OBESITY - A DISEASE CAUSED BY MALADJUSTMENT - CIBOMANIA
CAUSES AND PATHOGENESIS OF OBESITY: CIBOMANIA - BULIMIA - ANOREXIA
A complete QUANTITATIVE AND QUALITATIVE AVAIBILITY OF FOOD AND SEDENTARY LIFESTYE represent important conditions favouring obesity. These conditions are the cause of the geographic distribution of the problem. In the more economically developed countries where, especially in the last century, such conditions were preponderant, overweight is widespread, while where manual labour and scarcity of food prevail we find malnutrition caused by a lack of food.
The predisposing role of a genetic factor invoked by many is in our opinion not supported by convincing arguments; on the contrary, the common observation that with the coming of economic wellbeing and a sedentary lifestyle the problem has spread to all social classes, islands and continents, north and south, urban and rural areas and clearly indicates their fallacy. In reality, as we have seen during national and international congresses, the hereditary factor is easy to confuse with familial background. Are your parents obese? Then your obesity is of genetic origin. That is a simplification. Indeed, familial background is an environmental issue and one of the triggering factors that lead to an increase in the intake of calories and thus set off the process of putting on weight, as we shall see later on. Eating habits, like language and moral conduct, are learnt in the family: if mother and father speak with a lisp, the children will have the same pronunciation and there is no reason to bring genetics into the picture.
This issue is not indifferent as concerns the treatment of obese patients: in the case of unsuccessful treatment, physicians are easily induced to justify the condition by bringing the genetic factor into play and the patient finds in this an excellent excuse for discontinuing the cure.
Reduced nutritional thermogenesis, to which importance in causing obesity has recently been attributed, is not shared by all authors (D'Amicis et al., Alim. Nutr. Metabol. 13,:83-89, 1982; Maffeis C. et al., Nutr. Clin. 1, 1993) and, if at all, may represent the consequence of overweight and in turn play a further role in maintaining obesity. The same can be said for the reduction in resting energy expenditure (REE) found (and still to be confirmed) in obese patients who maintain their normal weight despite low-calorie diets (Adami G.F. et al., Min. Gastroenterol. e Dietol. 39,3, 1993).
For the onset of the process of putting on weight and the concomitant nutritional maladjustment, besides the availability of food and a sedentary lifestyle, a TRIGGERING FACTOR is also necessary, one that acts with sufficient intensity and duration and is not counterbalanced or neutralized by conditions unfavourable to its action. There are many triggering factors, but they all act with the same mechanism: under their effect, subjects are induced to introduce into the body more nutrients than their metabolisms require in ways that vary from case to case and for a sufficiently long period of time.
The persistence of this bad nutritional behaviour in turn causes a gradual and progressive adaptation of the digestive functions and this favours the continuation of the metabolic unbalance through a gradual and permanent compromising of the physical, neuro-endocrine and humoural mechanisms which normally control the correct physiological assumption of food on the central and peripheral planes (Maestri P., Clin. Dietol. 17,273-280, 1990; Marin et al., Clin. Dietol.,17, 53-63, 1990; Giovannini C., Clin. Dietol.,13,457-466, 1986; Blundel J.E., Alim. Nutriz. Metab. 3, 7-19, 1982).
We believe it is sufficient to advance the hypothesis that the metabolic self-control mechanisms, whatever they may be, when forced to deal with abnormal stimuli (triggering factors) for a long period of time, become ineffective and undergo functional and/or structural alterations and thus finally lose the capacity to recognize or react properly to peripheral signals to a greater or lesser degree. At this point, together with the accumulation of excess energetic substrates, the nutritional maladjustment (or metabolic unbalance) has already occurred and from that time on will condition the assumption of food. The pleasure that normally accompanies eating (appearance, fragrance and flavour of food), which is normally assuaged with the satisfaction of metabolic exigencies, becomes an end in itself and continues well beyond the actual need for calories, even though the gratification offered by food becomes less and less as the cibomania progresses.
