For much of his life, 32-year-old Michael Smith had a war going on in his head.
After a big meal, he knew he should be full, but an inexplicable hunger would drive him to pick up the fork again.
Smith is among the 42% of U.S. adults living with obesity, a misunderstood and stubbornly hard-to-manage condition that doctors have only recently begun to call a disease. Its root causes have been debated for decades, and solutions have long targeted self-discipline and a simple “eat less, move more” strategy with remarkably grim results: those who successfully slim down tend to gain back 50% of that weight within two years, and 80% within five years.
Indeed, most agree that, in the battle against obesity, one crucial organ has been overlooked. “Obesity, in almost all circumstances, is most likely a disorder of the brain,” said Casey Halpern, MD, an associate professor of neurosurgery at the University of Pennsylvania. “What these individuals need is not simply more willpower, but the therapeutic equivalent of an electrician that can make right these connections inside their brain.”
Throughout the day, the machine that is our brain is constantly humming in the background, taking in subtle signals from our gut, hormones, and environment to determine when we’re hungry, how food makes us feel, and whether we are taking in enough energy, or expending too much, to survive. Mounting evidence suggests that, in people with obesity, something in the machine is broken. But how do these circuits and pathways malfunction in the first place?
Ultra-processed foods — those containing hydrogenated oils, high-fructose corn syrup, flavouring agents, emulsifiers, and other manufactured ingredients — now make up about 60% of the food supply, and the evidence is fairly consistent indicating that the nutritional content of processed foods is not accurately conveyed to the brain, and some animal studies even suggest processed foods reprogram the brain to dislike healthy foods. Once these brain changes are made, they are hard to reverse, which is why changing the food environment via public policy must be part of the solution in combating obesity.
In the spring of 2021, Michael Smith began to take an attention deficit hyperactivity disorder medication called Vyvanse, which is now frequently prescribed for binge eating disorder. While it kept him from overeating for a time, the fried chicken and gummy bear cravings returned a few months later. His doctor then also put him on a second medication: semaglutide, or Wegovy, the weekly shot approved for weight loss in 2021. It works, in part, by mimicking glucagon-like peptide-1 (GLP-1), a key gut hormone that lets your brain know you are full.
As a result, Smith’s weight began to fall off. He says, “There is this misconception out there that you just need to put the fork down, but I’m learning it’s more complicated than that,” he said. “I intend to treat this as the illness that it is and do what I need to combat it so I’m able to keep this new reality I have built for myself.”
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