Fat People Aren’t Lazy Gluttons, They’re Just Nuts

An editorial in the American Journal of Psychiatry asks: “Should obesity be included [in the DSM-V] as a brain disorder?”

Terrific.

The thing is, what they’re really suggesting is that compulsive overeating should be included as an eating disorder alongside anorexia and bulimia–something I’m all for, actually. But you’ll notice it’s anorexia and bulimia that are already in the DSM-IV, not thinness. Classifying obesity as a psychiatric disorder would be like classifying bald patches as one, because some people have trichotillomania. What the hell are they thinking?

This, apparently:

Standard interventions based on promoting lifestyle changes to decrease excessive food consumption (dieting) and increased physical activity (exercise) are effective and can normalize weight if followed rigorously, but unfortunately they are incredibly difficult to sustain. The discrepancy between the successes of the metabolic treatments of consequences of obesity and the failures of behavioral treatments to prevent or reverse obesity highlight the fact that this condition is not only a metabolic disorder but also a brain disorder. Consideration of the mental component of obesity should be a key target in the treatment of obesity to facilitate compliance and minimize relapse.

I suppose I should give them some credit for admitting flat out that “lifestyle changes” = dieting, at least. But they lose me when they conclude that because diets don’t work, fat people probably have a brain disorder.

Never mind that for diets to work in the long-term, people would have to continue eating a severely, unnaturally calorie-restricted diet for the rest of their lives. That couldn’t have anything to do with it. And let’s definitely not talk about the fact that diets don’t work for thin people, either. It’s not just the “obese” who lose weight by restricting calories, then gain it back as soon as they begin eating like normal human beings. It’s also the many, many people who only had 10 or 20 pounds to lose in the first place. 95 percent of them gain it all back and more, just as surely as 95 percent of big ol’ fatties do. So, if a 5’3″ woman starts out at 130 lbs., diets down to 110, and ends up at 140 two years later, is that evidence that she might have a brain disorder? According to the logic in that passage, it sure is.

What really bothers me is that yes, some people do become tremendously fat by eating compulsivelyone of my own family members has twice been hospitalized at eating disorder clinics for just that. Compulsive overeating is essentially bulimia minus purging; it’s real, and it’s devastating. The first published article I ever wrote, in 1993, was on eating disorders, and when I tried to get quotes from doctors about compulsive overeating, I got a whole lot of “Huh?” So I would love to see compulsive overeating receive more attention as a legitimate eating disorder.

But that’s not what they’re proposing. They’re proposing that obesity be classified as an eating disorder.

To be fair, this editorial is merely floating an idea, and the authors are generally circumspect about presenting this as a diagnosis for some obese people, not all. Except in, you know, the frickin’ headline. And except for the part where they’re still advocating for classifying “some forms of obesity” as a disorder instead of “some forms of eating.”

Do you need more analogies besides anorexia/thinness and trich/baldness to see how unbelievably wrongheaded that is? How ’bout “Yellow teeth should be classified as a brain disorder because some people smoke compulsively”? “Gonorrhea should be classified as a brain disorder, because some people have sex addictions”? Do you need me to keep going? BECAUSE I COULD.

I’m the farthest thing from a doctor, but it’s just goddamned common sense that obesity is a symptom of the disorder they’re talking about, not the disorder itself. It’s also sense–though much less common, sadly–that just as there are thin people who eat normally and have no mental health issues around food, there are fat people who do. Bodies are different. So why on earth are they suggesting that a symptom should be classified as a disorder?

Well, here’s a thought: check out the first paragraph of that editorial. The very first thing they tell us is how catastrophic obesity is for individuals and society. (For now, I’m setting aside the fact that some of the claims they make are not at all cut and dried, no matter how many times they’re repeated.) Why start off with the cost of obesity, which actually has about as much to do with whether it’s a brain disorder as, I don’t know, the price of tea in China?

Maybe because you’re looking for funding?

And maybe because your sources for funding have proven themselves to be quite keen on “Obesity! Kills!” research in the past, not so much on “Obesity has myriad causes, many of which are beyond the individual’s control, and, except at the most extreme, weight has little effect on health”?

What’s so incredibly galling about all this is that compulsive overeating is often responsible for the sort of extreme obesity that does severely compromise a person’s health. Recognizing it as a disorder and taking it as seriously as anorexia and bulimia would be a marvelous step toward helping people with genuine physical and mental health problems. But framing it as “some forms of obesity” instead of “some forms of eating” misses the point entirely.

In case I haven’t mentioned it lately, despite being on the small side of fat, despite being able to shop in regular stores, I am officially, diagnosably obese. And if you haven’t seen me lately, this is what obesity looks like (kindly forgive the blurriness):

obesity.jpg

That right there is an obese person who, as a matter of fact, has some compulsive overeating tendencies–they run rampant in my family, and I have no doubt that there’s a genetic component to that, just as there is to fat itself. But I have neither a full-blown eating disorder nor any weight-related health issues. And still, given the way they frame the problem in this editorial, I could easily be categorized as someone who needs help for my brain disorder because I’m gonna die 20 years early and cost society all sorts of money.

Some of the fat people in my family and circle of friends do have both eating disorders and weight-related health problems. I would love to see them get better, more comprehensive, more dignified treatment for their illnesses. And what this editorial proposes could lead to that. But it won’t if the researchers–and those who fund them–can’t get their big, fat heads around the fact that obesity is sometimes a symptom of a brain disorder, not the damned disorder itself.

