Losing Weight is Complicated 

By Jamie Bussin and Dr. Sasha High

At the top of every episode of The Tonic Talk Show/Podcast I say the same thing: 

I’M JAMIE BUSSIN. I’M A FORMER COMMERCIAL LITIGATOR WHO USED TO WEIGH 242 POUNDS. WHEN I WAS 38 YEARS OLD I LOST OVER 50 POUNDS THROUGH A REGIMEN OF EXERCISE AND BETTER NUTRITION. IT TOOK ME A YEAR TO REACH MY GOAL. BUT I THOUGHT IF A TYPE-A PERSONALITY LIKE ME COULD DO IT, REALLY ANYBODY CAN.

Except, as I learned from Dr. Sasha High, who runs Canada’s leading medical weight management program for women, not everyone is capable of losing weight through exercise and better nutrition. This article is a digest of that conversation.

Perhaps it’s best to start this discussion with a better understanding of the factors that contribute to obesity. Obesity is multifactorial. 40 to 70% of our body weight is genetically determined. That doesn’t mean that one doesn’t have a choice in the matter or that there’s no point in even trying to lose weight. According to Dr. High, “genes are not going to dictate our weight, but they do give us a range of possibility, and so the analogy is like our genes are like a deck of cards. We don’t get to choose the hands that we’re dealt. We do get to choose how we play that hand and what we do about it.”

Lifestyle choices and environmental factors are also important. How walkable is the neighbourhood you live in? What access do you have to fresh fruits and vegetables? Are healthy foods affordable for you? 

Other factors that contribute to obesity include prescribed medications. For example, a high dose of steroids might increase your appetite and increase cortisol. Certain forms of birth control or diabetes medication might also impact your weight. 

Hormones also impact your appetite and interact differently for different people.

Is obesity a disease? A disease impairs normal functioning and has characteristic signs and symptoms. The way that the medical community defines obesity is -abnormal or excess adipose tissue or fat on your body that has accumulated and is causing health problems, (ie it’s impairing normal functioning). 

Does obesity have characteristic signs and symptoms? According to Dr. High, it does. “We can actually look at almost every organ system. Is it a disease of the mind? Is it a physical disease? It actually touches just about all organs. We know that obesity is associated with poor mental health, so it can be a factor in mood disorders. It’s also associated with things like ADHD and developmental disorders. We know it can cause mechanical problems, such as arthritis, back pain, urinary incontinence and sleep apnea. It can cause metabolic disease like heart disease, type 2 diabetes, fatty liver disease, as well as a number of cancers like endometrial and colorectal. So obesity is a disease because the excess fat tissue causes impairment to health and it can cause impairment to so many different systems.”

How is obesity currently treated? According to Dr. High, most physicians treat obesity in the traditional “calories in and calories out” paradigm as opposed to as a multifactorial disease.  That’s because of the way that physicians have been traditionally trained (or not trained). It’s only a recent phenomenon that obesity has been considered to be a chronic disease.

If obesity is a disease of the body and the brain, why has it become so prevalent? Our bodies and brains really haven’t changed much in thousands of years. The answer, in part, is because of our environment. Our ancestors lived in an environment where food was scarce and considerable energy was expended to hunt and gather in order to survive. Our brain also has three very important survival instincts that stem from the limbic system (a subconscious part of the brain):

  • avoid danger – our brain tries to keep us safe in our cave where there are no predators. 
  • seek pleasure – we seek things that help us survive as a human species, like reproduction and eating.
  • do what requires the least amount of effort. 

We are biologically wired to eat more food and move less, expend less energy and that works when food is scarce. But it doesn’t work in today’s obesogenic environment, where foods are engineered to hijack our brain to make us crave more and want more. So we overeat. And food is easily accessible -with the push of a button on our UberEats app. 

The reason why we see obesity increasing is because our brains are encountering this new environment that favours overeating and undermoving. And, on top of that, our brain is wired to prevent fat loss, because in the setting of food scarcity, fat loss would mean death by starvation. According to Dr. High, this is why we’re seeing the obesity epidemic in the Western world. 

So, logically, in order to lose weight, we should be making the lifestyle decisions necessary to be more active like our hunting and gathering ancestors. We weren’t meant to be sitting at desks in front of computers all day. Our bodies were designed to move. 

True. But that isn’t the whole story.  Chronic conditions like Type 2 diabetes or even lung disease, which have environmental causation factors and which can be treated in part through lifestyle changes, can and are also treated with medications. 

Says Dr. High “I think when we’re talking about obesity as a chronic disease, that does not mean that you have to take a pill or undergo surgery to treat it. It means we recognize that there are a lot of different factors involved in the development of obesity, some within our control, some outside and we need to optimize our health habits. And for some people, that also means they might need a little bit more help. They might need some medical treatment, whether that’s medical in the form of medications, or surgical intervention.

Lifestyle choices and health habits are for everyone, regardless of your health status. “Every single one of us needs to prioritize our health habits. Because in our society, most of us live on autopilot all day long and by default, we eat more, we exercise less, we don’t sleep enough and we are overstressed. So unless we make health a priority, it is not what happens by default.”

Another factor which makes fighting obesity a challenge is the stigma attached to the condition. When people with obesity experience stigma from their healthcare provider, they don’t go to medical appointments as frequently, they don’t go and get routine checkups or cancer checkups, they don’t abide by any recommendations from their physicians. The stigma actually impairs medical care. 

Often the result of the stigma of obesity is the emotion of shame. When we’re feeling ashamed as human beings, we tend to hide. Shame makes people feel small. We feel unseen or embarrassed, and when we are feeling those emotions, we do not engage in positive behaviours. We’re less likely to do the things that are going to be beneficial.  And so many people lose motivation to make positive lifestyle decisions over time. According to Dr. High, the result of ongoing bias and stigma is that people become disempowered and take actions that make them move further away from the goals that they have …such as long term weight loss. 

Is mental health a driver of obesity? There are three systems of the brain that factor into obesity. The first two: the (aforementioned) limbic system and the hypothalamus (which controls our energy in and out) are subconscious and therefore can’t really be treated through psychological or cognitive therapies. However the third system, the executive function, where we make logical decisions, is part of our conscious brain. 

It is there that psychological tools are most effective. For example, cognitive behavioural therapy can help those who’ve become fatalistic about their efforts to lose weight over time or those on restrictive diets who experience fear of missing out and binge eat in response. Similarly, mindfulness tools can help overcome mechanically mindless eating while watching television. 

In better understanding the contributing factors and nature of obesity, we can better treat it.