ANRED: Obesity. Is It an Eating Disorder?

Like most things, obesity is a complex phenomenon about which it is dangerous to generalize. What is true for one person is not necessarily true for the next. Nevertheless, we shall try to make sense out of conflicting theories and give answers to people who struggle to maintain self-esteem in a world that seems to be obsessed with youth, thinness, and the perfect body -- whatever that may be.

What is obesity?

A person with anorexia nervosa may define obesity as a weight gain of five pounds, from 89 to 94. A grandmother past menopause may call herself obese because she carries 165 pounds on her large-boned, muscular body. A modeling agency may talk about obesity when one of the women on the payroll puts 135 pounds on her 5'10" body.

None of these women is clinically obese. The anorexic and the model are underweight.

Men are split in their personal definitions of obesity. Many are just as concerned about overweight as women are, while others, frankly rotund, believe they are just fine, perfectly healthy, and universally attractive to potential romantic partners.

Clinically, obesity is described in terms of Body Mass Index, a more accurate measure than weight alone. A healthy BMI is 19-24. Simple overweight is a BMI of 25-29. Obesity begins at a BMI of 30. Morbid obesity begins at a BMI of 40. Super morbid obesity begins at a BMI of 50, and super-super morbid obesity begins at a BMI above 60.

(To learn your Body Mass Index, use the simple calculator provided by the Obesity Education Initiative.)

How many Americans are obese?

A 1999 study reported by the Centers for Disease Control and Prevention indicates that sixty-one percent of adults in the U.S. are overweight. A breakdown of that figure shows that thirty-five percent are slightly or moderately overweight, and that twenty-six percent are obese or super obese. In addition, about thirteen percent of U.S. children are overweight or obese.

Another government study published in October, 2002 indicates that thirty-one percent of the American public is obese. It further suggested that fifteen percent of young people between 6 and 19 are seriously overweight. Even ten percent of toddlers between 2 and 5 are seriously overweight. The study appeared in the Journal of the American Medical Association (October 9, 2002).

A more recent study indicates that about 31 percent of American teenage girls and 28 percent of boys are somewhat overweight. An additional 15 percent of American teen girls and nearly 14 percent of teen boys are obese. (Archives of Pediatrics and Adolescent Medicine, January 2004) Causes include fast food, snacks with high sugar and fat content, use of automobiles instead of walking or biking, increased time spent in front of TV sets and computers, and a generally more sedentary lifestyles than slimmer peers.

The prevalence of overweight and obesity is increasing in all major socioeconomic and ethnic groups, including children and younger adults between 25 and 44. (David Sacher, U.S. Surgeon General, December 2001)

What are the causes of obesity?

Too many calories. Consumption of more calories than are burned through work, exercise, and other activities will lead to overweight and obesity. In the late 1990s, Americans ate about 340 more calories per day than they did in the mid-1980s, and about 500 more calories per day than in the 1950s. The extra food was often some kind of refined carbohydrate (white flour or sugar) combined with fat, saturated fat in the unhealthiest cases. (University of California Wellness Letter, January 2002)

Too much good food, too little activity. A major factor leading to obesity is the ready availability in developed countries of inexpensive, tasty, food in combination with a sedentary lifestyle, including desk jobs and time spent watching TV, using a computer, and other "activities" that require little or no physical effort.

Restaurant food and fast food. People who can afford to do so are eating out more often than ever before. Restaurants and fast food outlets offer much larger portions than they used to. The amount of home cooked food eaten with family around the dining room table has decreased, but portion size has increased. Food prepared at home offers the easiest way to make healthy choices about fat, sugar, salt, and so forth, but in today's world, convenience often wins out over a home cooked meal.

The poverty trap. People on limited incomes often find whole grain products and fresh fruits and vegetables too expensive to serve frequently. The cheaper foods are those that easily lead to weight gain: refined carbohydrates (white bread, pasta, etc.) and other foods high in sugar, fat and starch.