17 thoughts on “Fat People Aren’t Lazy Gluttons, They’re Just Nuts

  1. I really like this entry. You beautifully dissect the muddled thinking and leaps of logic in this editorial. And I love your analysis particularly because this editorial is so typical of maintream discussions of fat. Everything gets conflated to death.

    People confuse “overweight and obesity” with unhealthy fat (and what amount of fat, is “unhealthy” and in whom and in what locations is an extremely difficult line to draw). They confuse fat with a “behavior.” (And which behavior is it? Eating too much? Eating “unhealthy foods?” Being “sedentary?” Or just eating a few more calories than you burn per day?) And by extention they confuse fat with “choice” and “immorality” and “laziness” and “negligence.” They confuse temporary weight loss with permanent weight loss. They confuse any kind of weight loss with “health.” They confuse hypothetical efficacy with actual efficacy (“diets would work if they could be followed” — i.e. diets would work if they worked). And on and on.

    But the reason obesity is being suggested as a new diagnostic category for the DSM, IMHO, is not so much that these people are as stupid as they sound to you and me. Call me a cynic, but I think this is mainly about insurance compensation for “treatment.” Take a look at this (particularly the last paragraph) and see if it makes you look at this editorial any differently.
    http://www.decisionresources.com/press_releases/pr_04_02_2007.htm

  2. Call me a cynic, but I think this is mainly about insurance compensation for “treatment.”

    That’s a really good point–and it also explains the “Obesity EPIDEMIC” meme that’s so thoroughly saturated all the reporting on it. I have no doubt we have pharmaceutical companies’ press releases to thank for that. Their weight loss drugs will be worthless if insurance won’t cover them.

    I still suspect the potential for research funding is also behind the DSM thing, though. That editorial read like a thinly veiled grant proposal to me. But in any case, it comes down to the same thing: how do we get more money, regardless of whether we help people? Sigh.

  3. Huh. I hadn’t thoguht of research. I don’t know how making something a DSM diagnostic category affects research funding. It seems like obesity research is already funded up the wazoo. But maybe this would open it up for NIMH grants specifically? Very interesting thought.

    What I do know is that if it is a DSM category then it would go a long way to getting insurance compensation for *all* of the following:

    1. Weight Loss Drugs (or any drug that could conceivably affect weight)
    2. Psychiatry and Therapy office visits (afaik these are no longer covered through most HMO’s unless there’s some kind of psychiatric diagnosis).
    3. Weight loss programs like Jenny Craig
    4. Weight loss surgery??? Dunno how the DSM would affect that, but it might.

    What would really really…really…suck is if all the fighting for mental health parity of the past decade would end up just being a means to fund the weight loss industry and psychiatrists trying to cure fat people of their “mental illness.”

  4. That was lovely – thank you! A friend of mine just pointed out your blog to me this morning and it’s a real treat.

    That notion of the difference between the symptom and the disorder *ought* to be pretty easy to make for, you know, an actual scientist. Duh! And I think you’re spot on about the influence of money in so much of what we’re told about “health”.

  5. I remember when Anorexia was considered a health problem and a mental disorder. Now they just call it healthy.

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  7. If ‘satiating the reward system’ suppresses appetite, does that mean constant insults and abuse are preventing us from satisfying our pleasure quotient, therefore giving us the munchies? Is this enough ‘motivation’ for them to stop their nonsense?

  8. “But it won’t if the researchers–and those who fund them–can’t get their big, fat heads around the fact that obesity is sometimes a symptom of a brain disorder, not the damned disorder itself.”

    It will take them time. They are, after all, psychiatrists. We must be patient.

    FWIW, I have heard that they are looking into designating binge-eating disorder as part of the DSM-IV (or whatever it’s called). What with the link between serotonin, and carbohydrates, and the hippocampus, and addictive behaviors, and all.

    But then the Calvinists can’t talk as much about sloth and gluttony, so I don’t know.

  9. “…because I’m gonna die 20 years early and cost society all sorts of money.”

    Ha!

    But, but … if you died earlier, wouldn’t you cost society less money?

    As Corky St. Clair would say, “I was just jokin’ …”

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  11. Well done, well done. I agree that compulsive overeating – which *is* my problem – should be listed in the DSMV along with other eating disorders, but obesity itself is just being fat, and that has too many reasons to list. I agree with the assessment that it’s probably at its root about insurance money/grant money.

  12. Great post. Just FYI, being listed in DSM does not automatically translate into insurance coverage. Most treatment for anorexia and bulimia, for instance, is not covered, unless you live in a state with mental health parity laws in place. And even then they’re not covered sometimes because some states make a distinction between “biologically based” and “non biologically based” mental health issues. WTF? Last time I checked, our brains were in our bodies and ergo mental health issues are biologically based.

    I think this is about insurance coverage for one specific kind of obesity treatment: gastric bypass. There are big bucks to be made there and lots of docs who want to climb on the gravy train, so to speak.

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  16. There is too much money to be made with the obesity problem. It is obvious as day that nagging everyone into voluntary starvation calling it a “lifestyle change” is not working. Call it what you want but a diet is a diet is a diet. And the diet must be done for life. Nor will nagging everyone into training for marathons will ever work. Isn’t compulsive dieting/exercising called something like Anorexia Nervosa??? So the health nags are ENCOURAGING mental illness! Are psychiatrists (and orthopedic surgeons) paying them off? Along with Jenny Craig, Bally Health Clubs, etc.?

    Don’t forget that if you ride a bicycle in the street, you reduce risk of heart attack – by increasing risk of death by car wreck!

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