The Biology
of Eating
and Weight
As therapists, we watch as theories about human dysfunction come and go. For a long time, conditions such as alcoholism and drug addiction were viewed and treated according to either a moral or a medical disease model. The understanding and treatment of eating and weight problems have followed along this path as well.
The moral approach maintained that folks who drank in excess or abused drugs lacked willpower and self-control and needed to conquer their impulses (and demons) in order to live a happy, healthy, abstinent life. People were considered to be at the mercy of their addictions until and unless they remained ever vigilant about staying clean and sober. Alcoholics and addicts had to be motivated, keep their eye on the prize, and devote their lives to being in recovery.
The medical model swung public opinion in the opposite direction with its assumption that drug addiction and alcoholism were “diseases” of the body, not the mind. Drunks were thrown into jail to dry out, as if purging alcohol from their cells would ensure their body’s proper functioning from then on. Addicts were shut away to kick their habits in the hopes that pains of withdrawal would be enough to keep them clean. In these scenarios, we can almost picture a demon rising up from a body and vanishing into thin air, leaving behind a purified and healthy soul.
A subsequent school of thought maintained that addictions were caused by family dysfunction, just as schizophrenia and autism were thought to be the result of inadequate parenting. Disenable the enablers, help children separate appropriately from their families, get them talking in therapy, and their substance abuse problems would be resolved. There was also a time when we believed that recovery would grow out of being educated about substance abuse: See how you’re hurting yourself, tell yourself you’re worthy of sobriety and you won’t have that drink, share your shame and remorse, buddy up, and your desire for drink or drugs will gradually leave you.
Although food fails to fit neatly into the category of addiction and disordered eating is not a disease per se, there are many similarities in the way food and substance abuse problems have been viewed and treated over the decades. Fortunately, science is acquiring knowledge by leaps and bounds about the underlying roots of many diseases and conditions, and we now understand that there are biological causes for many addictions, along with social and cultural counterparts.
Nowhere is this truer than in the field of eating and weight. We have already touched on some dysfunctional family dynamics that occur in childhood that may generate and promote eating problems (low self-esteem leading to poor self-image and self-care, excessive restriction producing feelings of deprivation, ineffective emotional management spawning emotional eating, the regular use of treats as reward teaching misuse of food, and nonnutritional family eating contributing to ignorance about a healthy diet). Although parental attitudes—and those of other relatives who are involved in child-rearing—toward food and weight are a large contributor to a client’s ability to eat “normally” and maintain a comfortable weight, socialization is only part of the story.
The rest is what we come into the world with—that is, our genetic makeup. In fact, a recent controversial theory maintains that 70% of our weight may be genetically determined (Kolata, 2007). You may be surprised—and dismayed—to learn that so much of a client’s (or your own) weight is fixed. Although many clients respond with disappointment, frustration, anger, and hopelessness to the realization that there is a limited amount they can do to reduce their weight, other clients feel validated and relieved. This statistic relieves the huge burden of believing they have not tried hard enough and do not have the gumption to stay slim. These folks have struggled unsuccessfully their whole lives to achieve or maintain a target weight (or weight range), and have never understood what they were doing wrong when the pounds crept back on. Instead of blaming their biology, they faulted their lack of willpower or motivation.
Only in the second half of the last century did science come to realize that the subject of eating and weight is about as complex as they come (right up there with addictions). The topic is complicated by the fact that, although we can stop drinking and taking drugs and enjoy life, we cannot stop eating or we will die. The most important point to remember when talking with clients about eating or weight is that because all of us start off at a different place in terms of biology, we cannot all end up at the finish line together. This truth is what diet proponents—and doctors, too often—do not say. Perhaps they fear that clients will never try to shed pounds if they realize that there are limits to how low their weight can go. Or perhaps, like therapists, they simply wish that they and their clients had more power to reach life-enhancing goals.
There are a number of ways that biology impacts the eating styles and habits of clients and their ability to achieve a particular weight. Although each theory about weight that comes along does not apply to every client, it is incumbent upon us as treaters to become relatively conversant with what science has to say about appetite and weight management.
Reflections for Therapist
1. What do you believe causes overeating and being overweight?
2. How does the idea that 50–70% of weight is genetically determined affect your thinking about helping clients change unhealthy eating patterns?
3. How could you present information about the biology of appetite and weight to clients so that they can understand and use it (handouts, book suggestions, etc.)?
