Undoing the Stigma of Obesity
NEW YORK—Nikki started gaining weight when she was 6 years old, and despite trying every program and everything natural she could think of—exercise, nutrition counseling, Overeaters Anonymous, Weight Watchers, and even a fat camp in Utah—by the time she was 23 she was carrying over 290 pounds on her 5’5″ frame.
Much larger than family and friends in her Ohio hometown, Nikki said she got used to being chided by her doctors for her inability to lose weight, excluded from family photos, and had to buy clothes in the “grandma section” of department stores because nothing else fit her.
After moving to the New York area in 2007 and spending time in the “very thin city,” she became so self-conscious that she didn’t want to leave her house. Although she had sleep apnea and high blood pressure, Nikki had never considered weight loss surgery because, “It seemed like the easy way out.”
Then she met a friend of a friend who’d had a procedure done with great results, so despite her fear of doctors, she decided to go for a consultation.
Nikki eventually opted to have gastric bypass surgery, which shrunk her stomach from the size of a cantaloupe to about the size of an egg, and re-routed her intestines. Within a year she had lost 150 pounds, and with attention to diet and physical activity, maintains her weight at around 150 pounds, which she says feels right for her body two years after surgery.
She now has a large network of friends, a ton more confidence, and has started drumming in a rock band.
These are exactly the kind of life changes her surgeon, Dr. Daniel Rosen, hopes for when he operates.
Dr. Rosen is a general surgeon who specializes in laparoscopic bariatric surgeries—weight-loss surgeries done through small incisions. He has made it his mission to help people understand obesity as a disease and why those suffering from it need the same care and empathy that we give to those suffering from diabetes or cancer.
Despite an increase in weight-friendliness in some arenas—namely in plus-sized fashion and pockets of America where overweight has become such a norm that people don’t recognize it as a health concern—the larger trend is still to stigmatize overweight people as lazy, unintelligent, and lacking self-discipline.
And perhaps surprisingly this stigma can come from the medical community. Nikki said the first weight-loss surgeon she consulted in New York was condescending.
However, it appears medical attitudes toward obesity may be on the road to greater acceptance. In a 2010 study by the American Public Health Association, an organization for health professionals, verified that “weight stigma is not a beneficial public health tool for reducing obesity or improving health,” refuting an earlier idea that stigma would pressure people into losing weight. And last year, the American Medical Association officially recognized obesity as a disease.
As part of his practice, Dr. Rosen educates people about the causes of obesity and why telling obese individuals to lose weight can be like telling the passengers on the Titanic to save themselves.
For thousands of years, societies hunted, fished, farmed, and gathered their food and it was normal to have large feasts followed by long famines. So humans who developed the ability to store fat well were more likely to survive in very harsh regions. The ability to easily store fat is now seen as a result of “thrifty genes.”
Dr. Rosen cited the example of the Pima Indians of Arizona who developed unusually high rates of obesity and diabetes after they adopted a modern lifestyle post WWII. The thrifty gene theory was the only way researchers could explain why these diseases were so much more prevalent in the Pima than in their Caucasian neighbors.
According to John Hopkins Medicine, thrifty genes may also affect Africans, Hispanics, and Asian-Americans; as well as Pacific Islanders and American Indians.
Obesity by the Numbers
Disease: Obesity was recognized as a disease in 2013 by the American Medical Association, changing the way doctors and insurance companies treat it.
Epidemic: 69.2 percent of American adults over 20 are overweight. Of this, 35.9 percent are obese, according to 2009–2010 estimates by the CDC. Around 18 percent of children ages 6–18 are obese and just over 12 percent of children ages 2–5 are obese.
Education: While women with higher education are less likely to be obese than less-educated women, there is no significant relationship between education and obesity in men.
Stigma: A study of undergraduates conducted by Michigan State University found that the students said they would be more inclined to marry a cocaine user or an embezzler than a person who was obese.
Geography: The Midwest has the highest rates of obesity while the Northwest as the lowest. New York has a 25–30 percent obesity rate, according to 2012 estimates by the CDC.
Historic Rise: There was a sharp rise in obesity in the United States between 1990 and 2010. In the ’80s there were no states with more than a 14 percent obesity rate. In 2010, twelve states had obesity rates over 30 percent.
Sources: Centers for Disease Control and Prevention, Michigan State University
We have a society that is “totally stacked” against the biology of many people, Dr. Rosen said.
Very savvy marketing and tasty, but intentionally unsatisfying processed, food clog modern grocery stores and food courts, and together with the increase in calorie saving conveniences, it should come as no surprise that two-thirds of Americans are overweight or obese.
Current numbers show one-third of Americans are normal weight, one-third are overweight, and one-third are obese.
At a recent talk to prospective patients, Dr. Rosen showed a picture of a kid’s cereal box and explained that the cute elf and rainbow colors on it were very likely the result of advice from a psychologist and extensive market testing. As to the food inside the box, it was constructed by food scientists with the goal of selling.
“They [processed foods] are created specifically with the goal of—not being nutritious—but being tasty. And not being tasty in a savory, delicious way, being tasty in a way that you consume it to a maximum and are compelled to consume more,” Dr. Rosen said.
