Dr Robert Cywes – The Old Mutual Health Convention presentation summary

Robert Cywes – Friday February 20

Why do some people get fat and some don’t.

A question is: why do people support the beliefs not supported by data?

Another is: what does a surgeon know about psychology and addiction

Sixty years ago at talks like this we were wringing our hands about the rise in lung cancer, heart disease and emphysema, (chronic non-communicable diseases – CNCDs) yet we completely ignored and argued against the evidence that tobacco was the culprit.

Today we sit here wringing our hands about obesity, diabetes, cholesterol and hypertension yet the world ignores the culprit drug. The most prevalent CNCDs killing us as a species are a consequence of drugs not well tolerated by human systems: alcohol, tobacco and the obesogenic drug – carbohydrates.

We are the first responders that can lead a forum of public understanding, education and legislation to contain access to the drugs that are killing us and develop alternative strategies to help our communities to combat addictive behavior.

I studied medicine at UCT under Prof Tim Noakes, who was one of my first teachers. That gave me the training to ask questions, observe trends and recognize behavior patterns that explain disease processes and treatments.

So let me tell you my story:

I am a paediatric and adult minimally invasive surgeon in transplant immunology. I’ve been treating carbohydrate addiction for over 15 years.

I have operated on 5500 to 6000 people. In my patients before and after their surgery, I’ve had 800 000 encounters with fat people. You’d be an idiot if you don’t learn from that.

The story starts with failure: as Prof Noakes says: “The current management of obesity is an accumulated wisdom, mixing fact, opinion, belief and magical thinking in unknown proportions.”

Over the years there has been an exponential increase in the risk of dying, and the belief that nobody dies because they are fat.

Panic sets in. Being fat is obviously bad, so we must lose weight. We have become very good at “scientifically” designing weight loss strategies based on this assumption. And every fat person becomes an expert – at failing weight loss programs. Because if the goal is to lose weight, you will fail.

Current medical therapy for obesity is a multidisciplinary programme that prescribes:

  • Diet
  • Weight loss medication
  • Behaviour modification
  • Exercise

Results are pathetic.

Even in surgery, 58% of people fail surgery. The most common reason is not because they don’t understand lifestyle. We don’t tell them what to do.

Many of my surgery colleagues say surgery is forever, and it has no role in obesity management. Yet it is an incredibly powerful weight loss tool. I can help people lose weight with a knife. But they need more help to keep the weight off and be healthy.

Obesity is not a cause; it’s a consequence of dietary change. We’ve been eating one way for 1.8 million years, and never been fat. That changed with chronic excessive carb consumption. Carbs are not a food, they are a drug, and obesity has little to do with calories or the law of thermodynamics. Weight loss and weight gain has a lot to do with it.

Your thirst centre is in the brain. Your hunger centre is in the brain and tightly controls your access to food. The human body requires food 1 to 3 times a day,

Why can I drink one or two bottles of water, during the day, but when faced with beer, I can drink much more. Why? Alcohol in beer has an endorphin releasing property.

An obese person is simply someone who primarily selects “food” and drink for its pleasure value rather than its nutritional value.

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The human body will not allow you to become fat from eating fat and protein.

Homeostatically, your body will shut you down when you’ve had enough. That doesn’t happen with carbs. Carbs override your brain’s hunger centre, and activate the endorphin centre.

Obesity involves a vulnerability to addiction, a consumed carbohydrate high that obliterates stress. Here’s the battleground: When carbohydrates are used in a dominant excessive manner over time harm occurs due to chronic toxicity.

Addiction occurs when the harm is ignored, and the behavior is continued.

Addiction is defined by a loss of control over the relationship with the substance.

Addicts develop an incredibly sophisticated mechanism of minimization, justification, trivialization, rationalization and denial to protect themselves from recognizing the harm and allowing themselves to perform the behavior despite the obviously harmful consequences

Carbohydrates are ubiquitously available – so why is everyone not fat?

What about people who are not fat? There is a vulnerability through lack of knowledge about abuse vs addiction and control vs abstinence. There is a psychopathology and psychophysiology to addiction that needs to be understood to help people overcome their addiction to carbs.

Who is vulnerable to addiction? The most commonplace source is with parenting. Obesity is not genetic but does cross generations.