Metabolism
Metabolism is the process by which living things turn food into energy. This energy is commonly measured in calories (the quantity of heat needed to raise by 1°C the temperature of 1 gram of water). This energy is then used to build new cells and tissues, provide heat, and produce fuel for physical activity.
To understand the concept of metabolism, think of the relationship of calories in and energy out. Of course, human metabolism is far more complex than such a simple equation, which is why some people do not consume a great many calories and still grow fat, and others appear to eat nonstop and stay trim. This difference is due to variations in individual physiology that influence how much energy a person consumes, expends, and stores as fat.
Animal and human studies over the past several decades have made great strides in understanding weight regulation, but it seems that every answer raises new questions. There is not even a consensus on the workings of regulating weight. Some research points to a popular explanation called set point theory (SPT), which holds that our bodies are preprogrammed genetically to maintain a certain weight and that we cannot remain for long either above or below this limit. SPT calls to mind a thermostat that keeps temperature steady within a range—switching off when the air reaches specific maximum and minimum points. SPT states that when the body’s “fat-o-stat” reaches its lowest setting due to voluntary or enforced food reduction, it automatically slows down its metabolic rate to conserve calories. These conserved calories are then stored as fat.
In terms of evolution, this process is highly efficient and human friendly; it is how our species has survived during famine and times of extreme caloric restriction. Some researchers maintain that the human body’s regulatory mechanisms may even be inclined toward conserving calories and preserving fat rather than eliminating it. Remember, our bodies have been hardwired through millennia for survival and our species has flourished because metabolism has been adaptive to changing food environments. In lean times, survival of the fittest meant survival of the fattest.
SPT is one way of explaining why many heavy people fail to reach or maintain a target weight: Due to dieting, their body’s metabolism slows down, storing more fat and making it virtually impossible, no matter how little they eat, for their weight to dip lower. Additionally, researchers have found that once restriction ends, at least in animal studies, the organism experiences increased hunger and eats more until its prerestriction weight is reattained. These studies underscore an important point to remember in treating overweight clients—willpower cannot override biology. SPT also accounts for how people who seem to be able to eat large amounts of food (or high-calorie foods) do not gain weight. When caloric intake exceeds their high-end set point, their bodies actually increase metabolism to burn off the extra calories so that they are not converted into stored fat (pounds). Unfair, but that is how some bodies work.
Research suggests that individual set points are influenced by many factors, including genetics, age (set points tend to increase with age), lifestyle (sedentary versus active), diet, smoking, and exercise (regular aerobics can lower set points). Challengers to this theory maintain that set point is not as fixed as previously assumed; during dieting and weight loss, metabolism may slow down, but once food consumption returns to normal, metabolism, too, returns to prerestriction levels. Challenges also suggest that physical activity plays a larger than heretofore thought role in modifying set points, which means that people can actually reduce their set point by increasing exercise.
Body Structure/Type
Not just metabolism, but body and bone structure influence size and shape. A person who is 6′2″ and weighs 220 pounds will look very different from another person of the same weight who is only 5′4″. Moreover, some folks are broad-shouldered and thick-boned (think football players), while others are small-boned and compact (think jockeys), while yet others are lithe and leggy (think dancers). Height and body structure are strongly influenced by ethnicity as well: the Japanese body type is, on the whole, different from that of the Mexican or Scandinavian. One look at a multigenerational family photo will show most people what they are likely to look like in years to come.
We all work within our limits—short, medium, or tall, small- or large- or long-boned; long-waisted or legged; petite, stocky, or athletic—and it is vital to remember that, for the most part (and except through surgery), we cannot do much to change our body build.
Appetite Regulation
Although the regulation of appetite is strongly influenced by metabolism, the equation of calories in and energy out is only one facet of the story. Most of what we know about appetite regulation comes from animal (generally rat) studies, but appears to pertain to humans as well. Moreover, because researchers often work with very different aspects of the appetite puzzle, at this point it is difficult to understand how all the parts fit together. In fact, it may be decades before scientific understanding is complete and comprehensive enough to use the information gleaned from animal studies to apply to human appetite in any meaningful way.
