Monday, October 25, 2010

Is Obesity Like Alcoholism?

Regular readers will recall that last week I attended a scientific symposium on addictions.

One of the books I picked up at that conference, and read on my flight to Montreal yesterday, is A. J. Adams’ UNDRUNK: A Skeptic’s Guide to AA.

While this book is a very quick and highly readable introduction to AA (Alcoholics Anonymous), about which I knew very little, today’s post is NOT about this book.

Rather, it is about a definition of alcoholism that I came across in the book, which apparently is the WHO definition for this condition.

The definition reads as follows:

Alcoholism is a primary chronic disease with genetic, psycho-social and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences and distortions of thinking, mostly denial.

Let us look at this definition of alcoholism and see what aspects of it (if any) apply to obesity.

No doubt, as readers of these pages know, obesity is most definitely a chronic condition, whose development and manifestations are influenced by genetic, psycho-social and envrionmental factors. In some cases obesity may be more genetic, in others more psycho-social and sometimes purely environmental, but certainly, obesity would fit the bill as far as this statement goes.

And yes, obesity is often progressive and fatal. Most people, let alone those struggling with obesity, experience progressive weight gain over time. Sometimes periods of rapid weight gain are followed by periods of weight stability or even weight loss, but in the long term, no one with obesity would carry their excess weight had they not progressively gained it over time (and often continue to do so).

And yes, obesity is no doubt fatal. This may not seem as obvious as in the case of the alcoholic who dies of liver cirrhosis or totals his car (and himself) whilst DIU, but when you start looking at the many ways in which obesity can kill you, from heart attacks to cancer, there is no doubt that obesity is fatal (often after ruining most of your life first – another similarity to alcoholism).

Many of my patients would also be the first to admit that their weight problems stem directly from their continuous or periodic impaired control over their eating (or drinking of caloric beverages – including alcohol). This is not a moral judgement – whether their loss of control is genetic, psycho-social or simply a consequence of our obesogenic environment, it is still a loss of control. Were they able to control their intake of excess calories, they would obviously not have the problem.

And of course many people who struggle with excess weight are preoccupied with their drug (food). Whether they are thinking about their next meal, trying to suppress their cravings, planning their diet, feeling guilty about their last binge, hoping to find the strength to say no to that dessert or second helping, or simply giving in and longing for the comfort and satisfaction that they get from eating – no doubt food is on their mind – one way or another.

And all the obvious adverse consequences don’t seem to deter. I have yet to meet a patient who wants to be obese (even the patients, who admit that their excess weight protects them from unwanted attention). Even those, who do not relate their many health problems to their excess weight, cannot but help thinking how much easier life would be, would they not have to carry around their excess weight for the world to see, every single step and moment of their waking day (and interestingly, not just the waking day – given the profound effects of excess weight on sleep).

Finally, is it not the profound distortion in thinking that keeps the commercial weight loss industry in business? The idea that obesity can be “cured” with some magical potion or herb that will burn fat or rev up metabolism or suppress appetite. The idea that, “If I can only kick-start my weight loss and lose the first 10 lbs, the next 100 will surely follow”. The illusion that the next diet will be the last for sure. The fantasy that if I only lost some weight, my brain would readjust its “setpoint” and I could return to the weight I had as a 21 year old. The unrealistic expectation, that an hour in the gym each day will help melt away the lbs, or skipping meals will help cut calories.

But most of all I see denial – denial to see excess weight as a problem, even when it clearly affects your health, your well-being, your appearance, your self-image, your sex life, your relationship, your happiness. Perhaps, in an ideal world, excess weight should have none of those negative consequences, but in reality it does. The options are to either wait till the world changes (and becomes fairer to people with excess weight) or to step out of denial and seek the help you need to conquer those lbs (and I am not talking about signing up for the next commercial weight-loss program).

Many, if not all of us have accepted that alcoholism is a disease. Does obesity, not often meet the very same criteria?

