In sharp contrast to the common perception of obesity as an overindulged state, I have come, over many years, to understand obesity as a manifestation of a malnourished state. It was partly through the act of fasting on Yom Kippur that my thoughts on obesity began to evolve in this direction. I wrote an earlier version of today’s post many years ago, as I was beginning to formulate my thoughts on this issue.
Once a year, on Yom Kippur, the Day of Atonement, Jews around the entire world fast from sundown to sundown. This year, Yom Kippur begins tonight, on Sunday the 24th of September, and continues through tomorrow night. Putting aside for now the reasons why we do this, I’d like to talk about the results of such an endeavor, the what happens when you fast. Well, for one thing, I don’t do a whole lot of anything else. Fasting really takes it out of me. I know that some people like to go for a walk to pass the long afternoon hours, but I am certainly not one of them. Except for a mid-afternoon nap, therefore, I normally spent almost the entire day sitting still. Lump on a log. Starvation mode. I also spend much of the day yawning, which is something I tend to do when I’m even just a little bit hungry. It used to be a bit confusing for patients with appointments in the late morning. But I wasn’t bored; I was just hungry.
Every year, when I get dressed the morning of Yom Kippur, I pick out a large woolen scarf to wear over my clothes. I do this whether the outside temperature is 40 degrees or 80. That’s because I spend most of the day freezing cold. It’s like taking a blanket with me, large enough to cover not only my own shoulders, but also those of others who happen to be seated close by. There is a pattern here. If I skip breakfast, I remain sedentary, cold, and exhausted. I am conserving energy. I am very grateful for the ability to stay still and keep warm. What does that sound like? Well, to a certain extent it sounds like some of my obese patients. I do not think this is a coincidence.
One stereotype of obesity is that people get that way because they’re lazy. I am going to challenge that assumption. What if heavy people are not lazy at all, but, rather, starving? Many weight loss initiatives recommend that people take frequent walks in order to lose weight. I’m not saying that we shouldn’t move; we should. But what about switching things around? Why don’t we recommend that people work on improving the nutritional value of their diet so that they have more energy to move?
Obese patients are routinely deficient in B vitamins, magnesium, Vitamin D, and other nutrients. Normal levels of Vitamin D, for example, run in the range of 40-50, but Vitamin D levels routinely run below 10 in the setting of obesity. In medical school, I learned that these markers of malnutrition were often associated with a diagnosis of alcoholism. Another common cause, it appears to me, is obesity.
This is not just about vitamins and minerals. It’s also about protein and fat. I have seen with my own eyes how some people need more water, or calories, than others. So it does not seem farfetched that some people might need more protein than others. Or fat, for that matter. What if some people can tolerate a low-fat diet without much difficulty, but others go into starvation mode? What happens when people get enough total calories, but not enough protein? We know what that looks like: it’s called kwashiorkor, it’s awful, and you can search to see for yourself. How many calories of protein does it take to sustain a 300-pound body? A lot more than you might think.
Overweight people often carry extra weight in their abdomen and beneath their chin in a pattern called central obesity. This pattern is a classic symptom of insulin resistance, which is caused by excessive amounts of stripped carbohydrates and the manufactured oils invented in the 20th century. The skin around their eyes looks pale and very puffy, a sign of protein deficiency. That puffiness resolves quickly as intake of high-quality protein and nourishing fats rises, and intake of stripped carbs falls. Their skin becomes brighter and smoother. Their clothes begin to fit better. Once in a while, a friend asks if they’ve had a haircut, or even a face lift!
People who consume adequate nutrition become less lethargic, and begin to move more. Maybe, instead of waiting until they’ve saved up a long list of reasons to make the trip, they surprise themselves by getting up to change a lightbulb, a battery, or a T-shirt. I believe that many if not most obese patients need more high-quality food, and not fewer calories. Some people are obese because they are in starvation mode, conserving energy and calories to the greatest extent possible. It’s harsh to assume that inactivity causes obesity, or malnutrition. If anything, I believe, it’s the reverse.
Wishing everyone an easy fast, and a sweet and healthy new year …