Last month, I attempted to be a medical advocate for my friend. I failed at this task due to my shock when her doctor poked her larger belly and asked abruptly, “What are you going to do about this?” She was not there to discuss weight and this behavior was so hostile, I froze.
This reminder of the discrimination fat people face every day inspired me to share some of the science that contributes to fatness beyond personal behaviors. Last month, I discussed how discrimination in healthcare settings repels minorities, including larger people. I also discussed how obesity has been induced in animals when the digestive bacteria is changed. I will continue the dialogue by discussing how pollution plays a role in obesity, as well as how the infrastructure of our cities influences our body size.
Environmental pollution can turn on genes that promote obesity, and for good reason. Left unchecked, toxins can float around our blood and interact with tissues, causing serious damage. Our bodies cope with this by sticking the toxins into our fat cells, where they can most safely be stored. Well, it turns out that when someone is exposed to more environmental pollution, their body adapts by turning on genes that create more fat storage sites. Some chemicals are even called obesogens due to their ability to promote obesity. And unfortunately, it isn’t just what you are directly exposed to. In animal models, these genes can be turned on for several generations. The bodies of our ancestors were trying to protect future generations by storing our toxins safely. And which members of our society are the most impacted by environmental pollution? Minorities and low-income families, many of whom can only afford housing in areas with more industrial pollution.
Our lowest-income communities face not only pollution, but they also face infrastructure environments that make healthy lifestyle choices much more challenging. Many lower-income neighborhoods have been dubbed “food deserts” for their lack of grocery stores and access to fruits and vegetables. Even if someone can find fruits and vegetables in their neighborhood, these items are too expensive for many low-income families. The most affordable food is often processed food due to government subsidies of the crops that get made into refined foods. Statistically, people who eat more subsidized foods are more likely to be obese.
Around 50 million Americans are estimated to be food-insecure, and blaming them for choosing affordable processed foods instead of fruits and vegetables is myopic. The structure of lower-income neighborhoods also contributes to obesity. Many lower-income areas have fewer bike paths and pedestrian routes. Many of the longest work commutes fall to lower-income families that can only afford housing far from their place of employment. These structural issues happen at a societal level and require public health thinking to address.
Like I mentioned last month, I am not trying to say that personal behaviors play no role in our body size. However, there are so many factors that are missing from the conversation around fatness. And something that deserves a reminder: being fat is not a behavior. In fact, when people change behaviors exclusively with the goal of changing their fatness, they often struggle to maintain those behaviors, because fatness may or may not change. When I work with patients on these topics, I ask them to stop weighing themselves. I invite them to explore concrete rewards they notice when they engage in health-promoting activities. My patients frequently report less fatigue, more energy, better sleep, better mood, better digestion, less stress and less chronic pain when they add more exercise or unprocessed foods to their routine. Making the connection between these intrinsic rewards and the behavior modification often results in long-term change. Again, the weight on the scale may or may not change as these behaviors become habits. But the health benefits have merit onto themselves, and once someone really integrates this body wisdom, they become unstoppable!
I hope this article inspires some new thoughts for you. I promise you, if fatness was something that could easily be “fixed,” most larger sized people would race to get access to the cure. It is a persistent struggle to be a discriminated group within society. Perhaps, recognizing some of the lesser discussed factors opens up compassion for the larger sized people in your life.
Be well!
Dr. Lauren Gresham is a naturopathic physician currently practicing telemedicine in Seattle. You can learn more about her by visiting www.totallylovablenaturopathic.com.
Editor’s note: Here is Lauren Gresham’s first column on obesity-related issues. It was published in The Daily Herald on Nov. 10.
Obesity has many factors beyond people’s choices
This week, I joined my friend at her medical appointment as an advocate. Fairly randomly, in the middle of the visit, her doctor abruptly poked her larger belly and asked, “so, what are you going to do about this?” Her appointment was not about her body size. This felt totally random and was so shockingly offensive that I froze. This sort of weight-shaming behavior inspired me to write this two-part newsletter for the next two months about factors that influence obesity beyond our individual control.
