Just as all calories are not equal, all people are not created equally. Just in casual observation you certainly have noticed different body types over the course of your life.
Over my 30 years of medical training, I have observed the arc of the weight gaining lifespan. When applied to individual cases, this knowledge can help to manage expectations in a realistic manner. It can also help to inform clinicians and patients about what is likely to be required to achieve a healthy, sustainable body weight. There are three broad types of obesity that affect Western civilization.
Type I Obesity
Type I obesity is that acquired at a young age, often noted in pre-school years. These are the chubby kids in grade school who go on to be the heavy kids in junior high. These are the patients who can’t remember a time when their body weight wasn’t an issue. Much like type I diabetics who are born with a genetic difference in their production of insulin, patients with type I obesity are born with a genetic difference in their metabolism. Even in a primitive culture with a leaner diet and a more intense energy demand over each workday, patients with type I obesity tend to stand out as being larger than their peers. In developed nations, when a patient with type I obesity is fed a Western style diet, unhealthy weight gain ensues.
In addition to rapid growth of fat cells, patients with Type I obesity also tend to grow in height earlier and develop sexual characteristics at a younger age than their peers. The early vertical growth can masquerade the ultimate consequence of the weight gain as parents may presume that their child will just be taller than most. In fact, more often, the vertical growth comes to an abrupt and early halt leaving the patient with no other option but to grow in girth. At this point most of these patients are shorter than their peers and have established eating patterns and a hunger drive that destines them for an even more severe weight gain cycle as the pubertal growth slows down.
A distinction should be drawn at this point between infantile weight gain and toddler waking. A chubby infant doesn’t necessarily lead to an obese adult. A chubby toddler makes the risk of lifetime obesity significantly greater. Directing toddlers into a non-Western style of food intake is critical to helping them avoid laying down a base of obesity that is almost impossible to change once it’s established.
As weight is gained in childhood, fat cells continue to divide. Fat cells act as reservoirs absorbing energy and expanding when weight goes up, then releasing energy and shrinking when weight goes down. Once established fat cells may divide, get larger or smaller, but they almost never can be destroyed or eliminated.
People with Type I obesity typically require a lifetime of treatment including intermittent cycles of pharmacotherapy, as well as ongoing behavioral support to eat in what is best described as an “abnormal, but healthy manner.” At least, abnormal by Western standards. We have been historically taught will have the effect of maintaining an unhealthy weight or even exacerbate weight gain in patients with type I obesity.
Unfortunately, people with Type I obesity have often been subjected to psychological harm, even abuse and neglect. Some of this is overtly malicious. The result of coldhearted biases on the part of people seeking to boost their egos by mocking individuals they perceived as being inferior to themselves. Most of the harm done is the result of ignorance. If you are a Type I obesity person, you likely have painful memories of awkward attempts by family members to “help you” control your weight. Comments from parents, maybe siblings such as “you really don’t need to eat that” as you’re about to have food can be profoundly demeaning and judgmental. Even physicians have been guilty of joining in the cultural bias against type I obesity. At times patients have felt their doctor’s frustration and disappointment as they are perceived to have “ignored” the advice the doctor has given them to lose weight. As if it were that easy. Merely telling somebody with type I obesity that they need to lose weight has about as much success as telling them that they need to grow 6 inches. In both cases, there is a genetic determinant at play. Fortunately for the type I obesity sufferer there is a growing awareness that this is not a psychological or social disorder, but rather a medical and metabolic entity.
Unfortunately, many of these patients have landed in a psychologist office trying to discuss their relationship with food. It’s really quite simple, type I obesity people are like the rest of us. They love food. They love to eat it. They simply have a metabolism that is unforgiving. It’s a waste of time to try to talk the weight off your body with the psychologist.
On occasion there can be false hope created by a brief cycle of weight reduction. Typically, this only amplifies the problem rather than helps it. Because the patient and the counselor have the false notion that if the patient just tries harder, they can achieve lasting success in maintaining a healthy body weight. The problem is not with the effort put forth by the patient. The problem is with the treatment plan.
