The understanding, prevention and treatment of overweight (página 2)

Elisa speaks:

"I’m tired … very tired anymore of my endless, ever losing struggle with my weight. I’ve tried, just about every diet, every gimmick, every book that promised, not an easy fix, or an easy cure, just hope. Hope! … That’s all. Everything I’ve tried has failed — and everything everyone else [I know] — has tried has failed too. Why is it? I am a sensible, bright and well-educated woman, why have I failed?"

Elisa is a very successful trial attorney and a violinist with the Saint Louis Symphonic Orchestra…

To Elisa’s plight one would like to respond offering an easy fix, an easy answer, a so-called "miracle diet," one that would work and solve her riddle. Reality and experience demonstrate that diets (as the word goes) do not work; that dietitians, "nutritionists", endocrinologists and dietary programs, as advertised in the popular media, do not succeed in the long run; and, that a number of so-called "experts" in this field are obese (by appearances) themselves; leading us to conclude, that the problem of treating and understanding the obese and her obesity is a most difficult one. (See my articles related to the obese "experts" in this field).

Why, may we ask, joining Elisa in her lament, should it be this way?

In response to this rhetorical question we offer the following considerations:

• Obesity has not being properly studied or understood by the proponents of its treatment.
• Most systems that attempt an explanation often base their knowledge in principles already dated and obsolete, or worse, relying on dated theories that have not been confirmed.
• Frequently, the advertisers of weight control programs advance ideas that are as illogical as the methods they propose are dangerous.
• In other words, obesity remains as inscrutable as an enigma, and as a formidable opponent to known treatment methods.

The Dieter’s Dilemma

In their celebrated book by the above name, Bennett and Gurin give us abundant evidence of the fallacies that proliferate in the field of treating the obese. But, as they conclude the book, they do so with remarks which, to most, sound as a pessimistic and hopeless note of desperate lamentation.

For they offer neither hope nor promise the expected palliative if not panacea.

We are forced to concur with these authors assessment, that obesity is a quasi hopeless problem in terms of its understanding and resolution, and that new and (perhaps) bold approaches are needed, if it is going to be rendered conquerable at last. We are also forced to admit that the dictum that maintains that "of obesity everyone tells and no one knows …" is a sad admission of truth.

The understanding of the predicament of obesity

In the past, when I wrote on the subject as I do now, at some point I would digress and offer, informed criticisms of the various commercial treatment programs that exist.

But, why waste our time? A review of the literature should satisfy anyone’s concerns.

What are the causes of obesity?

To some this question begs scorn. For everyone knows that overeating and under-activity leads to fatness. That’s it!

Not so … Not so… At least, that much we understand today. (See my articles covering the Fiduciary System).

Listen to these arguments:

• Why is it then, that over activity and dietary restrictions often (quite often) elude the expected results of a permanent weight loss, or lasting "cure" (whatever that is)?
• Why it is that most dietary programs are known not to produce enduring results (despite the promises of their proponents)?
• Why is it that, to date, we have failed to discover the "magic bullet" that will end it all?
• Why is it that obesity and new dietary programs follow a parallel course (or is it curse?) as follows
• More obese people in the population and more new and useless dietary systems that appear.
• How come?

Obviously, if there was a universal approach or approaches that would work, or if someone would have come up with principles of understanding that were legitimate or that would solve the riddle — by now the growing health and social problem that are posited by obesity would have ceased. But we all know that, sadly, that this is far from being, as of today, the case.

Let’s now examine what we know of the onset and of the development of obesity in its various forms and in its diverse manifestations:

Obesity obviously is a polymorphous phenomenon, much as the specialist in endocrinology has told us for long. Obesity could be the cause and/or the result of panoply of widely recognized medical problems for which treatment is available and for which treatment should be sought. But, for the majority of the obese and of those who are fat, or overweight, their problem is neither medical nor seems to respond to the nuances or vagaries of dietary restrictions. For obesity is not caused by thyroid dysfunctions (as some want us to believe), by a "slow metabolism" (or metabolic rate) or by a lack of physical activity. Succinctly put: obesity is not what whatever everyone thinks it is.

"Inside each fat person there is a skinny one anxious to leave…" (FEFL 1999)

How do we explain obesity?