There are different parenting styles consistent with dysfunctional emotive resolution

  • Permissive/Hedonistic: the fat family – Child never identifies a sense of self, simplistic coping skills. Rules are speed bumps without consequence, trivial goal setting, mistakes irrelevant, never need to learn.
  • Authoritarian: tough, tough, tough. Skinny mom fat kids. Distorted/eroded sense of self: never good enough, never allowed mistakes, never learns, told what to do. Strict rules with harsh consequences, ridiculously high expectations. Absorb emotional distress, triangulate to substance stress resolution pathways
  • Neglectful: No parenting guidance, false sense of self. Child has to create own rules, boundaries and habits

Modified authoritative styles are best to prevent addiction to carbs.

We need to look at how the addiction has developed. It all began with the ability to manufacture food (breast milk vs formula), the belief that fat consumption and physical activity equal obesity, and the indoctrinated misbelief that fat is bad and carbs are good.

There is no factual basis to support this hypothesis.

When food production became low fat, food tasted terrible but food makers introduced high fructose corn syrup, gluten fillers and carbs that replaced fat in our diet

Carbohydrates allow mass production through food processing with nutrient additives.

This has resulted in easy access and availability of the drug to everyone, including children and the

unrecognized powerful endorphin stimulatory effect of carbohydrates.

The reality is that obesity is not a weight or calorie problem. It is not a lack of physical activity problem. Diet and exercise programmes don’t work, except transiently.

Obesity is a substance abuse problem. And sugar is a drug, not a food.

It gives us glucose that is essential to life, but does not need to be consumed since it is produced internally (gluconeogenesis);

But the more you consumer sugar, the higher you get and the more you desire. Excessive carb consumption (frequency/quantity) results in excess calorie consumption and obesity. Research shows that 70-90% of an average obese individual’s total calorie consumption is carbohydrate. The result is both obesity AND malnutrition by reducing vital nutrients.

The greatest challenge to convention: thinking of carbohydrates as a toxic drug not a food; and seeing obese people as drug addicts not heavy humans.

Historically food has been defined as “healthy” based on the nutrients attached to the carbohydrate base; in addiction management it’s about the drug not the attachment (what I call the turd theory). If you dressed up dog poo and made it look good, would you eat it? Of course not.

If an obese person is an addict, the issue is that they have lost control of their relationship with their drug of choice. The issue is not whether it is healthy or not, the issue is that they cannot stop once they give themselves permission to start: abstinence model of all addiction management protocols

So, how can we provide the same nutrients without being attached to a carbohydrate load?

We need to understand the difference between true hunger and the need to eat, and that a snack is always an emotional event not a nutritional event (need to eat).

If children are snacking throughout the day, it means they are not getting the right nutrients to satisfy their hunger at mealtimes. They shouldn’t need to eat more than three times a day.

A bridge is a snack that does not contain calories to get us through the need to eat.

Portion control is just nonsense. We also shouldn’t use weight loss as a direct measure of success.

The prescription to beat obesity requires understanding that carbohydrates have a vital but harmful role. They keep us alive, but they are a poor source of nutrition, and a poor endorphin-releasing agent that keeps us sane-ish.

Success requires removal and replacement that involves:

Step 1 is about quality:

  • return to eating and drinking for nutritional value not endorphin value – food that used to be alive;
  • frequency: hunger versus the need to eat;

Step 2 is development of a diverse effort-based endorphin-releasing system

Step 3 is about handling relapse, what I call OAC – ownership, analysis, correction

Step 4: Building a strong sense of self and connectivity

I’ve developed a multidisciplinary cognitive behavioural therapy model for obesity.

  • The first contact goal: programme entry, new hope, not a diet.
  • Precare: that involves understanding family dynamics, engagement, capacity for change (preparation). The goal here is to build a relationship of trust never judgment: concept of change.
  • A “divorce” phase that may require medication, devices or surgery, and breaking habits and relationships (with snacks and carbs), and replacement – rules with consequence. The goal is rapid weight loss and , co-morbidity improvement.
  • Success phase – developing diverse new strategies for emotional emancipation. With action snacks and project development creating new habits and relationship with self . The goal is a new foundation to deal with life, and restoration of sense of self
  • Aftercare requires ongoing contact and reinforcement (maintenance). The goal is successful transformation of emotion management strategies – sense of self
  • Recapture – including use of pharmaceuticals, temporary devices and surgery.

We need more awareness of obesity as an addiction problem. I can help with surgery, but it is only a tool to achieve weight loss, and begin a journey.

If you look at a young girl, she is far more likely to die of obesity than breast cancer, yet less than one penny is raised against obesity for every $100 raised against breast cancer.

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