Food used as medicine. Some people attempt to numb or escape emotional pain and distress by eating. For various emotional reasons, including loneliness, boredom and depression, some people eat when their bodies do not need food, but the "fix" is only temporary so they continue to consume food. Look elsewhere on our Web site for more information about compulsive eating or binge eating disorder.

Diets and prolonged caloric restriction. When people try to make the body thinner than it is genetically programmed to be, it retaliates by becoming ravenous and vulnerable to binge eating. Ninety-eight percent of dieters regain all the weight they manage to lose, plus about 10 extra pounds, within five years. Yo-yo dieting repeats the cycle of weight loss followed by ever-increasing weight gain when hunger ultimately wins.

Medical problems. Some individuals are obese because of biological problems such as malfunctioning thyroid or pituitary glands. Others may have physical problems or disabilities that severely limit or prohibit exercise, strenuous work, and other physical activity.

In August 2007, in Boston, Massachusetts, research was presented that implicates a virus ( Adenovirus-36) that transforms human stem cells into fat cells that then go on to store additional fat. (N. Dhurandhar and M. Pasarica; American Chemical Society meeting, August 19-23, 2007.) Note: the research is not conclusive and does not justify consuming more calories than are burned in physical activity.

Genes. Studies published in the New England Journal of Medicine (March 2003) indicate that certain genetic factors are important and powerful underlying contributors to the development of obesity and binge eating.

Too much stress. New research suggests that there is a biological link between stress and the drive to eat. Comfort foods -- usually those high in sugar, fat, and calories -- seem to calm the body's response to chronic stress. In addition, hormones produced when one is under stress encourage the formation of fat cells. In developed countries, life tends to be competitive, fast paced, demanding, and stressful. There may be a link between so-called modern life and increasing rates of overeating, overweight, and obesity. (Study published in Proceedings of the National Academy of Sciences. Author is Mary Dallman, professor of physiology, University of California at San Francisco [2003]. A similar study appears in Nature Medicine, a journal published online by the University of California at San Diego; 2007.)

Holiday stress. Nearly half of U.S. adult women report increased stress during holiday periods. They try to cope with (often unrealistic expectations) for parties, presents and physical appearance. They feel obligated to participate in seemingly endless rounds of celebrations and gift exchanges. They want to make the season special and memorable for those they love, but time and budgets are stretched to their limits, and relief is imperative. Too often that relief takes the form of comfort eating and drinking and avoidance of exercise -- all of which can lead to weight gain. Comfort eating and drinking increase during holidays for men too but is more common in women. (surveys conducted by American Psychological Association)

Too little sleep. Recent studies suggest that sleep deprivation (anything less than 7-9 hours per night) can contribute to obesity. Bodies that aren't rested produce increased amounts of ghrelin, a hormone that triggers sensations of hunger. (Archives of Pediatrics & Adolescent Medicine, April 2008). Sleep deprivation also reduces the body's production of leptin, a hormone that regulates appetite, leading to increased cravings for candy, other sweets, and salty carbohydrates like chips and french fries. (Source: David Rapoport, MD, director of the sleep program at New York University School of Medicine. Reported in Health on Parade; August 28, 2005)

Moreover, shorting oneself just a single hour of sleep every night can result in increased hunger and higher blood sugar levels similar to those manifested by people with pre-diabetes. Those effects are reversed when the body gets the higher amount of sleep it needs and wants. (Spiegel, Karine, et al, Annals of Internal Medicine, December 2004)

Some causes of sleep deprivation escape easy recognition. For example, sleep apnea leads to multiple interruptions of sleep each night and blocks deep, restorative sleep. Shift work can also interfere with the body's sleep/wake cycle and leave late night workers feeling tired and drained.

Busy schedules that leave no time for the family to eat together. Dad is away on business. Mom is driving the children to after-school activities. The oldest teenager is working a part time job. Instead of eating a thoughtfully prepared meal consisting of reasonable portions and balanced nutrition, everyone grabs fast food with too many calories and too much salt, sugar and fat.

