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Sage Bariatric Working Against Obesity Prejudice

Usually, I like to talk about the science of obesity and bariatric surgery but this will be a more emotional topic: Obesity Prejudice.

Ever since I started doing bariatric surgery back in the mid ’90s, many of my patients have been accused of taking “the easy way out” with bariatric surgery.  This has always pissed me off, but until recently I had not stopped to analyze why this was so irritating.  My first thought was that I was reacting to an insult against me personally, and the work that I do professionally, that somehow these people were invalidating my whole professional focus.  I realized that no, there must be more to it, because medical skepticism was an old story. 

In fact, in the 90’s it was very common for my medical colleagues to openly question why I was “distorting normal gastrointestinal anatomy” to treat a “behavioral problem.”  Even then I didn’t take this as an insult but as a challenge to educate, and as the science around the Obesity Disease has grown it has become widely understood on an intellectual level that we are NOT treating a “behavioral problem” but really treating a metabolic/biologic imbalance.

So, this feeling of irritation seems not to be about me personally, and with more reflection, I’ve come to realize it’s a manifestation of OBESITY PREJUDICE.  Let’s look at that word prejudice for a minute – these definitions come from Dictionary.com.

Check me on this, is ‘obesity prejudice’ really the right term to use for this skepticism about treating obesity as a medical problem?  I really think it is the right term, and I’m being intentional about selecting a term that is odious, something that thoughtful and constructive people don’t do.  Let me unpack the skepticism about the medical/surgical approach to the Obesity Condition, then we’ll return to the definition of prejudice and see if it fits.  After we see if it’s an accurate description, we’ll see where it comes from and see about a better approach.

There’s always been this intuitive understanding that the obesity condition is caused by too much eating (too many calories in), and not enough exercise (not enough calories burned).  This idea has come from a simple layperson’s observation that these two factors have an impact on weight.  After all, your Aunt Jane (who happens to have no weight problem) has noticed this in her own life so it must be universally true, right?  It’s so obvious!

And in the early days, the medical community bought this narrative without a second thought.  When they did give it a second thought, they dressed the basic idea up with some terminology (“calories in” vs “calories out”), then applied some math to the situation and arrived at the “Thermodynamic Theory of Weight Loss.”  This was the prevailing medical practice until the ’80s and ’90s of the last century, and it’s still a reflex assumption for many physicians who have not taken the trouble to go back to school on the new concepts of Obesity Management.

I’ve invested a whole separate YouTube video (Thermodynamic Theory of Weight Loss: The Rest of the Story) in debunking the Thermodynamic Theory of weight loss, but here I’m just going to bring out one key mistaken assumption that didn’t show up in any of the math with that outmoded narrative. 

The assumption written into the entire fabric of that expired narrative about obesity treatment was that each individual has fully conscious control of their calories in vs. calories out.  This is incorrect and it ignores some key biology, but it was the universal belief for centuries and it led naturally to the assumption that each person’s weight is a matter of their personal choice and habits, their own discipline and willpower. 

Therefore, if a person does not “choose” to be fit then it must be due to a weakness of character, a failure to make smart decisions.  The next natural step is to conclude that the obesity condition is the personal responsibility of that individual; it is their fault.  And then, since they aren’t taking care of the problem on their own as they “should,” and since it’s such an obvious problem, why don’t we “help” them with a hefty serving of shame and blame to increase their motivation?  This is how obesity prejudice begins.

When I spell it out like this, most people agree it can’t be an accurate picture of what’s really happening with the Obesity Disease.  For example, even laypeople understand that genetics has a lot to do with weight.  I’m going to have a more to say about shaking off the old narrative and moving toward a better biologic understanding of the Obesity Disease in a minute, but I want to return to this term “prejudice” and to help you realize that it really is the interaction we’re talking about.  We’re going to break this down:

  • Unfavorable – obviously, society is judging those with obesity
  • Opinion or feeling formed beforehand or without knowledge, thought, or reason. – founded on old unexamined ideas, not on fact.  The assumption that obese people have 100% personal control of their weight is so deeply ingrained that it functions as an automatic reflex, so even people who (on one level) recognize biologic factors in the Obesity Disease often act as if the person with obesity should be able to fix it on their own.  Just a matter of will and discipline.

