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What is Obesity?



While I am on a brief holiday in Berlin, I thought I’d rerun a few earlier posts that discuss the issue of measuring obesity and how such measures may or may not be helpful in obesity management – as many readers may not have seen these posts before, comments are very much appreciated.

The following was first posted on July 28, 2008

Don’t worry – I am not going to take off on a discussion about whether obesity is a disease or “simply” a risk factor. I am also not going to discuss again obesity definitions – anthropometric or otherwise.

Today’s post is simply about an analogy that may help sharpen our clinical thinking around excess weight.

Think of someone who has an elevated plasma creatinine level (a marker of kidney failure) – the elevated creatine definitely tells us that there is something “wrong” with the kidneys, but that’s about it. From the creatine level alone we can certainly tell that the kidneys are failing in their excretory function, but we cannot tell what is causing the kidneys to fail – is it a pre-renal, intra-renal or post-renal problem? We can probably list a 100 reasons why kidneys could fail and obviously the treatment (apart from some very general principles) will very much depend on the cause, i.e. the actual diagnosis.

In many ways, one can look at excess body fat simply as a sign or symptom of the fact that there is a something “wrong” with energy homeostasis. The excess body fat tells us nothing about what the problem is – sure, it’s either excessive food intake or reduced energy expenditure – but that is like saying that the creatinine levels are elevated because the kidney is not excreting properly. I can think of a long list of reasons or factors that would contribute to excessive caloric intake or reduced energy expenditure: sociocultural factors, psychological factors, biomedical factors – figuring out what exactly is causing the energy imbalance is the real problem.

Only when we find what is causing the excessive intake will we have made a diagnosis of what is causing the problem – a few specific examples could include: poor meal planning, peer pressure, hedonic overeating, depression, obesogenic medications, binge eating disorder, defective satiety signaling, etc. The point is that till we know what is causing the overeating, we can’t fix it, which means we will have little success in treating the weight problem and will be limited to a “symptomatic” approach – just eat less!

Similarly, when the problem appears to be lack of activity, again the question is what exactly is causing the problem. Obviously if the problem is lack of time our approach will hopefully be very different than if the problem is back pain or lack of motivation (a possible symptom of sleep apnea, exhaustion or depression). A “symptomatic” but useless approach would be to simply recommend 10,000 steps. No better than offering an ice-pack to someone with a fever.

Just as the term “kidney failure” only tells us that there is something “wrong” with the kidneys the term “obesity” only tells us that there is something “wrong” with energy homeostasis.

In itself, neither the term “kidney failure” nor “obesity” is a real diagnosis – they are only helpful if they prompt further investigation into what might have or is still causing the problem. Only when we find the cause will we be on our way to solving the problem.

AMS
Edmonton, Alberta

11 Comments

  1. My first thought in response to this is “how can you say there’s an energy imbalance when someone stays the same size? Because they’re over a certain BMI? Bigger than someone thinks is attractive? The wrong shape?”

    Changes in habits can result in small changes in weight, but the weight will restabilize at a slightly higher or lower level. No big deal. I’ve gained or lost 5-20 pounds many times because something about my habits changed; I started or stopped walking to work, was injured and became less active, took up a new activity and became more active, went on a health kick, got into a new relationship and starting cooking lots of nice dinners with wine…

    If someone keeps continuously gaining weight (not just a little; a lot) then the first question they’d ask themselves is “Why is my weight moving upward? What changed? Why isn’t it restabilizing?” and the answer is that this almost never happens in a vacuum. Usually it’s in response to restriction – dieting. So, I’d be curious to hear from people who have gained 50+ pounds within a few years. Has anyone done it without having lost weight on a diet first? If so, what changed to set it off?

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  2. The two big ones for the grossly obese are food addiction and hyperinsulinemia, both of which the medical establishment have a hard time to accept. More links at my web site.

    No SGO6, HB attitude

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  3. My biggest weight gain was 20 lbs. But I have never ever lost more than 10 lbs. The weight gains were associated with my husband being transferred to a new community. I lose what was working in the previous community and it takes much longer to discover the healthy opportunities. The mix of factors that contribute to weight gain and weight loss were very different in each community eg I moved from a community where our house was between the grocery store and the doctor’s office but the big problem was receiving friendship sourdough starter that I tossed but not soon enough. The bathroom scale didn’t arrive so I wasn’t monitoring weight gain so it was my largest gain. In the next community the grocery store was over 10 miles away, I didn’t have a doctor for 5 years and at about the same time Curves interval gyms arrived and we went as a group. In the time without a doctor I developed Vit D deficiencies, thyroid hormone deficiencies and Vit B12 deficiencies. Then we moved to this community where I don’t have a doctor, am close to a grocery store, and people do lunch together. I don’t have health care so no prescriptions or testing for anything. The great thing here is the summer farmer’s market which now has a nutrition student selling vegan foods. It has a high seniors population so the exercise classes and activities are possible for people in their late 80s so I’m not hurting myself trying to not embarrass myself in front of young, fit people.

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  4. I gained 50+ pounds in less than a year–About 30 of those pounds came from quitting smoking, pure and simple. I replaced the cigarettes with food. The other 20 pounds–well, I’m not really sure. I know I wasn’t sleeping enough hours and I was unhappy–I used food to keep me awake and to soothe. I wasn’t exercising, either, which is too bad as I now know that would have been the better remedy.

