Previously published as a commentary by Dr Thatcher for the PCOS Association

Recently psychologist Phil McGraw, a guest on Oprah™, stated there is no biological reason why a woman should be overweight - that all weight problems stem from mental and emotional issues. This statement that obesity is solely a psychological problem is preposterous without clinical or scientific foundation. The only basis for such a statement could be an unbelievable lack of understanding, or the desire to stimulate controversy. In either case such a statement is reprehensible, if not harmful, to those who struggle daily with weight control.

Obesity is not a psychiatric diagnosis. There is not an obese personality type. True, those entering weight reduction programs have lower self-esteem and a higher rate of depression. So do all suffering from a chronic medical problem. Are we seeing not a cause of obesity, but just another one of its harmful effects?

There are several untenable positions on the origins of obesity. The first is that obesity is a matter of "self control." Rubbish. To equate obesity with an "emotional" problem is just wrong. While personality has a definite biologic origin, it is a later evolutionary acquisition. Emotion and consciousness are the last layers of our development in the formation of who and what we are. Weight and weight control are much more fundamental mechanisms. The metabolism of energy, and therefore weight, is the most basic life function, mandated for us to adapt to our environment and secure our evolutionary status.

Every human is a unique individual. Who we are is determined by a complex interrelationship of genetics and environment. This concept of relative contribution of "nature versus nurture" has been a classic scientific, if not philosophical question. Genetics seems to be winning out. Some humans have always been heavier than others. Whether this is a normal adaptive mechanism, or a pathologic exaggeration of a normal mechanism is not known. Regardless, weight and its control are much more than either self-will or emotion can explain or direct.

Genetic origins

Certainly, obesity has been around for a long time. Evidence of obese women has been found in Stone Age archeological sites across Europe. Major insights on obesity have come from a study of the Pima Indians of the Southwest. In their past an inability to store food as fat in times of decreased food supply could mean starvation. Now with a very typical Western diet, obesity and diabetes is the norm in this tribe. This is not due to overeating, but to a genetic predisposition. A concept often invoked is that of the "thrifty gene," a genetic constitution that has allowed considerable adaptive advantage and survival. Unfortunately, what was our best friend may be becoming our worst enemy. We know that the Pima Indians have a high degree of insulin resistance and it is possible that the thrifty gene may be reinterpreted as this disorder.

Insulin is a multi-purpose hormone produced by the pancreas that has one primary role: the maintenance of a constant supply of glucose. Glucose is the basic energy currency on which the body runs and must be constantly maintained within a narrow range. When food is consumed increased insulin results in the storage of glucose as fat. Insulin also retards the breakdown of fat into glucose. As such, insulin conserves energy; it promotes and maintains fat disposition. Some individuals are more insulin resistant that others; some are better at storing fat. Insulin resistance is genetically determined. What once was a valuable attribute for survival has now turned against us in times of food excess. Insulin promotes obesity and obesity further worsens insulin resistance causing additional weight gain to occur. Subsequently, metabolism slows and weight loss becomes more difficult.

Is there a single gene? Probably not one gene, but certainly a genetic predisposition. Scientists have recently isolated one regulatory signal called leptin. While once heralded as the Holy Grail of obesity, leptin now seems only to be one more piece of the puzzle. Eating behavior is strongly influenced by intricate brain centers of hunger and satiety. These centers are likewise controlled by genetics, but are also altered by our environment even before birth. Understanding of the control mechanisms that determine why we eat and why we gain weight is still in its infancy.

Glucotoxic environment

Surely there is a strong genetic component over which we have little control, but our environment and especially our conditioned responses to that environment, are playing an increasingly important role. Weight changes of the world population over the last 50 years have been much too dramatic to suggest solely a genetic cause. I would also argue that there have been at most minimal changes in emotional constitution of women during this time. In the United States in 1960, 15% of the female population was considered obese. In 1990, the prevalence of obesity had risen to 25%. Obesity and eating behavior is a genetically programmed evolutionary advantage operating in a “toxic environment” of unlimited food and low energy expenditure.

A woman of the 19th century who was working in the fields and chopping wood while breast-feeding may have weighed 180 pounds. Little could be done that could either improve her diet, or exercise pattern. However, by today’s medical classification she would be considered obese. Obese by modern standards, yet in excellent health. This 19th century woman’s genetic background had programmed her to weigh no less. In the 21st century, this same woman’s genetic descendant, driving to work, working at her desk, and eating at her work, might weigh 225 pounds. (Consider 180 pounds genetic, 15 pounds environmental conditioning, 15 pounds inactivity, and 15 pounds just plain improper eating.) Is there possibly a psychological contribution? Yes. Is obesity a psychological ailment? Certainly not. Can weight be lost? Yes, probably about 15-30 pounds. Will she ever weigh 140 pounds? Never. She has the same genetic make-up, but is in a very different environment from her ancestors, so much so that she is now at considerable health risk. The point is that our genes determine our potential, but our environment, only some of which we consciously control, realizes it.