We explain obesity as the most elegant and compelling example of an adaptation failure in the evolutionary sense. Let’s examine this assertion.

Eons ago, when we inhabited the savannah, our activities consisted primarily of hunting, gathering, foraging and scavenging in order to attain the imperative of our survival — the plan that Nature programmed for us to preserve our existence.

We had no agriculture, no husbandry, and no reliable means of preserving our spoils or of postponing their inevitable decay. Our basic method of solving the problem of the recurrent periods of, relative, abundance and of definite scarcity was to store excess fat in our bodies where it would stay for the short-lived interlude that would elapse before it was needed again. We, therefore, were programmed genetically and evolutionarily to go through periods of weight gain to be followed by its loss. In this simple arrangement rests our well-tuned strategy, devised in response to Nature periodic and alternating phases of scarcity and surplus.

Apparently, in the pristine and natural state of our habitat of long ago, there was little cause for the presence of hidden stresses of the kind that could not be easily identified, easily understood, easily processed, and easily resolved. There was no risk of triggering the deleteriously dangerous reactions in our bodies described in a masterful way by Robert Sapolsky in his book Why Zebras Don’t Get Ulcers. In other words, there was no stress created by the interaction of culture and physiology.

Our stresses of today; originating in situations created by the fluctuations of a marketplace economy, by the oscillations of the value of the stock placed in the exchanges, by the desire and pursuit of fortune, beauty, happiness, wealth, education, and prestige (so pervasive of to-day) then did not exist — as these and many others do haunt us today.

Stress, an often ignored and neglected factor in the causation of obesity, did not appear in the guises in which it does today.

Similarly, obesity can be explicated as the interaction between and amongst adaptive systems vs. environmental factors ran amok.

1. The adaptive systems are:

• The ease and efficiency with which our bodies store surplus food and energy as fat
• The ease, immediacy, and efficiency with which our bodies utilize such accumulated stores
• The natural physically active way of our life of yonder
• The natural management of stress by means of adaptive inborn mechanisms and techniques

2. The environmental factors are:

• The overwhelming presence of rich, palatable, highly nutritious (fattening), accessible, socially proffered, highly advertised, well marketed, and ubiquitous food
• The proliferation of diet methods, dietitians, of so-called "nutritionists," diet books, USDA recommended (and by all means absurd) food groups and "pyramids"
• The appearance of sources of surplus — new stresses — that for thousands of years seem to have proliferated without the parallel development of adaptive mechanisms to reduce them
• Our sedentary life styles where, even "sports" (such as golf) are practiced aided by the utilization of vehicles and while imbibing alcoholic beverages and consuming food.

Basically these are the causes for our seeming irresoluble problem that I broach, this time, in this monograph.

In summary:

• We become and remain obese simply because we eat too much, and because
• We enjoy, as well, the excessive and heavy foods that we overvalue and with which we indulge
• We become and remain obese because we have adopted a sedentary way of life that retains and preserves the amount of energy we ingest.
• We become and remain obese because we suffer persistent and chronic stresses, created by our civilized ways of living, that cannot and that will not be reduced.
• And, we become and remain obese, because we have indulged in the pursuit of endless diets whose ultimate result and sequel have been to add pounds and fat to our bodies rendering these fatty reserves resistant to removal.

Let us discuss the role of the cerebral hypothalamus in the understanding of obesity.

The cerebral hypothalamus

Is the region of the brain lying below the thalamus forming the floor of the third ventricle of the encephalon. It contains a control center for many of the functions of the autonomic nervous system, and it has important links with the endocrine system because of its rich interaction with the pituitary gland that underlies it.

The hypothalamus is involved in the control of body temperature, sleep, sexual function, eating and weight regulation, and through certain pathways it modulates our moods and affects.

Our interest in this gland comes from the fact that, in our experience, only through a regulatory change in its function can permanent weight loss be achieved.

The hypothalamus regulates the accumulation and loses of weight without being obedient to any volitional act in our part. Now, that we have a brief and superficial understanding of what the hypothalamus does, I would like to repeat something that through the years of my work with patients suffering from all of the eating disorders many professional people utter (without the vaguest idea of what they are saying). Here it goes:

"Eating disorders are control issues …" Simple and true — yet unsolved.

