From the same newspaper (and author, Gina Kolata) who told you exercise has no impact on bone health comes a new claim: obesity is the result of environment and genetics, your personal choices don’t matter, and the only effective treatment for extreme obesity is bariatric surgery.
 
The New York Times is hardly alone. The last few years have seen a flood of videos and articles suggesting that body weight is largely or entirely out of your control. These come packaged with the message to accept everyone whatever their weight, avoid disordered eating, and fight discrimination. Although the aims are noble, the claims behind them aren’t, and the evidence simply isn’t on their side. 
 

All Diets Fail, So Why Even Bother? 

As Ms. Kolata and others are quick to point out, most diets fail. 97% of obese people in one survey claimed they had attempted to diet, often multiple times, and failed. This is consistent with most clinical studies which show that weight loss is difficult, and keeping the weight off is even harder. 
 
It’s a stretch, however, to go from “most people fail” to “you have no control, just give up.” Let’s compare dieting to quitting tobacco. Successful quitters take an average of 8-14 attempts before they manage to quit for one whole year. However, if you count those who have not yet succeeded, the best estimate is that it takes a heavy smoker an average of 30 attempts or more to quit.1
 
It would be deeply irresponsible to tell someone “nobody succeeds at quitting smoking, so let’s just focus on being healthy at a pack a day.” So why is it acceptable with obesity?
 
We know it can be done. I am awed by stories like that of Leah Lutz who, with the help of her coach and community, went from 275 pounds to being a national champion Master’s powerlifter in the 72kg (158lb) weight class in less than five years. On a larger scale, the National Weight Control Registry tracks the progress and habits of over 10,000 people who have lost significant weight and managed to keep it off for over a year, and there are undoubtedly tens of thousands more success stories in the US alone. 
 
All change is hard, and obesity, especially extreme obesity, is complex. It comes wrapped up with feelings of comfort, identity, community norms, habits, self-belief, and ambivalence. On top of that, there is a vast wealth of misinformation and well-marketed diet strategies seemingly designed to create short-term success and rebound weight gain. That doesn’t mean you’re doomed to fail. 
 

It’s Not You, It’s Your Environment 

The New York Times article concisely captures this sentiment and reflects the views of many on this issue: 
 
“Researchers say obesity, which affects one-third of Americans, is caused by interactions between the environment and genetics and has little to do with sloth or gluttony.” 
 
The problems with this statement are myriad. The first is the idea that this is the consensus of the scientific community. It’s not. This is the Center for Disease Control’s statement on the causes for obesity:
 
“Obesity results from a combination of causes and contributing factors, including individual factors such as behavior and genetics. Behaviors can include dietary patterns, physical activity, inactivity, medication use, and other exposures. Additional contributing factors in our society include the food and physical activity environment, education and skills, and food marketing and promotion."
 
It’s clear that the CDC sees the importance of personal behaviors in maintaining a healthy weight, but the point at issue here is beyond that. “Lifestyle change doesn’t work” advocates paint us as passive and helpless, battered by our environments like trees in a hurricane. Our environments may be powerful, but they are not static, nor are they entirely outside of our control. 
 
If your “food environment” isn’t great, you can still make smart choices between the available options, including the option to eat less total food (say, a handful of potato chips rather than a whole bag). If a Vietnam POW can train to do over 1000 pushups while recovering from torture, your “physical activity environment” is sufficient to get in a workout. If you’re reading this article, the education is available through the internet. Skill development is a process you choose, and there is nothing so compelling about any food marketing that you have to buy what it’s selling.
 
If the environment alone were responsible for our weight, you would expect that correcting the environment would fix the problem. The evidence suggests otherwise. Several studies have shown that placing full-service supermarkets in “food deserts” has little if any effect on BMI or fruit and vegetable consumption.2,3,4,5 Nutritional labeling may better inform the consumer,6 but they rarely change the behaviors of those who are not already eating well.7 Interestingly enough, done incorrectly, they can even backfire, encouraging buyers to make worse choices.8
 
I will agree with Ms. Kolata on one point: the problem isn’t sloth or gluttony. Losing a lot of weight can be very difficult mentally, emotionally, and physically. The environment can make an already difficult change even harder. And that’s the real issue here.
 
For all their good intentions, the naysayers are part of the problem. By shouting from the rooftops that dieters are doomed to fail, they become part of that toxic change environment. They enable friends and family to sabotage their loved one’s efforts and engender a sense of hopelessness. They’re the enemies of healthy change.
 
the obesity epidemic
Telling overweight people that there's nothing they can do is both incorrect and unhelpful.
 

It’s Not You, It’s Your Genes 

To be fair, their argument is not that simple. The NYT article states that it’s the interaction of our environment and our genes that makes obesity inevitable in some people, not the environment alone. The argument usually goes that we have evolved to seek salts, sugars, and fats, and modern designer foods (specifically crafted to taste salty, sweet, and fatty) interact with our genes to trigger addictive behaviors. On top of that, modern labor-saving devices and retail work mean we don’t have to move a lot to stay alive.
 