Appetite and weight are regulated by the brain through chemicals that bring it information about the body’s energy and fuel needs. The brain acts like a store’s computer by processing data on whatever inventory is available and what stock is needed by customers at any given moment. Just as a store owner may increase or decrease inventory according to customer demand, the brain regulates stores of fat in relation to the body’s energy needs. When more energy is needed, more food needs to be taken in, and the brain stimulates appetite. When no more energy is needed and enough fat is available, the brain sends out messages of satiation. The brain may also lower or raise the body’s overall energy needs according to what is in its fat stores (that is, it burns more when there is plenty of fat and less when stores are reduced). It can even reallocate energy away from nonessential body systems so that energy is conserved for survival.
The hypothalamus is the region of the brain best known for energy-related activities such as sensing hunger and satiation. What we call appetite regulation happens during the hypothalamus’s ongoing assessment of chemical comings and goings. At its simplest, the main components of this chemical information system are ghrelin, which is produced in the stomach and signals that the stomach is ready for a meal, and hormones such as leptin and insulin, which act on cell receptors to influence hunger. Leptin and insulin also have another role on this information grid: Along with glucose and peptides PYY (peptide tyrosine tyrosine) and cholecystokinin (CCK), they promote satiety while suppressing appetite.
The above description of hunger and satiation is rudimentary. In reality, there are many more chemicals involved in triggering and stopping eating, and the way they work is both subtle and complex. When all these chemicals exist in the correct balance and proportion and do their job well, we receive just the right amount of food to maintain a healthy weight for our lifestyle. However, when these chemicals are lacking or out of balance and fail to do their job, appetite becomes disregulated and we have difficulty managing weight.
Our bodies establish levels of these chemicals in part by what is passed along to us in our genetic makeup. If we are fortunate, we get a balanced complement of appetite regulators; if not, an imbalance may generate weight problems. Regulation of chemicals like ghrelin and leptin, however, is not the only way that genes play a part in determining weight. Through scans of genomes (the complete data about heredity that is encoded in an organism’s DNA), scientists have found certain gene mutations that are linked to obesity. The discovery of these genes illustrates that genetics can predetermine our tendency toward obesity or slimness and sets us up for weight management success or failure. It is unclear exactly how these genes interact with the environment to generate a specific weight or range, but it is generally accepted that genes strongly influence body weight through mechanisms not yet fully understood.
Neurotransmitters
Most of us are familiar with the terms neurotransmitters and neuromodulators, especially if we treat clients who take medication for anxiety or depression. These are chemicals that relay, amplify, and modulate electrical signals between a neuron and another cell, biochemical agents that transmit information from one cell to another to regulate mood and affect. Clinicians may be most familiar with the neuromodulator serotonin, which exerts a soothing influence on unpleasant emotions. Other frequently mentioned chemicals are the neuromodulators dopamine, which regulates bursts of intense concentration and feelings of euphoria; norepinephrine, which causes generalized, sustained alertness; and the neurotransmitter gamma-aminobutyric acid (GABA), which promotes relaxation.
In order to understand the connection between appetite regulation and neurotransmitters, we have to step back and examine how the brain works in terms of pleasure and reward. Sigmund Freud may have erred in many of his theories, but he was spot on when he posited that human beings move toward pleasure and away from pain. Now science is able to identity the specific brain circuitry that registers pleasure and is stimulated by, among other activities, eating.
Food is meant to taste good and bring us pleasure or we would not eat it or enough of it to stay alive. It makes sense that the brain would register delight in food and that this pleasant feeling would be recalled and associated with what we have ingested. Further, it makes sense that foods that would contribute most to our survival would be high in fat, sugar, and calories (leading to fat storage) so that we would be attracted to them and eat more of them.
One way that pleasure registers in the brain is through the release of dopamine. When we eat a chocolate-glazed doughnut, the subsequent pleasurable burst of dopamine we feel makes it likely that we will reach for this same food again and again. Because of their chemical makeup, carbohydrates raise serotonin levels naturally and act as natural tranquilizers. In fact, some experts think that individuals who crave carbohydrates have a low level of serotonin and turn to carb-rich foods to help regulate their moods.
Food Addictions
It is interesting to ponder whether food could be said to have addictive properties—through natural or chemically added ingredients—or if compulsive eaters merely feel as if they are addicted. Although there are adherents on both side of this debate, the scientific jury is still out. Traditionally three criteria have been used to establish addiction: (a) increased tolerance of a substance demands that more of it be ingested to achieve a “high”; (b) psychological cravings for a substance must be in evidence; and (c) physiological withdrawal symptoms must be felt in the absence of a substance.
