For years the assumption has been that “obesity” leads to pain. Many patients have had the experience of looking for explanations of pain issues, only to have the problem never investigated and told to lose weight instead. Then years later, find out that their pain was actually the result of an underlying issue, made worse through a lack of early treatment. You might have seen a comic or visual joke involving a visibly injured patient and the doctor saying “have you tried losing weight?”
In my book, Young, Sick, and Invisible, I discuss how this same trope was directly responsible for my own autoimmune conditions being ignored long enough to cause long term and severe disability and damage.
In a recent post, I had responded to an intentionally insulting comment with a long explanation of how their assumptions about my use of a mobility aid and my weight was influenced by a series of misunderstanding about obesity, pain, and disability. Included among this explanation was the statement that “obesity” or rather weight gain, can often be a symptom of chronic pain rather than it’s cause.
In response to this statement I received a question, and while the phrasing made it clear the comment wasn’t actually a legitimate inquiry but another chance for the commentor to engage in fat shaming, the underlying question sparked my interest.
Heavily edited, the question was this:
“I understand how obesity can contribute to pain by putting stress on joints, but I don’t understand how the opposite can happen. Can you Please explain it to me and help me understand? How does Pain cause Weight Gain?”
To begin, the concept of “obesity” is widely misunderstood and is oppressive in and of itself. As a knowledgeable friend recently explained it – The word is based on the Body Mass Index scale (BMI) where the ratio of height and weight was determined and everyone who scored within certain parameters was considered as having a healthy BMI while anyone whose BMI was above this range was deemed obese. A person who had very little body fat, but was very muscled, especially in relation to their height, would be classified as obese. In fact, since muscle tends to weigh more than fat, a body builder is more likely to be classified as obese than what most people consider to be representative of an “obese” person.
The concept that obesity is synonymous with fatness is a misunderstanding that has become accepted as a standard, and is used by doctors to excuse their own medical negligence when it’s the result of internalized biases regarding fatness.
What’s more, more and more evidence suggests that body fat percentage is not actually a reliable indicator of an individuals health, nor is there actually a reliable standard as to what fat percentage can be considered healthy and which is unhealthy. That rather fat distribution and percentage is really just a variation in body type much the same way that shape, height, etc. are.
The attempt to pathologize fatness ultimately makes as much sense as claiming that a certain eye colour is an indicator of overall health. Contrary to popular belief, just being fat is not in itself unhealthy. A fat person can be just as healthy as someone who is considered slender. What is unhealthy is when there is a sudden significant increase or decrease of body fat percentage outside of regular growth and development. In the specific case of an increase in body fat levels, what is unhealthy is when it is spurred by malnutrition, stress, and immobility which in addition to spurring weight gain also have a measurable negative impact on blood pressure, blood sugar, and arterial plaque. Even in this case, it’s not the weight gain in particular that is of actual medical concern, but rather the specific effects on those measured stats.
The medically accepted myth that fatness all by itself is unhealthy is another example of the fallacy that correlation signifies causation. Additionally, this accepted fallacy has had significant impacts on our social understanding of body size and health.
A more accurate way to look at the connection between a high body percentage and pain would be that it can contribute to pain when an underlying problem exists, and when the specific individuals natural body fat percentage is significantly lower than what it is now. There are many people out there who are fat, who not only experience no pain whatsoever, but also have perfectly healthy stats.
In fact, the social convention of proper weight is so distorted, that the little abdominal bulge many women spend years trying to eliminate, is actually not the result of fat but is actually their internal organs pressing up against their abdominal wall.
Weight on it’s own, doesn’t cause pain. Rather, in an event that someone has an underlying condition that may cause pain, carrying more weight than their body naturally would under optimal conditions, can put additional stress on the injury site and make pain more intense. The impetus for the pain however, is still the initial underlying injury or condition.
What many ignore is that pain and its related symptoms can actually be the cause of accelerated weight gain and that the best way to address both is to treat the underlying cause of pain and to treat the pain itself.
How can this be?
To start, pain can cause weight gain in much the same way that stress does.
If you’ve ever had a tattoo done, you’ve likely experienced a shortened variation of the same physiological processes involved.
About halfway through getting mine, the artist stopped what we were doing, and handed me a soda and a snack. I asked why, and he told me that it’s happened in the past that people have passed out or become dizzy because of a drop-in blood sugar caused by the pain. If you’ve ever performed, you likely noticed that you were starving after the show. All of these are related. They’re all the result of spending time in the state commonly known as “Fight or Flight”.
Although Fight or Flight suggests the response is meant for negative interactions only, the reality is that the state can be triggered by any cause of physiological stress, including pain.
