In the Shadow of Obesity (Part I)
By Eric Blau, MD, FACP

Introduction
I remember that in the first decade of my career, if I had a 300-pound patient on my exam table, I would desperately have been searching my mind to find something other than the obvious to discuss. The possibility of considering why a person was obese was inconceivable; it was totally out of the question. The edge of an abyss was not something I was about to approach in a naive and inquiring manner. Why would I risk leaving the security of conventional medical knowledge to learn by observation and inquiry of what was before me?

And yet, years later I was to wonder why do people get fat? Where in nature is obesity? Why are so many obese adults born prematurely at low weights? What does it mean that a recently seen 850-pound, 29-year-old old woman was one of the first long-term survivors of severe prematurityjust under two pounds at birth? Should we even think about this? Is this medicine? It certainly has nothing to do with what we learned in medical school and residency. Isn't it better to read about intermediary neurotransmitters and obesity, especially if one doesn't think about the implication of "intermediary" or "transmitter"?

On the following pages are four photographs taken by Eric Blau, MD, an internist with SCPMG and an accomplished professional photographer. His efforts in medical photojournalism have already been reviewed in a recent book column of The Permanente Journal. These photographs, intermediary transmitters in their own way, will someday appear as part of a book he is now working on that provides the patients' views of their obesity, but only to those physicians who dare ask.

A note from physician and photographer, Eric Blau, MD

As a society, we spend millions of dollars annually in a mostly futile attempt to lose weight. In a culture already obsessed by health and youth, we tend to discriminate against the overweight among us, finding them lazy, out of control, and lacking willpower. As physicians, we reinforce these cultural models by pointing out to our overweight patients the health risks of obesity. Clearly, the ideal of beauty is not that of the overweight: fashionable clothing is created for the thin.

It is always a revelation when information becomes available to make me rethink basic paradigms of medicine. My training and most of the current literature on obesity led me to believe that morbidly obese people had abnormalities that probably were genetically acquired. I thought it was only a matter of time before these would be characterized and medications developed to alleviate the suffering of millions of Americans.

When I first learned of the Adverse Childhood Experiences (ACE) study and the relation between abuse and morbid obesity, I was shocked and skeptical that it was true. But after interviewing dozens of morbidly obese individuals, I am a believer. Over and over again, I would hear people state that they overeat well past the point of satisfactionusually in response to some psychological trauma. It appears all too frequently that marked weight gain began with trauma, and becomes an habituated reaction to new life stresses. Obesity is a complex disorder and not all overweight persons have been traumatized, but unless one is aware that at least a large percentage of the grossly overweight have had severe emotional trauma, it is unlikely that successful therapies will be devised.

Rather than argue the case myself, I would prefer to let some overweight persons tell their own stories. These are excerpts from interviews that focused on how being overweight has affected their lives, and how their lives have affected being overweight.

It took almost two weeks for us to find him. I went in after him several times: I volunteered for every outbound mission in his direction. We found him spread-eagled between two trees and skinned alive. There was only one thing that was recognizable about him, and they made sure that it wasthat was his face. They left that intact. They didn't touch it a bit. The rest of him looked like something you'd find in a slaughterhouse.

I got weird for a while. I spent a lot of time dwelling on the fact that my friend died over there. I became a risk-taker. I increased my smoking to 8 packs of cigarettes per dayand it hasn't changed, it's just gone in a different direction. I have morbid obesity, advanced cardiovascular disease, diabetes, and limited respiratory function. Do you see a pattern here?

Everybody looks at the downside of obesity, of alcoholism, or drug abuse. But there is an upside, too. There has to be, or people wouldn't do it."

"When I was young, about four I think, I was molested by a teenage boy. After that, my mother would often call me in the house from playing, pull down my clothes, and check me out; it was humiliating. Later, when I was growing up, I was labeled mentally retarded, and men used to think they could do things to me and no one would believe me.

When I am stressed, I eat. Food is my friend; it's there for me. Especially because my family isn't. I don't eat because I'm hungry I'm never hungry. I eat because it's there. If it's cake, I'll eat it 'til it's goneeven if I'm feeling full. I feel good when I'm eating it. But after awhile, I realize that I can't eat enough to stop the pain."

"I was rather slender until I was seven years old. Beginning about that time I was sexually abused by my father. It continued until I was fourteen. I never told anybody. He kept telling me it was our secret and that I shouldn't tell anybody. In junior high school I realized how taboo this was and how I could actually get pregnant. I was terrified! It was then that I put a stop to it. I had a very low opinion of myself. I think children who are abused somehow think it is their fault. I felt guilty and that I was not terribly worthwhile. I weighed two hundred pounds then.

I've recognized that I always eat when I'm lonesome, unhappy, or hurt. And I spent a lot of time hurt by other people who didn't realize that I was hurt. I'd seem like this jolly person, and then I'd go home and cry half the nightand eat. I'm a binge eater. I can sit down with a box of cookies and eat the whole boxI think because I'm alone. And I eat even when I'm full. I've eaten a package of cookies even when it's made me sick to my stomach. But I'd continue to eat them because they tasted goodI guess."

"No matter what you do to your face, your body is still there. I'm a hairdresser. I can make my hair look fabulous. I do great makeup. I look good without makeup: I'm an attractive female. I'm intelligent, I'm energetic, but it doesn't matter because below the neck I am who I am. And that's hard because even though you as an individual may not be superficial, society truly is. And I don't know if it's just that our society has become more superficial in other ways, too. Maybe we're a culture of teenagers.

Food doesn't give you a hard time. Food doesn't create arguments. It doesn't talk. My favorite food when I'm unhappy is pasta with my Mom's homemade sauce."

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