The real danger

For most, food is now plentiful. However, our 21st century diets have increased in calories; they are energy dense. At the same time, our caloric expenditure has slowed. Interestingly, the formerly adaptive genetic predisposition to store fat that once permitted survival and reproduction now places humans at an increased risk for morbidity (illness) and morbidity (death). Almost 100 million Americans are overweight (a body mass index, or BMI, over 25), or obese (BMI over 30.) Does this mean that one third of our population are depressed? Maybe some in the psychological community would like to think so. The truth is that we facing a health problem of epidemic proportions. Most deaths can be attributed to problems directly or indirectly related to obesity.

Obesity is an excessive storage of body fat. Implied in the definition is that the fat stores are high enough to impair present health or to put the individual at higher risk for future health impairment. It is not just being "few pounds overweight." When seeking medical help for any number of medical reasons, much too often the obese patient has been told to “eat less” and “exercise more.” Unfortunately, many obese patients, and possibly their serious medical problems, are dismissed with the remark, “If you would only lose weight,” and perhaps the unspoken thought, “If she only control herself." This approach is obscene.

Repeatedly, it is stated that weight is gained when calories taken in exceed calories used, and reducing calorie intake to less than calories used results in weight loss. Of course, this must be true, but equally valid must be subtle innate difference(s) in the way each of us utilizes calories. Sure, it is undeniable that the only way that weight can be lost is when the calorie use exceeds the caloric intake but it is much more complicated than this. As weight is gained the body changes its metabolic pathways such that more energy is conserved and weight loss is harder.
Obesity should be considered a legitimate, chronic, lifelong medical disorder and approached as such. It would be ridiculous to treat an individual with elevated blood pressure for one month and after it returns to normal stop therapy. Obesity, like hypertension, is a sign of a much broader based physiologic alteration. Metabolically, obesity is a result of a long-term positive energy balance. It may be possible to be fat and fit, but obesity is clearly linked to multiple medical problems.

The perfect form

Studies have suggested that most women in the United States are unhappy with their bodies. Regardless of their size they view themselves as too fat. An estimated 50% of women are trying to lose weight. What has caused the change in the perception of the Western idea of perfect female form is unclear. Still, change it has and women have been victimized by the idealized fashion model figure of today. Thinness has come to symbolize success, control and attractiveness. This “ideal” form, created either by a Madison Avenue marketing firm or insurance company, is shared by very few and unobtainable for many without malnutrition. This image is also promoted by the "beauty industry" in products ranging from cosmetics to fashion. Doctors and diet gurus also are seeing large financial rewards for various preparations dispensed in an attempt to attain that form. The association of obesity and psychological disturbance promotes the stereotype and a negative reinforcement.

The real harm

Obese individuals are victims of job, education, and medical discrimination Society has issued a mandate of thinness with pervasive societal discrimination when these requirements are not met. Children comparing silhouettes of obese versus thinner peers associated the obese silhouette more often with the characteristics lazy, dirty, stupid, ugly, liar and cheat. Studies have shown that obese individuals complete fewer years of school, have decreased entry rates into prestigious institutions and are less likely to enter professions judged to be desirable. These negative stereotypes extend deeply into the medical profession, where little attention has been directed to understanding the psychosocial burden of obesity. The degree of discrimination is directly related to the degree of obesity. It 's a shame that obesity is such a socially acceptable form of bigotry.

The condition known as polycystic ovary syndrome (PCOS) is the archetypal example of a relentless struggle with weight control. Many with PCOS also have serious skin problems such as excessive hair growth (or loss), and acne. While not medically serious, there is also a major threat to self-image. As if these major assaults on femininity are not enough these women are also having problems with becoming or staying pregnant. Many PCOS patients have a lifelong battle to maintain a weight that many still would consider “fat.” The ignorance of Dr. McGraw's statements just sent another arrow flying and another wound has been inflicted on these women.

No human endeavor is so filled with myth. We are living in a schizophrenic society that both reveres thinness and at the same time promotes obesity. There is much work to be done to assist our patients and clients with healthier lifestyles and improved self-image. Pathologic dieting for cosmetic reasons or preoccupation with thinness should be discouraged. Eating patterns can be changed through behavior modification. Surely, help from our colleagues in the psychological and counseling fields is welcome and appreciated. But, let's not get the issue confused by saying that obesity is an emotional illness.

It is anticipated that in the not too distant future that honest treatment for obesity will be at hand. Probably, we will be able to successfully treat obesity even before we completely understand it. At present we are at the dawn of the day, but there are many still in the dark and facing the wrong horizon.

Sam Thatcher MD, PhD
Center for Applied Reproductive Science
Johnson City Tennessee
February 6, 2001

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