Eating disorders: namely anorexia nervosa, bulimia nervosa, obesity and dieting are issues of control. Now we will see how this happens to be.

Obesity as a control issue

It bears repeating that, since the early beginnings of my lengthy and drawn-out career in understanding and treating patients with eating and its disorders, that the one point that seemed to pervade ideas in causation for most, if not all, practitioners, was the concept that "eating disorders (chiefly anorexia nervosa) are issues of control." This thought being stated as if "issues of control" were the sole and exclusive problems affecting the minds of girls suffering these conditions.

The whole idea, as most ideas gaining currency in the minds of mental health workers, had not originated with them but it was merely borrowed from the early writings of Hilde Bruch, who postulated this one, among other concerns, as the psychodynamic underpinnings buttressing the development of anorexia nervosa. Not as the only one as we were led to believe was the case.

Good… but not for very long…

Since from all appearances, it seemed obvious that "control issues" are just that, "control issues." This resulted in the implicit position that wasting words in explanations of what it was meant to be — would be superfluous at best, or unnecessary at worst. For said reasons, no one ever bothered to explicate to my own satisfaction, just what "control issues" really are.

But, what remained clear to all, was the issues of control were the patient’s manipulations to run the show, manipulating those around.

In other words: Control = Manipulations.

I don’t see in this manner and that point of view does not satisfy me, because is not supported by the realities of my experience.

An explanation of how I view the matter of "control issues" is advanced below.

Control issues

In order to achieve the often-elusive objective of permanent weight management, one has to be in control of certain aspects of one’s life, namely:

• Control of the demands of the hypothalamus
• Control of the amounts of stress suffered and buffered
• Control of one’s health
• Control of one’s moods
• Control of one’s foods
• Control of one’s leisure times and activity levels

Yes indeed, one has to be in control. Not the dietitian next door.

The problem here, is that one has to be either knowledgeable about what it’s involved in attaining this nirvana of self-control, or one has to be guided by someone else who knows.

This is where the difficulties begin, for no one with only a superficial smattering of the complexities involved and of the knowledge required, can achieved this goal — as many, too many, brazenly attempt.

The Dieter’s Dilemma… Wm. Bennett & J. Gurin

When one goes on a diet

The act itself of thinking about going on a diet is interpreted by our regulatory mechanisms as impending stress. Perhaps, because of such an impending Paleolithic catastrophic premonition, the young anorectic often develops amenorrhea, even before her dietary restriction begins.

Hunger and starvation are life-threatening events and as such our homeostatic mechanisms register them.

What the organism interprets as stressful circumstances associated with scarcity of food and consequent hunger, leads the individual to become restless, worried about food sources, concerned with hoarding and eating, and apprehensive about the unpleasantness of feeling the impending food shortage.

With this mind-set of imminent disaster the prospective dieter launches her crusade against her perceived ponderousness.

To be sure, diets begin on a Monday, after the weekend obligatory ritual of "farewell to goodies" has elapsed. With a will for heroic deeds the dieter begins his private odyssey.

For it is a heroic feat, that ordeal of entering a period of self-imposed starvation, living in a world of abundance.

It’s as well an act against nature — that of enduring food deprivations while food is plentiful — Therefore, hunger, temptations, moodiness, lack of resolve and will power will make this endeavor almost impossible to achieve.

Diets, for these reasons, are usually soon aborted leading to compensatory immediate weight gains.

This aspect of the dieting activity is seldom, if ever addressed by the impersonal dietary programs of the world, whose chief goal is to capitalize on the established rationalization that diets are "fun" because they briefly result in the (often) elusive weight loss and elevated auto esteem. The assumption, here, is that the dieter self-esteem will be strengthened on her resolve to lose pounds by the steady decline of the way the arm of the scale (that instrument of torture) moves. We’d wish that this would be the case.

In the stark realities of life, the initial excitement derived from the weight-loss experience is the individual’s sense of sacrifice, of self-doubts to keep it off for the long haul and the feeling of privation and denial in the face of others who seemingly are succeeding at controlling their figures without sacrifices.

Then, as a corollary of hunger there is the demand, the pressing clamor from an organism in a state of emergency due to unmitigated famine and unresolved food shortage. An organism rebelling against its fate, of a forced activity, for which nature did not program it. An organism that, in the end, will manage to defeat the resolve of its owner, expressed in the desire to remain svelte against all odds.

