Epicurus: could he be the father of the modern behavioral approach to obesity?
Epicurus: Could it be the father of the modern behavioral approach to obesity?
Anastasios Papalazarou, MSc, PhD*
Corresponding author: Dr Anastasios Papalazarou, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.
Obesity continues to grow in epidemic proportions and is widely viewed as a chronic public health problem that poses a major financial burden on health care systems across the world . According to the latest data provided by WHO, 39% and 13% of adults over 18 were overweight and obese, respectively . The weight loss industry at the same time has also been growing exponentially. We are constantly being bombarded by diets, “magical” fat-melting formulations, “miraculously-painless” machines, drugs working as appetite suppressants and metabolism boosters, allegedly contributing to an effortless and rapid weight loss. Furthermore, individuals highly motivated and disciplined to lose weight manage to lose it in the initial stages but fail to maintain the weight loss in the long run. Successful weight loss maintenance appears to be affected by a complex interaction of environmental, biological and behavioral factors, however, behavioral modification approach is considered as the cornerstone of interventions for obesity management .
Behavioral modification has been identified as an important contributor to weight maintenance over the last couple of decades. The basic principle is mainly framed in the content of changing the way of thinking and feeling about food. It is well established that eating is not a process of surviving but a behavior that is strongly linked with emotions, rewards, external stimuli, that lead to food consumption for reasons other than hunger. Thus, adopting behavioral and cognitive based approaches to an individual’s eating habits is of vital importance in terms of obesity management.
This is where Greek philosophy enters the scene. Epicurus (341-270 BC), is considered amongst the greatest philosophers in the world and according to his theories, the purpose of life was how to achieve happiness and tranquility. Following in the footsteps of the majority of Greek philosophers in the post-Socratic period, he stated that our behaviors should not be based on emotions, but only on direct observation and logic. Epicurus’ philosophy suggests a pathway of thinking, in which our choices should be based on mindful and conscious principles. This is the approach behavioral modification as a treatment of obesity also aims to adopt. I would like to take this opportunity to share with you some of his views and how they fit into the modern approach of obesity.
Reinforcement pathology and obesity
Reinforcement pathology occurs when excessive motivation to eat meets low impulse control of food . This situation has been linked to obesity by many studies [5,6]. Food reinforcing defined as level of willingness to work for food and inability for delayed gratification defined as choice of smaller immediate rewards instead of larger delayed ones, are the main constituents for reinforcement pathology. The combination eventually leads to choices that contribute to increased energy intake. In a recent study of siblings’ behavior, it was shown that food reinforcement and inability to delayed gratification are primary behavioral processes contributing to the siblings’ discordance in weight . Epicurus, distinguishes between two different types of pleasure: “moving” pleasure (kata kinisi) and “static” pleasure (katastimatiki) . "Moving" pleasures are predominantly temporary pleasures and occur when one is in the process of satisfying a desire immediately and involve an active titillation of the senses. “Static” pleasures, on the other hand, are a longer-lasting state of balance contributing to the virtue of tranquility (ataraxia). The ability of refraining from getting something smaller now for the pleasure of being able to have something bigger or better later, contributes to a more substantial and long-term balance, as the maintenance of a healthy body weight and well-being is. Epicurus, tens of centuries ago, proposed that "things that cause excessive pleasure now, can prove to be detrimental in the future," as well as "by avoiding doing things now, you may not get the pleasure you would like, but in the future, you may do things that bring more pleasure." In other words, he believed that we should not be striving for temporary, short term pleasures, because we are increasing the likelihood of damaging our mental health in the long term or even losing out on even greater happiness. We should, therefore, weigh our decision before giving in to the temporary pleasure . A frequent example he used was wine, for which drinking a small amount can bring on an extremely pleasant state, but yielding to greater quantities can have detrimental long-term health effects
Flexible vs rigid control of eating
Flexible dietary control may be a more beneficial approach than rigid dietary control for managing disordered eating . Flexible control promotes a mindful way of eating and predicts better weight loss, as opposed to rigid control which has been associated with dichotomous thinking style around food consumption, resulting in the perpetuation of an eating disorder state . In other words, someone has better chances in controlling his weight effectively by adopting a more flexible diet, rather than a strict and depriving one. One could consume everything including desert as long as he/she complies with moderation. That is precisely why diets should be individualized and inclusive, considering each person’s needs and wishes so that they are feasible to carry out. Epicurus believed in the same balanced premise too, thousands of years ago. He proposed that our search for pleasure is legitimate and we must pursue it, but he was warning against overindulgence because it often leads to pain .
