Inception

It all starts with an idea.

"An idea. Resilient, highly contagious. Once an idea has taken hold of the brain it's almost impossible to eradicate."

- Dom Cobb (Inception)

The idea that obesity can be cured by dieting is a great example of inception. Not in the, Leonardo DiCaprio broke into your subconscious kind of way, but in the sense that the idea has been planted into your mind, and slowly becomes your own. For people raised in North America (and likely elsewhere), the inception begins at a very young age. While it is difficult to pinpoint exactly when it occurs, most 5 year-olds are familiar with dieting for weight loss, the extent of which appears to be related to maternal dieting practices (1). The idea is nurtured with constant reinforcement from our environment, and allowed to develop deep roots, becoming a belief. This presents a problem.

"I think it's better to have ideas. You can change an idea. Changing a belief is trickier. Life should be malleable and progressive; working from idea to idea permits that. Beliefs anchor you to certain points and limit growth; new ideas can't generate. Life becomes stagnant."

- Rufus, the 13th Apostle (Dogma)

The common belief that obesity can be cured by dieting is a problem because it has other implications.

• It implies that there is something wrong with the diets of obese people (for the most part, I agree). However, along with this comes the fallacy that normal weight individuals must therefore have good diets. Importantly, this misconception is not limited to diet - take a look at Homer Simpson for an example of how we view obese people (D'Oh!, Mmmm..., Woo hoo!). This is also the foundation of weight bias, one of the few prejudices that remains socially acceptable today.

• It implies that the cause of obesity is modifiable behaviors. In a superficial sense, I agree. The connection is simple enough to follow - obesity is the storage of excess calories as fat that results from prolonged period of consuming more calories (eating) than you expend (exercising), both modifiable behaviors. This simplistic view of obesity is the basis for the eat-less, move-more approach to its prevention and treatment (seems to be working well so far). This attitude further stigmatizes obese individuals, this time implying that their failure to do anything about their weight reflects a lack of will power.

I would argue that this bleak view of obese people is collective ignorance, and needs to be addressed before we can or will do anything to address the current obesity epidemic. Unfortunately, people can't easily be persuaded to change a belief, a sobering truth that I have come to appreciate in my attempts convince people that the eat-less, move-more paradigm is destined to fail. My efforts, while largely unsuccessful, have not been fruitless. I have learned much about the epistemology (way of knowing) and justifications for this belief, leading me to the concept of inception.

While I would like to blame TV shows like "The Biggest Loser" and convincing testimonials of guaranteed, quick and easy weight-loss diets for planting the idea, it is just as likely that it came from health authorities doing their best to spread the eat-less, move-more message. This view is so pervasive in our society that most people take for granted that it is a fact. Once indoctrinated, our perceptions of reality are skewed to reinforce the belief. Obese people are on our radar, and when we see them buying fast food, or chowing down on a bag of chips, it reaffirms what we know. Add to this the fact that everyone knows someone who has lost weight, and we have all the evidence we need to justify our current view of obesity and obese people.

Before going further, I would like to acknowledge that obesity is related to individual behaviors. There is no doubt that weight-loss is achievable under controlled circumstances. However, this does not mean that obesity is caused by individual behaviors - a small, but important distinction. My rationale for such a seemingly contradictory statement is that I believe that our behaviors are the conduit through which our environment causes obesity, an idea that I will elaborate on in future posts. For now, I would like challenge some of the assumptions related to the eat-less, move-more paradigm.

Dieting is an effective treatment for obesity. Depends on your perspective of effective. I would hardly call a treatment with a success rate of less than 5% effective. These odds are likely to conflict with our own experience (perception) of dieting success (can you name 19 people who failed at dieting for every 1 person that succeeded). What is more concerning is the potential consequences of a failed diet attempt in the other 95% (depression, rebound weight gain).

Obese people have worse diets (and lifestyles) than thin people. A widely-held belief for which the evidence is relatively weak and inconsistent. Take a study of 5,890 Canadian adolescents (11-16yo) for example (2).

% of normal, overweight and obese subjects not consuming F & V daily:

Fruits 64%, 71%, 68% (boys) 58%, 62%, 59% (girls)

Vegetables 61%, 67%, 61% (boys) 53%, 59%, 52% (girls)

% of normal, overweight and obese subjects consuming unhealthy foods daily:

Soft Drinks 27%, 31%, 36% (boys) 17%, 16%, 21% (girls)

Sweets 26%, 20%, 20% (boys) 24%, 18%, 20% (girls)

Potato Chips 12%, 10%, 11% (boys) 7%, 4%, 7% (girls)

Cakes/Pastries 6%, 7%, 10% (boys) 4%, 2%, 6% (girls)

The authors note that it is possible that the failure to find a consistent trend may be due to the fact that "overweight and obese individuals are more likely than normal weight individuals to misreport food intake". I wanted to be sure to acknowledge this possibility, but emphasize that the fact still remains that normal weight individuals have nothing to brag about.

Obese people don't lose weight because they are unmotivated and/or lack will power. I highly doubt this to be the case. Given our attitudes towards obesity and open bias towards obese people, I believe that there is incredible impetus to be thin in our society. The multi-billion dollar industry is proof enough that we are motivated to lose weight. Unfortunately, biology is not on our side - there are powerful mechanisms (leptin deficiency) that are working on both energy intake and expenditure to counteract weight loss attempts (more on this to come).

To be clear, I am not suggesting that obesity is unrelated to lifestyle, or that obese individuals are not liable for their actions. Nor would I argue that we should cease and desist all public health efforts to promote healthy eating and physical activity. What I am proposing is that we adopt a more sensitive and sensible view of obesity as a disease. This is a condition that has serious physical and psychological complications, and we have limited tools for managing it. The argument that people with obesity are somehow reaping what they sow undermines our ability to address the root causes of the condition, and perpetuates the cycle of inception. To overcome this, we need to cast aside this stereotype and see the world through unbiased eyes (best to start with a mirror). Keep in mind, when you point your finger at someone else, there are 3 more fingers pointing back at you.

1. Abramovitz BA, Birch LL. Five-year-old girls' ideas about dieting are predicted by their mothers' dieting. JADA 2000; 100(10): 1157-63.

2. Janssen I, Katzmarzyk PT, Boyce WF, et al. Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. Journal of Adolescent Health 2004; 35: 360-7.