Affect Theory as Applied to Obesity.
A discussion of this may be found at: DISCUSSION
Why do 95 percent of people regain weight within two years? Is that not the question we need to answer if we are to get anywhere with the epidemic? After many years of frustration trying to find a way to address this fact I wish to share with you a system I have come across that at least puts all the cards on the table in a rapid, efficient, and responsible way. It has always seemed to me that many times in clinical medicine we ask questions that only beget more questions. We make many good observations but never seem to have the time to look behind them. The huge and overwhelming observation that we make is that no matter what we do as far as therapy, 95 percent of people regain their weight. It is not that we are not trying to find out why, it is just that all of our efforts seem to be at the same observational or mechanical level. I think the following gives a new way to guide our thinking. I have applied this clinically, as a solo practitioner. Nothing works very well, so let’s see if we can find out at least why nothing works very well.
Here is what I do during an office visit:
In my practice I have typed on a single page the essential points that I have gleaned from my reading and experience. I tell the patient that if they do not understand or incorporate all of the major headings that I mention they will not succeed with weight lose and maintenance. The page summarizes: Thinking about environment, metabolism, proper diet, the need for family involvement and the role of medication.
Environment: I tell my patients that about 4/100 people were overweight in the last century, and that now 33/100 in the United States are overweight. Also in some sub-groups that number is 50/100. I ask them why that is, in a rhetorical fashion. I first say that right out of the box they should not beat themselves up so much, as it is obvious just by those numbers that something bigger than ourselves is playing a role in obesity. It is not ‘their’ fault. It just is, and only in understanding their environment will they win the battle or even have a chance. Then I enumerate a few things that are obviously contributors to this system whereby 1/3 of all people become overweight. The first thing is that life is more complicated and that is immediately proved by the fact that they are there in my office wanting to loss weight, something we never had to discuss before. A further litany of things is then stated: In general we have more daily stress, many more choices of food, the fact that the United States produces 1000 calories/per person/per day extra per capita. I point out that we go to a fast food restaurant and get an ‘extra’ large fry for $.25 more. They get $.25 and we get many more calories we don’t need. We are marketing ourselves to death. Finally the simple invention of rapid transportation has overwhelmed us. Trains bring food from afar, we get in the car and go to the food, and in fact the car now is often usurped in that we have a convenience store often within walking distance. The walk is so short that we don’t expend much more energy than when driving.
We, as a society spend millions on convincing ourselves to eat, eat, eat. Yet we do not give ourselves the credit of appreciating that we can give patients and ourselves the simple ability to examine their surroundings. We are swimming in a sea of food and blame the fish for eating.
So number one on my list is THINK. I am careful to point out that this is not something obvious that we might naturally consider. Things moved very quickly to engulf us in this century and since eating is the most basic and natural of activities it is not surprising that we never think about it as hurting us, or not at least until it already has.
Next I say that likewise just as the above aspects of life have sabotaged us so too has our metabolism. Our metabolism was made for a different time. The above technological revolution has overtaken us and has now made life difficult, and boy is it difficult! Now the man in the street has to know a good bit about evolution and biochemical controls of his body to maintain something he never in several millions had to think about. Then I go through a quick explanation of how dieting makes us gain weight.
Again the patient should not beat themselves up, as it is simply unreasonable for anyone to expect the average person to know how their bodies react under situations of starvation. And it is a leap of great abstraction to understand that your body can be starving in the midst of plenty. It is difficult to ask people to do essentially the opposite of what seems so intuitively correct. “I am big, because I eat too much. I will be thin if I do not eat so much.” This is wrong, and so the second point. If you diet you will gain weight. So I say that if they are eating 3000 calories and should be eating only 2000, and they go on a 1500 calorie diet, the first problem is that it is very psychologically hard to drop 1500 calories from one’s daily intake. One cannot help but think that they will benefit from all fifteen hundred calories not eaten. I point out that the first 1000 of the 1500 calories will only maintain the weight or nearly so. Next, going so far under the 2000 calories normally needed tells your body that it is starving. This is crucial to understand. We are in an ocean of technology, but up until this century we were not. Earlier there was no reason to put stoppers on eating too much, but there were certainly reasons for the body to gear down, as we were often in situations of food scarcity. So we must realize that our bodies will stop using 2000 calories and gear down some to accommodate the intake drop. So of the 1500 calories, we end up with only a few available to take off the weight. If we are ‘disciplined’ we take off twenty-five to fifty pounds, but what happens? All diets end because they are difficult and taste bad. Then let’s say we do try and eat right after the diet, and we go back to a diet of 2000 calories. But what happens? Since our bodies are in a starvation mode, not burning 2000, but say 1800 calories we begin to gain weight. We start the diet at 180 pounds and end at 185 pounds and in between lose 50. So step two is that you must think about your environment as well as know this basic principle of your metabolism, or you will gain weight. My basic take-home message: If you diet you will gain weight. Third principle: We must have activity. On my handout I do not use the words ‘Diet’ or ‘Exercise’. We must expend the equivalent energy of walking four miles a day, or we will gain weight. The best thing is to have a hobby that requires activity and then we do not have to exercise. I point out that it all goes back to thinking, or unfortunately having to think about your environment in ways we never had to before. We never had to be concerned about gaining weight or getting activity. Life is made all the more complicated as now we have to think about those things. Stress builds and we are all the more likely to eat.