Unfortunately, however, one important difference remains – in obesity, food abstinence is not an option (even if some of my patients have done just fine by completely giving up certain foods).

I look forward to what my readers have to say to this striking analogy.

AMS
Montreal, Quebec

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20 Responses to “Is Obesity Like Alcoholism?”

  1. Pierre William Trudel says:

    Thank you so much for the direct line you are taking Doc.
    Pierrette & I have become well aware of the denial effect when it comes to overweight and obese people.
    Hiding behind all that weight does not take the shame, blame, or denial away. Running from it is just like an alcoholic.
    I also have never found an obese person that would not trade places with a healthy person. Not listening to common sense needs to be studied and looked at. Why the constant denial when listening can offer solutions and alternatives that alcohol cannot.
    Thanks Dr Sharma for being so honest.
    Pierre William Trudel
    Thee Quest For Perfect Health
    theequest.com

  2. Sandy Iredale says:

    The only time I was ever thin was when I was actively alcoholic. Since sobering up, my weight has ballooned to a bmi of 47 (and climbing). I’ve often considered drinking again, just to stop eating. There is no doubt in my mind that I’m transferring addictions. Now I’ve got a lot of work to do.

  3. ML says:

    Hi Dr. Sharma,
    Interesting blog today. I’m just wondering what your response would be to the ‘Health at Every Size’ advocates, many of whom are nutrition and health professionals. They would likely argue that one’s body weight should settle on it’s own, and that efforts to lose weight through diet, physical activity, or other measures should not be taken. It’s hard to accept that belief in the current environment that we live in.
    Thanks.

  4. fred says:

    It is nice to see the medical community actually looking at what has worked for many people, as long as we are able to work it.

    But we can abstain from sugar in all forms, processed grains, and manufactured oils. Other starches if necessary.

    In Northern Alberta we have Overeaters Anonymous and it’s offshoots – FA, FAA, GraySheet, HOW, CA, and the like. You might try the web northernlights.oagroups.org.

    The program taught me to separate “real” from “concepts”, and started me toward recovery. The zero step is to give up sugar, processed grains, manufactured oils and any thing else that causes cravings (likely due insulin resistance, and over supply of insulin).

  5. Lucy A. says:

    The insight that you shared on addiction of eating versus drinking is bang on. The hardest job of going through weight wise and losing some weight is to retrain my thinking on portion sizes. I worked food service were super sizing is pandemic my understanding of potion size was distorted. I stll have to work on avoiding high fat extra’s. Meal planning is a real challange becuase I have ADHD the small mericale of starting and keeping a food juornal.When I look back the high calorie days (I use calories nbecause they are a tangable measurment) are the days that I go out to eat. The meal planning didn’t work for me with my ADHD. I am looking into the possiblity of having polycyst ovairian syndrome, therefore, a module on medical conditions that agrivate weight lose or cause weight gain would be beneficial. Thank you.

  6. Jenny says:

    Following up on what Fred said, there is also Edmonton’s (now also gone international) 12 steps of Anorexics & Bulimics Anonymous which offers the interesting perspective that it’s the process, not the foodstuff that is addictive. Their book is a facinating read and although it’s written about anorexia and bulimia, I see similarities with over-eating as well.

  7. Linda says:

    Having been an employee of the allopathic medical community (still am through marriage),where in 1978 I asked why do we do a certain type of surgical procedure as frequently, the MD answered it’s the way we eat. While he was smoking and eating a saturated bucket of popcorn. Waistline off the chart. Yet there was the denial! I have numerous surgical iatrogenically induced conditions I live with at age 57 which were given to me by domestic violence while I was under age 18 by alcoholic/antinutritional food parents, (only for ID not blame). So my drugs can go anywhere from surgical narcs, to a good bottle of wine, to a favorite meal including dessert. Here’s my denial. This is a lifelong acknowledgement of conflict between health and instant gratification. More conflict than just that but I have six children I don’t want to give this inheritance to, so we openly discuss the risks. Thank you for addressing this dilemma for what it truly is!