Decreased opportunities for organized sports. In many places budget cuts have reduced or eliminated youth sports and adult recreation opportunities. Physical education in schools is becoming a thing of the past as fiscal belts are tightened.

City planning and development that discourage bike riding and walking. In many places driving a car is essential if one is to get to work, to school, to shopping and to other necessary destinations. In some neighborhoods, crime or fear of crime keeps people from walking or biking to work, school and stores.

Mass marketing of unhealthy and fattening foods to children and adults. Psychologically sophisticated ads, commercials and product placement entice children and adults to over-consume junk food and unhealthy food that is low in nutrition but high in fat, sugar and salt.

Researchers believe that in most cases obesity represents a complex relationship between genetic, psychological, physiological, metabolic, socioeconomic, lifestyle, and cultural factors.

Miscellaneous factors associated with obesity

The children of overweight parents are more likely to be overweight than the children of thin parents.

If friends and family members offer comfort in the form of food, people will learn to deal with painful feelings by eating instead of using more effective coping strategies.

Poor folks tend to be fatter than the affluent.

People living in groups that frequently celebrate and socialize at get-togethers featuring tempting food tend to be fatter than those who do not.

Even artificial sweeteners are implicated in weight gain and obesity. In a recent study at Purdue University, rats that were given artificial sweeteners ate three times as many calories as rats given real sugar. Researchers hypothesize that the engineered sweeteners interfere with the body's natural ability to regulate food and caloric intake based on the sweetness of different foods. ("A Pavlovian Approach to the Problem of Obesity," International Journal of Obesity, July 2004)

Some individuals eat great quantities of food, exercise moderately or not at all, and never seem to gain weight. Others walk past a bakery and gain ten pounds. No two people are the same, and no two obesity profiles are identical.

Health risks associated with obesity

Hypertension. (High blood pressure, a contributor to stroke and heart disease). Overweight young people (20-45) have a six times higher incidence of hypertension than do peers who are normal weight. Older obese folks seem to be at even greater risk.

Diabetes. Even moderate obesity, especially when the extra fat is carried in the stomach and abdomen (instead of hips and thighs), increases the risk of non-insulin dependent diabetes mellitus (NIDDM) ten-fold.

Cardiovascular disease. Both the degree of obesity and the location of fat deposits contribute to the potential for heart and blood vessel disease. The fatter the person, the higher the risk. People who carry extra weight in the trunk area (stomach and abdomen) are at higher risk than folks who store fat in hips and thighs.

Cancer. Obese men are at elevated risk of developing cancer of the colon, rectum, and prostate. Obese women are at elevated risk of developing cancer of the breast, cervix, uterus, and ovaries.

Endocrine problems. Irregular menstrual cycles; other menstrual problems; and pregnancy complications, especially toxemia and hypertension. Hormone imbalances of various kinds may contribute to, or be the result of, obesity.

Gall bladder disease. Obese women 20-30 years old are at six times greater risk of gall bladder disease than their normal-weight peers. By age 60 almost one-third of obese women will have developed gall bladder disease.

Lung and breathing problems. Obesity can impede the muscles that inflate and ventilate the lungs. Obese individuals may have to work hard to get enough air and over time may not be able to take in the oxygen needed by all body cells.

Arthritis. Obese individuals are at increased risk of developing gouty arthritis, a distressingly painful disorder. In addition, excess weight stresses vulnerable joints, in particular the back and knee, which may develop osteoarthritis, a mechanical rather than metabolic problem. A 2005 survey published by the American Orthopaedic Foot and Ankle Society found that even if people escape arthritis, increased rates of foot and ankle pain are found in individuals who are overweight and obese.

Premature death. Research indicates that obese people die sooner than their normal weight peers.

One important piece of good news

Obese people do not seem to have any more psychological problems, or more serious psychological problems, than folks of normal weight. Many of the problems they do have are a consequence of anti-fat prejudice and discrimination. Some studies have suggested that many obese individuals are less anxious and depressed than normal-weight peers.

What can be done about obesity?