Fourth there is only one way to eat. Essentially we need Fruits, Vegetables, Lean Meats and Grains. We have complicated things and ignore the obvious. Cultures have always and everywhere eaten these things. They have usually eaten them in balanced ways in terms of protein, fat, and carbohydrate content. We complicate the most basic part of any culture and give the patient a ‘meal’ plan. It all goes back to thinking about the environment. We only have to think about fat grams as we are producing too much and selling it back to ourselves, killing ourselves. We have to then be interested in food. I tell them I have no idea of their budget, of their ethnic likes and dislikes. I can tell them that every culture on earth eats the same ingredients. They just prepare them in many ways and it is the patient’s responsibility to find out what they like as good nutrition recipes are available.
It is a FAMILY MATTER. Just as if you do not enjoy your food you will not succeed, unless you make the effort a family matter you will fail. If you are the cook then you must love your children and mate enough to get them involved. If you are fixing two meals it will not work, as it is too time consuming and expensive. I end with a few caveats of “If you don’t buy it you won’t eat it,” and that if medication is used it is the least important aspect of the treatment. One must have long term goals.
In summary patients must try and understand their environment, know the basics of their metabolism, get the proper activity, and eat the right things in a family environment.
We have all heard this before. I would think that we would all agree with the above. Each point taken by itself is clear and actually simple by itself to implement. But here is why I say all these things are necessary, and while in itself explains the obesity problem also creates a big question. Why is it that not everyone is overweight then? And why is it that only 5 percent of people keep the weight off? Why is it that I am twenty pounds overweight when I go through this reasoning every day? One reason is simply that I am a biological organism in this huge sea of change. That can be understood simply in terms of the above. Note however what goes on inside of that organism when it is hit by all the stimuli discussed above, aside from its prehistoric metabolic machinations? I think Affect theory gives us all we need to complete the picture. The Affect Theory, as developed by Silvan S. Tomkins and articulated and expounded on by Donald Nathanson can, in my mind, be summarized in the following few pages. Let it be clear from the outset that I am not asking at any point for anyone to be a psychiatrist or therapist in any of our common understandings, which are based on our own frustrations with knowing the above but yet not having a way to ‘put it all together’ and have effective plans for acting and advising. No, I am asking you to take another step in your knowledge of basic biology. To reconsider something else you already know and use, and that is that organisms in an environment respond to that environment from stimuli received and that these interactions take place in space and time. Furthermore, that the organism then builds up a memory of those interactions. Then it is clearly the case that complex systems will and do build up, and those systems will have negative and positive aspects.
The theory is then summarized by me in the following way. According to Tomkins
there are nine human affects which may be translated into nine emotions which are
biological. They are: (please go to this summary of AFFECT THEORY and then come back by pushing the 'back' botton on your browser and continue on.)
It should be clear by now where I am going with this. I believe then that we have at hand a method that answers all of our begged questions. We do our patients a disservice if we do not have them think about why they are eating. We do them a disservice by giving them medication unless we point out to them that medication can simply be another avoidant behavior. Why is it that we hear three different opinions about weight loss?: Give no meds, give them for 3- 6 weeks, and some say they have to be continuous. Why is this? I think yes, indeed one needs to be on medication forever unless they understand what is driving them to eat. One needs to ask the patient what and how they are feeling? How is their nervous system informing their mind and thought processes? How are they responding to that input? What in the environment is causing the physical reaction in the first place? Be it their mate, job, or memories of past trauma. Must we find out all these questions, must we become psychiatrists all? I think not. In my experience in presenting these ideas in a matter of fact non threatening way the logic of it spills out. We see on the chart our only options. We see graphically how and why we are hurting ourselves. I point out to them that unfortunately the chart shows us that life is pretty tough. We all know that and we all want to avoid it. The chart itself becomes a threatening, shaming experience and produces a crisis because one cannot bear the logic of it. If we are not psychotic we then have to admit to the logic. Admitting to the logic gives us no wiggle room to ask for any magical cures. Not having magical cures, we have to look to ourselves for the answer. Only when the patient can ask, “Can you help me help myself lose weight?” can there be hope. We all knew that. At least I did, but now I know why it is true, if the theory is true. If the theory is not accurate it certainly puts us on the road to truth.