Research has shown that eating certain foods can increase dopamine levels in the brain, but this elevation is not enough to prove that food is addictive. It only suggests that specific foods register in the reward circuitry of the brain in much the same way as alcohol and some drugs. There also is evidence that rats appear to become addicted to sugar water, but it is not clear that the problem is not one of psychological dependence rather than addiction, there being such a thin line between the two.
The problem with using the addiction model with food is knowing how to respond even if physical dependence exists. Identifying a substance as addictive is helpful when users have a choice regarding its usage, as with drugs and alcohol. But to tell clients to completely abstain from eating carbohydrates, the foods that are often viewed as addictive, is another story. First of all, we need to eat some carbohydrates to remain healthy, and second, shunning fat and sugar, the “addictive” components of carbohydrates, most often leads to deprivation and rebound eating.
Food Allergies
Related to the topic of food addiction is food allergies. Typical food allergies include wheat (gluten), soy, dairy (milk), eggs, peanuts, and shellfish.
According to the Food Allergy and Anaphylaxis Network, about 4% of Americans—more than 12 million—have food allergies characterized by an adverse reaction triggered by the immune system (“Food Allergy Facts and Statistics,” available from the Food Allergy and Anaphylaxis Network Web site). In a bona fide food allergy, the immune system mistakenly identifies a specific food or a component of a food as a harmful substance, causing cells to make antibodies to fight the culprit food or food component (the allergen). When an individual eats even the smallest amount of that food, the antibodies sense it and signal the immune system to release histamine and other chemicals into the bloodstream.
Symptoms of a food allergy usually develop within an hour after eating the offending food and may include hives, itching, eczema; swelling of the lips, face, tongue, and throat, or other body parts; wheezing, nasal congestion, or trouble breathing; abdominal pain, diarrhea, or nausea; and vomiting, dizziness, light-headedness, or fainting. Other reactions do not involve the immune system (and consequent release of histamine) and are not allergies but food intolerances. Because they may cause many of the same symptoms as allergies—nausea, vomiting, cramping, and diarrhea—people often confuse the two. Food intolerances may make an individual uncomfortable, but they are not valid allergic reactions. Common allergens are milk, eggs, peanuts, tree nut, seafood, shellfish, soy, and wheat.
Clients often insist that they have a food allergy because they “cannot” stop eating a certain food. Offending foods are often carbohydrates that are high in sugar and/or fat. Current research suggests that people who eat sugar and crave more of it do not have an allergy to sugar, in spite of the fact that eating it may trigger a craving for more. The only way clients will know if they have a food allergy is to be tested by a health professional.
Asking clients about their reaction to certain foods will help them start making a connection between ingestion and their physical response. It is important that clinicians stay neutral about the veracity of food allergies and addictions and that we encourage clients to seek medical testing and advice to get answers. Some clients will insist that they have food allergies, while others may have never considered the possibility. Our role is to aid clients in getting to the truth. More information about how to assess and address food allergies and addictions can be found in upcoming chapters.
To help the client identify food allergies, ask:
1. Are there foods you think you might be allergic to?
2. What physical reactions do you have when you eat these foods?
3. Have you talked with your doctor about these reactions?
4. Would you consider getting tested to find out if these are true allergies?
5. If you don’t have an allergy to foods you overeat, why else might you have trouble with them?
Weight Loss Through Diet Programs and Plans
Initial theories about weight loss were based on the simple premise of eating less. They were made slightly more complex by adding the instruction to exercise more, based on trying to balance the equation of calories in and energy out. However, we now know that there is much more to weight management than simply counting calories. Science has proven that what we eat is as important as how much we eat.
Although various weight-loss plans and programs abound, the basic message of healthy eating remains virtually the same as it always has been: Eat smaller portions composed mainly of fruits, vegetables, and whole grains (except if you are allergic), choose unprocessed rather than processed foods, and take it easy with edibles that are high in salt, fat, sugar, and artificial additives.
To explore and critique even the most popular diets of the last decade is beyond the scope of this book, but it is vital that clinicians have an understanding of what clients with eating and/or weight problems go through in order to avoid getting fat, to lose weight, or to keep it off. For some clients, dieting takes over their life, consuming most of their attention and energy. It dictates their social life and has the characteristics of other addictions. For others, dieting is an on-again-off-again romance: Weight is lost and regained, body fat is subtracted and added. Some dieters stick to one plan alone and return to it over and over. Others go from plan to plan in the hopes of finding the magic cure. Dieters may be on a formal plan, become members of a program and attend weekly meetings, or merely count calories or fat grams in the comfort of their kitchen.
