HJAR Jan/Feb 2024

CHANGING THE CARE: OBESITY 18 JAN / FEB 2024 I  HEALTHCARE JOURNAL OF ARKANSAS   the release of dopamine. The amygdala helps regulate our mood and sensitivity to stress and is a major reason why smokers tend to reach for a cigarette when they become stressed or why so many people experience emotional- or stress-related eating. The dorsal striatum is involved in forging powerful associations be- tween people, places, and situations that can trigger intense cravings for these substances, while also encoding certain habits and behav- iors into our daily lives. Lastly, the prefrontal cortex is a site of higher executive function and cerebral processing, where, despite know- ing that tobacco or a certain calorie-dense, nutrient-poor food is harmful to our health, we indulge in the behavior anyway. Despite per- sons wanting to quit smoking, stop using an addictive drug, or stop eating when they are stressed or bored, alterations in our prefrontal cortex result in impaired judgment and pre- dispose us to the temptation of intense crav- ing that only diminishes after we experience the release of dopamine. Persons who find themselves in this pattern who are reading this article know exactly what I am talking about, and they feel guilty about it. They blame their lack of will power and think of themselves as failures for not being able to resist temptation. The reality is that some of them never stood a chance against the forces they are up against. What the food and beverage industry figured out, long before the healthcare profession in many cases, is that the right concentrations of fat, salt, and sugar can trigger activation of these craving loops in the brain through the release of dopamine within the mesocortico- limbic system, thus mimicking the effects of other addictive substances such as alcohol, to- bacco, or even opiates. Despite our progress against tobacco use, it is still the leading cause of preventable death in the world, and there is still dramatic variation in use of evidence- based therapies that are effective for cessation. Heavy alcohol use is the third leading cause of preventable death in the U.S., and fewer than 10% of patients who may benefit from treatment for alcohol use disorder receive it. And, the rise of opiate-related deaths in this country, the so called “deaths of despair,” has been largely responsible for the U.S. seeing a decrease in life expectancy for the first time in decades. The same neurobiology of addiction that plays a role in the development of the vari- ous substance use disorders can likewise play a role in the development of obesity, often be- ginning as early as childhood. The complete pathogenesis of obesity is quite complex and beyond the scope of this article, but suffice it to say, that these deliberately configured combinations of fat, salt, and sugar stimulate dopaminergic circuits in the brain that not only lead to cravings but can also be associ- ated with emotional- or stress-related eating. Instead of blaming people who suffer from obesity or the parents of children with obesity, we should be seeking to better understand the nuances and complexity of this disease, along with its root causes. We should be dem- onstrating empathy for them while consis- tently delivering evidence-based treatments to them. There is a reason why the drug nal- trexone is effective in the treatment of alcohol use disorder, opiate use disorder, and obesity, but only by understanding the neurobiology of addiction can we understand its effective- ness. We should never stop trying to develop more effective treatment modalities such as integrating behavioral health into primary care; or defining the precise role, method, and in- tensity of nutritional support counseling and health coaching; and understanding how fac- tors such as self-efficacy, intrinsic motivation, and motivational interviewing work together to facilitate behavioral change. And we should be open minded to embracing public health strategies and policy changes that will help us impact this epidemic. Lastly, we also need to understand how genetics, epigenetics, ad- verse childhood experiences, and the lottery of life play a role in chronic condition devel- opment and progression, including obesity. The lottery of life Outlined meticulously in his book, The Gene: An Intimate History , Siddhartha Mukherjee, tells the story of the Hongerwinter and follows the research journey of an English embryolo- gist, Conrad Waddington, who as far back as the 1950s was trying to understand how envi- ronmental signals might affect a cell’s genome. He termed this phenomenon “epi-genetics” which literally means “above genes.” The story of the Hongerwinter offers us powerful lessons around the lottery of life. In September 1944, under the occupation of Nazi Germany, the “Instead of blaming people who suffer from obesity or the parents of children with obesity, we should be seeking to better understand the nuances and complexity of this disease, along with its root causes. ... And we should be open minded to embracing public health strategies and policy changes that will help us impact this epidemic.”