And when people eat in food courts, the content and volume of the music is also programed to increase hunger and thereby spending, he said.
On top of poor nutrition, obesity is compounded by sedentary lifestyles, stress, and lack of education, according to Dr. Rosen.
After we get home from our desk jobs, “Our leisure activity tends to be a lot of low-calorie burning endeavors. Like, instead of surfing it’s channel surfing,” he said.
The mental stress we feel during the day is the same to our body as the stress of being in a long-term survival situation.
Thoughts like: Will my insurance pay for my treatment? Will I be able to make this deadline? Still feel to our bodies like: Winter’s coming and we’re low on food stores, or there’s a rival tribe tracking us, Dr Rosen said.
“Your body doesn’t know the difference between real stress like that and these manufactured stresses that we live with everyday,” he said.
The body reacts to these stresses by releasing cortisol—a hormone that is part of our flight or fight reflex and affects our gut hormones and feelings of hunger.
Part of the way we are conditioned to handle stress is by eating, Dr. Rosen said, because we will need energy reserves to run or combat an enemy.
Another gap fueling the obesity boom is lack of education, both in schools and doctors offices Dr. Rosen said.
“I see patients who are never given any information in public schools about nutrition and are fed this litany of advertising of what they should be eating,” Dr. Rosen said.
Although a third of Americans are obese, a 2007 study by the National Consumers league showed that only 12 percent of U.S. adults had been told by their doctor that they are obese. Dr. Rosen said this still holds true for many of the patients he sees for the first time.
Risks of Surgery vs. Not Having Surgery
Bariatric is a term for any surgery whose primary goal is weight loss, procedures that come with their own stigma—of being unsafe, unnecessary, and a lazy way to lose weight.
Part of the unsafe stigma comes from early medical errors, like when doctors removed too much intestine causing patients to become extremely malnourished later on.
Advancements in technology have made it much less invasive and laproscropic bariatic surgery is done only with small incisions in the abdomen, instead of cutting the abdomen open.
And when you consider the risks, of surgery, Dr. Rosen said, you also need to consider the risks of being obese.
Obesity is not measured in pounds but rather by a body-mass calculation, which compares height and weight.
Normal BMI is 18–24, overweight is 25–29, obese is 30–39, and over 40 is morbidly obese, which means a person a person will most likely suffer from obesity-related diseases such as, high blood pressure, diabetes, osteoarthritis, heart disease, and even some cancers.
Bariatric surgery, is only intended for those who are obese or morbidly obese, and who, for a combination of genetic and environmental reasons, cannot realistically expect to reach and maintain a healthy weight through diet and exercise.
The different surgeries have different risks associated with them. Some of the surgeries’ complications can include leaks in the gastrointestinal system; protein and vitamin deficiency when too much intestine is bypassed as less intestine means fewer nutrients are absorbed; and something called dumping syndrome, which happens when refined carbohydrates like those made with white flour or sugar, are rapidly “dumped” from the newly created stomach pouch right into a part of the intestines, which can’t absorb them well.
The overwhelmed intestine responds by diluting the food and quickly pushing some of it downstream to spread the work of digestion. Dumping syndrome cause symptoms ranging from abdominal cramps, nausea, and diarrhea to dizziness and headaches that can last anywhere from a few minutes to an hour.
Nikki said she had to learn through trial and error what her body could and could not handle as it recovered from surgery and now she can eat just about everything she could before, except sugar, which will trigger dumping syndrome in her.
The risk of death from gastric bypass surgery is around 0.5-1 percent, but the weight loss and improvement in obesity related diseases that happen after bariatric surgery, can greatly increase a person’s life expectancy, as well as their quality of life.
Dr. Rosen explained that more than 7 out of 10 persons with a normal BMI will reach 70 years old, but only half of people with a BMI of 40 will live that long and only about 2 out of 10 will see their 80th birthday.
In short, bariatric surgery can increase life expectancy from 60–65 years to 80 and beyond, which for some people is definitely worth the risk of surgery, Dr. Rosen said.
“It’s the difference between meeting your grandchild and walking them down the aisle…. That’s worth a lot,” he said.
Bariatric surgery is only part of the road to getting to a healthy weight. Lifestyle changes are essential, otherwise the person can gain all the weight back, which some people do.
For many people who struggle with obesity, it may not be possible for them to lose around half their body weight and keep it off without the help of bariatric surgery. Dr. Rosen says the treatment shouldn’t be considered the easy way out. He compared a patient whose heart function has deteriorated to the point where they need a transplant. That patient would never be shamed for undergoing surgery or considered lazy for taking the easy way out. They would be applauded for making a proactive choice to improve their health and prolong their life.
Nikki said she was able to lose 30 pounds or so through diet and exercise, but could not lose more no matter what she did. The gastric bypass took the weight off—ending her sleep apnea and lowering her blood pressure to the point that she no longer takes medication for it.
“Having the surgery sort of made it a level playing field,” she said.
Dr Daniel J. Rosen is a fellowship-trained board certified general surgeon and Associate Director of Bariatric Surgery at Wyckoff Heights Medical Center. He offers free monthly seminars on obesity and weight loss surgery at both his Brooklyn and Manhattan offices. Call (866) 429-5961 for more information.