As we can see, the onset of the disturbance does not differ substantially from what takes place in the case of smoking and drinking. Any sufficiently repetitive experience paves the way to proper learning or adaptation (riding a bicycle, swimming) or improper learning (maladjustments) that later become permanent. Even when we stop smoking we never return to the initial state of the non-smoker; when the occasion presents itself (to our great joy, but most of all to our great sadness) a few cigarettes are enough to make us smokers once again since the initial adaptation, which took several months or even years of arduous experience, is still present.
With the beginning of the nutritional maladjustment, the appetite increases, bringing with it a desire for snacks and, most of all, the feeling of satiety disappears: the end of the meal, which before was facilitated by the timely intervention of this physiological signal, becomes over a more or less long period of time, depending on the sensitivity and cultural training of the subject, a conscious, responsible act that requires, as we have said, an arduous psychological and energetic commitment. The precocious onset of a conflicting relationship with food (the desire to eat against the fear of getting fat) will further aggravate the maladjustment.
The cibomania sets in when patients, realizing that they are putting on weight and prodded by any reason whatsoever (health, appearance, work, sports and so on) try to react by deciding or accepting the need to eat less. Those who are not willing to put up with the more or less painful lack of satisfaction in putting an end to a meal without feeling satiated, or who refuse to accept the necessary sacrifices, will surely put on weight progressively, with the well-known consequences as concerns health, appearance and psychological wellbeing and their fallout on the quality of life. For the moment they will not be afflicted by the torment of the cibomania, but uncontrolled eating and the consequent progressive putting on of weight cannot go on indefinitely: the onset of illnesses such as diabetes, arthritis, heart attacks, strokes and so on, will once again bring to the fore, this time in a dramatic and urgent form, the need for a more responsible relationship with food.
It must also be kept in mind that the seriousness of a cibomania is not the same in all cases. Usually it is proportional to the extent and duration of the overweight, up to becoming uncontrollable in the most serious cases of obesity. For this reason, the quicker the proper therapy is applied the easier it will be not only to lose weight, but also to maintain the results in the long run. Moreover, the many stressful situations that capture the attention of the patient to the detriment of control over food intake represent a frequent cause of the aggravation of the cibomania; such situations require appropriate, competent and painstaking psychotherapeutic treatment by the responsible medical professional. Without this, dieting will be to little avail. Control over a cibomania requires a great deal of serenity, self-control and the time necessary to organize and put into practice the planned diet. When it provides frequent convivial occasions, the social environment may also represent a serious obstacle to proper eating behaviour. Finally, control over a cibomania becomes all the more difficult when numerous and inadequate treatments have been followed in the past, especially when accompanied by the administration of anorectic drugs of the central kind; when they are discontinued the maladjustment returns stronger than ever, accompanied by the rapid recovery of the lost pounds owing to the total lack of re-education they provide.
As we said before, cibomania is the name we give to the fatigue required to maintain proper nutritional behaviour. But to ensure that the effort is not completely in vain, when not even self-defeating, it is essential to know exactly what, and how much, to eat. It is quite frustrating to hear everyone say "eat properly"! In reality, establishing with precision the nutritional requirement of a given individual is an extremely arduous task. Not even the most experienced dietician can establish precisely what a patient's energy consumption is without first studying the results of a careful clinical and anthropometric examination and a detailed motor investigation and then taking into account the many factors that determine an individual's metabolism (age, sex, height, constitution, hormonal situation, physical activity). Almost in all cases the patient's self-imposed restrictions, or those suggested by persons who are not experts, turn out to be too strict and thus are doomed to fail. The greatest risk comes through repetition of these unsuccessful attempts; in such cases the problem of food becomes preponderant in the mind of the patient, with further negative influences on eating behaviour. In most cases the consequence is a worsening of hyperorexia; on the contrary, in other cases a restrictive mechanism sets in, regardless of whether or not there is a condition of excess weight.
