether about general claims of this sort. So much of the futile effort to "cure" obesity has rested on the premise that obesity, overeating and food cravings are metaphors for some other psychic hunger.

It isn't that I reject the notion of symptom as compromise formation. Symptom can indeed represent compromise, but it is far from established that this is always the case. Moreover, there is the question of whether fat should generally be seen as a symptom. This is not to say that fat has no meaning. It has subjective meanings for the "fat" person and it has social meanings.

But my own experience with patients is that "fat" the "symptom" ought not be regarded as a settled question. Words like "definitely" don't apply to the psychic dimensions of fat.

Metaphors can be useful, but we can easily forget that they are metaphors, not psychic reality itself. I think the psychic hunger metaphor may be a case of such an error, just as the fat as insulation metaphor may confuse metaphor with psychic reality.

Novalis said...

It's also interesting to note (sub)culture-wide differences. The NYT article noted in the post mentions that the difference between obesity rates in Mississippi (#1 at 34%) and Colorado (#50 at 20%) is huge and difficult to account for by economic means alone. The article suggests that Colorado has a "culture of physical activity." Do the physically more active move to CO, or become more active once they move there? Both probably.

Dr X said...

I've never been to any town with quite so many fit, hardy-looking people as Boulder, CO. I enjoy physical activity and love hiking and have been to Colorado and Utah many times. Twenty years ago, I gave serious thought to moving to Colorado.

Walking down Pearl Street(the pedestrian only main retail drag in Boulder) one day, I ran into an acquaintance who had been a partner in a Chicago business that sold outdoor clothing and supplies--a lot of hiking stuff. I asked what he was doing there. Turns out they had opened an outlet right on Pearl Street in Boulder, partly because he wanted to move to Colorado.

I think Colorado both inspires physical activity and it inspires the physically active to relocate to Colorado. You can't not go for hikes. It's irresistible. I wouldn't be surprised if the intense local culture of physical activity--hiking in summer, skiing in winter--has something to do with the lower levels of obesity.

Novalis said...

I guess it follows that hiking in Mississippi is eminently resistible; I can't imagine what I would do there besides sitting around reading Faulkner and drinking sweet tea (if not something stronger).

Novalis said...
This comment has been removed by the author.
Retriever said...

100 and humid in my swampy neighborhood today. Forced myself to walk a mile at lunch, but that was it. Now playing with the new Ipad while my oldest drives us up north to (hopefully) cooller temperatures. One walks fast there, particularly once the horseflies start after one.

Dr. X, interested in your comments on psychic hunger. Because I vacillate between thinking that, yes, it's a huge factor and other days when I decide it's all genetic and/or virally triggered and/or related to meds. Obviously, my focus on anorexia leads me to ponder psychic hungers. But also my mother's battles with weight after 40. I watched with horror as a radiantly beautiful (albeit mad) woman gained and gained. I really don't believe it was all meds. She was tormented in so many ways. She only found a modicum of peace after my sister and I finally persuaded her to come back to church and faith became more personal for her, during the.last two years of her life.

Anonymous said...

Dr X,

Sorry, I probably should've said SOME people definitely over-eat as a form of compensation for some existential lack. While it's also true that others over-eat due to an excessive joie de vivre - a total embracing of life's lifeness with no compromise.

I still maintain that 'psychic hunger' does in certain cases manifest as overindulgence in some seemingly unrelated area of life in order to fill that void. So in such cases, obesity would be considered a symptom. And of course, what starts off as a compensatory measure becomes an entrenched way of being due other flow on affects that then feed back into the the original manifestaion of the problem, so the individual ends up being a tangled mess, viciously cycling interminably on new fuels, where causes and effects become confused.

Anonymous said...

Oh wow. Where do I start? Obesity is certainly a subject that interests me. It interests me on both a personal level and on a societal level. In relation to the blog, I have to disagree that a dieter must fall out of love with food. To me that is a ridiculous idea. People (Americans in particular) need to learn how to have a healthy love affair with food. I actually think that the obese need to love food more in order to find an effective way to be healthy.

For the most part, the obese in this country eat really shitty “food.” I think that an argument could be made that it is not even food at all----just chemicals and artificial trash. Fast food, sodas as well as mass produced cookies & chips provide virtually no nutrition or benefit for the body. If one really stopped to relish in a Big Mac, I think that they would find the experience to be unsatisfying. A Big Mac is crap. It lacks quality ingredients. There isn’t much texture to what one is chewing. There isn’t a contrast in flavors.

If a person really loves food and is passionate about what they put into their body, they are going to seek out quality foods. If I want a burger, I want the beef to be as local as possible and fed grass instead of steroid injected grains. This beef is going to have flavor and texture. I want my burger topped with actual cheddar cheese that was made with milk. I want the lettuce to be green and crisp. I want the tomato to have a vibrant red and juicy. Sure, I’ll take some special sauce, but I want it made with fresh eggs and real spices.

The solution to solving the problem of obesity isn’t a simple one at all. But, I think that it needs to start in childhood. Children should not be given sugar laden cereals that are void of fiber. Children should not be promised dessert for a reward. Children must learn that good health comes from high quality food. All people need to learn that the food that we consume has a huge impact on our lives, so we should spend a bit more time thinking about it. Don’t just pull something out of the freezer, because it is easy. Spend some time shopping for and preparing your food. Also, spend some time eating your food----don’t eat in front of the TV or while driving. Sit down at a table and chew---savor every bite. Know what the ingredients are and where they came from. Be passionate and love your food. The reward will be amazing.