So, what should you do? The first step is trying to forgive anyone who ever hurt you or wasted your time with misguided efforts to help you lose weight. They just didn’t know any better. The second part is to simply dismiss all the idiots who mocked you. They aren’t worthy of your mental energy. Remember, your goal is not to look like some picture in a magazine. Your goal is to live at your healthiest weight. In some cases, your healthiest weight will be what others might perceive as obese. Part of living with type I obesity is learning to manage your own expectations as well as society’s reaction to you. As long as you keep in mind the principle of embracing the people who love you, and disregarding the opinion of the idiots, then you will proceed through life with a healthy mind, soul, and body.
Type II Obesity
Type II obesity can also be described as “adult onset obesity”. This typically can begin in young adulthood starting as soon as the late teens or early 20s. It often corresponds to the completion of the pubertal growth cycle. As such, it typically occurs earlier in women than in men. This may explain the so-called “freshman 10” that women tend to gain upon entering college. Truthfully, men gain the same amount, they just don’t seem to care about it as much.
Anyhow, this type of weight gain is sneaky. As it begins, we typically write it off to changes in lifestyle. Our lives have gotten busier. We don’t exercise as much. For some of us the time of training for competitive sports has come to a close. While all these explanations have some validity, the underlying cause is a shifting metabolism that is coming headlong into the toxic obesogenic western lifestyle.
All of those youthful eating habits that our dynamic metabolism allowed us to get away with are now coming back to damage our health. A metabolically dynamic 14-year-old can get away with chips after school and ice cream at dinner. A metabolically plateaued adult cannot.
If recognized early and intervened with by nutritional change, Type II weight gain has a great prognosis. These are the type of patients that may have success with self-directed programs. Oftentimes, eliminating the obvious targets can be successful.
You don’t need a nutritionist or doctor for that matter to tell you that eating ice cream and chips are bad if you want to lose weight. It becomes a choice between two desirable pathways. On the one hand, it’s fun to eat junk. Researchers demonstrated that it makes us feel good. It can calm an irritable mood. Food can keep us company on a cold lonely night. On the other hand, it’s satisfying to look good and feel good. Choosing one path over the other is within our power. Somehow imagining that we can have both is self-delusional.
If left untreated, Type II obesity can evolve into a more recalcitrant form less amenable to a gentle course correction. In fact, much like the type I obesity patient, new fat cells can be created later in life making subsequent weight loss that much more difficult. In this manner, a “Type II” person can evolve into “Type I” if left untreated.
Type II obesity patients have the good fortune of having a milder form of the disorder. For example, if there are two patients both entering the same weight loss program, both weighing 250 pounds and one is Type I obesity while the other is Type II, the Type II patient will lose weight more rapidly and keep it off more easily. Type II patients have the potential to make other people challenged by their weight feel less capable by comparison. It’s important to remember that the weight you are carrying is a symptom of an underlying disorder. While the end result – excess body weight – may look the same from one person to the other, the causes may be entirely different. Therefore, there is no value in attempting to generalize with regard to weight loss. This can explain why some programs can appear to work great for one patient but readily fail many others.
Because of its insidious onset, Type II obesity has the potential to cause corrosive harm to your health. For example, at one point maybe your doctor notices your high blood pressure. Many medicines used for blood pressure control can interfere with fat metabolism thereby accelerating the weight gain. The next thing you know, cholesterol becomes an issue. Medicines used for cholesterol control often can interfere with sex hormone production further escalating the downward cycle of your health and well-being, interfering with maintenance of muscle mass. The next thing you know you get depressed because you’re having sexual dysfunction, you’re overweight and on multiple medicines. Your doctor starts you on antidepressant drugs which further suppress sex drive and accelerates weight gain. Welcome to the world of the downward cycle. Fat, tired, sexually dysfunctional is no way to go through life. Unfortunately, conventionally trained physicians, nutritionist, and psychologist don’t have an up to date approach to treating the obesity epidemic.
If you recognize that you are suffering from Type II obesity, before your physician starts you on medicines that are treating symptoms of your obesity-such as blood pressure, cholesterol, diabetes, arthritis and sleep apnea -make sure that the root cause has been addressed first.