Resources are diverted away from processes like digestion in order to free them up for use by various muscles, your body releases insulin in order to speed up the absorption of sugars for use by muscle cells, and the body stores partially digested and undigested fats for processing once the “threat” has been dealt with one way or another.
This state is only supposed to last a relatively short period of time. It’s meant to be an emergency response to immediate danger. When this state is prolonged, it can lead to a variety of side effects including weight gain as the hindered digestion defaults to storing what it breaks down as fat stores. Your metabolism slows down on a more permanent basis, affecting your long-term predisposition towards weight gain.
In addition to the active inhibition of proper digestion through existing in an emergency response state, even when youre NOT in the “fight or flight” state physiologically, in order for proper digestion to occur a body must be able to rest.
Studies have shown that people who don’t get sufficient sleep are more likely to experience higher rates of weight gain and malnutrition. As those of us who experience pain on a chronic basis know, pain can interfere with proper sleep. It’s harder to fall asleep when you can’t get comfortable. It’s harder to stay asleep when the smallest movement can result in a jolt of pain that wakes you up. It’s harder to go through all the necessary stages of sleep when you can’t stay asleep for long enough to go through them all.
Lack of sleep inhibits your overall ability to relax making it harder to go into a physiological at rest state at all. Without this ‘at rest’ state necessary to facilitate proper digestion, the body is unable to break down fats and defaults instead to storing them for future processing, similar to putting work into an inbox to work on later because right now you are busy with a big project that’s coming due. Just like with your work, if you never have a chance to clear that inbox, the work just continues to come in and the pile just gets bigger and bigger.
2. Restricting Ability to Move
Imagine if every time you took a step, you felt as though your entire leg was going to shatter. It felt as though you could feel what felt like cracks forming in your tibia, as though you could feel the pressure of that step causing damage.
I don’t have to imagine what that’s like. I’ve lived it.
The cause was Psoriatic Arthritis, a genetic condition, which had flared and was causing very high levels of inflammation which in turn was causing active damage to my bones. No, it wasn’t shattering my tibia. Instead, with every step I was grating away bits of my cartilage and also causing structural damage to the head of my femur.
Even with a cane, the daily pain I lived with was immense and frequently overwhelming. Walking itself was painful, but would also increase how much pain I would be later once I stopped walking.
I began actively looking for ways to cut down on walking. Even just the walk to the bathroom could be overwhelming, so anything I could do to reduce how much I had to do on a daily basis, was done. This included waking up a whole hour earlier, so I could take two or even three buses to class, rather than taking one bus and walking a longer distance. This included taking money out of my food budget so that I could take a cab somewhere.
It’s human nature and really just animal nature, to avoid the things that cause pain. . There is a good reason for this. Pain is a physical response to harm – it indicates that something bad is happening. When touching a stove, the pain is the signal your brain sends to tell you that the heat of the stove is causing damage to your body in the form of a burn. Without that signal, you might keep holding on to the stove until your hand is much more severely injured. In the case of depression, pain is one of the physical responses to a lack of adequate levels of various neurotransmitters in the brain.
This signal-response system is so important, that the inability to feel pain is actually a very serious disorder which can cause people to horribly injure themselves without realizing until it’s too late. If they accidentally lean on a hot burner for example, it’s not until someone else points out what’s happening, their clothes catch fire noticeably, or the smell of burning becomes noticeable that they become aware of what’s happening. By this point, the damage to the part of them that is being burned may be severe. They have to perform physical examinations multiple times a day, since they have no signal to let them know if somethings wrong.
When movement creates pain, then movement is avoided; then exercise is avoided, and in many situations that can actually be the more medically sound option. In my case, for example, doing the things that cause me pain – walking, moving around, were also causing additional physical damage that meant future movement was being restricted. The damage from trying to force myself to keep going despite the pain is directly responsible for my current difficulties in walking, standing, and so on. It caused structural changes that actively reduce range of motion in such a way as to make certain tasks impossible, such as say tying my shoes.
I have been ordered by doctors to avoid things like running, like riding my bike since doing so causes my bones to grate each other in a way that causes damage. I have been told to avoid activity when my arthritis is flaring to reduce the overall damage being done in the state of inflammation.
The avoidance of exercise isn’t “laziness”, or a lack of ambition, or in many ways even a choice. It’s the rational and reasoned response to being in pain. Those people not in pain however, will often ignore this reality and punish us for this “choice”, creating both physical and psychological barriers that force these same people to engage in activities that lead to more severe disability, more long-term pain, and further reinforce the physiological processes that are responsible for the increased weight gain.
3. Energy Cost
Sometimes the things that cause or worsen pain, cannot be completely avoided because they’re just the reality of existing in this world. Nothing I do will ever stop me from needing food to live, which means I have to acquire this food by some means, but the consumption of which on its own in my case, leads to an increase in pain. Eating causes me physical pain, but it’s not like I can choose to never eat again.
