When Eating is Your Answer to Pain
"The people who did best, and lost the most weight, were often thrown into a brutal depression, or panic, or rage. Some of them became suicidal. Without their bulk, they felt they couldn't cope." (p. 108, Lost Connections, Johann Hari)
What is your immediate response when you see someone who is extremely heavy? What thoughts (judgments) go through your mind? As a healthcare provider, I was taught to assess the external factors of obesity: height, weight, gender, age, diet intake, and level of exercise; to calculate body mass index, measure waist circumference, and if you were really thorough - calculate the waist to hip ratio. Then - especially if a patient had a co-morbidity like diabetes or high cholesterol, the expectation was to educate the patient about the importance of weight loss. As if morbidly obese patients didn't already know that.
Now, obesity is a complex phenomenon. Getting to the root of why requires acknowledgment of the multifactorial nature of human weight gain - from the genetic template received from our parents to the bacteria in our gut influencing our rates of metabolism; whether as a child you were given repeated antibiotics for ear infections or maybe cultural messages of food you'd grown up eating; and then there's the issue of accessing healthy food that so many Americans living in poverty face.
Here's what's not recognized enough though - getting to the root of why requires us to assess for internal factors as well, because disordered eating is often the solution a patient has found for emotions their brains deem too threatening to feel. Not uncommonly, these emotions stem from childhood adversity. In fact, the 10 categories captured in the ACE survey came out of a failed weight-loss study, in which patients who lost the most weight gained it back. Thankfully, rather than judging them, Dr. Vincent Felitti asked them why...and then began asking what was happening around the time that they first started gaining weight. It turned out that 55% of the patients in his program had been sexually abused, and even more, including the men, had had severely traumatic childhoods.
Instead of asking patients what they are eating, the question we need to be asking is why they eat. For people with a history of childhood adversity, the benefits of obesity tend to fall into 3 categories: it's sexually protective (you're not seen as attractive to men), it's physically protective (you are less vulnerable to violence), and it reduces people's expectations of them. Being morbidly obese is paradoxically a way to be overlooked, left alone. It's a way to retreat from a world that has hurt you.
Obesity isn't the problem - it's a symptom of something not seen. And patients need to be heard and affirmed when they trust us enough to tell us the truth, rather than being judged as just giving an excuse for their inability to lose weight. Sustained weight loss is possible when both internal and external factors are acknowledged and addressed...it is healing to be heard and affirmed! And that is a message of hope.