Type III Obesity
Type III weight gain is the result of hormonal and metabolic changes that occur in midlife and beyond.
For some patients, this is the most vexing form of weight gain. Fortunate to be born lean, they most often have avoided the Type II form of weight gain through genetic endowment, regular exercise and careful eating habits. Things seem to be going along pretty well for them until they hit midlife hormonal depletion, better known as menopause and women, or andropause as it is referred to in men.
It turns out that our sex hormones are very active in controlling the flow of energy in our bodies and in directing how we store and subsequently burn energy. As our sex hormone levels diminish, fat starts to accumulate in our midsection. In women the primary culprit is fading estrogen and progesterone. There is a hormone (estrogen sensitive lipase) that helps direct calories towards muscle and away from fat. As the hormone diminishes through menopause, the food energy that we consume is more readily stored in our fat cells leading us to accumulate more fat on our frame. In addition, testosterone levels are also declining and women throughout menopause. Testosterone is essential for maintaining ideal muscle mass. Since the amount of muscle mass roughly dictates what are resting metabolic rate will be, less muscle mass means a slower metabolism and more easy fat accumulation.
The story is similar for men. Fading testosterone levels leads to decreased muscle mass, slowing metabolism, and mid-abdominal fat accumulation. It is easy to see where this will lead. More fat, slower metabolism, decreasing hormones, the cycle becomes self-perpetuating.
Hormonal shifting, like other aspects of weight gain, is an individual commodity that affects people unevenly. Some will navigate their midlife and older years with only minimal and tolerable changes in body composition. They are the fortunate few. More people will be inclined towards profound changes in body size and shape at this point of life, despite their best efforts. Addressing this biological inevitability with changes in eating patterns and increasing intensity of exercise can have a beneficial effect and delay progression.
As I have mentioned, muscle mass correlates with resting metabolism. The type of exercise that I have found to be most valuable in altering the midlife hormonal decline, or Type III obesity is power training to develop muscle mass. Unfortunately, as people advance in their chronologic age, they either intuitively cut back on exercise intensity or are directed to do so by ill-informed physicians or trainers.
When a younger person who is training intensely sustains an injury, the advice given is a cycle of rest, rehabilitation, then a return to full intensity training. On the other hand, when a person who is a bit older acquires the same type of injury, there is a presumption that he ought not to have been training so hard in the first place due to his age. Rather than put him through a cycle of rest and rehabilitation with a return to intense exercise, the advice is often to sacrifice intensity in order to avoid injury. This is precisely the wrong prescription. It will lead to a “stair step” decline in vigor with a corresponding increase in adiposity. It may be true that changes in the type of exercise may need to be contemplated to work around certain injuries, but the intensity ought not to be compromised.
Part of the reason why midlife obesity seems to afflict women so profoundly is likely due to their historical lack of power training. Even some of the most fit women will avoid intense muscle building activities on the mistaken worry that they will become “bulky” all this tends to do is accelerate the rate of body change and amplify the speed of hormonal depletion.
The treatment for Type III obesity often requires the restoration of proper hormonal balance. In some cases, this can be achieved with the proper use of over-the-counter supplements and hormone boosters. In other cases, it requires the use of testosterone and bio-identical estrogen and progesterone.
I feel these types of treatments are fully justified in the face of life altering Type III weight gain. I have seen cases of patients who have a body mass index of 25 being told by their primary care physician that they do not have a weight problem. While that may hold true in the rigid medical sense, when a patient who has lived their life at a body mass index of 20 and can no longer fit into their clothes, has lost her sexual self-esteem in a manner that is starting to adversely affect their relationship, has started to become depressed and tired, safely reducing their body weight from a suboptimal to a more optimal level is a life enhancing outcome.
While it can often be an independent event, type III obesity can complicate and aggravate both type I and Type II obesity. In these cases, a blended treatment approach is required to achieve optimum body weight.
Dr. Stephen Petteruti is a board-certified family physician specializing in functional medicine, bioidentical hormones, IV Vitamin therapy and weight loss. His practice Intellectual Medicine 120 is in Warwick, Rhode Island.
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