Goal setting represents another tool in the armamentarium of modifying behavior as a treatment of obesity. It involves setting targets in terms of body weight, level of physical activity and dietary habits. This technique is encouraged to be incorporated to lifestyle modification programs and it can be a powerful and effective method in changing behavior and attitude towards food. Great expectations reduce the chances of success and often create disappointment, so targets should be realistic, measurable and feasible . Similarly, Epicurus considered that great desires and unrealistic aspirations can often lead to failure, decrease compliance and increase the chance of dropping out of programs and ultimately prevent us from achieving happiness. The phrase "Whoever is not satisfied with a few, will not be satisfied with anything" is famously attributed to him. Realistic desires can help us achieve the “static” pleasure state .
External stimulus – social support
Another important element in the behavioral approach to treatment of obesity is the adaptation of the external environment, like our family, friends, colleagues. It has been established that social support has a direct positive effect on weight management. People living in a supportive environment do better than those who are constantly exposed to food temptations. Social support reinforces the individual’s ability to effectively carried out planned actions and provides a fundamental assistance in overcoming a variety of difficult barriers for modifying behaviors . Epicurus was a firm believer in the support of the external environment and especially by friends, in helping us reach the "static” pleasure state. He would frequently, praise the value of friendship in his lectures and speeches and considered good friends supreme good. He would state that "it doesn’t matter what you eat, but with whom you eat it". Good friends can advise, help or even correct a bad decision. Consequently, Epicurus argued that the creation of a secure external environment makes a decisive contribution to making the right choices in life .
Self-determination refers to our natural and intrinsic behavioral tendencies and is considered an element of crucial importance in the behavioral therapy of maintenance of the ideal weight. It is linked to the individual’s ability to regulate regulating food intake consciously . Specifically, the individual makes a conscious decision about which food to consume or avoid, according to personal goals. Self-determination reflects one’s autonomy defined as the need of individuals to make their own personal decisions and not use someone else’s knowledge as a ‘guide’.
A recent study showed that the individual’s internal belief to control his/her life and keep the ownership of his/her choices, also known as internal locus of control, has been associated with improved weight loss and better long-term maintenance outcomes . Along the same wavelength, millennia ago, Epicurus suggested that we should critically appraise whether or not to pursue temporary pleasures in terms of achieving long-term happiness. Every decision should be conscious and made based on our own beliefs. We should take into account that even the perception of pain can be beneficial, if it will eventually lead us to a good outcome later; short term pain for long term gain. For instance, the act of depriving ourselves of a desirable treat could eventually have a positive effect in our long-term desire for achievement of a healthy weight and overall, well-being. Epicurus introduced for the first time the term “ofelimismos” (taking advantage of a current action in the future) stressing the need of getting the ownership of a behavior now that ensures access to happiness in the long run. Besides, he characterizes “delusional” pleasure the one that gives you temporarily joy now, but does nοt reassures static pleasure.
The philosophic direction of Epicurus towards happiness focuses on the emergence of the conscious achievement of physical and mental health and ultimately, bliss. This will happen when the individual manages to make informed decisions, avoid temporary pleasures and set goals that aim in long-term gain to achieve long-term tranquility. Considering that mindfulness is the cornerstone of the modern approach to obesity and the fact that Epicurus’s theory embraces similar principles thousands of years ago, he could reasonably be considered the father of modern behavioral treatment of obesity.
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