In terms of approaches, low-fat diets have long been popular and brought on the advent of hundreds of low- or no-fat products that fill our supermarket shelves. Unfortunately, while the idea seemed to make sense, it turns out that people have a very difficult time sticking to reduced-fat diets. Moreover, fat restriction and physical and emotional deprivation often cause rebound overeating or binge eating high-fat foods.
Some weight-loss plans are based on sound medical and nutritional research, while others have little or no scientific underpinnings. Moreover, diets that were based on what was solid evidence at one time often fall out of favor when science produces new or challenging information. Although quite a number of diet gurus have done extensive research to make their cases and appear to sincerely want to help people stay fit and healthy, it is sadly obvious that other diet proponents’ claims are ludicrous and that these pseudo-experts are only taking advantage of gullible people desperate to be thinner.
There is no end to weight-loss approaches. There are diets that say to eat little or nothing from entire food categories and others that promote eating from only one or two groups. There are plans based on personality, activity level, lifestyle, blood type, or biochemistry as well as ones that must be followed in rigid phases. Some programs require purchasing prepackaged foods or adding specific supplements to a food program. Nowadays, most well-publicized diets include purchasing a book and following what it says religiously.
There is nothing to say that a diet must even include real food. Shakes, which purportedly provide the dieter with a complete nutritional package, may take the place of meals or act as a replacement for a meal or two. Fasting, which involves taking in nutrients through prepackaged drinks or supplements, may function as a way to jump- start a diet or be used as an approach of last resort.
Because overeating has been viewed similarly to overdoing it with alcohol or drugs, it is not surprising that the most popular treatment model is based on substance abuse recovery, that of individual counseling and/or group support. Weight Watchers, Jenny Craig, LA Weight Loss, and Overeaters Anonymous all have combinations of weigh-ins, counseling, and member-to-member support. These programs include any or all of the following: controlled food intake through behavioral dos and don’ts, abstinence from certain foods, counting calories or fat grams, weighing food, keeping a food journal, reducing portion size, raising awareness about eating behaviors, changing one’s attitude toward food, and daily encounters with the scale.
Nowadays, theories about weight loss are being churned out and overturned at breakneck speed, and it seems that the more scientists learn about eating and weight, the better they understand that there is no one-size-fits-all approach to taking and keeping weight off. Appetite and body size are highly idiosyncratic, and programs that successfully promote maintaining a healthy, comfortable weight must not only be realistic and doable, but need to take into account an individual’s culture, biology, genetics, gender, age, and lifestyle.
To explore the client’s diet history, ask:
1. Could you describe the diets you’ve been on, including how you felt being on them, how much weight you lost, and how long you were able to keep it off?
2. What was the hardest thing about staying on a diet?
3. What was the thing you liked most about dieting?
4. Do you understand how dieting can cause rebound eating and make you fat?
5. Even if you don’t diet, are there any aspects of dieting that you could use in achieving and maintaining a healthy weight?
Hormones and Eating/Weight
There are a number of hormonal conditions and diseases of which clinicians need to be aware because they may cause weight gain. If you suspect that a client has a hormonal imbalance, you can review and discuss symptoms together and suggest she talk with her doctor. Some clients may be relieved that there is a medical problem causing weight gain or preventing weight loss, but remember that many clients will be frightened at the thought that there is some “wrong” with them, so tread lightly.
There is the possibility (suggested by research, but unproven) that weight and body fat increase during the decade following menopause. You and your client might think in this direction if she tells you that she has been slim her entire life and only put on weight since she stopped menstruating. In this case, she will benefit from having her hormones tested to see if an imbalance may be causing increased weight.
Hypothyroidism, a condition in which the thyroid gland produces too little hormone, slows down metabolism and may cause weight gain. Symptoms may include coarse and thinning hair, dry skin, brittle nails, a yellowish tint to the skin, slow body movements, cold skin, inability to tolerate cold, feeling tired or weak, memory or concentration problems, constipation, heavy or irregular menstrual periods that may last longer than 5 to 7 days, goiter (enlarged thyroid gland), swelling of the arms, hands, legs, feet, face (particularly around the eyes), hoarseness, and muscle aches and cramps (“Hypothyroidism: Topic Overview,” available from the WebMD Web site).