It makes sense that our genes haven’t kept up, and in this environment, of course we’re fat. Unfortunately, not everything that makes sense is correct. From the Harvard School of Public Health:
 
“What’s increasingly clear from these early findings is that genetic factors identified so far make only a small contribution to obesity risk—and that our genes are not our destiny: Many people who carry these so-called “obesity genes” do not become overweight, and healthy lifestyles can counteract these genetic effects.”
 
This shouldn’t really surprise anyone. A general “gene” answer to the problem is weak. How are our parents and grandparents less obese than we are despite living in the same environment? How do success stories exist if their genes and environment haven’t changed? Can genes overcome the basic laws of physics (calories in/calories out)? 
 
There is some evidence that certain genes may make it more likely that one person may become obese than another given the same environment and habits, but they are certainly not our destiny.
 

Obesity Isn’t That Bad, After All…

Some will take a completely different approach. Instead of arguing that obesity is dangerous but inevitable, they will argue that obesity isn’t really a health risk at all. The argument usually goes that it’s activity level, not body weight, that matters for health. People who are destined to be obese just need to focus on being active and happy and health will naturally come with it. 
 
Before I continue, understand that this argument actually has a lot of truth to it. I’m looking to put it in context and not dismiss it, so I’ll start with what’s right about it. 
 
Our definitions of ‘overweight’ and ‘obese’ are an issue to begin with. One of the largest reviews to date found that those who were overweight or had mild obesity (BMI of 25-35) actually had slightly lower overall mortality than those of normal weight.9 Although there is always the possibility of GIGO (garbage in, garbage out) skewing the data, it’s safe to say that being ‘overweight’ is not an automatic death sentence and being low-level obese (assuming other major risk factors like smoking are in check) may not be quite as terrible as we thought.
 
Also, greater physical activity and higher quality diets do improve health regardless of weight and total calories, and there will be people who remain overweight and show no signs of metabolic issues (“healthy obese”), at least for a while.10
 
Unfortunately, “healthy obese” is usually a temporary state. A large, 20-year cohort study came to a disheartening finding: 
 
“After 20 years, approximately one-half of healthy obese adults were unhealthy obese, and only 10% were healthy nonobese. Healthy obese adults were nearly 8 times more likely to progress to an unhealthy obese state after 20 years than healthy nonobese adults… The natural course of healthy obesity is progression to metabolic deterioration.”11
 
Once the metabolic deterioration starts, especially in those at higher levels obesity, the costs are significant. Obesity is directly correlated with higher mortality, high blood pressure, type 2 diabetes, heart disease, stroke, and numerous other conditions. The total costs attributed to obesity are estimated at $147 billion a year in the US alone, and obesity is rapidly becoming the single greatest source of ill health in the Western world.12 In other words, it is a big deal.
 
down several pants sizes
The best guarantee for health is to lose the weight.
 

What About Bariatric Surgery? 

The one major issue I haven’t addressed from the headline article is the question of bariatric surgery. Bariatric surgery works by reducing the size of the stomach, mechanically limiting how much we can eat. For reducing bodyweight and resolving both obesity and its secondary consequences, it has proven remarkably effective. Is it, as the New York Times would suggest, the best and only real option for the very-obese? 
 
Bariatric surgery has improved a lot over the years, and the surgery itself is relatively safe, but there’s a risk any time you cut someone open, and those risks don’t stop with the surgery itself. 5-10% of people will experience serious short-term serious complications, and it must be carefully monitored in the long term.13 Because the diet itself is so dramatically reduced and the gut mechanics change, micronutrient deficiencies are common. In addition, due to the sudden loss in body mass and preexisting parathyroid issues common in extremely obese patients, there is a higher risk of osteoporosis. In short, a patient will likely have to manage their diet, supplementation, and medical status for the rest of their life.
 
What does this all mean? There are some people for whom bariatric surgery is appropriate, especially those with a BMI over 40 who have previously tried diet and exercise strategies and would otherwise simply continue on as before. Doctors should stay informed about the risks, rewards, and contraindications and be willing to discuss them with their patients or refer when appropriate. 
 
Dieting and failing in cycles is painful and potentially harmful. If the options are disordered eating, early morbidity and disease, or bariatric surgery, talk to your doctor because it may be right for you. But ignore the naysayers who insist that outside of bariatric surgery, you’re doomed to fail (I’m looking at you, Gina Kolata). 
 

Aren’t You Being a Little Harsh?

The Health at Every Size principles statement “rejects judgments about health and any discourse about individual responsibility around health.” They do this to prioritize self-esteem and promote empowerment: if you are not responsible for your health, you don’t have to be ashamed of yourself regardless of how you look or what medical condition you may have. From this starting position, you can then consider options to work towards well-being. 
 