…not only does society blame the person for not fixing their own disease, society judges them as being less intelligent, less motivated, less able, less worthy.  

THAT is what makes me mad, and the main purpose of this piece is to call out obesity prejudice so we can understand it better and hopefully find a better way forward.  To get there, I’ll need to review a more accurate way of thinking about Obesity Disease.  It just so happens that moving away from obesity prejudice should lead to more effective and constructive approaches to the condition, instead of remaining stuck in that failed old “willpower” narrative.

By the way, I definitely believe in personal responsibility, personal effort, and personal choice.  The difference for me is that the mind and the will need to work with a powerful existing biologic system that is ONLY PARTIALLY subject to conscious control – more on that later.

So here’s one image of the prejudice that results.

Back to Obesity Prejudice for a moment – where is it coming from?  Obviously, it’s coming from Society as a whole.

Notice however that some of the most painful blame and shame are coming from those who are close to you, from family and friends.  Everyone has an “Aunt Jane” who feels perfectly free to give her opinion that what works for her ought to work for you too, right? 

But I believe the most poignant source of the blame and the shame are from the selfsame individuals who suffer from Obesity, against themselves. 

The old willpower narrative has been so pervasive for so long, that on a deep reflexive level it is even believed by people who know they’ve done everything that is humanly possible.  

Just about every new patient I meet in the initial consideration of surgery says something like, “I know I should just try harder.  I feel like a failure.”  They’ve internalized the Willpower Narrative to such a degree that they assume it’s true.  They don’t even realize they are making the assumption.  This is coming from people who have used willpower with diet and exercise to lose 50 or 100 pounds, which is an AMAZING accomplishment.  These people generally follow a food plan that is quite sensible and healthy, but it just doesn’t lead to weight loss with their distorted biology.  These are people who are fully successful in career, family, projects, so somehow they lack focus and willpower?  NO, that doesn’t make sense. 

This self-blame situation makes me sad, and I hope with this piece I can convince some of you to stop shaming and blaming yourself. 

MAYBE with some of these concepts and language tools, you can bring family and friends around to a more constructive understanding,

…and it will take a while but I certainly hope that someday society’s understanding will align with science rather than with the old willpower/blame narrative.

As we discuss a more accurate and constructive story to understand the Obesity Disease and as we hopefully move away from Obesity Prejudice, let’s understand that prejudice is an evil action but those who have and display prejudice are (mostly) not evil people.  They are simply misguided by ingrained assumptions written into the old narrative, and if they have a willing heart to accept new ideas they can let go of harmful and counterproductive action.  Why am I as a logical surgeon bringing “heart” into the discussion?   Because these deeply ingrained narratives have the character of religious beliefs.  Compelling information alone does not change traditional assumptions, one needs to feel open to new ideas as well, one needs to feel the effort of change is worthwhile.  That’s why I want to begin with you as the one who is already living with this – I hope you believe it is worth some energy and some work in order to let go of the self-blame and guilt you may have felt over your failure to “do it on your own,” or “lose weight the right way.”  (notice the judgment 😉 )

I hope we’ll use these and other ideas to move emotionally away from the willpower narrative of obesity to a “medical management” concept like we use for diabetes.  Most people understand that diabetes management includes a conscious focus on proper diet, BUT patients are not expected to fully control their diabetes with willpower.  It is understood that diabetes is a biologic/metabolic disease that can be impacted by choices and discipline, but also that medical management and drug treatment are often necessary.  There’s no blame in this, and the lack of blame means that patients come forward willingly for the treatment they need.  Since there’s no negative judgment, medical professionals address the diabetes condition proactively, and they naturally adjust the intensity of treatment to the stage of disease in each patient, instead of holding serious intervention until the patient proves they are “worthy” by

“trying hard enough,” which is the old-school tradition in obesity treatment.  I just want us to treat the Obesity Disease in a way that is logical, proactive, and constructive like diabetes.

I’m not going to talk about the basic science that underpins the conceptual transition from the willpower narrative toward the biological approach to obesity management, but I’m going to use that knowledge to describe a more modern understanding of the relationship between the mind/will, vs. the body/biology.  The real story is that the mind and biology are inextricably intertwined with each other, whole books are written about this, but for our purposes here it will be really useful to think of them as separate entities that work in a relationship.  The Willpower narrative assumes that biology is a domesticated junior companion of the Mind.  The Mind is considered to be in control, and biology conforms to the will of the Master. 

