When Behavior Becomes a Disease
We all indulge in food, some more than others. Those who enjoy more than their fair share tend to show it on their waist line. In society, we describe their behavior as a personal choice or a lack of self control. In medicine, we manage their behavior as a medical condition, which we diagnose and monitor through a ratio, the body mass index, or BMI.
It was first developed by mathematician Adolphe Quetelet, who used the ratio to define the distribution of body types found in society. Today it remains the standard for diagnosing obesity, but we are increasingly finding limitations in it.
It is proving to be less accurate at extreme weights because we are now learning that the ratio of height to weight is not linear. Rather it is a complex relationship that varies in ways we do not fully understand. This may appear as nothing more than a mathematical glitch that evens out in the end, but we should be leery of being so dismissive, particularly given the rampant rise in obesity – despite the efforts of so many to promote healthy eating.
It is now projected that by 2030, half of all Americans will be obese. But no matter what we try, be it food logs, awareness campaigns, or tax penalties for unhealthy foods, we see little to no success against obesity. The problem is not that the treatments are ineffective, but that we are not addressing the core perceptions around the act of eating, which in aggregate lead to obesity.
Each person has a complicated relationship with the food they eat, predicated on a host of factors, including the current mood of the person eating. A person who eats an extra slice of cake to cope with stress has a different frame of mind than a person who eats an extra slice of cake to celebrate a recent achievement. Though technically the same act, the perceptions are different. The varying levels of stress produce varying responses in the physiologic hormones involved in correlating the satisfaction of eating with food consumption – these then create different perceptions around the act of eating itself.
This context is proving to be as important as the foods eaten in combating obesity. It explains why food taxes are inconsistent and unpopular. The idea behind such a tax is to create financial disincentives against eating unhealthy foods. It assumes people will modify their behavior to avoid additional costs and therefore, will eat properly.
If you tax ice cream through such a penalty, you assume people will buy less ice cream and eat more healthily. But this only holds true if people are in the same emotional state when making purchasing decisions for food. We know this is not true, as multiple studies have shown that those who go to the grocery store while hungry purchase more high-caloric food than those who are not. Ice cream, a notorious stress food, is often consumed by those looking for food as comfort. They are less price sensitive at the time of purchase and more likely to purchase ice cream regardless of its cost, which negates the original purpose of the tax.
Additionally, a tax may appear unfair to those who live a healthy lifestyle and purchase ice cream less frequently. They may feel disproportionately burdened for having to pay an additional tax despite being more fit.
One possible solution would be to develop a sliding tax scale that distributes an ice cream tax based on a person’s BMI. Those with a higher BMI would pay a higher tax, and vice versa. But this would disproportionately affect those with certain body types or metabolic conditions that produce misleading BMI values, which we noted is inaccurate at extreme weights.
Any proposed solution to obesity that restricts or modifies the act of eating will inevitably fail. This is also why most treatments for obesity fail – we focus on restricting food consumption when instead we should focus on the perceptions of food among the obese.
When we discuss the merits of a food tax, we consider overeating as a behavior that leads to a disease. We see overeating as a symptom or a cause of obesity, not a disease in its own right. But recently, Psychiatrists defined a new disease called Binge Eating Disorder (BED), in which uncontrolled over-eating is the disease – not a symptom of obesity. By expressing a behavior as a disease, we shift our perception of that behavior and change the context around overeating.
When we change the perception of overeating from a symptom to a disease, we identify different treatments options because we see things differently. Instead of food logs to monitor weight, we should monitor stress and correlate it with eating patterns. Such a shift in focus reflects the magnitude of perceptions in healthcare – and makes the difference between ineffective treatments versus those that are highly effective.
So if we want to make strides in reducing the incidence of obesity, then we should focus on how the disease is perceived by the patient – that is the real disease.
Antibiotic Prescriptions Associated With COVID-19 Outpatient Visits Among Medicare Beneficiaries, April 2020 to April 2021
Outpatient Visits for COVID-19 and Associated Antibiotic Prescriptions Among Medicare Beneficiaries Aged 65 Years or Older, by Setting, US, April 2020 to April 2021. The volume of COVID-19 visits differed by setting: emergency department, 525 608 (45.8% of all visits); office, 295 983 (25.3%); telehealth, 260 261 (22.3%); and urgent care, 77 268 (6.6%).
Source: Journal of American Medical Association Network