Cushing’s syndrome, when the adrenal glands produce too much cortisol, leads to fat buildup in specific areas of the body. Symptoms may include a round or puffy (“moon”) face, increased fat around the neck and upper back, or enlarged waistline; thin, fragile skin that bruises easily, slow-healing wounds, ruddy complexion, purplish stretch marks across the body; irritability, anxiety, insomnia, and sadness; backache, broken bones, loss of muscle tone or strength; menstrual irregularity, facial hair growth in women, erection problems in men, loss of sex drive; and hypertension (“Cushing’s Syndrome: Symtoms,” WebMD Web site).
Polycystic ovary syndrome (PCOS) is the result of a hormonal imbalance that produces an increase in fat cells. Symptoms include fertility and menstrual problems, acne, weight gain or trouble losing weight, extra facial and body hair or thinning scalp hair. Metabolic syndrome (also known as syndrome X) is a cluster of health conditions related to insulin resistance and metabolism disregulation. Symptoms include obesity, high blood pressure, high cholesterol levels, and resistance to insulin. PCOS, getting older, lack of exercise, and abdominal obesity are also associated with Syndrome X (“Polysystic Ovary Syndrome–symptoms,” WebMD Web site).
Medications and Eating/Weight
Unfortunately, various prescriptions drugs—including oral contraceptives, steroids or hormone replacement therapy, and diabetes, antidepressants, antiseizure, migraine and blood pressure drugs—may cause weight gain in certain individuals, although studies do not confirm that this is true across the board. Because the use of these drugs is on the upswing and it is likely that many clients are on one or more of them, it is crucial for clinicians to help them assess whether medications are affecting eating or weight. Clinicians also need to be on the lookout for medications that cause weight loss. Because some prescription drugs react idiosyncratically, they may generate weight gain in one individual while causing weight loss in another.
Generally the potential for weight gain (or loss) is written on the printed material that accompanies prescription medications. However, not every reported side effect will be listed. Weight-related information may be available in a Physician’s Desk Reference (PDR) or from a client’s doctor, pharmacist, or the company that manufactured the medication. In cases where clients’ self-report is reliable, it is possible that weight gain is a by-product of a medication they are taking, although it is not listed as such. Clients should always be encouraged to discuss problems with medication, and certainly the discontinuation of them, with their prescribers.
Other Influences on Eating and Weight
As if heredity and biochemistry are not enough to consider, there are other factors that may contribute to how people eat and how much they weigh. If a client is under substantial stress at home or on the job, she may be reaching for food in an attempt to alleviate stress. Lack of sleep also may increase the production of appetite-stimulating hormones while decreasing the output of hormones that signal satiation.
To assess causes and contributors
to eating and weight problems, ask:
1. When was your last medical checkup that included hormone testing?
2. Have you talked with your doctor about the possibility that you might have an underlying hormonal problem that is affecting your eating or weight?
3. How much sleep do you get at night? Do you know that not getting enough sleep might affect your ability to lose weight? How is your sleeping?
4. Do you understand that a substantial amount of stress may be causing you to reach for food? Do you have a stressful life?
5. Have you thought about other ways to deal with stress or ways to reduce your stress level?
There are theories asserting that the escalating weight of Americans is due to everything from pollution to air-conditioning and heating. Toxic air and chemicals may alter our hormones, while indoor climate control keeps our body at a steady temperature so that it need not “work” to heat up or cool down. Ironically, even the fact that fewer Americans smoke than ever before may be a factor in increasing obesity rates because reduced nicotine intake has been correlated to increased eating. It may even be true that obese people are more fertile than lean ones, which would lead to there being more obese people in every generation.
In decades to come, as scientific research focuses more closely on appetite and weight, we will likely learn that both are influenced by a combination of factors that include heredity, environment, socialization, and biochemistry. For now, it is vital that clinicians help clients understand that there is a strong biological component governing appetite and predicting weight. It is our job to help clients assess whether they have underlying illnesses and conditions that contribute to eating and weight problems, and move them toward getting testing and treatment. Clients should not make the mistake of holding themselves 100% accountable for their weight struggles, but must put their energy into doing whatever is possible to become healthy and fit.