No matter how much pain I am in, I still have to do my laundry, go to my appointments, run errands, go to the bathroom, and otherwise do the same things that anyone else does to continue existing.
Just existing with constant pain is an energy drain. It makes tasks that were once relatively simple, use up a lot more of your physical and mental resources.
Imagine it like having to wear a 20 lb weight while doing your regular tasks. Even if you are able to carry it relatively easily, you will still end up being more tired than you would have been than if you were able to do it without having to carry that weight. It has nothing to do with how fit you are, how mentally or physically strong you are, if you make dinner while wearing a 20 lb weight, you will use more energy making dinner than if you weren’t. It’s the same with pain. Note that this is not the same as when that weight is an actual part of your body in much the same way that just because your legs can support your weight, doesn’t mean you can physically lift something that weighs the same as you.
Doing regular every day tasks while being in pain is like wearing that weight belt while you go about your daily life. Regardless of whether you actively notice or rather pay attention to the pain or not, the simple fact that it exists creates an additional energy cost. Just like with the weight-belt example, even if you become somewhat used to whatever is creating the cost – the fact that a cost remains will still be the case. There will never be a time where the amount of energy needed to perform the same tasks will ever be lower or exactly the same while you wear the weight-belt/experience the pain, as when you aren’t.
Now imagine if you had to carry the weight in one hand and couldn’t put it down even though it made doing everything harder, or had to wear it in such a way that it made it difficult to bend. This additional barrier means the tasks might take a bit longer to perform, which means you are carrying that additional weight for longer than you otherwise would, which further drains more energy than the same task otherwise would.
The Spoon Theory written by Christine Miserandino writes in more detail about this energy cost in relation to chronic illnesses as well as the potential consequences for attempting to ignore this energy cost reality or having to work beyond your energy resources. Since this post focuses on the results of that reality, I encourage anyone who wants to understand this idea further to refer to this piece.
The result of this increased energy cost can understandably impact the quality of our diet.
One of the most frequent results actually being that we eat significantly less than we should be, which from a weight gain versus weight loss standpoint is one of the worst things you can do. Why? Because the body’s response to starvation is to slow your metabolism down further, meaning you now have two different physiological body systems that are promoting fat storage rather than full digestion. It’s the exact same reason why diets ultimately don’t work, because the act of triggering weight loss through the restriction of certain nutritional elements including calories, leads to your metabolism slowing down in response. It’s a built-in survival mechanism from a time when we are a species were much more affected by relative availability of food throughout the seasons.
This is also why a lot of people who deal with chronic pain will find themselves gaining weight even when they eat significantly less than most people, and even when they go days without eating. Our bodies desperately try to keep us alive by responding to any influx of food by storing away as much of it as possible for future use in the form of fat, and in this way to keep the body alive during times of scarcity, similar to the ways a bear’s body will store fat to be consumed by the body during hibernation. It may also store water similarly, leading to bloating and further enhancing the physical perception of weight gain.
To go back to the aforementioned inbox example, it’s as though not only is the work continuing to pile into your inbox, but on top of that it is going to take you even longer to finish your current project meaning it will be even more time before you are able to tackle the ever increasing pile.
Another solution to acquiring food despite a lack of physical energy necessary to make full meals, is to either order food or to purchase ready made easy to reheat meals that require less energy to make. The effects of Systemic Ableism, however, mean that many people who experience chronic pain are also forced to live in poverty. As a result, the foods that are available are often those that are less healthy or more likely to contain ingredients that are liable to result in additional weight gain, bloating, and so on. This predisposition to lower quality meals can be because those meals themselves are less expensive or because low income housing is more likely to be found in what are known as food deserts.
Additionally, many of these meals can be easier to consume when dealing with some of the related side effects of pain such as nausea. Since the nutritional content of these meals is less complete than one might otherwise find in more complete and thus expensive meals, more of it is needed to provide the same necessary resources for continued survival. These types of calorie dense and nutritionally light meals physiologically encourage overeating since it’s the only way for the body to meet the necessary daily requirements.
As many people who are outside of what society deems acceptable levels of fat will tell you, it’s not uncommon for people to actively shame you for eating anything they decide is unhealthy. To decide that you eat too much and decide to lecture you about it.
In addition to direct shaming from people who come at you to tell you how disgusting you are, or offer uneducated advice about what you should be eating, there are the many ways society shames us every day: with pictures of people with similar body types as us being used as objects of derision, with comedy sketches who rely on mocking people for their weight or eating habits, with people reaching for fat-mocking insults when looking to shame or ridicule people who are legitimately bad therefore creating a society wide mental association between fatness and immorality.
