New evidence suggests that obesity might be incurable. So why does the government propose to punish sufferers?
By George Monbiot, published in the Guardian 12th August 2015
Is overeating more addictive than crack cocaine? It’s hard to compare addiction rates, or to produce a clear definition that holds true across all substances and behaviours. But consider this crude contrast. Between 10 and 20% of people who use crack cocaine become addicted to it. Across a 9-year study of 176,000 obese people, 98.3% of the men and 97.8% of the women failed to return to a healthy weight. Once extreme overeating begins, it appears to be almost impossible to stop.
A paper published in the journal Neuroscience and Biobehavioral Reviews proposed that “food addiction” is a less accurate description of this condition than “eating addiction”. There is little evidence that people who are driven to overeat become dependent on a single ingredient; instead they tend to seek out a range of highly palatable, energy-dense foods, of the kind with which we are now surrounded.
The activation of reward systems in the brain and the loss of impulse control are similar to those involved in dependency on drugs. But eating addiction appears to be more powerful. As the same paper notes, in laboratory experiments “a majority of rats will prefer a sweet reward over a cocaine reward.”
Once you become obese, an article published in the Lancet this year explains, biological changes lock you in. Fat cells proliferate. The brain becomes habituated to dopamine signalling (the reward pathway), driving you to compensate by increasing your consumption. If you try to lose weight, the body perceives that it is being starved, and powerful adaptations (such as an increase in metabolic efficiency) try to bounce you back to your previous state. People who manage, against great odds, to return to a normal weight must consume 300 fewer calories per day than those who have never been obese, if they are not to put the weight back on. “Once obesity is established, … bodyweight seems to become biologically stamped in”. The more weight you lose, the stronger the biological pressure to get back to your former, excessive size.
The researchers find that “these biological adaptations often persist indefinitely”: in other words, if you have once been obese, staying slim means sticking to a strict diet for life. The best you can hope for is not a dietary cure, but “obesity in remission”. The only effective, long-term treatment for obesity currently available, the same paper says, is bariatric surgery. This can cause a number of grim complications.
I know this statement will be unwelcome. I too hate the idea that people cannot change their circumstances. But the terrible truth is that, except through surgery, for the great majority of sufferers, obesity is an incurable disease. In one respect it resembles cancer: the changes in lifestyle that might have prevented it are unlikely to be of use in curing it.
Fat-shaming is worse than useless. Another paper found that the more weight-conscious people are, the more likely they are to overeat: the stress it induces is a trigger for comfort eating. As Sarah Boseley points out in her book The Shape We’re In, “the diet industry … is one of the biggest frauds of our time”. For the obese, temporary reductions in weight will almost inevitably be reversed.
People who are merely overweight, rather than obese (in other words who have a BMI of between 25 and 30) appear not to suffer from the same biochemical adaptations: their size is not “stamped in”. For them, changes of diet and exercise are likely to be effective. But urging obese people to buck up produces nothing but misery.
The crucial task is to reach children before they succumb to this addiction. As well as help and advice for parents, this surely requires a major change in what scientists call “the obesogenic environment” (high energy foods and drinks and the advertising and packaging that reinforces their attraction). Unless children are steered away from overeating from the beginning, they are likely to be trapped for life.
You might have expected this knowledge to lead to acceptance, empathy and an end to stigmatisation. Fat chance. A fortnight ago, just after the figures I mentioned at the top of this article were published, David Cameron announced a review that could lead to obese people being deprived of social security payments if they fail to accept “treatment” for their condition.
This review, conducted by Dame Carol Black, has already pre-empted its conclusions: eight times it describes obesity as “treatable”. Really? How? It will consider the case “for linking benefit entitlements to take up of appropriate treatment”. Are Cameron and Black proposing that benefit claimants will be forced to undergo surgery? Or will they be pressed into a useless and punitive dietary regime? These proposals look to me like a transfer of blame for the disease away from food manufacturers and advertisers and onto those afflicted.
Why do we have an obesity epidemic? Has the composition of the human species changed? Have we suffered a general collapse in willpower? No. The evidence points to high-fat, high-sugar foods that overwhelm the impulse control of children and young adults, packaged and promoted to create the impression that they are fun, cool and life-enhancing. Many are placed in the shops where children are bound to encounter them: around the tills, at grasping height.
The disease will keep ravaging the population (and slowly overwhelm the health service) until these circumstances change. But the government’s sole contribution has been to tear down mandatory controls, replacing them with a voluntary – and therefore useless – “responsibility deal” with manufacturers and retailers. It allows them to choose whether or not to use the traffic light system, which is the most effective way of informing people about the likely impact of what they eat. And many corporations, unsurprisingly, choose not to. As far as nutritional content is concerned, food manufacturing is effectively unregulated.
Industry and government will resist the obvious solutions until they can be resisted no longer. Eventually, the change will have to happen: similar restrictions on advertising, sponsorship, display and accessibility to those imposed on the tobacco pedlars. One day, though not before many thousands have needlessly died, it will become illegal to advertise any food or drink that merits a red traffic light warning. They will be sold only in plain packaging, with health warnings, on high shelves.
Does this seem draconian to you? If so, remember that obesity afflicts a quarter of the adult population, and is rising rapidly. It causes a range of hideous conditions, just one of which – diabetes – accounts for one sixth of NHS admissions and 10% of its budget. If smoking demands fierce intervention, why not overeating?
This is the choice we face. To recognise that the only humane and effective means of addressing the obesity epidemic is to prevent more people from being hooked, by restricting the pushers. Or to continue a programme of fat-shaming, bullying and compulsory treatment, whose only likely outcome is unhappiness. Now ask yourself again: which of these two options is draconian?