  8. Abalone says:

    I question the framing of the comparison as between alcoholism and obesity rather than between alcoholism and compulsive overeating, a recognized disorder in its own right. The latter seems the closer parallel. While the first two sentences of the WHO definition work for obesity, the third doesn’t. Obesity is not “characterized by…impaired control” of a substance but by excess body fat (as roughly measured by BMI). Instead of being definitional for obesity, “impaired control” would be primarily causal. Addiction is the essence of alcoholism. Comparing alcoholism with obesity suggests that addiction is the essence of obesity when it’s only one factor.

    RE the title question, the commonality between alcoholism and eating disorders was the basis for Overeaters Anonymous, which has been in the toolkit for five decades. While it may be useful to reflect on that commonality every now and again lest the substance-abuse element of obesity get lost in the rush for diet pills and surgery, I don’t see how this line of inquiry is likely to be fruitful in terms of new strategies or tools.

    RE the reclassification of obesity is a disease, I recall when alcoholism was so classified. It appears that classification is part definitional and part political. In the US, at least, the intent was to destigmatize alcoholism and to get insurance coverage for it. Et tu, obesity?

  9. Arya M. Sharma, MD says:

    @ Abalone: You are probably right in pointing out that alcoholism is more like compulsive overeating rather than all of obesity. In fact, I admit that I have previously blogged on how diverse and heterogeneous obesity actually is and how it’s hallmark is excess fat deposition – no more, no less.

    Thanks for pointing this out and reminding me of my previous stand on this,

    AMS

    p.s. as also blogged before, obesity has long been considered a disease and has its own classification code in both ICD-9 and ICD-10

  10. Arvind says:

    Dear Dr Sharma,
    I love to read your blog.
    as regards the current topic i would like to point out that there exists an approach to ‘managing’ or treating alcoholism which is opposite to that of AA and it is ‘controlled drinking’. Admittedly the approach is controversial but it has its own followers, some belonging to the mainline addictionologists. This approach would fit in with the approach followed in management of obesity wouldn’t it?
    You may have already gleaned some information about this but for your readers i would like to forward the following links: http://www.medscape.com/viewarticle/473554_8 and http://www.livescience.com/health/071204-bad-alcohol.html.
    I am interested in your views about this.
    Arvind

  11. Sandi T. says:

    Thanks, Dr. Sharma, for this blog. It reflects my struggle to control binges and maintain my weight loss. I recognize I have both food (peanut butter–moderation atttempts have repeatedly failed, leading to abstinence as the only choice) and eating addictions (giving in to binging despite full recognition of its harmful consequences, both for myself and my relationships.). This has become progressively more severe over time. My struggles with food and eating have increased my compassion for others who struggle with addiction. I find it helpful to focus on choices and responsibility, one moment at a time, as opposed to self-punishing more with guilt, blame, and shame: after all, no one chooses to develop an addiction. Teaching myself not to judge and instead to accept that I choose to deal with this problem has been helpful in cutting binge slips/relapses short. Sometimes binges or cravings serve as feedback for potential trigger foods as well (often too high in even healthy carbs or fats, or emotionally linked to past rewards). Humbly accepting my own and our shared humanity is an ongoing process. I appreciate small joys more lately, possibly as a result of this struggle. So be it–to give up the struggle (other than to trust a higher power to get me through it) is not an option I choose.

  12. Katie Jay says:

    Dear Dr. Sharma,

    Wonderful blog! Thank you for raising this important subject. Understanding carbohydrate sensitivity (a.k.a. carb addiction) is critical for many people working to overcome obesity. The language we use with obese patients who have had weight loss surgery, including the way we frame the inevitable ups and downs on their journey, can make a big difference in outcomes. Finding langauge that does not trigger a shame response is critical. We have a long way to go, and I appreciate your contribution to this ongoing dialogue that must happen if a paradigm shift is to come about.