The result is that those of us who eat significantly less because of the way pain interferes with our ability to get and make food, are more likely to actively avoid eating even more than before since society tells us that the fact that we are gaining weight means we are eating too much. This can be true even when on most days, all you manage to eat is a handful of crackers and a slice of cheese.
During the time in my life when I was gaining the most weight, I was actually eating one meal a day, and that one meal was still significantly smaller than what everyone else around me was eating. Despite this, it was always assumed by doctors, strangers, even family members, that I was eating too much. At times, it got to the point where I felt ashamed letting people see me eat.
Even when eating was the appropriate expected activity, like when going to a restaurant with people, or at a family dinner, I would feel the need to in some way act to hide the fact that that’s what I’m doing. I would put a hand in front of my mouth as I took a bite, completely unconsciously, simply to at least somewhat block out the fact that food was entering my mouth. I didn’t even realize I was doing this until multiple people pointed it out.
Even when doctors did make a point to stress the need to eat more frequently, the implied assumption was often still that that one meal I was having was much bigger than it should be. The assumption was that I was having a higher than necessary influx of calories in a short period of time, overwhelming my metabolisms ability to process all of it properly leading to improper digestion. That this one meal was a feast that would more reasonably be spread out across several hours.
Additionally, the very act of drawing attention to my weight at all just increased my anxieties around food. The message being sent, whether intentionally or otherwise, was that my weight mattered more than my health, whether or not I was in pain, whether or not my physical survival needs were being met. That in the absence of a physical ability to lose any weight, that continued treatment depended on either losing weight or not doing anything – including eating – that might lead one to believe that I was to blame for any weight gain that occurred. This prioritizing of weight over health is so ingrained in our culture that even though I was on steroids which were known to cause weight gain, the assumption of my doctors was still that it was the result of some failing of mine, something I was actively doing wrong rather than the expected result of taking prednisone. That when it was revealed not to be the case, that medical professionals including doctors still felt it appropriate or suggest treatments that were considered dangerous for people with my conditions. Which were for example known to lead to difficulty in maintaining healthy levels of necessary nutrients and so increase the likelihood of malnutrition and deficiencies, to a person who was already experiencing malnutrition and vitamin and mineral deficiencies because of crohn’s disease.
This shaming, strengthened by the associated poverty, and made difficult to avoid because of the realities of living with pain, means that many of us will develop disordered eating patterns that in particular when combined with the physiological effects of the pain itself, can make weight gain unavoidable.
The more I was blamed for gaining weight even when I was actively making healthy food decisions, the depressed I would feel. That, along with the strain of being in pain, would make me crave the endorphin rush that can accompany the consumption of things like chocolate, or the dopamine fix that comes from enjoying comfort foods.
The act of indulging in these cravings though, even when they were not only rare but understandable, would in turn make me feel guilty and hate myself. The guilt and self-hatred would only reinforce the need for comfort and so create even more psychological pressure to indulge.
The well-meaning attempts to curb this indulgence by friends and family actually made the situation worse, since it only confirmed what I already knew. That I was disgusting. If I was disgusting anyway, than I might as well have one more chocolate. It wasn’t just the psychological pressure either, since my body was in many ways starving due to hindered digesting by both the effects of pain and just Crohn’s itself. My blood tests frequently showed a deficiency in Sodium, Magnesium, Iron, etc.
The more psychological stress I was experiencing the more my Crohn’s would respond by flaring, even further compromising my ability to absorb adequate nutrients. The more malnourished I was, the more physiological hunger intensified the psychological craving for certain foods.
It got to the point where I felt the need to start hiding food again, start hiding the wrappers from candy or only eat when other people weren’t around.
What I actually needed was understanding, was help not feeling like my worth was dependent on whether or not I was gaining weight. I needed help to break out of the shame spiral that made me seek comfort in food since I couldn’t expect it from those around me.
The less I was punished for having the occasional chocolate or fast food, the less I sought it out. The less I was made to feel like my weight was correlated with how much affection I would receive, the less pressure I felt to outwardly perform healthy habits and the more I just created real healthy habits.
When doctors avoid effectively treating pain, or other similar issues, because the treatments might promote weight gain in a patient that is already overweight, they are actively making the situation worse. When people shame the use of accessibility devices by calling them obesity scooters, or shooting dirty looks and comments and people who use them, or making jokes about the people who use mobility devices, they are contributing to the problem. When bureaucracies make it harder for people to get access to adequate accessibility, they are creating a situation whereby weight gain becomes unavoidable. All of these things contribute to positive feedback loops which directly cause weight gain while actively keeping away the tools necessary to break the cycles.
As long as society and doctors value appearance over reality, our medical system will find itself failing patients, and will further find itself failing in its stated objective of reducing overall social weight levels.