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  5. Sometimes all we need in so called fight to loose weight is a support. From friends and family. An blogs like this one to help us with the inspiration.

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  6. The point is that till we know what is causing the overeating, we can’t fix it, which means we will have little success in treating the weight problem and will be limited to a “symptomatic” approach – just eat less!

    I think this is one of those “correct in principle” things. I keep remembering what one fellow — who most of you probably already know, Sean Anderson — has said about just working the solution and finding clarity and understanding the problem in time. It works for more than just weight loss, which I know from my own experience with other challenges. Sometimes you have to just take a leap and move ahead with the rote solution, and as long as you keep looking for the fundamental problems, the rote solution will at least keep you moving in the right direction to where you can gain a little distance on the problem.

    Of course, you have to still pursue an understanding of the fundamental problem while you implement the rote one. You can’t just go on autopilot, ever. But sometimes progress and understanding come alongside one another.

    The idea that until we FULLY AND TOTALLY UNDERSTAND SOMETHING COMPLETELY, we are doomed to failure is not only wrong but sabotaging. It’s too easy to just toss up your hands and go, “Why even try?” As if until perfect enlightenment on any topic alone is the only thing that will bring success. There’s a lot of imperfect people with imperfect understanding out there who have nonetheless found success. Better understanding can help the successes stick, but until then, there is always a way to move forward.

    I’m just bothered by the implication that can be drawn from this statement that until one has obtained perfect understanding, one cannot improve at all and might as well not even take that first step. The last thing any group of people facing any difficult challenge needs to hear is, “Until we achieve total understanding of your problem — which may never happen in your lifetime — you’re doomed, doomed I say!” Humans understanding NOTHING perfectly and still manage to succeed at things.

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  7. Sorry for the second comment:

    It also gives people a tailor-made excuse for avoiding making inroads on a problem where success may actually involve confronting some emotionally intimidating things, up to and including the “Okay, now what?” reaction that anyone has when completing a rite of passage. You’ve been to grad school as a doctor — you must have heard this joke:

    Q: How do you point off the stomach-churning agony of finishing your thesis?

    A: Read another book! Repeat as necessary.

    It’s easy to use “I don’t understanding the problem perfectly yet,” as an excuse to keep from just dropping the hammer on something. Weight loss — and again, any challenge like that — involves confronting a lot of things up to and including, “So now that I have met this challenge and hit my goal (lost weight, gotten my PhD, had a baby, gotten married, gotten divorced), if my life doesn’t become a SuperLife™ does that make me a failure?” Saying that you are doomed to fail anyway if you don’t have perfect understanding is a great reason to stay in limbo.

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  8. Dr. Sharma –

    I’ve been reading your blog for a few weeks now and I must say, I have learned so much and gotten so much perspective out of it. I lost 30 pounds (40 pounds at contest weight) to become a bodybuilder and have kept the weight off for over a year, but I do so with much conscious thought and effort. Until I began reading your blog, I just kind of assumed it was what I needed to do to keep the weight off, but now I have an explanation as to why.

    I am in the process of applying to graduate schools in hopes of attaining my PhD nutritional research. Ultimately, my goal is to continue working towards much of what you discuss here (obesity prevention) and how to apply it.

    Thank you for all you have unknowingly provided me these last few weeks and I look forward to continuing to learn from you.

    Juliet

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  9. Janis says: Sometimes you have to just take a leap and move ahead with the rote solution, and as long as you keep looking for the fundamental problems, the rote solution will at least keep you moving in the right direction to where you can gain a little distance on the problem.

    When the rote solution you choose (food restriction) has been in use for many decades and is counterproductive – it moves most people in what you would consider to be the wrong direction, over the long term – then you have to start asking questions like “Is weight diversity really a problem?” and “Is weight diversity really caused by differences in eating habits?” “Is weight loss even a good goal?”

    The only reason I think this blog is worth following is because some of those questions are being asked, or at least hinted at.

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  10. We can probably list a 100 reasons why kidneys could fail and obviously the treatment (apart from some very general principles) will very much depend on the cause, i.e. the actual diagnosis.

    ELMM is a general principle that we should apply right away (in a similar way that a general principles in treating kidney failures will be applied) while we are investigating the root of the problem.

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  11. I think DeeLeigh has a good point, that when I’m eating healthy foods and exercising, I don’t experience weight loss, I experience weight maintenance. My weight hasn’t crept up over decades due to worsening food habits (they’ve gotten better) but has had distinct periods of increasing, usually during some extremely stressful time. Freshman 15, new job, even though I eventually adjust and find healthy foods and places to exercise, it takes concerted effort to lose the weight I put on during the transition. Sometimes I think that the obesity crisis is really a sign of good antibiotics and other winter foods. I think our tendency to put on weight comes from the same preservation instinct as bears overeating in the fall to prepare for winter hibernation. If I experienced a week or two annually of eating poorly or not at all – because food is scarce, because I’m not feeling hungry, that could be a 5 pound difference every year. On the other hand, when food was naturally scarce in winter, we developed an instinct to overeat if we did find some; especially with our cold office environments, we’ve extended winter and shortened summer.

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