Putting this in context of my tenants of thinking about environment, metabolism, activity, and proper food we can then see why none of these things work unless we address the emotional or affective life of the patient. Affect and emotions are not interchangeable. Affect is biological and informs the mind. The mind, depending on its history, and where it is in the world has only so many options to get through the day and manage many, many competing desires and attention-getting stimuli. If we are overwhelmed, it is not surprising that we then ‘fail’ in managing all by eating. The over abundance of food, it being sold through ads right and left, the absolute availability of it are in themselves shaming. Add to that the overwhelming counter messages of shame in that we are told over and over again that we need to be thin. We are shamed again. We have crisis after crisis, after shame crisis in any one day. What is the most readily avoidant behavior available: Food (emotional sedation).
The key to success then is developing a strong interest in food and appropriate nutritional eating in obese people. If food is a negative, noxious stimulus then we fail. We are shamed by food. I might say that I have an ‘excuse’ that I work fourteen hours a day running around a big city replacing plate glass, and I have to get what I can to eat. In a way the man is right. I want you to understand though that even that situation is shaming. It is a crisis for the man. How do I eat well? I want to eat well. I want to lose weight but I have other priorities. Let us at least give him that. If you add a bad marriage or previous childhood trauma, or whatever to his now horrid techno-trap of running around the city it may indeed be overwhelming. How do we help him get control of his life? We cannot do it through medication, giving him diets, or telling him to exercise. We also do not have to send him to a therapist. He may need one, but first we need to center all of our patients and teach them from whence the problem comes and I know that we can all do that. It does take time, especially initially, but afterwards you will see a growth and an efficiently in your practice that is quite astounding. You will be on the same page as your patients. What then of medication? I have been very confused about this until now. It is no surprise that I was confused. The only reason, aside for any physical problems with giving medication, for not giving it was that physicians thought it was a matter of ‘will” power and that medication was only a crutch. This was not good enough for me, although I never prescribed it until recently. My reason for starting was that it was obvious that many, many people where not going to lose weight on their own. Many middle aged patients needed knee surgery or were having increasing pain and no one had anything to offer them. So I started on a limited basis prescribing and admittedly with limited success. I now think I know why. Unless the root cause is addressed there is no hope. I feel I can now prescribe the medication with the knowledge that if the patient understands the role of crisis-shame in their eating that they will not take the medication for very long, if at all. It is however very much their responsibility once I point out that the medication can easily become avoidant behavior. It only replaces eating, and other negative behaviors will arise as the negative affects are still pushing them forward. Medication can only boot strap a program of self examination and provide for a few weeks of some positive feedback.
From the theory it is obvious that we do not want negative feedback. It is therefore important to be vigilant for any adverse side effects or indications that medication would harm or extenuate affects. If the patient is quite distressed a stimulant might make them more distressed. In similar fashion any program that instructs the patient, or even suggests that the patient weigh themselves daily, or when they come to the office only sets the patient up to be shamed. Shame only leads to crisis and potential sabotage. We are looking to long-term positive feed back to maintain interest in food, not in weight loss or gain. We must and only encourage healthy eating. Likewise the old suggestion of putting a picture of your overweight self on the refrigerator is also, I think, very dangerous and shaming. Better would be to place one there where you are at your best?
What of the role of genetics. As a clinician I say that it is all fine and well that we push ahead, but it tells me nothing as far as what I do for the patient. It will be a long time before we have a test to determine the existence of such a gene. Then if we have therapy, which it looks as if we will, what good will it do if the behavior is driven by shame. Will the behavior not only be expressed in another way? Our patient is thin, but now beating his wife?
A discussion of this may be found at: DISCUSSION
SHAME AND PRIDE: Affect, Sex, and the Birth of the Self, Donald L. Nathanson.
A discussion of these ideas can be found at Affect and Script Theory.
An online discussion on this paper can be found at:
Comments sought and appreciated, positive or constructive.
BOOK AND CD'S