The simplistic answer: eat less and exercise more.

A more helpful answer:

Work with a physician to identify and correct any underlying medical, biological, or metabolic problems contributing to excess weight.

Check with a counselor to see if you are using food for a purpose that food cannot fulfill: love, comfort, escape, an antidote to boredom, and so forth. If you are self-medicating with food, work with the therapist to come up with better ways of managing stress, painful emotions, and problems.

Don't ever diet or restrict calories when you are legitimately hungry. If you do, you will set yourself up to binge later.

Eat normal, reasonable, moderate amounts of a wide range of healthy foods. Portion control and exercise are probably the two most important factors in a successful weight management program. Emphasize fruits, vegetables, and whole grains. Don't cut out sweets and fats completely. If you do, you will crave and sneak them. Besides, your body needs the nutrients found in fats and carbohydrates. Just don't overdo it.

Eat a nutritious breakfast every morning. Ninety-six percent of everyone who loses weight and keeps it off eats breakfast every day, according to Ann Yelmokas McDermot, a nutrition scientist at Tufts University (USDA Nutrition Research Center). If you skip breakfast, later in the day when your blood sugar drops and fatigue and cravings build, you will be vulnerable to binge eating or overeating.

Get enough sleep every night. Scientists have found that sleep deprivation increases levels of a hunger hormone and decreases levels of another hormone that makes you feel full. The combined effect may lead to overeating and weight gain. (Two studies are summarized in USA Today, December 7, 2004, page 1-D)

Very important: Exercise consistently. Get regular amounts of moderate, self-loving exercise. Start with a few minutes of walking and slowly extend the time until you can do 30-60 minutes a day, 3-5 days a week. If you haven't exercised in a while, be sure to check with your doctor first.

Find a support system. Friends are great; so are support groups. There are both online and in-person opportunities. Check our Links page for suggestions.

Be gentle and realistic with yourself. If everyone in your family is round and sturdy, chances are you will never be a super model -- but you can be happy and healthy. Also remember that healthy, realistic weight loss takes time. Losing one-half to one pound a week isn't very glamorous, but if you go any faster, you will make yourself hungry, and hunger will inevitably make you overeat.

What about diet pills, other weight-loss products, and weight loss programs? Surgery?

Over-the-counter products. There are many items in drugstores and health food stores that claim to help people lose weight. None seem to be both safe and effective. The ones that are effective are only minimally so, and they have significant side effects and health risks. The ones that are safe don't seem to be very effective in helping folks lose weight and keep it off. Think about it: if there really were a safe and effective weight loss product available over the counter, everyone in the Western world would be slim. Our best advice: save your money.

Prescription medications. In spite of a tremendous amount of research, there still is no magic pill that melts pounds away effortlessly. Obese people and their physicians had great hope for fen-phen, a combination stimulant and antidepressant, but those hopes were dashed when some of the people taking it developed potentially fatal heart problems. New medications are available, and more are in the pipeline. Talk to your doctor about their pros and cons. For the time being at least, the steps outlined above in the section titled "What Can Be Done About Obesity" seem to be the safest and most effective way of reducing excess weight.

Commercial weight loss programs. The Annals of Internal Medicine, a professional journal, in 2004 published a study showing that of ten popular programs, only the then 41-year-old Weight Watchers has documentation to back up its claims of success.

Surgery. For some obese people, gastric bypass (and stomach stapling, gastric banding and related techniques) may be a lifesaving measure. The procedure is major surgery and is associated with risk of significant side effects and complications. For this reason it should be considered a treatment of last resort. Also, to be successful, the patient must cooperate with an entirely new way of eating and managing food. If nothing else has worked for you, and if your medical situation warrants such a drastic approach, talk to your physician to see if you might be a candidate for this procedure.

Please Note: ANRED information is not a substitute for medical or psychological evaluation and treatment. For help with the physical and emotional problems associated with eating disorders, talk to your physician and a mental health professional.

Page updated April 21, 2008

Obesity. Is it an eating disorder?