This month, I am going to discuss how our healthcare environment creates harm towards fat people as well as fascinating information about how our gastrointestinal bacteria plays a role in our body size. Next month, I will continue the dialogue by discussing how our toxin exposure and our neighborhoods contribute to our body size, and I will also discuss some new paradigms around fatness to consider.
If you have never attempted to lose any significant amount of weight (let’s say, 30 or more pounds), I speculate that it is really hard to understand how demoralizing this experience can be. Due to having evolved with periods of famine, we have many hormonal and neurological tools to keep us out of a caloric deficit. Hormonally, when we restrict our calories, we experience less satiety, more hunger signals, slowed metabolism and ubiquitous changes across our nervous, hepatic and skeletal muscle systems to reduce fat loss. Our physiologic survival mechanisms kick in and do everything possible to stop the weight loss.
What does this actually feel like? For many, these hormonal sensations lead to constant, persistent feelings of hunger and deprivation. As the days wear on, the animalistic brain takes over, to the point where many people become fixated on food. And statistically, 95% of dieters eventually get worn down by this constant barrage of hormonal warfare and quit their efforts. And despite the abysmal statistics for dieting success rates, we blame the individual. It is their lack of willpower, their shortcomings, their laziness, that failed. Never mind that practically any other medical intervention with a 5% success rate would be considered an ineffective therapy — it is the individual in the diet failure that gets blamed.
Please do not misunderstand me. I am not saying that individual behaviors have no part to play in our health. Vibrant health is built slowly and steadily, over many rituals and habits. There are many societal, genetic and environmental factors that contribute to obesity, and there are many personal actions that contribute, and they are all important. However, the other factors are often not spoken about enough, and in fact, shaming fat people for unsuccessful weight loss has ironically been associated with other health issues, such as eating disorders, depression and cardiovascular problems.
Weight stigma is prolific across the medical field. When a marginalized group regularly experiences discrimination and hostility seeking healthcare, they are less likely to return to those environments. Because do you know what sucks worse than being sick? Being sick and surrounded by hostile, discriminatory people!
We have strong correlative evidence that resistance to return to health-care environments is at least one major contributor to worse health outcomes in different minorities (people of color, members of the LBGTQ+ community and larger-sized patients). In a variety of articles, negative attitudes towards people with larger bodies occurs across a variety of health professions, ranging from nutritionists to family doctors. These environments make the experience more stressful for patients. They make it less likely patients will seek care and follow treatment plans, and increases mistrust of providers. Negative words, such as “weak willed” and “overindulgent,” surface more in the medical charts of larger people. And what my friend experienced is actually quite common where non-weight related appointments get turned into “teaching moments” where they get shamed about their weight.
One factor that is not often discussed: Our digestive bacteria plays a role in our body size. In 2015, a previously thin woman received a fecal transplant from her obese daughter to treat her severe gastrointestinal infections. Sixteen months after the transplant, the patient reported a weight gain of 34 pounds. Despite efforts to diet and exercise, after 36 months, the patient had gained 41 pounds total. Since then, researchers have been able to produce similar results in rats, inducing obesity by changing the bacteria inside the animal’s digestive systems. Today, there are many emerging studies with mixed results assessing if fecal transplants can actually be used as a treatment in obesity. We still really do not understand the clinical implications of this, or why certain folks have certain bacterial environments, but this information is paradigm-shifting. A discussion about our digestive microbiome deserves a seat at the table whenever we talk about fatness.
Next month, I will continue the conversation about more of obesity’s underrepresented contributing factors.
Dr. Lauren Gresham is a naturopathic physician currently practicing telemedicine in Seattle. You can learn more about her by visiting www.totallylovablenaturopathic.com.
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