Now maybe, we can appreciate and, even understand, why all diets fail, and the reason why the diet industry is so cagey in their claims which turn out to be more spectacular than real:

For diets are, nothing more than the disease that they purport to cure.

To succeed we must be in control

This is the place where our "plan" (not a diet) and methodology is explained. In the manner in which we will now describe it is how we differ in our approaches from others. This is, as well, where the exact nature of our gritty and resolve is when put to the litmus test of verification.

To be in control, in our way of thinking, signifies that we are conversant with the issues that we are planning to address. It implies as well, that our knowledge and understanding of obesity is better than the one of the average person (or even, better than the one of those that call themselves, dietitians). It also implies that we are aware of the many fallacies that abound when it comes to the facts that are said to pertain to this field.

Let us, then, make a brief stop to reflect on just a small number of the facts and misleading notions that abound surrounding this realm.

Facts and fallacies

• That obesity is a genetic condition. If it were so, then the widespread corpulence that just arrived in Asia would not have occurred, as it is a common trait for habitants of the area to be of slight and delicate built. The problem in all of Asia is the introduction in their dietary strategy of fast foods, of the type responsible for the presence of obesity in America and elsewhere.
• That all the various and different types of the food we consume are metabolized identically. The fact is that our organism does process what it ingests according to environmental and internal parameters in delicate interactions. An Eskimo consuming a diet primarily composed of animal fats and scanty in amounts of vegetables will survive as well as an Inca living in the Andes and consuming only corn (maize), beans and calabash. In other words each person will have an eating strategy calibrated to the place where she lives.
• That exercises are an essential component of a reasonably good weight reduction program. As far as that goes, this is a mixed bag; physical activities release endorphins in our blood, enhance our energy levels, impart a general sense of wellbeing, but are not by themselves sufficient to make one lose weight.
• That fatness is an inevitable sequel of overeating and inactivity. Studies demonstrate amply that this is far from being the case. (See my Sisyphus article).
• That diets work. If this well accepted and entrenched premise were true, then we would not be in the quandary we now find ourselves, about corpulence.
• That diet pills, diet foods, and all the diet stuff that they sell us in the section dedicated to these gimmicks in the supermarkets are helpful. Expensive that they are … Helpful they are not.

And in this vein we could continue to successfully demolish and explode all the myths that have been woven into the very fabric of the various plans and programs aimed at weight reduction and control.

Having concluded the previous section with the use of the word "control" we now broach what it is to be, really, in "control".

To be in control:

1. Is to accept the fact that most of us, living amidst our affluence and enjoying food galore, are over nourished to the verge of imperiling our health and appearances.
2. Is to accept the fact that food cannot be viewed as a "sport" that we practice for the pleasures involved.
3. It is to realize that, while we manage to consume enormous amounts of calorie-laden foods, a vast portion of the rest of our human race does not have enough to eat. That a child celebrating her birthday consumes more energy, during the pagan festivity, than a laborer toiling under the sun, will have at his disposal.

That it is grotesque for us to support or patronize events (such as gastronomic functions) where the consumption of palatable food will take place — only for the taste and the mere enjoyment of it.

• It is to commence to view food as "our daily bread," as some sort of a divine concession and not as an oral luxury to which we are entitled and should consume ad nauseam.
• It is to discard the deceptive notion that three square meals a day (first proposed by the mythological Greek Palamedes) are essential for a human adult.
• It is to view, the use of food for social purposes, as a contradictory proposition that we must revise as a responsibility to ourselves and to those we love — beginning with the education of our children to its potential joys and avoiding probable sorrows.
• It is to characterize foods as edible and as inedible. Relegating the candy and dietary sections of any supermarket as belonging to the latter.
• It is to enjoy food as a deliberate and not as an automatic activity, responding and being controlled simply by our taste buds. In other words, to place on the way we ingest our meals the same care and thoughtfulness that we must place on how spend our money. Never done wastefully and never done in haste.
• It is to accept that nature has placed premium limitations on our eating strategy for survival. Limitations that we are not supposed to exceed without paying the high price that will be exacted from us, when we transgress: namely obesity and its complications.
• It is to be willing to acknowledge that in order for us to be successful at losing weight in the long run, that we will have to make lasting and sweeping changes in our present living styles.