    You might enjoy Dr. Gabor Mate’s book about addiction (he works in Vancouver, BC), “In the Realm of Hungry Ghosts.” Mate discusses, “…the many manifestations of addiction across all strata of society….” And provides, “…deep and original inquiry into the nature of addiction….” He explores both nature and nurture — and it’s fascinating.

    Warm regards,

    Katie Jay, MSW

  13. AcceptanceWoman says:

    It’s taken me a few days to respond as I was reeling in disappointment at the comparison you make between the two.
    As the daughter of an alcoholic, I can tell you that obesity differs in many important ways from alcoholism. I have never verbally abused another person under the influence of food. I have never used food as an excuse to harm another person, physically or verbally. As many have observed, it is nearly impossible to live with someone who is actively alcoholic. But living with people who carry excess weight is a great pleasure for many.
    I do not deny that for some people who have binge eating disorder — there may be similarities in terms of some aspects of addiction, but alcoholism is it’s own disorder, one that tends to wreck havoc on families and children.
    I did not suffer because of my mother’s excess weight (and her at times compulsive behavior around eating) anywhere near I did to the degree that I did under my father’s alcoholism.
    We all have addictive behaviors, but the extent to which they cause harm to ourselves and others vary.
    It disturbed me greatly, someone who has maintained a more than 40 pound weight loss for more than 10 years, who now weighs about the same as I did before my child was born almost 6 years ago, who eats mindfully and exercises and is extremely conscientious about managing diabetes, to be told that I am in denial by the mere fact of being obese. I am as far from denial as a person can get, I’m more likely to be described as painfully self-aware.
    I do not sit idly by and wait for the world to become more fair, I actively work to make it more fair, not only for me, but for everyone. I also work hard to be as healthy as I can be.
    Reading this blog post had a valuable lesson for me. I observed that I had two reactions, initially, there was self-doubt, and worry, and fear of rejection. Then there was anger, as I wondered how can you say globally that all people who carry excess weight suffer because it affects “your health, your well-being, your appearance, your self-image, your sex life, your relationship, your happiness.” This appears to contradict your own Edmonton Obesity Staging System — it denies that there can be obese people who are happy, attractive, have a positive self-image, active and healthy sex life, relationships. We can debate whether or not it’s possible to be obese and healthy (my definition of health is different than yours, I know) — but to cast all who carry excess weight as being in denial is both unfair and inaccurate.
    I am disappointed. I have admired your usually well-reasoned and compassionate approach, and I hope you will reconsider what you have written.
    Feel free to contact me via my blog if you wish to have more conversation about this.

  14. Arya M. Sharma, MD says:

    @AcceptanceWoman: You make some very excellent points in your comments (I guess I was “provocative” enough to stir up the pot).

    Your point that obesity is different from alcoholism because it does less harm to others, is extremely well taken. There can of course be no comparison between the impact of alcoholism (domestic violence, drunk driving, emotional abuse, etc.) and obesity – no doubt obesity has non of these effects.

    However, the perspective taken in my post was from the view point of the person suffering from compulsive overeating – as you can see from the other comments (and from what I have learnt from my patients), the individual struggle for many is not very different from the struggle faced by people with alcohol addiction. It was this analogy that I was after, because it has important consequences for how we think about compulsive overeating and approach it therapeutically.

    As you also point out, not everyone with obesity is in denial or is unhealthy – but, unfortunately, most are. In the city of Edmonton alone, there are an estimated 25,000 people with severe obesity, 90% of whom have at least one obesity related health problem (most have more than one). Currently, only 3,000 patients have been referred to the only tertiary obesity program in the city, so the reality is that almost 22,000 Edmontonians with severe obesity are not seeking professional help in the public health care system. Whether this is due to denial or simply related to lack of time, lack of knowledge, lack of interest, I do not know – but the numbers suggest that not everyone is concerned enough to seek help.

