Monthly Archives: August 2017

Elbow-and-Mouth Disease

I was a lowly medical student in Memphis, TN, just trying to get from one day to the next without revealing my ignorance. He was a distinguished, respected physician with a reputation for both wisdom and compassion. And so I was completely taken aback by his offhand question as we walked down the hallway:

Do you know what that woman has? She has elbow-and-mouth disease. It’s a very serious disorder; every time her elbow bends, her mouth flies open!

It’s been nearly 30 years ago, and I still remember the moment, as it slowly dawned on me that this wise, compassionate mentor was making fun of an obese woman. He was a wonderful teacher… an observer of human behavior… always willing to fight for the underdog. He would have laid down his life for a child in need. He was the kind of person I wanted to be when I grew up. And yet… he was perfectly comfortable passing judgment on a woman he did not know, based on absolutely nothing other than passing her in the hallway.

In retrospect, it is entirely possible that the white-hot anger I experienced in that moment was foreshadowing of my future. I managed – to the utter shock of those who know me now – to somehow bite my tongue and not end my medical career before it ever began. But the wrongness and unjustness of that experience never left me. And now, decades later, as the medical director of a childhood obesity center, I experience a similar degree of mean-spirited ignorance on a nearly daily basis.

“You really need to stop feeding her junk food and think about her long-term health…” says the young teacher to the father of a 7-year old girl who eats fruits and vegetables with every meal, is allowed candy twice a month, and hasn’t eaten pizza in more than 6 months.

“Don’t you think if she just buckled down and took it seriously that she could make it happen without surgery?” says an acquaintance to the husband of a woman about to embark on a bariatric surgical procedure, after decades of following every reputable diet and exercise plan to the letter, without success.

“Can you believe how he’s let himself go?” whispers a woman enjoying her double-fudge mocha drink, in reference to a former classmate at the next table eating a salad.

In general, I don’t think people intend to be mean. I think they are, in their own minds, “calling a spade a spade.” Perhaps they feel they are speaking the truth in love, or are trying to intervene out of a sense of protection. Some of you may hear your own similar words, in similar situations, and you may be asking, “Isn’t it reasonable, to see an obese child or adult and say the words that need to be said? Isn’t it rather obvious that their lifestyle is dangerous to their health?”


Here’s why:

First, calling people out and saying words that we believe need to be said is not helpful, nor is it even slightly effective. It may make you feel as though you’ve done your part, but the reality is that you have caused very real harm. It isn’t as though an overweight person is unaware of the issue; they see it on themselves each time they look in a mirror… and they see it reflected in the expressions of others every minute. The issue is NOT a lack of knowledge, and careless and ignorant words only compound the problem.

Second, these comments are inaccurate and ignorant. They reveal a profound lack of understanding of what causes obesity, the discouraging lack of options, and the approaches to helping with prevention and treatment.

In the absence of disease, our bodies are really, really good at maintaining balance. Whether it’s the amount of fluids in our bodies, our temperature, or the amount of blood flowing through our veins… each of these are maintained in precise balance, despite wide variation in our daily activities and circumstances.

The balance of energy and fat is no different. Every day, we are driven by our brains to take in 1.5 to 2 times more calories than we actually need, in case we are involved in a car accident or a natural disaster or a life-threatening illness that requires extra reserves. And then, when such a disaster doesn’t occur, our bodies efficiently shed the excess 40-50% of calories taken in, through our metabolism and our brains directing our activity level and food intake. This happens completely without our recognition.

Every. Single. Day.

I recently attended a conference in which the speaker eloquently illustrated the remarkable nature of this precise balance. Dr. Lee Kaplan, Associate Professor of Harvard Medical School, described, “For a person between the ages of 21-65 to maintain their body weight within 20 pounds, the body must precisely match the daily intake and expenditure of calories within 0.2%. That is a difference of 4-5 calories per day — less than one-half of a potato chip!” (Blackburn Course in Obesity Medicine, Treating Obesity 2017, Boston, MA).

Think about the last time you had the flu, or an operation, or anything that really knocked you down. Did you think to yourself, “Well, I’d really like to go hiking today, but I suppose that because I’m on day 3 of the flu I should really rest instead because that would be better for my health.”

Heck, no! You didn’t think ANY of that! You were laid out in bed and could barely drag yourself to the bathroom. Why? Because YOUR BODY DEMANDED REST, by completely shutting down the release of endorphins and other hormones that give us the energy to be active.

How about that time your car broke down in the middle of the summer, and you had to walk 2 miles in your work clothes to get back home? Did you say to yourself, “It’s warm outside and I’m likely losing moisture… so I should seek water in order to restore my fluid balance.”

Nope. Your body DEMANDED WATER, and so your degree of thirst led you to gulp down three straight glasses of water.