I sympathize with this approach, I really do, and all these articles and videos come down to this: 
  • No one should be shamed, mocked, or ridiculed for their weight or health. Shame is rarely a good motivator and often makes it harder to change.
  • Everyone deserves informed autonomy; the choice to decide whether or not change is worth the cost. 
  • Everyone deserves respect and dignity, not bias and discrimination.
  • No one has to meet an arbitrary beauty standard to be happy.
  • Some people will be overweight or obese through circumstances entirely outside of their control or due to life challenges that would overwhelm most mere mortals.
 
All of these are true, but none of them can change the facts: we are responsible for our actions, and our actions have a great impact on our health. Although we are influenced by other factors, we are the masters of our fate. Our culture didn’t eat that donut. Our genetics didn’t force us to marathon The Walking Dead when we promised ourselves we would train. 
If we don’t prioritize health, that is our choice and our right, but we are not “entitled to make up our own minds about what 'health' means.” A cell is insulin resistant or it is not. Your cancer is benign or it is not. Obesity (especially without serious muscle mass) saps our health and vitality.
 
But how do we take responsibility for our health without identifying with it? How do we get fitter without feeling ashamed about not being fit already? We accept where we are, move in the direction we commit to, live in each moment, and accept the process. 
 
We would never judge a child learning to walk or mock someone learning a language for making a mistake, and we can apply this same principle to ourselves. By living in each moment, learning from our mistakes, and accepting where we are on the road to progress, we can retain our dignity without surrendering to fate.
 
How can you sort through all the conflicting science out there?
 
References:

1. US Department of Health and Human Services. "Reducing tobacco use: A report of the surgeon general." National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health (2000).

2. Cummins, Steven, Ellen Flint, and Stephen A. Matthews. "New neighborhood grocery store increased awareness of food access but did not alter dietary habits or obesity." Health Affairs 33, no. 2 (2014): 283-291.

3. Elbel, Brian, Alyssa Moran, L. Beth Dixon, Kamila Kiszko, Jonathan Cantor, Courtney Abrams, and Tod Mijanovich. "Assessment of a government-subsidized supermarket in a high-need area on household food availability and children’s dietary intakes." Public Health Nutrition 18, no. 15 (2015): 2881-2890.

4. Dubowitz, Tamara, Madhumita Ghosh-Dastidar, Deborah A. Cohen, Robin Beckman, Elizabeth D. Steiner, Gerald P. Hunter, Karen R. Flórez et al. "Changes in Diet after Introduction of a Full Service Supermarket in a Food Desert." Health Affairs (Project Hope) 34, no. 11 (2015): 1858.

5. Dubowitz, Tamara, Madhumita Ghosh-Dastidar, Deborah A. Cohen, Robin Beckman, Elizabeth D. Steiner, Gerald P. Hunter, Karen R. Flórez et al. "Diet and perceptions change with supermarket introduction in a food desert, but not because of supermarket use." Health Affairs 34, no. 11 (2015): 1858-1868.

6. Hobin, Erin, Heather Lillico, Fei Zuo, Jocelyn Sacco, Laura Rosella, and David Hammond. "Estimating the impact of various menu labeling formats on parents’ demand for fast-food kids’ meals for their children: An experimental auction." Appetite 105 (2016): 582-590.

7. Rising, Camella J., and Nadine Bol. "Nudging Our Way to a Healthier Population: The Effect of Calorie Labeling and Self-Control on Menu Choices of Emerging Adults." Health Communication (2016): 1-7.

8. Lee, Morgan S., and Joel Kevin Thompson. "Exploring enhanced menu labels’ influence on fast food selections and exercise-related attitudes, perceptions, and intentions." Appetite (2016).

9. Flegal, Katherine M., Brian K. Kit, Heather Orpana, and Barry I. Graubard. "Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis." JAMA 309, no. 1 (2013): 71-82.

10. Blüher, Matthias. "The distinction of metabolically ‘healthy’ from ‘unhealthy’ obese individuals." Current Opinion in Lipidology 21, no. 1 (2010): 38-43.

11. Bell, Joshua A., Mark Hamer, Séverine Sabia, Archana Singh-Manoux, G. David Batty, and Mika Kivimaki. "The natural course of healthy obesity over 20 years." Journal of the American College of Cardiology 65, no. 1 (2015): 101-102.

12. Finkelstein, Eric A., Justin G. Trogdon, Joel W. Cohen, and William Dietz. "Annual medical spending attributable to obesity: payer-and service-specific estimates." Health Affairs 28, no. 5 (2009): w822-w831.

13. Schauer, Philip R., Bartolome Burguera, Sayeed Ikramuddin, Dan Cottam, William Gourash, Giselle Hamad, George M. Eid et al. "Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus." Annals of Surgery 238, no. 4 (2003): 467-485.

 

 

 

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