    So while i can only congratulate you on your success and on belonging to the minority of “healthy” obese people (EOSS Stage 0), and apologise for not being clear that obesity of course does not come close to causing the same level of distress to others as alcohol does, your success and candidness is perhaps not the rule.

    Thank you again for your comment – this is what the blog is about – to discuss topics that are relevant to people struggling with excess weight and the professionals who work in this field – the positive and negative responses to this post clearly shows how much such a discussion is necessary.

    AMS

  15. AcceptanceWoman says:

    Thank you for your genuine and thoughtful reply.
    I’m actually EOSS Stage 2 — I was diagnosed with type 2 diabetes 16 years ago at the age of 25. (My last A1C was 5.7).
    You raise an interesting question, though, that might be able to be answered through epidemiological study — among people with obesity, what percentage in the population are in which stage? My hypothesis would be that there would be age and gender and other demographic differences, and that most of the people currently seeing health providers regularly would be in stage 2 or later, but the actual distribution in the population is a good question.
    Where my perspective differs from yours, and it’s probably the difference between 1) public health and medicine and 2) patient with excess weight and doctor without excess weight, is that I don’t find focusing directly on weight as helpful or the best tactic, on a population or individual level. Just as many of the things that are causing our current “obesity epidemic” weren’t set in motion to get people to become fat, the things that are likely to reverse the trends, both on a population and individual level, are not going to come from the sole drive to no longer be fat.
    For me, focusing on the pleasure of physical activity, and the benefits of eating healthfully, and the enjoyment I get from being active, social, spiritual, intellectually alive are what get me going and keep me going.

  16. AcceptanceWoman says:

    Also, I think that there are many reasons why people who are obese and have health problems don’t seek treatment for obesity — the perceived lack of efficacy of treatment is one, but a major one would be stigma.
    I don’t think denial is the right way to describe it.
    I think that resignation is probably a better way of describing it. If you are aware of efficacious treatment, and what that looks like realistically (not making fat people thin, but helping people manage their conditions and perhaps any associated addictions, if present) — that would be a starting point for conversation. Here’s what’s available, here’s what works, here’s what to expect, here are the potential risks and benefits. It’s not that people are in denial (some are, but many aren’t) — it’s that there’s not a good track record of success or sufficient support in place when people are ready to make a change, in many cases.
    I’m not blaming the health care system when I say this.
    I point the finger at misguided tactics, and the weight loss industry that prays on people. And a lack of realistic expectations.
    Okay, sorry, I won’t reply any more for now!

  17. Ellie says:

    Working in psychiatry, I see similarities; certainly I see overlap in terms of use of overeating as an avoidance behavior (not always formally diagnosed binge-eating, just overeating) and alcohol as an avoidance behavior. I have often had good results with patients who are both obese and alcoholic using mindfulness-based cognitive therapy – you may want to explore this in your reading. I wish I had time to write more on this right now but I am post-call – feel free to email.

  18. Teri says:

    I have read a number of the articles of 2010, it seems to me that we are really in a time of search. The search for the keys that will solve the obesity problem. I will share, that I too have been on the search for the last 30 years. At one time I was only 15-20 pounds overweight and then when I became pregnant I gained over 120 pounds. Since that time I have done and tried everything from the magic herbal pill, to phen-phen, to the lap band. Even the band has not helped, sometimes I thought it would be better to be around my head. There is no cure as of yet. We are not using solutions that work. As I am now in recovery and will be for the rest of my life, I believe what we are really missing here is immersion. We know that the only way to truly learn a language is to be immersed, we have immersion classes and schools, we go to other countries to learn the language and we live with parents who teach us the language. Just as an alcoholic needs to go to rehab, so does the obese patient. Some may have to go for longer periods, other may have to go for a shorter program. I have just returned from one (out of country). The information I received covered the 4 keys to success, Nutrition, Exercise, Education and Therapy for recovery. These areas were covered daily very much like addiction rehabilitation. The other key importance was the staff were 50% of those that have recovered and are recovering. The are considered life coaches and are involved the the facilitation of each category. I would love to bring the program to Edmonton. I have walked in the shoes of those that need help and I would love to pass this gift on.