Special environmental circumstances or endogenous psychological conditions may lead in this stage to extreme eating behaviours, such as bulimia or anorexia nervosa of nutritional origin. Even the food-crazed can undergo sporadic episodes of compulsive overeating, but their behaviour remains clearly distinct from that of those suffering from bulimia. What is lacking is the sense of shame, secrecy, self-denigration, emphasis of physical appearance and, most of all, there are none of the extreme compensatory reactions of those suffering from bulimia, such as self-induced vomiting, administration of laxatives and diuretics and episodes of anorexia or excessive increases in physical activity (see also C. Fairburn - Overcoming Binge Eating - Guilford Publications, March 1995). In those affected by bulimia, the early onset of a vicious circle of transgression and reaction quickly leads to devastating effects on body and mind, with the inevitable involvement of family and work environments. On the contrary, the disturbance of the food-crazed remains on the individual level with no important repercussions on family and work environments, on personal relations or, in most cases, on the psyche. After a binge, they react by simply vowing not to eat so much at the next meal. On the contrary, in those affected by bulimia, with a rapid alternation between transgression and reaction, the time free from the fixation of food is progressively reduced, while those with a cibomania suffer from this only for limited periods of time (especially after meals) and do not think about food during their daily occupations.
We are of the opinion that most of those suffering from bulimia and anorexia nervosa of dietary origin would have avoided falling into these dramatic situations if only they had known what to eat to avoid putting on weight. When the diseases are in an advanced state, treatment is certainly far more difficult than the simple cibomania that accompanies overweight. However, even in these cases, besides psychological support and the prescription of a diet, it is advantageous to inform patients of the true nature of these disturbances in a frank, calm and understandable way. The main difficulty usually derives from the fact that people come late for treatment after they have established a distorted acceptance of their bodies; they are not at all worried: the problem is with the members of their families who sent them to the doctor!
In the initial stages, both anorexia and bulimia present an evident relationship with a cibomania and can easily be remedied by limiting the condition to that of a cibomania. In some cases it is sufficient to provide patients with an appropriate diet to reach or maintain the proper weight. But together with the required psychological support it is necessary to explain frankly and get patients to accept the concept that a cibomania can be made more tolerable, but never completely eliminated.
The conviction that it is possible to gain weight even when eating little is quite widespread among patients, and also among some physicians (Fricano - Clin. Dietol. 16: 49-54 - 1989). This induces them to search for an explanation in factors other than diet, such as stress ("worry makes me put on weight"), heredity ("everybody in my family is fat"), constitutional tendency ("I tend to put on weight"), assimilation ("lately I assimilate everything"), endocrine dysfunctions ("my organism doesn't burn fat properly") and so on. The statement "I don't eat much" is wholly subjective and meaningless, and usually patients themselves realize this during the investigation into their eating habits. What one person considers "not much" may be too much for another person, and most likely the judgement is expressed in comparison to what people would be capable of eating without limiting themselves. What is certain is that in accordance with the law of the conservation of energy, which is perfectly valid for the human body (Quagliariello - 'Scienza dell'alimentazione' - Idelson 1-5 1966), an increase in fatty tissue is justified only by the ingestion of more calories than are consumed, even when there is no direct evidence of this fact (Magnati G. et al. - Atti Congr. Naz. Obesità - 1992).
In conclusion, the emerging of an effective triggering factor in the presence of causes favouring obesity sets off a process of overeating and therefore overweight which, if lasting over a period of time, determines a stable alteration of complex homeostatic mechanisms and, perhaps, of thermogenesis itself. We are thus of the opinion that in the same way as psychotropic substances, alcohol and nicotine, food is also capable of creating phenomena of adjustment (maladjustment), abuse, tolerance and addiction. Thus obesity is the metabolic manifestation of an illness caused by a maladjustment.
We are going to review the main, triggering factors in the next chapter.