'obesity is triggered by brain chemistry, not willpower'

living with elevated weight caused by obesity can be life-changing — and not in a good way. more than seven million canadians are more likely to be overlooked for jobs, be poorly treated by their physician, and suffer criticism from those who believe that greater self-control can prevent obesity.

according to dr. sean wharton, co-author of the new canadian obesity guidelines and medical director of the wharton medical clinic , a community based internal medicine, weight management and diabetes clinic, obesity is actually a progressive, complex and chronic disease that’s triggered by brain chemistry and not by lack of willpower.

he says that the pervasive belief that those with obesity lack discipline and self-control creates bias and stigma so thick and so intense that it sometimes prevents people from seeking help for the disease. avoiding medical care may lead some down the path of health risks caused by the disease, such as type 2 diabetes, high blood pressure, heart disease, stroke, arthritis and cancer. it’s not uncommon for people with obesity to also experience debilitating anxiety and depression .

let’s start with the question at the root of misperceptions of obesity: does overeating cause obesity?
overeating does not cause obesity, but obesity causes overeating. obesity is biology and genetics. if the genetics of your hedonic system — in your brain — say that you need to eat food in the evening to feel better, it’s going to be really hard to deal with that every single day, for the rest of your life. if you fix the neurochemical in the brain, you fix the behaviour of overeating.

walk us through that process.
our genetics are the primary drivers of weight regulation. genes code for specific regions in the brain primarily the mesolimbic lobe (hedonic area), the hypothalamus (the hunger centre) and the frontal lobe (the executive area). these areas of the brain are designed to prevent weight loss and encourage the regain of weight. the degree of the intensity of weight preservation is dictated by genetic coding. neurochemicals and specific hormones dictate the degree of hunger and cravings. the ability to modulate or dampen these neurochemicals will determine how effective an intervention is at preventing weight gain or weight regain after weight loss.

so, obesity is not our fault.
correct, it is not necessarily all the patient’s fault. blame and shame is the most common approach to elevated weight, and the biggest barriers to care are bias and stigma, which leads to discrimination. the finger wagging, paternalistic approach that some physicians use contributes to the false narrative that we can shame a person enough for them to change their behaviours over an extended period. this approach does not work for those who have a family history of the disease and genetic factors working against them. as doctors, we’re supposed to provide unbiased, compassionate care, not assign blame.

the blame and shame culture is prevalent online as well.
you may see a picture of somebody with elevated weight, and the impression that most of the images display leads you to think that they are not very bright, they don’t dress well, and that they are always sweating. those stigmatizing images start to form a viewpoint. if you show a child in kindergarten an image of a child living with obesity and an image of a child with a disability, they will never choose a child with obesity as their playmate. at such a young age, they’ve already assigned negative attributes to the child living with obesity as “not bright, “lazy” and “not fun.” when someone implies or explicitly states that a person with obesity doesn’t deserve care because they’re not bright enough or disciplined enough to manage their weight and health, it forms an impact on the person with the disease. even people who live with obesity have internalized bias. they think of themselves as not bright, not capable and not worthy of care. this has to change.

when people come forward to ask for help, what treatment options are available?
psychological intervention, pharmacological therapy and bariatric surgery are the main pillars of therapy. pharmacological therapy will be a game-changer and will help revolutionize obesity management in the same way it completely changed and revolutionized hypertension, depression and diabetes. pharmacological therapy works by addressing the neurochemical imbalances in the brain that are driving eating behaviours.

what about other interventions?
we have seen positive results with cognitive behavioural therapy (cbt). the first thing is to be cognizant when you’re using food as a soothing mechanism and then working on changing that behaviour by addressing the root causes. cbt addresses and identifies antecedent that leads to overeating behaviours. you have to get yourself out of the environment that promotes hedonistic eating. cbt is very different than accountability — when you’re on the jenny craig or weight watchers program, accountability is about weighing in, it’s someone telling you to eat better, and educating you on carbs, fats and fibre. cbt is about understanding your own vulnerabilities and how to make changes within your environment or how to interact with the environments that we find ourselves in.

tell us more about bariatric surgery.
i’d like to see greater availability of bariatric surgery across canada so that people who have severe obesity can get the help they need. unfortunately, bariatric surgery is most accessible in ontario and quebec, but not in other provinces. the cost of the surgery is covered by the government, and it can cost up to $20,000 — this may be a barrier for some provinces. i would also like to see greater coverage of pharmacological therapy. in the most recent new england journal of medicine trial , with a once weekly injection, one third of patients achieved over 20 per cent of sustained weight loss, which is nearing surgical levels.

in the next 25 years, what do you think the treatment options for obesity will look like?
pharmacological therapy is going to make a significant difference because it will allow people to do the psychological treatment such as cognitive behavioural therapy in a much more effective manner. medications will also assist patients in both pre- and post- bariatric surgery.

will new drugs that help people with obesity look and feel better end the stigma?
the stigma will only come to an end when people living with obesity are respected for who they are. effective treatments should not be the answer to end the stigma. we should treat the people we love and care about with a much greater level of respect and dignity.