  19. Linda says:

    Over ten years ago, I read “Drinking, A Love Story” by Caroline Knapp. I saw myself in almost every page. I highlighted passages that I still read today. I don’t drink, but am obese and am a compulsive eater. While the poison is different, the feelings, triggers, etc., appear to be the same to me.

  20. Dee says:

    The diet industry would certainly like us to believe that everyone who is obese is “addicted,” as their profits would soar. It is true we are all food-dependent–just as we are oxygen-dependent. But your opinions regarding food addiction are easily countered by evidence of a genetic component to weight– just as height is influenced by genes.

    Does anyone really doubt that humans survived geologic periods of extreme cold because some humans were able to eat less and maintain reproductive health during those periods? Some human bodies were designed for different conditions, and it is that flexibility which brought humans forward to the present. The problem is that we no longer live in times of starvation and unavoidable cold. That is, in general, good fortune.

    No doubt, there are humans who have addictions to food, just as other addictions exist. Think about this: drugs, yes, sex, yes, but what about those who compulsively eat dirt or other things? So, yes, there is likely such a thing as “food addiction.” But is it likely that such a high proportion of the population is “addicted” to food? Probably not. It is more likely that some part of population has a genetic predisposition to easy weight gain. They are eating “modern” food and no longer working physically to survive in the way that some bodies were designed by evolution to perform to bring us forward to the present moment.

    Of course, those people are going to be “deniers” in your analytic framework. But, what are the other possibilities? They may be telling you the truth. Does social exclusion and depression at that exclusion have a component in weight gain? Quite possibly. Some people lose weight without obvious calorie reduction when stressed. But recent research indicates that some people gain weight without obvious calorie increase when stressed. Again, from an evolutionary standpoint, “weight-gainers” kept humankind alive through periods of famine, cold, and other environmentally stressful situations.

    Some humans, without any obvious environmental differences, are taller (or shorter) than others around them. But the height or lack thereof IS influenced by the availability of other factors–food being an obvious one. We already know that food has influenced human height. That is easy to track, and we have. Is it also likely that human weight increases in the presence of abundance? Yes, that is quite probable.

    In the near future, science will find a way to “prevent” weight gain, and all of those who are obese will look just like everyone else. The question will then become, now what human difference will we use to discriminate against others? How will we decide to give economic advantages to some and take it away from others? And what will the diet industry turn to in the pursuit of big bucks? There is certainly an economic component to all of this, isn’t there?

    A final piece of the puzzle about weight-gain is the development of compulsive behavior in the presence of withdrawal. All of these “miraculous” weight-loss plans involve near-starvation and pain. Look at the psychological research on what happens when you deny people normal life-producing elements. They begin to more actively seek those elements. Again, evolutionary fitness probably results in those who are too cold and suffering remaining physically strong enough to find a way to produce warmth–and survival. Did fat people in the Ice Age go out and find food for very thin people who could not seek their own food for survival. Is it because there were weight-gainers around at that time that thin people also exist? Have the personality elements of generosity and kindness also survived along with fat people? Maybe. Does it not make sense that those who were hungry but remained strong enough to find food for everyone in the group also brought humans forward to the present? Possibly.

    Fat people are part of the human genome. We just don’t like them anymore, because they aren’t useful. Too bad, because there are really a lot of nice, hard-working, sharing, and good fat people. It would be shameful to convince all of them that they are addicted and defective in some way. A better plan would be to help them to eat and abstain in a way that works for them in our present eating and exercising environment. according to their metabolic design. And quit abusing them, too, of course.
    I’m saying that there are some people with an addiction, but it will be necessary to tease out that group of people from those who are just naturally chubbier, but abused by others, perhaps, depressed, but, yes, pretty normal in their approach to food. Put a little truth in this column, please.

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