To The Editor: This letter is in response to the editorial by Nora Volkow, M.D., and Charles O’Brien, M.D., Ph.D., “Issues for DSM-V: Should Obesity Be Included as a Brain Disorder?” (1), published in the May 2007 issue of the Journal. While I agree that many people suffer from an inability to restrict their food intake, I am in strong disagreement with naming a body size as a psychiatric disorder.
The editorial states that “obesity is characterized by compulsive consumption of food and the inability to restrain from eating despite the desire to do so” (1, p. 708). However, Garner and Wooley (2) cited “the tremendous body of research employing a great variety of methodologies that has failed to yield any meaningful or replicable differences in the caloric intake or eating patterns of the obese compared to the nonobese.”
The editorial by Drs. Volkow and O’Brien claims that “the discrepancy between the successes of the metabolic treatments of consequences of obesity and the failures of behavioral treatments to prevent or reverse obesity highlight the fact that this condition is not only a metabolic disorder but also a brain disorder” (1, p. 708). That is to say, our urge for food is a “brain disorder” similar to our urge for water and air! Unlike other substances, we cannot live without any of these essentials. Perhaps it is time to reconsider our behavioral treatments to prevent or reverse obesity. Recommendations for treating obesity include various forms of influencing people to override their urge for food. We already have a psychiatric diagnosis for those individuals who best succeed at overriding their bodies’ urge for food: anorexia nervosa. Another problem with the body-size-as-evidence-of-eating-disorder approach is that some people are naturally thin and do not have an eating disorder. In addition, many people with average-sized bodies do have an eating disorder: bulimia nervosa.
I propose that most people who feel out of control around food, despite their intentions to restrict it, may simply be reacting to undereating (dieting). Ancel Keys’s classic study, The Biology of Human Starvation(3), followed a number of physically and psychologically healthy, young, conscientious objectors, who were placed on one-half their normal amount of rations for several months. In the refeeding phase of the study, the subjects were insatiable until after they regained their lost body weight and fat. It is my view that as fatness increasingly becomes the subject of moral panic (4), we are putting more and more of our population into a starvation experiment, which has been replicated for the better part of a century and, in my opinion, contributes to increasing numbers of eating disorders as well as expanding fatness on our bodies. I recommend instead the possibility of including dieting as a related eating disordered behavior, which is frequently iatrogenically induced.
As J. Eric Oliver points out in Fat Politics (5), there is much money and prestige currently available for treatments for obesity. Pressed by both high insurance costs and low insurance payments, many of us are motivated to increase our incomes by identifying fatness as pathologic. Many more of us sincerely desire to help people afflicted by their unpopular body size and its reception in present society.
There is one approach that improves the physical and mental health of obese people as well as people of smaller sizes: the health at every size approach. I have used this approach for many years in my practice (6). The success of the health at every size approach has been documented in an experiment (7) comparing it with the classic eat-less/exercise-more approach (which Drs. Volkow and O’Brien accurately acknowledged as incredibly difficult to sustain). Nondieters who gave up restrained eating, accepted their size, and tuned in to body signals of hunger and satiety improved their physical and mental health, independent of weight change and in contrast to dieters.
If we are truly interested in helping people who are out of control around food, we should stop creating more of them by continuing to push dieting. We should advocate for people taking good care of themselves via such avenues as self- and size-acceptance, enjoyable movement, and nourishment of one’s body, soul, and relationships. Moreover, we should stop considering adding to the tremendous amount of prejudice and stigma against individuals with unpopular body size by presuming that they possess a psychiatric disturbance.
1.Volkow ND, O’Brien CP: Issues for DSM-V: should obesity be included as a brain disorder? Am J Psychiatry 2007; 164:708–7102.Garner D, Wooley S: Confronting the failure of dietary and behavioral treatments for obesity. Clin Psychol Rev 1991; 11:7483.Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL: The Biology of Human Starvation. Minneapolis, Minn, University of Minnesota, 19504.Campos P, Saguy A, Ernsberger P, Oliver JE, Gaesser G: The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiology 2006; 35:55–605.Oliver JE: Fat Politics: The Real Story Behind America"s Obesity Epidemic. New York, Oxford University Press, 20056.Bruno BA: Worth Your Weight. Bethel, Conn, Rutledge, 19967.Bacon L, Stern J, Van Loan M, Keim N: Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc 2005; 105:929–939
Dr. Bruno reports no competing interests.
This letter (doi: 10.1176/appi.ajp.2007.07071073) was accepted for publication in October 2007.