In summary, to be in control is to adopt a strategy of eating and in living that would fit our stage in life, our ecology, our health requirements and our own goals. This type of commitment signifies our resolve to deal with and, to be successful in solving the enigma and the puzzle of our corpulence.

Now let’s move into something practical…

The Human Adaptive Eating Strategy (ECHA)

The strategy nature has devised for our alimentation and survival is characteristically one that would fit an organism destined to disperse, to migrate, to be mobile and to survive in a diversity of habitats. An organism that, without a heavy coat of fur covering its skin, would still manage to live in sub-zero temperatures with the same ease with which it could live in the desert, under water, in the mountains and in the littoral.

A highly adaptable and resilient animal, without limitations or constrains on what it could eat or could not, or what it would need to either survive or to adapt to adverse and diverse set of circumstances. In other words not a specialized eater (as camels or cats) but an omnivorous animal, born from a placental pregnancy, helpless at first, with no visible armor, with no powerful jaws, with no gift of flight or speed, with no crushing corpulence; but with a powerful and unequaled brain, the depository of the most developed intelligence ever seen in Nature. This animal happens to be us, aptly classified as Homo sapiens sapiens: The wiser among the wisest.

We now can begin to understand why we talk of a "plan" when we discuss our eating behaviors. We call it a plan, for we have surmised that it is our own particular and specific eating strategy, the one and only which we must follow, on our tactic to recover our lost bearings on the tables of epicurean delights.

This strategy, having sprung from Nature’s own balance, is easily deducted from what Nature has to offer. Simply put, being allowed to eat from all sources of food, we should utilize accordingly those foods which are most in abundance, which are easier to obtain at a low risk and which are easily stored (both as fat in our bodies and in our dwellings.)

Plants and vegetables, insects, fowl and birds, small vertebrates, fish and larger game (preferably hunted in groups, with makeshift weapons or scavenged from the hunt of other, better suited species). This is, concisely summarized, our eating strategy and plan.

There are some caveats that must be addressed at this point. Although, this is a general plan derived from our natural necessities, it is not a plan that can be adapted universally by all at this time in our history; for we have managed to dislocate the bearings of the stability we used to enjoy and the plan would require adjustments aimed at pacify the established rules operating in our world of pseudo science.

I guess a disclaimer here would appear useful, something to the effect that this plan must be opted at one’s own risk and peril. Risking criticism and generating controversy have never intimidated me, so that the Plan (with capital letter) remains applicable if only with appropriate modifications imposed on it by its very nature.

The Paleolithic Prescription

In another landmark of refinement in writing in the field of our eating strategy is the book whose name I entered above. The knowledge the authors impart therein is timeless and of tremendous importance to workers in this field, yet very few know of its existence, few have read it — having lapsed into undeserved publisher’s oblivion.

Borrowing from these and other sources we offer our exegesis of the surest manner of losing weight, while traveling the path with alacrity and sanguine premonitions.

The Plan

We offer the Plan in a succinct, yet descriptive manner. The only warning I would like to introduce now is the fact that this Plan, since is not based on dietary restrictions or heroic sacrifices cannot promise its adherents a lineal, uninterrupted progression of weight loses, but a steady, gradual and parsimonious way of achieving the goal. The following are its main premises:

• Do not suffer from hunger. In order to be in control of hypothalamic dictates, one must not be hungry. That means, however that one has to learn and to be able to distinguish from a caprice, a whim, and real hunger—a physiological imperative. This has to be learned, because for far too long our eating has been prompted by habit, impulse or by social prodding. We must then (surprise!) learn how to eat again.
• In order for us not to suffer from hunger we must establish (as a general in the field plans his battle strategy) we must apportion what, when, how, where and what not to.
• If one is used to eat breakfast. What to eat? Fresh fruits, bread made of non-sifted flour, poached eggs and/or juice. Sugar is out. Why is this so? Please, acquire and keep handy your copy of Sugar Blues6. Remembering that breakfast (no matter what the experts tell you) is not, and (for logical reasons) cannot be the important collation that it’s billed to be. Butter, lard and other animal greases are also out. Fat being unquestionably the food that most expediently we convert and store as fat (followed closely by refined sugar.)
• What to drink. Water. Yes, pure and clean, fresh H2O. Not milk, which is totally irrelevant after we finished lactating from our mother’s breast. Of course, nothing we say goes against the use of natural fruit juices. We must abstain from sodas and refreshments, which are rich in sugar, empty calories and carbonic acid.
• If, owing to the fact that we are used to snacking during the day, we must have those to avoid hunger, we can use freely fresh fruits and vegetables.
• For lunch, we can consume a balanced diet of plenty of complex carbohydrates, vegetables, salads, lean meat, fish or poultry followed by fruits. Eat well and be satisfied. Consume Dominican casabe the bread of the poor on which the rich should thrive.
• Snacks, because at first we are accustomed to eating at will, should be limited to the same order of things we ate in the morning.
• For dinner tuna in water, baked potato, plenty of vegetables and plenty of fruits.
• And, remember to walk briskly at least, half an hour a day; swim, ride your bike or do whatever aerobic exercises you’d like to do with enthusiasm. Not in order to lose weight, but to minimize and reduce stress.

This simple plan, can achieve the goal of lasting and/or permanent weight loss without spending a penny on its application.

People ask whether the use of wines and liquor are permitted on this Plan. With some discretion, they are permitted and even considered useful to the Plan. Cases are to be considered on an individual basis. Not permitted are cordials and beverages based on sugars.

Others ask if this Plan fits adolescents, children, the infirm and the elderly—if this Plan can be adapted to the treatment of the "super-obese."

Adolescents and children survive on this plan all over the world. The majority of the human race does not have access to the foods with which we poison ourselves and undermine our health.

For the very young and the elderly (particularly if infirm) medical considerations should always be taken into account.

For the very obese, for the diabetic, or for those whose general condition require medical as well as dietary concerns, the Plan can be successfully adapted. Treatment approaches for these groups are more selective and proceed in different and more convoluted fashion, as it will be explained in the next section.

The role of physical activity in the treatment and control of obesity

Once, I was involved in the management of the case of a woman made famous by the set of bizarre circumstances surrounding her final days.

Karen, a young, single woman, suffered severe head injuries in an automobile accident, resulting in brain death ¾ ¾ she laid in a protracted coma, until her adoptive parents were allowed (through seeming interminable, legal maneuvering) to disconnect her life support systems.

As she lay motionless in bed, with tubes connected to her body, a nasal-gastric tube assured her of a balanced nutrition. What nobody had noticed (until I called it to the dietitians’ attention) was that the patient had been receiving for weeks the enormous amount of (approximately) 9,000 calories a day ¾ ¾ this incredible quantity without gaining (even losing) weight.

According to the calculations of dietitians, it’s dogma that the intake of 3,000 daily calories will (inevitably) result in the accumulation of one pound of weight for that day. Why wasn’t Karen fat, if it was so?

Karen wasn’t fat, because we do not gain or lose weight neither by the number of calories consumed ¾ ¾ after all, she wasn’t moving at all!

Let’s talk about the role of exercise in weight control

Exercise is good because we are active animals. Exercise make us feel good, for it reduces stress, but for the amount of food in excess we ingest, exercise by itself is not remedy opposing it being turned into fat. Then it’s easy to understand why, the poor people that carry their ponderous anatomies through the streets of the Mirador remain permanently obese, and equally surprising, why anorexics who do not engage in any physical activities, remain overly-slim.

Weight can be lost and maintained gone, by watching your food intake and nothing else — so, that going to a spa in order lo lose weight is as much of a fallacy, as it’s easily supported by the evidence.

In summary

The author of this article is conscious that the treatment of overweight, as currently applied, is a deceptive racket. The author of this article has, as well, analyzed with greater certainty the causes and cures of fatness. And, as such remains convinced of the fact that obesity is the triumph of an instinct over reason, as previously postulated.

Based on all the premises and arguments presented, I conclude, that my assertions contained in my published works on the Hobson’s choice, remain axiomatic.

Therefore, unless obesity is addressed as a hypothalamic disorder awaiting the key of true therapy, that it will remain, as it has, an enigma in waiting of a resolution.

Bibliography

Furnished to those who request it.

Félix E. F. Larocca MD