When it comes to the daily balance of our bodies, we don’t tell them what to do; rather, they tell US what to do. By and large, we obey. We have a bit of control, so that if we need to go to the bathroom we can wait until the end of class or the end of church. But, we couldn’t wait until the next day!

Obesity is NOT the result of a chosen lifestyle of bad behaviors; it is the behaviors that result from a faulty set-point in the body’s internal balance of fat and energy.

A faulty set-point in our blood pressure causes hypertension.

A faulty set-point in our temperature causes a fever.

And a faulty set-point in our fat balance causes our brains to direct our calorie intake and expenditure to reach that set point… resulting in obesity.

In each of these diseases, as well as thousands of others, there are ways we can help the process and ways we can hurt it. Countless diseases recommend “first line” treatment of appropriate diet and exercise. And time and time again, humans from all walks of life find themselves unable to manage their high blood pressure with diet alone, and seek medicine to help. Because they are too lazy to exercise and too stubborn to eliminate salt? Perhaps that plays some role. But for the most part, it’s simply that the set-point of their blood pressure is messed up and needs correction.

Back to weight balance.

Our natural reaction when weight gain has occurred is to try to lose it. Eat less; be more active. And, when the set-point is correct and healthy, this works perfectly. That’s why many people can return from vacation, shed the extra five pounds, and move on. Or healthy women can gain 30 pounds, deliver a 7 pound baby, and within a month or two return to their previous weight. It’s the precise balance of fat and energy, doing its job. The person feels internally driven to “get back into shape”, and in the process feels better, healthier, and more normal.

But when the fat set-point is NOT healthy, and a person tries to cut down their calories and increase their activity level, all hell breaks loose. The body sends out a 5-bell alarm that something is REALLY WRONG, and needs all hands on deck to recapture the weight that is being lost. Instead of feeling internally, naturally driven to shed extra pounds, these folks instead feel as though their bodies are fighting them at every turn – because they are.

One study showed that if a person reduces their caloric intake and loses 15 pounds, there is a surge of EIGHT DIFFERENT HORMONES to reclaim that weight (Sumithran, et. al., NEJM 2011; 365:1597-1604). These hormones control hunger, satisfaction, sleep, activity level and more. They literally work in tandem to hold us prisoner until the fat balance is restored. Remember, our bodies know how to get rid of 40-50% extra calories on any given day… so holding on to a few extra is no big deal.

We have lots of work to do in the medical community, to translate our rather recent understanding of the physiology into effective solutions. We must treat obesity as the disease that it clearly is. Some behavioral changes have a positive impact on metabolism, and regular exercise certainly improves our overall health although the impact on weight loss in adults is disappointingly small. Some medicines have a small but positive effect on the set-point of fat. Surgical options have the greatest success in both weight loss as well as correcting associated abnormalities like diabetes and hypertension, but are currently (perhaps incorrectly) reserved as a “last resort.” Children represent a golden opportunity to instill healthy habits from birth, attempting to prevent coexisting illnesses before they happen.  I also have much personal work to do, in organizing the facts so that I can communicate them in a way that’s clear and understandable. Stay tuned, because there’s more to come.

But in the meantime………

Think about the part of yourself that is most embarrassing. The thing that makes you feel vulnerable, insecure, less-than. The thing that would be horrifying to be made public. The thing that you bury deeply inside, and share only (if at all) with the people you trust the most in the world.

How would it feel, if you had to wear that part of yourself on the outside of your body and announce it to everyone the moment you walk into a room? How would it feel for everyone to not only see your greatest area of weakness, but also blame you for it? And how would it feel for the entire room to make that collective judgment without you having any ability to explain or defend yourself?

THAT is how it feels to be morbidly obese. It invites judgment and criticism and unhelpful advice and unfair blame and profound ignorance. It is indefensible, because the judge and jury are in from the first glance.

My friends who face this particular challenge aren’t lazy or gluttonous; they are incredibly courageous. They are willing to keep walking through doorways, despite the ignorant assumptions awaiting them on the other side. They are truly happy (most of the time) for the thin people who believe themselves to have created their health rather than being the fortunate recipient of it. They bravely walk each step throughout their day literally carrying heavy physical burdens with very little complaint. They are the victims of biological cruelty. And they bear their burdens with toughness and persistence and beauty and grace.

I don’t remember anything about the woman that spurred my mentor to make his unfortunate joke all those years ago. But when I see her all around me, in all ages and genders and occupations and circumstances, I do not see elbow-and-mouth disease. Instead, I see courageous beauty.

Will you join me in looking beyond the surface? Will you trade judgment and criticism for empathy and humility? Will you try to listen and learn and understand and be a part of the solution? And when you see my courageous friends, will you look for their beauty and toughness and grace?