Even if biology gets a bit spunky or playful, there is no question about who is in charge.

This represents the Willpower narrative of weight control.

The real story is that the biology is a much bigger beast than the Mind, and the biology has its own powerful habits, reflexes, and urges that may or may not fit with the Mind’s fine conscious ideas.  

In reality, we can only survive if biology is powerful and complex.  The conscious mind has no scope to monitor and adjust survival systems such as blood flow, temperature regulation, or breathing.  The fat storage system is another one of those survival systems, and some degree of fat storage is absolutely necessary for any mobile organism to survive between meals.  The problem is that for many people in our modern civilization, some combination of genetics and the environment (most likely including the industrial food supply) causes this powerful unconscious system to fall out of balance so that the body biology WANTS to store large amounts of fat.  Intellectually we know the excess fat is not healthy, but this is a place where the powerful biologic system is determined to follow its own instincts, mostly regardless of what the Mind believes is best.  

This concept of the Mind as a rider on a large untamed beast with its own impulses can help explain one of the tricky things that helped the Willpower narrative seem so natural and obvious.  The fact is that most who have excess fat can lose some weight through diet and exercise.  At first blush, it seems obvious to conclude that more diet and exercise should lead to more weight loss, but 98% of those with serious obesity run into a “wall” and can’t get lower even with strenuous effort.  Picture this as the Mind/rider trying to get the Biology/Beast to go somewhere against its impulses.   The Mind/rider can often get the Biology/beast to start moving in the desired direction, but the further the beast goes from its impulses the more rebellious it becomes.  It stops moving, and the efforts of the Mind/rider to make it move further by yelling, whipping, or kicking at the beast are more likely to make it angry than to make it move.  This is real biology, and in the case of obesity, the Biology is stubbornly preserving the fat storage in obedience to its survival impulse.

This concept also captures biologic variability among individuals.  Many people have a healthy biologic balance, and in those lucky folks, the Biology/beast is perfectly content to maintain small/healthy fat stores.  The Mind/rider is perfectly happy to take credit for the fact that the Biology is performing in a healthy way (Aunt Jane proclaims that loudly, right?), but very often it more luck than will or intelligence.  

Fortunately, we can seriously reshape the relationship between Mind/rider and Biology with medical and surgical management.  As I’ve explained more extensively elsewhere, bariatric surgery actually works on a hormonal biologic level, so that the body on a basic survival level no longer WANTS to hold onto the excess fat.  This is like rewiring the impulses of biology, and in current medical jargon, we say we are reducing the body’s set point for fat to a lower/healthier level.  Now, this is not a magical change where everything is suddenly moonbeams and rainbows, 

…but still it’s fair to say that we convert the Mind/Biology relationship into one that is much more healthy.  The Mind now has tools for guiding the Biology/body, and the body is trained with a predisposition to perform in a healthier way.

Earlier I said that I’m all about personal responsibility and conscious focus, and it’s really important for our bariatric surgical patients to do a lot of work to keep that healthy balance and to keep the mind/body working in harmony.  Without regular and conscious attention to the body, training it, and nurturing it, the body’s impulses will get off track and the Mind will again find itself as a helpless Rider.

In the context of bariatric surgery, “regular and conscious attention” means at least:

  • Healthy eating
  • Regular exercise
  • Daily vitamin supplements
  • Regular blood work
  • Time invested in long term follow up

…and those factors are minor compared to the gumption it takes to put yourself on the operating table and to have some (otherwise normal) internal organs rearranged.

So, real medical and surgical management of the Obesity Disease is a lot of work, and that’s another reason it pisses me off when my patients are accused of taking the “easy way out.”  The fact is, that these folks have already been doing a lot of hard work over the years but it hasn’t paid off.  Really, if it’s not working then why keep beating your head against the wall?  Hopefully, the difference (with our help) is that the work pays off with health benefits. 

At the very least, if you are a person suffering from the Obesity Disease then stop being so hard on yourself.  Break the cycle of blame and self-criticism in your own head.  Give yourself some grace, and give yourself some credit for the work you’ve done even if you didn’t achieve lasting success.  Then once you accept that you are not to blame, use that focus and will (that you DO have, likely in ample measure) to get yourself the medical assistance that you deserve.

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