When Weight Is the Symptom

Recently, I watched a YouTube interview in which Oprah Winfrey spoke with Dr. Ania Jastreboff about weight and obesity. The discussion was particularly compelling given Dr. Jastreboff's expertise in the field. A physician-scientist and endocrinologist at Yale School of Medicine, she serves as the founding director of Yale's Obesity Research Center and was the lead author of SURMOUNT-1, the pivotal tirzepatide trial published in the New England Journal of Medicine. Her research has focused on the neurobiology of appetite for more than two decades, and she recently co-authored the book Enough with Oprah Winfrey.

In the video, Dr. Jastreboff argued that obesity is best understood as a neuroendocrine disease rather than a failure of willpower. When we eat, the body releases hormones that communicate with the brain to regulate energy balance and determine how much fat is stored. However, in today’s environment, with ultra-processed foods, chronic stress, inadequate sleep, and increasingly sedentary lifestyles, this regulatory system can become disrupted. As a result, the body begins to defend a higher level of body fat than is biologically healthy. In many ways, the body is responding exactly as it evolved to do, but within an environment that human evolution never anticipated.

She goes on to explain why medications can succeed where willpower alone often falls short. These treatments act on the same brain receptors involved in appetite regulation and reward processing, helping to recalibrate the body’s defended weight set point. As a result, hunger is reduced, cravings become more manageable, and the persistent mental preoccupation with food, often described by patients as “food noise”, begins to fade. For many individuals, the constant internal dialogue surrounding food can quiet significantly, making weight loss far more achievable. The weight is the symptom, she says, the way high blood sugar is the symptom and diabetes the disease.

I find that point particularly compelling, and like Dr. Jastreboff, I see weight as a symptom rather than the problem itself. While her work has deepened our understanding of the biological mechanisms that influence weight, I wondered whether there is also room to consider the psychological factors that shape eating behavior.

Dr. Jastreboff describes obesity as the result of multiple interacting forces: biology, genetics, hormones, the brain, and the environment. When she speaks about the environment, she is often referring to what researchers call an obesogenic environment. An obesogenic environment is an environment that makes it easy to gain weight and difficult to maintain a healthy one. Yet environment is a broader concept than the one typically discussed in obesity research. It encompasses not only the physical conditions in which we live but also the experiences that shape us throughout our lives. A chaotic childhood, relationships, loss, adversity, chronic stress, trauma, and major life transitions all leave their mark on the brain and body. The environment caused the wound, the wound changed the brain, and the changed brain is the one now regulating appetite, reward, and weight.

Enter the landscape into which GLP-1 medications arrived. For many individuals, the story of weight gain involved more than biology alone, but when a powerful medication that quieted appetite became available, the pounds came off. The biology got treated, beautifully. The psychological work, in too many cases, still was not assigned, still was not required, still was not offered. Perhaps that helps explain why, after discontinuing GLP-1 medications, patients typically regain about 60% to two-thirds of the weight they lost within a year, with many eventually returning close to their pre-treatment weight.

The pattern many of us on the psychological side are beginning to observe is that, for some individuals, the weight comes off but the distress remains. The preoccupation with food may dissipate, yet the underlying anxiety, shame, or emotional pain can persist, sometimes resurfacing in new ways. Addiction medicine has a name for this phenomenon: behavioral substitution. The behavior changes, but the need driving it remains.

I wouldn’t dispute that manipulating brain chemistry can change behavior; the real question is whether that tells us what caused the behavior in the first place. SSRIs can reduce anxiety, benzodiazepines can reduce fear, and stimulants can improve attention, but their effectiveness does not prove that anxiety, fear, or attention difficulties are purely biological diseases. Likewise, the fact that GLP-1 drugs reduce appetite and food-related thoughts does not establish that obesity is primarily a disorder of appetite regulation; it only shows that appetite regulation is one point of intervention.

Similarly, the claim that “psychology acts through biology” is technically true but can become unhelpful if taken too far. Of course all thoughts, habits, beliefs, emotions, and social experiences occur in brains, but if every psychological explanation is redefined as biological simply because it has a neural substrate, then meaningful distinctions disappear. Emotional eating becomes biology, trauma becomes biology, food marketing becomes biology, and cultural norms become biology. At that point, the biological model risks becoming unfalsifiable because it can absorb virtually any observation without being challenged. The strongest challenge to a primarily biological account is that obesity rates have risen dramatically over the past several decades while human genetics have remained essentially unchanged.

Biology provides answers to one set of questions, while biography speaks to another, not because science lacks explanatory power, but because it is asking something fundamentally different. Here is what no medication can do: it cannot make you wake up as someone with a totally different past. Your history is still your history, your pain is still your pain. If you have spent years carrying the effects of trauma, adversity, or emotional damage , changing the body does not automatically heal those wounds. Medication may alter weight, but it cannot, on its own, undo the beliefs, fears, and coping strategies that emerged as adaptations to difficult life experiences, they do not disappear when the body changes. The inner critic was never located in the body, it lives in the mind, and the mind needs its own kind of treatment.

While this perspective diverges in some respects from Dr. Jastreboff's view, it is not intended to dismiss her insights. Her work has helped countless people reclaim their lives, and its contributions to the field remain significant. Rather, this perspective seeks to explore questions that may warrant further consideration and discussion. What I am saying is that “obesity is a disease” and “the eating behavior is also psychological” are not competing claims, they are two layers of the same truth, and they need two kinds of expertise sitting at the same table. So I think the questions worth adding to the conversation are the ones the scale cannot answer. Not instead of is the medication working? but alongside it: working toward what, and for whom? Not instead of what does this person weigh now? but alongside it: what does this person believe about themselves, and has any of it changed?

We have learned to screen for blood sugar before we prescribe. We rarely screen for the trauma, the depression, the anxiety, the emotional drivers that made food a coping mechanism in the first place. As a system, we have handed out prescriptions far more readily than we have ever handed out referrals for therapy. Pairing the two, the pharmacology and the psychological support that should travel with it, is not a correction of the science, it is the natural completion of it.

Here is a link for those of you who would like to view the full Oprah/ Dr. Jastreboff interview: